Episode #29 Technology and Anesthesia Patient Safety Reboot

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. Today we are going to hear from a member of the APSF Committee on Technology, Dr. Bob Thiele and discuss the intersection between anesthesia patient safety and technology.

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

To kick off the show, I reached out to Dr. Thiele to ask him a couple of questions about anesthesia patient safety and technology and I am going to let him introduce himself.

[Thiele] “Hi, my name is Bob Thiele and I am an associate professor of anesthesiology at the University of Virginia.  I run a translational research lab focused on the development of technology in anesthesia and critical care, and I am a member of the APSF committee on technology.”

I asked Dr. Thiele to share his thoughts about the relationship between anesthesia patient safety and technology.  Let’s take a listen to what he had to say.

[Thiele] “This relationship was best captured by the Institute of Medicine, which published its book “To Err Is Human: Building a Safer Health System:” in the year 2000.  The IOM state:

“Anesthesiology is an example of a local, but complex, high-risk, dynamic patient care system in which there has been notably reduced error…. anesthesiologists confronted the safety issues presented by the need for continuing vigilance during long operations but punctuated by the need for rapid problem evaluation and action. They were faced with a heterogeneity of design in anesthesia devices; fatigue and sleep deprivation; and competing institutional, professional, and patient care priorities. By a combination of technological advances (most notably the pulse oximeter), standardization of equipment, and changes in training, they were able to bring about major, sustained, widespread reduction in morbidity and mortality attributable to the administration of anesthesia.”

In my opinion, safety through technology is central to our identity as anesthesiologists – past, present, and future”

Thank you, Dr. Thiele for your insights and don’t worry we will be hearing more from him later on in the show.  Now, let’s look a little closer at the relationship between advanced medical technology and safe anesthesia patient care. To do this, we are also going to head into the APSF archives to discuss an article from the winter 2013 APSF Newsletter, “Training Anesthesia Professionals to Use Advanced Medical Technology” from the APSF Committee on Technology. While technology has certainly changed in the past 8 years since this article was published, the overview and recommendations are just as important today.  To find the article from the APSF homepage, click on the Newsletter heading, 4^th one down is APSF Newsletter archives. From here scroll down until you see 2013 and then click on Winter 2013. The article is the 2^nd one in the column on the left. Let’s boot up our technology and get into the article!

This article includes recommendations from the ASPF Committee on Technology from 2013 and comes with the following disclaimer that recommendations developed and supported by the APSF are intended to assist professionals who are responsible for making health care decisions with a focus on minimizing the risk to individual patients for rare adverse events rather than necessarily on practices that balance all aspects of population health quality and cost. You can read the full disclaimer in the article and I will include the link in the show notes.

The APSF is committed to anesthesia patient safety by involving not only the medical professionals providing anesthesia care, but also representatives from the medical device industry to reach this goal.  This collaboration is something that we see as part of the Rapid Response to questions from our readers. For the 2013 article the committee on technology developed recommendations for Advanced Medical Technology Training. Anesthesia training involves learning about pharmacology and physiology and technical skills to intubate, but it is also important that practicing anesthesia professionals are able to correctly and safely use advanced medical technology and this article offers a guide for learning, assessment, and documenting the competency for the use of advanced medical technology. Before we go any further, let’s review some definitions and examples that you can find in the appendix. First, advanced medical technology includes “medical devices and software systems that are complex, provide critical patient data, or that directly implement pharmacologic or life-support processes whereby inadvertent misuse or use error could present a known probability of patient harm.” Did you use anything that fits into this category today? Here are some examples of this technology. Go ahead and raise your hand each time, I give an example of advanced medical technology that you used the last time you were providing anesthesia care.

• Anesthesia machines or workstations and mechanical ventilators
• Patient monitoring systems which may include cardiovascular, respiratory, neuromuscular, and electrophysiological monitoring
• Complex diagnostic imaging systems including doppler velocity and ultrasonic imaging, such as one of my favorite pieces of technology, transesophageal echocardiography
• Medication delivery systems including infusion pumps
• Energy delivery systems including defibrillators and pacemakers
• Cardiovascular support devices including intra-aortic balloon pumps or ECMO
• Point-of-care diagnostic/laboratory devices including ROTEM or TEG or even arterial blood gases
• Anesthesia and other health care documentation or informatics systems if they include medication ordering, clinical decision support, or diagnostic components on which an acute life-affecting diagnosis or therapy will be based.

Did you get a workout in by raising your hand? I know that I did.  Some days we may use all of these advanced medical technologies to care for patients. The APSF Committee on Technology states that even though anesthesia professionals have not been required to demonstrate competency for anesthesia technology to care for patients in the past, this is an important part of safe patient care and just like other medical professionals are required to demonstrate competency for the use of medical technology such as the use of lasers, fluoroscopy, and point-of-care laboratory devices.

Let’s take a look at the obstacles to training on advanced medical technologies. The APSF committee on technology identified barriers to training programs for  learning about new technology in 2013 that included the following:

• Lack of recommendations from anesthesia professional organizations to demonstrate competence prior to using advanced medical technology during anesthesia patient care.
• Time constraints due to clinical workload and busy OR schedules
• Availability of accessible training programs and can be completed in a time frame that is appropriate for busy anesthesia professionals.
• Not being able to offer CME credits for training on technology that is provided by industry representatives even though this training from industry representatives may be preferred given their expertise with the technology and incentive to provide the training.
• Difficulty maintaining a formal training program after an initial time period for newly fired anesthesia professionals. The industry representatives are often on-site and available for training immediately after implementing a new device, such as new anesthesia machine or a new transesophageal echocardiography machine, but if faculty are hired without this training the following year, they may not have access to any formal training on this technology.

Advanced medical technology is a major part of anesthesia care for patients. The APSF advocates for health care organizations to develop appropriate policies and procedures for technology training and maintaining competency for using this technology safely.

Now, let’s get into the considerations that were developed in 2013 by the APSF committee on technology to help guide training on advanced medical technology for anesthesia professionals, anesthesia technicians, health care organizations, and technology manufacturers. This kind of training often involves collaboration from relevant stakeholders including anesthesia professionals providing clinical care, anesthesia departments, the medical device industry, health care institutions, and other patient safety organizations.

First up, we have the considerations for anesthesia professionals and advanced medical technology competency which may include the following:

• Knowledge about the setup, function, operation, and information necessary to provide safe and effective patient care when using the device.
• Consistent, safe, and effective use of the device.
• Consistent use of a device’s safety features with ability to take action to avoid known potential for patient harm.
• Identification of non-functioning devices with the ability to troubleshoot and respond appropriately to maintain the highest level of patient safety.
• And finally…demonstrate competency assessed by various mechanisms. For example, written or oral examination, demonstration of safe use to an observer, use of the device in simulations.

Next, we have the considerations for Health Care Institutions which may include the following:

• First, a requirement for appropriate advanced medical technology training and demonstrated competence before an anesthesia professional is permitted to use a (new or existing) device to care for patients unless a person with demonstrated competence is present throughout the procedure.
• Providing formal advanced medical technology training programs for every anesthesia professional including ensuring that newly hired anesthesia professionals receive the training before starting in the OR or clinical care environment.
• Documentation of an individual’s participation in technology training, education, and assessment.
• Evaluation of the advanced medical technology training program to ensure that it is meeting its goals.
• Establishment of a schedule for reassessment of anesthesia professionals’ continued competence.
• Allocation of time for training and assessment within the regular workday. This may be a significant challenge, but it is vital.

Finally, let’s review the considerations for the Technology Manufacturer which may include the following:

• Using a rigorous, user-centered, human factors design process to create devices that are easy to learn to use, easy to use, easy to remember how to use, and that fail safely and gracefully.
• Development of effective training materials and instructions for use.
• Creation of standardized user training and competency assessment materials, based on user-centered design and validation methods, which can be used by institutions to comply with these recommendations.
• Assist customers in the implementation of user training and competency assessment materials and procedures.

Many of these considerations have been incorporated into anesthesia training on advanced medical technology, but it is important that we continue to do so with new medical technology especially given our increasing complex patients, procedures, and busy clinical schedules.

Since we just reviewed an article from our archives, I want to return to the present and look to the future. I also asked Dr. Thiele about what he envisions for the future with regards to technology and anesthesia care and patient safety. Let’s take a listen to what he had to say.

[Thiele] “First: We will continue to push the envelope on development of non-invasive and advanced hemodynamic monitoring technology (good examples are fluid responsiveness, non-invasive blood continuous pressure monitors, and NIRS-based real-time measurement of cerebral autoregulation)

Second: Decision support and automation are coming; closed loop anesthesia, glucose control, and hemodynamic monitoring.  Look at Maxime Cannesson’s work

Third: Data science; still years away from being prime time but this is the future.  Work being done at Michigan (MPOG) and Cleveland Clinic (Sessler’s group) is paradigm shifting”

Thank you, Dr. Thiele for your insights. Given the outlook for the development of newer advanced medical technology, it will be vital to reflect on the considerations for anesthesia professionals, health care organizations, and technology manufacturers to maintain appropriate education, training, and competencies in order to use the technology safely and effectively all the while providing safe anesthesia care.

That is all the time we have for today. If you have any questions or comments from today’s show, please email us at [email protected].

Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.  You can find us on twitter, Instagram, Facebook and LinkedIn!  See the show notes for more details and we can’t wait for you to tag us in a patient safety related tweet or like our next post on Instagram, like us on Facebook, or connect with us on LinkedIn!! Follow along with us for the latest news and updates in perioperative and anesthesia patient safety.

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

© 2021, The Anesthesia Patient Safety Foundation