Episode #190 The First International Anesthesia Patient Safety Conference Recap, Part 1

February 21, 2024

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Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel.  This podcast will be an exciting journey towards improved anesthesia patient safety.

The First International Conference on Anesthesia Patient Safety 2024 took place on February 8-10th in Tokyo, Japan. This conference was sponsored by the JSA, JFA, APSF, and the ASA. This podcast will bring you live coverage of the event, so you won’t have to miss a thing. This is the first episode in our series.

Did you know that the Japanese APSF Newsletter is the second most read Newsletter in the world!! This was the first APSF International Translation Partner and served as a catapult for additional translations to help spread the word about anesthesia patient safety around the world.

First up, we are talking about the keynote address by Steven Greenberg, “APSF Newsletter, Past, Current, and Future Directions.”

Next, we review the first conference session. This is the JSA Safety Management Division Chief’s Session entitled, “Emerging Infectious Diseases and Perioperative Medical supplies – What have we learned from the COVID-19 Pandemic?” Throughout the pandemic, healthcare systems were faced with world-wide shortages of anesthetics and medical equipment. This session focuses on problems in the current system and considerations for innovations to ensure adequate supplies going forward in Japan, the United States, and the global chain.  Our speakers that we cover today include the following:

  • The first speaker is Kazuyoshi Aoyama and he talked about “Patient Lives and Safety of the Medical Staff During the COVID-19 Pandemic.”
  • The next speaker is Mark Warner to talk about “APSF Involvement and Consensus Statements for COVID-19 Pandemic.”

Aoyama recounts his experience at the University of Toronto Hospital for Sick Kids where they worked to optimize PPE allocation with the Perioperative PPE Stewardship Program to help streamline distribution and limit locations where PPE was needed, follow guidelines from the CAS, WHO, and local IPAC recommendations and trigger early warnings for possible shortages and schedule operating room staff based on PPE availability. For more information, check out this citation:

Mandhari MA, Caldeira M, Dickinson M, Donnell CM. Perioperative personal protective equipment stewardship (POPPiES). Can J Anaesth. 2020 Sep;67(9):1279-1281. doi: 10.1007/s12630-020-01676-7. Epub 2020 Apr 29. PMID: 32350813; PMCID: PMC7189635.

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© 2024, The Anesthesia Patient Safety Foundation

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. A very exciting and monumental anesthesia patient safety event took place on February 8-10th in Tokyo, Japan, the International Conference on Anesthesia Patient Safety 2024. This conference was sponsored by the JSA, JFA, APSF, and the ASA. This podcast will bring you live coverage of the event, so you won’t have to miss a thing.

Before we dive into the episode today, we’d like to recognize Nihon Kohden America, a major corporate supporter of APSF. Nihon Kohden America has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Nihon Kohden America – we wouldn’t be able to do all that we do without you!” It was so nice to meet some of our podcast supporters from Nihon Kohden at the ICAPS 2024 conference as well! Thanks so much for listening!

Did you know that the Japanese APSF Newsletter is the second most read Newsletter in the world!! This was the first APSF International Translation Partner and served as a catapult for additional translations to help spread the word about anesthesia patient safety around the world.

To kick off our conference coverage we are going to review Steven Greenberg’s talk about the past, present, and future of the APSF Newsletter. This is where it all started on the road to no patient harmed by anesthesia care. Greenberg reminds us that safety is still a problem. After the COVID-19 Pandemic, the World Health Organization in 2022 reported the following concerning patient safety statistics:  a 60% increase in central line-associated bloodstream infections, 44% increase in methicillin-resistant staph aureus, and a 43% increase in catheter associated urinary tract infections.

As we can see, there is still work to do to improve patient safety. Greenberg also reminds us how far that we have come towards improving anesthesia patient safety. The field of anesthesiology has done this with leadership in healthcare organization safety, implemented standards in basic monitoring, conducted long term analysis through the closed claims database, created ASA’s Patient Safety and Risk Management Committee, and created the first US Patient Safety Foundation, yup, that’s us, the APSF, and we developed simulation training so that anesthesia professionals could keep patients safe from less common threats to patient safety such as local anesthetic systemic toxicity and malignant hyperthermia. Simulation training means that anesthesia professionals are equipped with the knowledge and skills to take care of patients in these rare situations even if they have never done so before.

Now, let’s take a closer look at the APSF and the APSF Newsletter. In the first ever APSF Newsletter, the important concerns included minimal essential monitoring during anesthesia, development of a closed claims database, and the dangers of hypoxemia and hypercarbia and how we could detect these events before patients came to harm. Over the next 35 years, the APSF has worked hard to improve anesthesia patient safety in many different areas. Here are some of the highlights.

Operating room fires: The APSF developed the OR Fire Prevention Algorithm which focused on which patients were at risk and which situations increased the risk. Do you conduct a fire assessment prior to starting a surgical procedure or during the time-out? According to the Patient Safety Authority there has been approximately a 70% reduction in OR fires from 2004 to 2016.

Postoperative visual loss: Risk factors associated with the development of ischemic optic neuropathy especially during spine surgery have been studied and identified. With education about this threat, ischemic optic neuropathy has decreased almost three-fold from 1998-2012.

Neuromuscular Blockade Monitoring: An important question is what would you expect if you were the patient? There are serious risks related to residual neuromuscular blockade. In 2023, the ASA passed the updated guidelines on monitoring and antagonism of neuromuscular blockade. The guidelines discuss the use of quantitative monitoring for patients who receive neuromuscular blocking medications, administration of Sugammadex for patients with deep, moderate, or shallow depth of block, the use of neostigmine as a reasonable alternative for patients with shallow blockade, and that with quantitative monitoring once the TOF ratio is greater than or equal to 90%, then no reversal is needed. We have come a long way from only monitoring with the 5-second head-lift. Appropriate monitoring and reversal can help to prevent residua neuromuscular blockade and respiratory complications.

Opioid induced respiratory depression: This is such an important topic. The APSF recommends that pulse ox be used for patients not on supplemental O2 and monitors of gas exchange should be used for patients receiving supplemental oxygen. This was a special focus of the APSF in 2018-2019 with many articles in the Newsletter focused on this critical topic. This is also a topic that we have talked about on this podcast before. Check out episodes #162 and #163 when we discuss strategies for keeping patients safe from opioid-induced respiratory depression throughout the perioperative period. The next step may be to provide continuous monitoring for up to 12 hours after opioid administration or until discharge.

Medication Safety: This is a big threat which occurs frequently with an incidence of about 1 in 20 to 1 in 274 anesthetics delivered. Substitution of the intended drug with another is the most common type of medication error. The goal supported by the APSF is to create a no-blame culture in order to help decrease medication errors. Another important resource is the look-like drug vial stories and gallery on the APSF website. I will include the link in the show notes as well. Thank you to all of the patient safety champions who have sent in their pictures of look-alike medications and stories.  The APSF focused on this issue during the 2010 Stoelting Conference. This multidisciplinary conference highlighted 4 vital areas for future medication safety. It is easy to remember with the initials, STPC, which stands for:

  • Standardization of high alert mediations
  • Technology which may include the use of bar-code scanners or SMART infusion pumps, or alerts and alarms in the electronic medical record
  • Pharmacy with pre-filled syringes and infusion bags
  • And Culture which must involve effective communication, respect, and teamwork.

The medication safety conference was then repeated in 2018. New recommendations from the APSF following this conference to help prevent medication errors include evaluate medical dispensing for high-risk medications, only use the system override in urgent or emergent situations, ensure two-person medication verification systems every time an override is used, utilize appropriate monitoring when patients receive high-risk medications, move away from a culture of normalization of deviance to a patient safety culture, and empower others to report on actions that may put patients at risk.

Another important APSF initiative is working with industry and this collaboration continues today as the Rapid Response to Questions from our Readers column. This allows end-user anesthesia professionals to directly address patient safety concerns with representatives from industry who may then make changes in their products or technology or provide guidance about correct usage of devices. This is one of our favorite APSF columns to talk about here on the podcast.

Greenberg highlights the APSF’s commitment to international collaboration. This has led to newsletter translations as well as continued sharing of knowledge and ideas. An excellent example is the APSF article, “Current Status of Sugammadex Usage and the Occurrence of Sugammadex Induced anaphylaxis in Japan.” This is one of the most read APSF articles. Another example is this International Conference on anesthesia patient safety bringing together so many professionals from around the world dedicated to keeping patients safe. It is very exciting that the international readership has increased over the readership in the United States during the past year.

One area where the APSF played a critical role was during the Covid-19 Pandemic. This included an International Covid Safety Educational Outreach initiative which led to developing the “Update on the Perioperative Considerations for Covid-19 SARS-CoV2” with revisions and updates as more information become available. Further collaboration and statements from the ASA and APSF directly impacted bedside care and gave anesthesia professionals tools to keep patients and themselves safe.

The APSF Newsletter has expanded from a three times a year Newsletter to include more high yield content. Have you seen the “In the Literature” section or any of the “Articles Between Issues?” We have covered these columns on the podcast and we will continue to do so going forward. The APSF also has a new column in the ASA monitor. Going forward, the APSF is committed to supporting the global exchange of information with additional Newsletter translations, building connections on social media, and increased international authored Newsletter articles. The goal is to maintain sustainable safety changes through a cycle of spreading knowledge, implementing new initiatives, and adhering to patient safety culture. Greenberg closes his talk with the quote from Mahatma Gandhi, “Live as if you were to die tomorrow. Learn as if you were to live forever.”

We have time talk about some of the first conference session. This is the JSA Safety Management Division Chief’s Session entitled, “Emerging Infectious Diseases and Perioperative Medical supplies – What have we learned from the COVID-19 Pandemic?” Throughout the pandemic, healthcare systems were faced with world-wide shortages of anesthetics and medical equipment. This session focuses on problems in the current system and considerations for innovations to ensure adequate supplies going forward in Japan, the United States, and the global chain.

The first speaker is Kazuyoshi Aoyama and he talked about “Patient Lives and Safety of the Medical Staff During the COVID-19 Pandemic.”

His talked highlighted the availability of personal protective equipment or PPE early in the pandemic taking into consideration the high demand and the limited supply. He recounts his experience at the University of Toronto Hospital for Sick Kids where they worked to optimize PPE allocation with the Perioperative PPE Stewardship Program to help streamline distribution and limit locations where PPE was needed, follow guidelines from the CAS, WHO, and local IPAC recommendations and trigger early warnings for possible shortages and schedule operating room staff based on PPE availability. I will include a citation in the show notes for more information about this program. Previous infectious disease outbreaks in Canada included SARS in 2003 and H1N1 in 2009 which led to stockpiling millions of masks in Ontario which were found to be expired before they could be used during the COVID-19 Pandemic. Going forward, will Canada be prepared for the next pandemic? The preparation includes stockpile of gloves, masks, N95 respirators, and gowns with careful attention to rotating the supply to avoid expiration of needed equipment. The final message is that we need to be ready for the next outbreak which could happen at anytime.

The next speaker is Mark Warner to talk about “APSF Involvement and Consensus Statements for COVID-19 Pandemic.” Warner served as the president of the APSF during the pandemic. At the start of the pandemic, anesthesia professionals had the following burning questions, how do we make sure our anesthesia team members are safe?, how do we best care for our patients? And how can we quickly disseminate new knowledge and helpful information?

Warner describes the challenges related to peer review of new knowledge since peer review at the beginning of the pandemic was challenging with very few reviewers having a strong background in virology or pandemic epidemiology or the science of healthcare workers protection. Journals and non-peer reviewed publications were flooded with early reports and creative ideas. It was difficult to determine what was reliable, credible, and useful, what should be widely disseminated, and what caveats should be added at the time of their publication.

Many journals established rapid communications or publications with minimal peer-review and some authors took advantage of the high acceptance rates and submitted fraudulent information or papers filled with only preliminary data. Many were later proven to be inaccurate. Journals played a role since they wanted mass media attention. Did you know that 60% of PubMed indexed COVID-related articles in anesthesia journals were published in just 3 journals: the British Journal of Anaesthesia, A&A, and Anaesthesia. At the same time, social media was used to further disseminate this knowledge with a greater reach and visibility including twitter and regular media links. National anesthesia societies used a different approach and were careful in their use of media and made sure that their information was reviewed and discussed prior to dissemination. This was the approach used by the APSF as well. Thus, information from the APSF proved to be more reliable and clinically relevant than information coming to clinicians from mass media.

Between December 2021 and March 2023, information from the ASA and APSF was accessed more than 5 million times by people from 240 countries in the world. This information was updated frequently and clinically relevant to day-to-day practices.

Warner concludes his talk by highlighting the roles for National Societies and Journals when it comes to the next pandemic or major healthcare event.

National anesthesia societies have the following responsibilities:

  • Have a historical recall for how to handle emergency situations such as a pandemic
  • Rapidly appoint teams to carefully consider and develop consensus statements and FAQs to help clinicians
  • And resist seeking mass media coverage.

Journals have the following responsibilities:

  • Develop protocols on how to provide appropriate peer-reviewed articles in emergent situations
  • Carefully consider and restrain efforts to gain mass media coverage.

Important questions today when thinking about the COVID-19 pandemic are: What worked? What didn’t work? And What should we do differently next time?

There is still so much great content from the first session and the entire conference. Mark your calendars because we will be back next week!

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2024, The Anesthesia Patient Safety Foundation