Episode #282 Building Safer Anesthesia Teams In A Locum-Driven World

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. The October 2025 APSF Newsletter is out with all new articles as we continue to work towards improved anesthesia patient safety. But before we cover the new newsletter articles, we have a special article between issues shows so that we can cover some of the articles that have been published on apsf.org since the June Newsletter, and there are some really good ones.

Before we dive further into the episode today, we’d like to recognize Merck, a major corporate supporter of APSF. Merck has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Merck – we wouldn’t be able to do all that we do without you!”

Our first featured article today is “Patient Safety with a Transient Workforce: Navigating the Terrain of a Locum Tenens-Driven World” by George Tewfik and colleagues. This article was published on-line June 30, 2025. We often talk about how important communication and teamwork are when it comes to anesthesia patient safety and this article focuses on what happens when our teams are comprised of new and frequently changing team members. There are staffing shortages in the United States and around the world which may make it difficult to provide anesthetic services on a day to day basis and cover call duties and on a larger scale, to be able to implement complex policies and procedures. This has led to the use of locum tenens or per diem anesthesia professionals to fill gaps caused by attrition, retirement, and expansion and help maintain adequate availability of anesthetic care services.

Let’s start with the definition and some background information. Locum tenens are short-term healthcare professionals that are usually used to cover clinicians for leave during periods of high demand, or in areas facing clinician shortages. In 2022, 88% of surveyed healthcare facility managers reported using locum tenens physicians with 28% of those using locum anesthesiologists or certified registered nurse anesthetists in the prior 12 months. Does your institution use locum tenens clinicians?

Advantages of having an available temporary workforce include the following:

• Making sure that services remain available especially in underserved or rural areas
• Filling gaps during clinician shortages or when regular staff are unavailable.
• Alleviating the workload of permanent staff to help decrease the risk for overwork and related errors

Disadvantages may include:

• Locum tenens professionals being unfamiliar with hospital specific protocols leading to communication errors or mismanagement
• Variability in the quality of care
• With frequent changes there may be disruptions in established workflows and communication

And all of these are important considerations that may have a downstream effect on patient care and patient safety. For example, there may be a situation where a locum anesthesia professional does not know who to contact for help in an emergency situation or may not know where to go in the hospital to respond to an emergency in a different department.

There may be a significant difference between permanent or full time staff and locum staff when it comes to orientation, continued education, mandatory training sessions, grand rounds, didactics, quality improvement measures, and evaluations.

And now it’s time for one of our favorite segments on the podcast. It’s time to dive into the literature.

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We are diving into the shallow end though since there is not a lot of data. First up, let’s look at a 2024 qualitative study based on interviews with locum tenens clinicians in the United Kingdom. You can find the citation in the show notes.  Results from this study revealed threats to patient safety for locums clinicians that included unfamiliar environments, policies, and computer systems. Have you ever witnessed a locum clinician struggling to log on to the computer? Another important threat to patient safety is the lack of clear direction and leadership when there are a lot of locum clinicians on staff. In addition, team dynamics may be compromised if locum clinicians are excluded from the team and there is the potential for lack of accountability with independent contractors.

Another study in England looked at general practitioner visits over a 12-year period. There were no statistically significant effects on patient safety parameters including emergency admissions. Interestingly, patients who saw a locum practitioner were 22% and 8% more likely to receive prescriptions for antibiotics and opioids, respectively, but consultation with the locums practitioners decreased return visits by 12 % within 1 week and decreased referrals and additional tests by 15% and 19% respectively.

Let’s turn our attention to patient safety data on locum tenens and anesthesiology. Unfortunately, at the time of this article, there are no major studies that assess the impact on patient safety and quality specific to anesthesia care. Hiring locum tenens clinicians usually comes down to a financial decision or to provide coverage quickly.  There is a 2024 study by Cross and colleagues that addresses a financial consideration for hiring. The investigators developed a Python simulation model to evaluate costs between hiring locum tenens and full-time anesthesiologists. The breakeven point was found to be 665 hours or 11 weeks at an average of 60 hours per week. After this point, it is more cost-effective to hire a full-time anesthesiologist. There is evidence that locum tenens physicians do not have a higher mortality rate, adverse event rate, or malpractice payout rate. Another area where data is lacking is on the impact of patient safety for locum tenens clinicians including certified registered nurse anesthetists who may be hired to fill staff shortages.

There are challenges inherent in building a robust safety program may be increased when relying heavily on temporary workers, but there is some good news. There are steps that can be taken to improve patient safety to help address each of these threats. We hope that you will check out Table 1 in the article to see this list, and we are going to go through these now.

The first barrier is lack of familiarity with the environment. The potential solutions include the following:

• Site specific orientation
• Consider limited deployment
• Standardization of environment/available resources

The next barrier is limited involvement with clinical governance. Here are some potential solutions:

• Use of regular clinical audits
• Requirements for professional development
• Mechanisms for feedback from locum tenens staff

Another barrier is non-compliance with policies and procedures. Potential solutions may include:

• Regular education for all staff
• Use of systems that mandate compliance with all staff (checklists, attestations, etc.)

Scope of practice effects may be another barrier to patient safety. Here are a couple potential solutions:

• Clear delineation for clinicians regarding responsibility
• Orientation of all staff (temporary and permanent) regarding roles

The last barrier that we are going to cover today is inhibited information exchange with these potential solutions:

• Use of checklists/cognitive aids
• Establish clear communication pathways between staff
• Include locum tenens in communication

Outside agencies are often responsible for credentialing and medical licensing for their locums tenens staff, but before these clinicians engage in patient care it is vital to provide appropriate orientation to the physical space, available equipment, resources, policies and procedures, and electronic health record documentation. Another consideration may be to deploy locum tenens anesthesia professionals only to the areas where they have been oriented, like the main operating room, and not send them to remote non-operating room anesthesia locations where they may be unfamiliar and far away from help if needed. We have talked about it before on this show, but we know that patients undergoing non-operating room anesthesia and procedures are at higher risk for severe adverse events. If we add clinicians who are not familiar with the environment to the equation, there may be an even higher risk for patient safety.

Communication and teamwork are critical ingredients for patient safety for all staff. So, it is important to consider how to improve communication for all staff including locum tenens staff. Do you have a clear communication pathway in your department? This may involve integrated electronic health record messaging, Slack, WhatsApp, or alternative communication technologies. It is critical that locums staff are included in routine departmental or group communications which may include information about changes in workflow or equipment or new expectations for staff. The goal is to make sure that all anesthesia professionals in the department are on the same page when it comes to policies, procedures, and expectations.

Another important consideration for improved patient safety is standardization and accessibility of resources such as medication and equipment. Lack of standardization in perioperative care, such as for documentation, stocked medications, available airway equipment, demands that every new clinician must orient to new surroundings and this goes for temporary and permanent staff. There is a time-cost here as well since when more aspects of clinical care are standardized, less time and effort are required for orientation. The authors provide an example of the use of the Joint Commission Universal Protocol which requires a pre-procedure verification process, procedure site marking, and time-out for any Joint Commission site. This is an expected and anticipated component of perioperative patient safety and since it is standardized, it is easy to implement across different sites and institutions.

Going forward, the staffing shortages are likely to continue in medicine and anesthesiology and the use of locum tenens staff will likely increase. The authors leave us with this call to action: “Understanding these unique factors that may affect patient safety more significantly with use of locum tenens staff and addressing these factors is the first step to mitigating the effects and successfully incorporating locum tenens professionals into a group’s overall strategy to improve perioperative patient safety.”

Are you using locum tenens clinicians at your institution? What steps have you taken to help maintain your group’s overall strategy to improve perioperative patient safety? Let us know by sending us an email at [email protected]. We want to hear from you and we can share your story right here on this podcast.

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.

Have you checked out the newest APSF Newsletter? The October 2025 APSF newsletter marks the 40 year anniversary of the APSF Newsletter. We are so excited to start talking about these articles on the podcast in the coming weeks so we hope that you will continue to tune in. Can you tell one friend, colleague, or trainee about this show too? We would love to continue to spread the latest news, research, and more about perioperative patient safety with an even bigger audience.

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

© 2025, The Anesthesia Patient Safety Foundation