Vienna M&M Meeting Studies Safety

Jeffrey B. Cooper, Ph.D.

ICPAMM originated from a group that first met in Boston in October 1984, during the International Symposium (now Committee) on Preventable Anesthesia Mortality and Morbidity. The September ICPAMM meeting in Vienna was the planned follow-up of those original discussions. Sixty-two participants attended, representing 19 countries. The objective of this meeting and this informal organization is to enhance international communication of ongoing research in anesthesia mortality and morbidity and of patient safety activities. Such communication should stimulate innovation in planning research and in formulating strategies that will minimize the risk of anesthesia.

The meeting opened by addressing the question, “Are there differences in anesthesia mortality and morbidity among countries?” There were then reports of patient-safety activities and research in Canada, France, Holland, the United Kingdom and the United States. In the afternoon session, two discussion sessions were held: “How to Resolve the Monitoring Controversy9” and “Selection and Assessment of Anaesthesia.” Plans were formulated for cooperative international surveys .

Death Rates

In the first presentation, Dr. Jeffrey Cooper compared estimates of anesthesia-related mortality and morbidity from studies in several countries. The major hypothesis was that there are not large differences in the rates of anesthesia M&M among the industrialized countries. Rather, differences suggested by results of various studies are primarily due to the differences in methodologies. It was argued that the approximate rate of anesthesia mortality among all patients is 1 per 10,000, but that the risk to the relatively healthy patient undergoing an elective procedure is probably on the order of 1/50,000 to 1/100,000. Dr. Cooper suggested that each medical “culture” has adopted practices that minimize the mortality rate to a level acceptable by its society By emphasizing how those different practices work in each culture, other countries can learn how to adapt some elements so that each could improve upon its current performance.

The reports of patient-safety activities strongly indicate that this a subject of international interest. Several major studies of anesthesia mortality, morbidity, or complications have recently been completed or are underway (France, Canada, UK) and others are planned (USA, West Germany). Dr. JM Desmonts reviewed data from the recent French study and emphasized how recommendations and actions were implemented from the results. Similarly, Dr. Jan Crul described how a Dutch national committee that he chaired reviewed available data and prepared recommendations from which standards of practice were implemented.

Dr. E.C. Pierce reviewed the extensive list of patient-mw activities in the United States: the ASA video-tape patient-safety program; analysis of closed anesthesia malpractice claims; completion of a manual on quality assurance; cooperative efforts between the ASA and US FDA Bureau of Devices and Radiologic Health to promulgate recommendations for pre-use inspection of anesthesia apparatus; organization of a task force which, in cooperation with the US Center for Disease Control, is planning a national study of the incidence of anesthesia mortality and morbidity; adoption of standards for minimal monitoring. Of special significance is the organization of the Anesthesia Patient Safety Foundation in October 1985.

Monitoring

Difference in national approaches to monitoring standards was noted. In Holland, standards require only what monitoring instrumentation must be available; in the USA, the standard proposed (and since approved) by the American Society of Anesthesiologists defines what actually must monitored.

Drs. E.S. Siker and Keith Sykes took opposing views on the subject of the benefits and problems associated with the increasing use of monitoring instrumentation in anesthesia. Dr. Siker cautioned that those who ask, “Can we afford more monitoring?” should more rightly ask, “Can we afford not to have more monitoring?” Dr. Sykes urged that our financial resources were better spent on assuring adequate training of new anaesthetists. Not surprisingly, each debater took the opportunity during the discussion to counter his own original arguments, attesting to the complexity of the controversy. During the discussion, Dr. I.S. Gravenstein briefly described a study in progress investigating how the anesthesiologist processes information and acts upon it. Dr. Cooper noted preliminary results of an ongoing study suggesting that pulse oximetry had the influence of reducing certain types of complications.

Dr. Anthony Adams reviewed a list of criteria generated at the 1984 meeting for identifying appropriate candidates for anesthetists. But, his presentation stressed the more important need to identify the “wrong” people since the-se were the greater contributors to adverse outcomes. In the discussion, Dr. Ronald Katz reported his experience that, almost without exception, trainees dropped from anesthesia training programs complete programs elsewhere and eventually stay within anesthesia. Other discussants Confirmed the international prevalence of this phenomena. Several participants described attempts in various countries to have forms of “trial” period for prospective anesthesia trainees. This has the advantage of preventing entry into a formal program by individuals who are not well suited to the profession.

It was noted that the increasing supply of physicians, (experienced already in Europe, but also increasingly in the United States) will probably lead to a greater pool for selection of anesthesiologists. This is likely to generate a much greater emphasis on developing effective mechanism for selecting the right candidates.

Several projects were proposed for completion before the next meeting. There will be a renewed effort to develop standardized definitions for anesthesia related mortality and morbidity A renew by Dr. Stephanie Duberman in the book recently edited by Dr. John Lunn [see review in this issue] will be distributed to meeting participants. Dr. Adams will direct an effort to survey members of this international group about experiences with failures of anesthesia candidates. Also, various members will work to design a survey to identify the extremes and ranges of judgement for required monitoring in illustrative cases. Dr. Gravenstein will organize a survey to assess opinions of the maximum working hours for anesthetists.

The next meeting is scheduled for May 22, 1988, the day preceding the opening of the World Congress of Anesthesiology in Washington, DC.

Dr. Cooper, Massachusetts General Hospital, is on the APSF Executive Committee and is the organizer of ICPAMM.