Episode #191 ICAPS 2024 Recap, Part 2: Learning from the Covid-19 Pandemic and NORA Considerations

February 28, 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 second episode in our series.

Make sure you check out Episode #190 for the first part in our series covering the first ever International Anesthesia Patient Safety Conference. We are picking up right where we left off with the rest of the speakers from the first session.

We are reviewing the following talks today:

  1. Bu-Wei Yu talks about “Anesthesia based therapy- A very effective lifesaving method for critically ill patients with COVID-19.” This talk focused on clinical features of covid infections, radiological changes, and pathological changes related to a new virus invading the body.
  2. Tokujiro Uchida and his talk, “Looking Back on the COVID-19 Pandemic to Prepare for the Future.” This talk reviewed the experience from a hospital in Tokyo during the pandemic with considerations for creating zones within the hospital, screening and testing patients, appropriately triaging patients, and securing medical supplies.
  3. Mary Dale Peterson talks about, “The American Society of Anesthesiologists’ Response and Collaboration with Governmental Entities in Saving Lives During the COVID-19 Pandemic.” Highlights from Peterson’s talk include an overview of crisis management.

Next up, we move on to the next session in the conference, an International Table Discussion on Non-operating Room Anesthesia with speakers from the United States, Japan, and Korea. Here are the topics that we discuss today.

  • The first speaker is Emily Methangkool to talk about “Challenges and Opportunities in Non-operating Room Anesthesia.” Methangkool opens by highlighting important considerations for patient safety in the GI suite.
  • The next speaker is Megumi Okuyama with a talk all about “Sedation education and practical training for non-anesthesiologists – Our challenging pursuit to achieve sustainable patient safety.” The conclusion of this talk is that safe sedation can be accomplished by non-anesthesiologists with interprofessional collaboration, education and training, and screening patients with support from the anesthesia team when needed for high-risk patients.
  • The next talk is “Challenges and Safety Standards for Pediatrics in the Non-Operating Room Anesthesia Environment” by Norifumi Kuratani. He provides insight to keeping pediatric patients safe in the MRI suite and Cardiac Cath Lab.
  • The final talk in this session is “Massive intraoperative hemorrhage in the obstetric suite” by Sophie Sohn. This is a critical threat to patient safety since obstetric hemorrhage is the most common cause for maternal death. Maternal safety bundles provide a framework to be prepared for massive hemorrhage.

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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. We are back for the second episode in this series.

But before we dive into the episode today, you’ve heard me recognize our corporate supporters on this show, but there’s another supporter who is absolutely essential – YOU! Every individual donation matters so much. Please visit APSF.org and click on the Our Donors heading and consider making a tax-deductible donation to the APSF.

Make sure you check out Episode #190 for the first part in our series covering the first ever International Anesthesia Patient Safety Conference. We are picking up right where we left off with the rest of the speakers from the first session.

The next speaker is Bu-Wei Yu to talk about “Anesthesia based therapy- A very effective lifesaving method for critically ill patients with COVID-19.” This talk focused on clinical features of covid infections, radiological changes, and pathological changes related to a new virus invading the body leading to overexcitation of the sympathetic and immune system with the end result of pulmonary capillary cell damage, severe lung consolidation, and tissue and organ hypoxia. Anesthesia rescue therapies were utilized including general anesthesia with neuromuscular blockade before intubation to help protect the anesthesiologist as well as modification of the ventilation system to help remove or destroy live virus in the air and decrease viral transmission.

Our next speaker is Tokujiro Uchida with his talk, “Looking Back on the COVID-19 Pandemic to Prepare for the Future.” This talk reviewed the experience from a hospital in Tokyo during the pandemic with considerations for creating zones within the hospital, screening and testing patients, appropriately triaging patients, and securing medical supplies. One of the important challenges was securing adequate ventilators. This is where a major automobile parts manufacturer stepped in to support the production of ventilators in response to the chaotic supply chain. Nihon Koden also increased the ventilator supply. This represents the importance of collaboration between healthcare, industry, and the government to meet the challenges posed by the pandemic.

During the pandemic, there were multiple factors contributing to the shortage of medical supplies, such as production of raw materials and products concentrated in China, global container shortage, and complex distribution of supplies throughout Japan.  Going forward, the goal is to maintain a stable supply with initiatives in supply contracts with the supplier to maintain a two-month inventory, diversity of procurement sources with overseas and domestic manufacturing, a circular inventory system, and emergency joint procurement and database of inventory management.

The final speaker for this first session is Mary Dale Peterson to talk about, “The American Society of Anesthesiologists’ Response and Collaboration with Governmental Entities in Saving Lives During the COVID-19 Pandemic.” Highlights from Peterson’s talk include an overview of crisis management with the following considerations:

  • Planning – You need to have your disaster manuals ready and be able to address the stages of prevention, mitigation, preparedness, response, and recovery
  • Structure – creating an Incident command center
  • Relationships – improved communication and collaboration including with government
  • And Agility – ability to act with limited information

Peterson also discusses the creation of the Covid-19 Task Force early in the pandemic to help set and address priorities including PPE for physicians and wellness resources, critical care education for patients, ventilator and medication shortages, funding for the provider relief fund, payment protection program, and Medicare accelerated payment program. Trauma-informed leadership was used, when possible, to listen to people on the front lines, hear their concerns and provide protection, preparation, support, and care as needed. Lessons learned during the pandemic including the importance of prior relationships built on trust that can be leveraged during a crisis, prioritize goals for each and day and each week, critical communications to quickly disseminate knowledge that is needed to provide safe patient care during a crisis, and listening, empathizing, and thanking throughout the process.

We are moving on to the next session in the conference, an international table discussion on Non-operating Room Anesthesia with speakers from the United States, Japan, and Korea. Here we go.

The first speaker is Emily Methangkool to talk about “Challenges and Opportunities in Non-operating Room Anesthesia.” Methangkool opens by highlighting important considerations for patient safety in the GI suite including

  • More serious complications associated with ERCP procedures than with upper endoscopy procedures.
  • MAC cases are more likely to be complicated by hypoxia
  • General anesthesia cases are associated with more vasopressor use

The question remains, what is safer, Mac or GA? This is an ongoing debate. We have seen higher rates of sedation related adverse events due to difficulty with oxygenation and ventilation during MAC cases. It is also important to note that anesthesia services are likely needed in the GI suite and anesthesia care during these procedures leads to lower rates of procedure and sedation failure, decreased hospital days, and excellent proceduralist and patient satisfaction and this is especially true for longer procedures that require deeper levels of sedation.

Why are there so many complications associated with NORA care? This is likely due to the combination of increasing procedural complexity for patients with increased comorbidities. We are pushing the boundaries on what can be done with procedures outside the operating room and there is the idea that NORA procedures are minimally invasive or short or with lower risks, but we need to re-think this going forward and remain vigilant.

Let’s take a look at some of the root causes of adverse events:

  • Location: which may be far away from the general operating rooms so that it is difficult to get help and additional resources
  • Ergonomics: since the space allocated for anesthesia is very small with limited patient access and decreased visibility
  • Equipment: since this may be different than what you are used to in the main operating rooms.
  • Unfamiliar procedural team and vice versa: In addition, the procedure team may not be comfortable with a patient under general anesthesia, and, on the flip side, the anesthesia team may not be knowledgeable about the procedure.
  • Production pressure may lead to short cuts and compromised patient safety.
  • The cognitive burden may be higher in NORA with clinicians having higher anxiety, effort load, and frustration in NORA compared to the main OR.
  • Communication may be a big problem especially when anesthesia professionals feel like visitors in the NORA space. These issues can lead to patient harm.
  • Additional concerns related to teamwork and communication include the creation of ad hoc teams, unfamiliar with procedures and personnel, qualified personnel not available, the idea that it is “just a mac” case (How many of you have heard that phrase? Have you ever used that phrase yourself?), the lack of defined roles and responsibility during NORA care.

So, what can we do to improve NORA patient safety? You may not be able to change the physical space, but there are other steps to take.

  1. Appropriate patient and procedural preparation. This involves patient optimization and preparation, planning for the shared airway, using the same monitoring standards as the OR, and ensuring adjunct airway devices are available which may include nasal CPAP, HFNC, and a procedural oxygen mask.
  2. Improved situational awareness with safety huddles, standard care pathways and protocols, liaisons between the proceduralists and the anesthesia team, interdisciplinary conferences, and in-situ simulations to build teamwork and improve communication.

Remember, there is significant risk for patient harm during NORA, but we can mitigate that risk by taking some of these important steps.

The next speaker is Megumi Okuyama with a talk all about “Sedation education and practical training for non-anesthesiologists – Our challenging pursuit to achieve sustainable patient safety.”

What happens when non-anesthesia professionals provide sedation? There is a risk for severe hypoxia, delayed recovery, and increased recovery room length of stay. In addition, endoscopists may be unfamiliar with sedative medications and remember, patient complexity is increasing.

An important question to think about is who should or could perform sedation? When trained anesthesia professionals provide sedation, there are less events of bradycardia and awareness. When it is not possible for anesthesia professionals to provide care for all sedation cases, then non-anesthesiologists may need to provide sedation and can likely do this safely with proper training.

Okuymama asks another important question. What can anesthesiologists do to improve sedation quality and safety with minimum manpower resources? Here are some considerations:

  • Help with standardization of sedation protocols and incident management
  • Help create safer sedation protocols for Propofol administration
  • Provide education on sedation techniques and incident management for endoscopists, nurses, and clinical engineers
  • Perform sedation for high-risk patients in the operating room.

There is a call to action for anesthesia professionals to be safety leaders. The Chiba Safe Sedation Program provided authorization with sedation management guidelines and the use of propofol by non-anesthesiologists, education and airway management practice, and surveillance of all hospital sedation cases. The program also helped to clarify the roles for the endoscopists who were required to do the following:

  • follow the guidelines
  • have a designated person for vital sign monitoring
  • attend the educational program
  • provide information on sedation quality and safety
  • use of Propofol with certified staff only
  • and ask anesthesiologists for help with high-risk patients.

In conclusion, safe sedation can be accomplished by non-anesthesiologists with interprofessional collaboration, education and training, and screening patients with support from the anesthesia team when needed for high-risk patients.

The next talk is “Challenges and Safety Standards for Pediatrics in the Non-Operating Room Anesthesia Environment” by Norifumi Kuratani. He opens the talk with the quote from Maya Angelou, “Do the best you can until you know better, then when you know better, do better.” This is an excellent call to action for keeping patients safe during anesthesia care.

We have talked about keeping adults safe during NORA care, but what about pediatric patients? There are important considerations for keeping pediatric patients safe.

  • Procedures may not be able to be done in the operating room due to time constraints
  • Procedures may be brief and non-sterile
  • The challenge for pediatric patients to stay still, especially when they are in an unfamiliar setting, such as an MRI machine.
  • And remember, pediatric patients are not small adults.

There are important safety standards that should be followed to keep pediatric patients safe during NORA including the following:

  • Patient preparation including a thorough evaluation of medical history, recent illness, physical exam, airway, consent, and fasting
  • Suite preparation including size appropriate equipment and supplies and MRI compatible when needed, ASA standard monitoring with the ability for recording, continuous vigilant observation, and emergency team and response.
  • Medications in NORA to provide sedation, immobility, and analgesia with the goal is to customize care for each patient and procedure.
  • Recovery and discharge area with continued monitoring by healthcare providers in dedicated area so the pediatric patients can only be discharged home when awake and alert and stable.

Let’s look a little closer at some of the Peds NORA spaces.

First up is the MRI machine. This is not the most child friendly space. It is loud and may be frightening. Plus, the high magnetic field requires special MRI compatible devices, observation may be difficult during the exam, and the goal is hemodynamic stability and rapid recovery so that the patients can go home soon after the exam is completed. If possible, the goal is to optimize the environment so that GA and maybe even sedation is not needed and for some pediatric patients this can be accomplished with the help of child-life specialists, Virtual Reality, Music, and Games.

Let’s more into the cardiac Cath lab. Procedures may include measurement and imaging for diagnostic procedures as well as interventions. Adverse events in this space are more common and may include cardiac arrest. Challenges for providing safe care in the pediatric Cath lab include diverse patient demographics with unique physiology, anatomy, and developmental considerations, anesthesia considerations, procedure-specific risks, equipment and space constrains, communication and coordination, and emergency response.

There is a call to action for anesthesia professionals to meet the challenges in this environment by adapting OR safety protocols for the remote setting and acquiring in-depth knowledge of the procedures in order to help keep pediatric patients safe during NORA care.

The final talk in this session is “Massive intraoperative hemorrhage in the obstetric suite” by Sophie Sohn. This is a critical threat to patient safety since obstetric hemorrhage is the most common cause for maternal death. Keeping patients safe requires accurate measurement of blood loss and increased monitoring for any patients with estimated blood loss greater than 500mls. Maternal safety bundles provide a framework to be prepared for massive hemorrhage. This includes readiness, recognition and prevention, response, and reporting system. The readiness components include a hemorrhage cart, medication kit, response team including blood bank professionals, transfusion protocols, and education and drills on the unit. Recognition involves assessing the risk for hemorrhage for each patient and identifying risk factors and being able to quantitatively determine blood loss. The response involves when and the how. Stage one is to treat the etiology and prepare blood and increase monitoring and this moves on to Stage 2 with continued bleeding and then to Stage 3 when there is a concern for the development of DIC.

There are still so many more excellent talks from the conference and more ways to keep your patients safe, no matter where you are in the world.

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