Episode #4 The 2020 APSF President’s Report

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel and I am your host. Thank you for joining me for another show.

Today, we are going to talk about the 2020 President’s Report, delivered this year by Mark Warner, MD the current president of the APSF.  You can find this report by clicking over to the APSF Newsletter archives and checking out the February 2020 edition. We’ll also put a link in the show notes for this podcast.  Warner starts his report with a call to action for APSF and the specialty of anesthesiology to focus on high-value issues that absolutely need to be addressed and then gives us all a call to action as individuals who take care of patients undergoing anesthesia care to concentrate on the safety of each of our patients every day.  It is this passion for patient safety and mission of no patient ever harmed by anesthesia that drives those of us within the APSF family and hopefully all of you listening to this podcast and this is something that you can share with you colleagues and institutions and healthcare systems as well.

So, what are these high-value issues that need to be addressed?

What better way to share them, then with a top 10 list.  So, now I give you the APSF 2020 Top 10 Perioperative Patient Safety Issues that we believe require targeted attention, continued or renewed discussion, and further support regardless of your practice environment and location.  Can I get a drumroll please?

[Drumroll]

Number 1 is the Prevention, Detection, and Mitigation of Clinical Deterioration in the Perioperative Period.  Although it may sound simple or obvious to be prepared and stay vigilant, and that we can prevent problems by detecting them earlier, this is exactly where we have an opportunity to improve care.  This includes early warning systems in all perioperative patients, monitoring for patient deterioration with continuous postop monitoring on the floor, opioid-induced ventilatory impairment and monitoring, and monitoring for early signs of sepsis…and finally early recognition and appropriate response to the decompensating patient.  As they say, timing is everything, and this is true in patient safety as well.

The second priority for 2020 is Improved safety in out-of-OR locations such as endoscopy and interventional radiology.  This is so important because some of these locations can be far away from supplies and additional sets of hands. As a result, these locations can have particular vulnerabilities when the rare emergency or unexpected event occurs. An important consideration during the Covid pandemic continues to be safety for patients and anesthesia professionals in the endoscopy suite.  Upper endoscopy procedures, transesophageal echocardiographies, and bronchoscopies may increase the risk of aerosolized airborne pathogens. One proposed solution to minimize the risk of contamination of the endoscopy suite environment was to provide general endotracheal tube anesthesia for all of the procedures.  However, this method is not without risk for aerosolization of viral particles if there is coughing during intubation and extubation and it may be difficult to provide general endotracheal anesthesia in an endoscopy suite especially if there is no anesthesia machine available.  Other risks include hemodynamic instability, aspiration, and difficult airway management. For some patients…patients with full stomachs for emergency procedures…general endotracheal anesthesia may be the best choice.  For other patients, during the covid pandemic and going forward, monitored anesthesia care with IV sedation will likely continue to be appropriate and safe.  The question is, how can we do this safely? A simple and low cost mitigation strategy is using a plastic endoscopic oxygen facemask as a barrier against airborne pathogens during and after endoscopy.  The Procedural Oxygen Mask is an example and has been FDA-approved for upper endoscopies. It is a clear plastic O2 mask with self-sealing oral and nasal endoscopy ports and a capnography port, which is vital for monitoring, and an optional oxygen reservoir side bag if a higher FiO2 is needed.  In addition, all of the healthcare providers in the room should wear proper PPE.

Next up, is Developing a Culture of Safety by highlighting the importance of team work and promoting interpersonal relationships and interactions that support patient safety. There has been considerable progress in this area over the past years, but there’s lots of room for even more improvement. We highlight the importance of effective leadership and patient safety culture in the June 2020 newsletter in the article by Albright-Trainer and colleagues.  The authors discuss the importance of effective leadership in medicine to develop a patient safety culture within an organization.  An environment of psychological safety is necessary so that people feel safe to communicate any threats to patient safety and this allows leaders to take timely action to protect patients and employees. A positive and psychologically safe environment will lead to an improved culture of safety, but wait there is more…other benefits will likely include higher job satisfaction among employees, decreased burnout, and less medical errors.

The 4th priority is another big one that we have been working on for a while, but there is still more work to be done…and it is…Medication Safety including paying attention to drug effects, correct and safe drug labeling, drug shortages, medical safety through technology such as barcoding and RFID, and having appropriate processes in place to avoid and detect drug errors.

The next priority, number 5 is  Perioperative delirium, cognitive dysfunction, and brain health.  It is not enough to keep patients safe only while they are in the OR, but we need to be thinking about and researching how to keep their brains safe and functioning throughout the perioperative period and beyond.

Our 6th priority is especially pertinent these days and it is Hospital-acquired infections and environmental microbial contamination and transmission.  This is an important issue that spans from the individual with hand hygiene and maintaining sterile fields to healthcare systems and institutions with appropriate contact precautions and monitoring. While this obviously isn’t specific to COVID, the current pandemic certainly makes this a highly relevant priority.

We are now at the 7th priority which is something that we do every day as anesthesia providers, talk about our patients.  This priority calls for improvements in patient-related communication issues, handoffs of care, and transitions of care.  If you are starting to think about implementing a handoff protocol, here are some opportunities to consider including administration and staff support for the new handoff protocol, editing to fit local needs, training at the onset and ongoing training, pilot testing with feedback from the staff to team leaders and to the staff during the testing phase, trialing the handoff protocol in simulated scenarios and simulation centers. Threats may include team leadership to head up the new initiative and obstructionists. The APSF has created a roadmap to create an effective handoff and I will link to it in the show notes. Start with an audit to access the need for a new handoff protocol, then discuss the results of the audit with the staff. Next, you are going to have to obtain support from leadership and administration as well as assign a team leader and a focus group or committee.  The next step is research in the literature and reviewing existing protocols and you can use this research to draft a tool and then review and edit and adapt the tool to fit local institutional and practice setting needs. At this point, it is important to consult with a human factors expert to weigh in on the new protocol and finally, you are ready to try out the new tool and get feedback from the stakeholders. Examples of key handoffs include operating room to PACU or ICU handoff as well as provider handoffs during transitions of care due to fatigue or provider scheduling.

The 8th priority shines the spotlight on how we can make anesthesia safer in terms of airway management difficulties, developing and maintaining skills for safe airway management and appropriate use of airway management equipment and other aspects of airway equipment including malfunction, supply, developing new technologies to help keep our patients safe.

We are now at the penultimate priority.  Healthy anesthesia professionals are better able to provide safe patient care and that is why the 9th priority in this list focuses on anesthesia professionals and burnout including what are the effects of burnout and how can we better recognize and manage burnout.

Alright, we made it to the 10th priority in our top ten list.  This priority has implications in all of our other patient safety priorities that I already discussed today and it is a constant threat to patient safety and the priority is Distractions in procedural areas.  We know how dangerous distractions are when we are driving and staying safe on the roads and distractions in procedural areas are just as dangerous for patient safety.  We need to be able to identify and remove distractions to help keep our patients safe when they are in our care.   Especially in the modern day with technology being so tightly linked to patient care, distractions related to this tech represents a double-edged sword.

That was quite a top 10 list highlighting some of the most important things that we need to focus on right now to help keep our patients safe.  But it is not all encompassing.  There are other issues that may have a big impact depending on your location and resources including limitations on personnel, equipment, and medications. These important resource limitations are most prevalent in lower resource countries and it is important that they are priorities for global and regional partnerships.  The APSF  is working with the World Federation of Societies of Anesthesiologists (WFSA) to help strengthen education and maintain a consist high level for subspecialty fellowships offered by the WFSA around the world.  These fellowships are for anesthesiologists from low and middle-income countries to develop additional skills in the field of anesthesia and take on new leadership roles when they return to their home country.  This program is responsible for providing 400 fellows from 62 countries the opportunity learn new skills and further their education in 8 anesthesia sub-specialties. The APSF also works with the Patient Safety Movement Foundation to create anesthesia-specific patient safety curriculums for anesthesia professionals and training programs in high and limited resource countries.  Another way that the APSF is making a difference in patient safety across the world is with our newsletter and social media campaign that has reached over 600,000 anesthesia professionals offering patient safety recommendations, articles and more.

For 2020 and going forward, Warner calls us all to remember the Golden Rule and “treat others as you would like to be treated” when it comes to patient safety. This action item does not cost any money and it can have a big impact. If we were the patient, how would we want to be treated and then treat our patients like that every time they are in our care. If we do this, we will likely be able to decrease personal errors during the perioperative time period and thus reduce perioperative morbidity due to medication errors, neuropathy, and hospital acquired infections.  Warner’s report offers questions that we should all ask ourselves before we assume the care of a patient.

• “Have we used checklists to ensure that we have everything we need at hand when we proceed with anesthetic care?
• Have we actively avoided contamination of our equipment and medications to reduce the risk of microorganism transmission perioperatively?
• Have we made the effort to know our patients and their risk factors for potential intraoperative or postoperative complications?
• Have we allowed production pressures or distractions (e.g., cell phones) to interfere with our focused efforts to provide the best care we can?
• Have we provided the appropriate handoff communication before leaving the patients in another anesthesia professional’s care?
• Are we “treating our patients as we would like to personally be treated”?”

And what about when we think about all patients who need anesthesia care? For a larger perspective, Warner suggests that we all ask ourselves:

• Have we participated in our local institutions to develop the clinical pathways, practices, and policies that increase their safety throughout the perioperative period?
• Have we worked within our institutions and with our colleagues to improve team interactions and implement the cultural changes that allow all members of the perioperative team to point out actions that might cause patient harm?
• Have we taken leadership roles, locally or beyond, that allow us to make a positive impact on the perioperative safety of the populations we serve?”

Together, the APSF, other organizations, and industry partners can further the mission that no patient is harmed by anesthesia with research, recommendations, new equipment and medications, just as important is the big step that each of us can take every time we provide anesthesia care, “treat them as you would want to be treated.”  We must all take personal responsibility for the safety of our patients.

Thank you to Mark Warner for that 2020 President’s Report.

Well, that is all the time we have for today.  Thank you so much for joining me on this journey towards improved patient safety.  If you have any questions or comments from today’s show, please email me at [email protected].

I hope that you have been enjoying listening to this podcast.  Don’t forget to subscribe to the podcast through iTunes or your favorite podcast app and we would love it if you could share this podcast with all of your work colleagues, friends, and family and don’t forget to leave us a review. Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.  Plus, you can find us on twitter @APSForg.  Follow along with us for additional patient safety information. And you can be part of the conversation by tagging us on twitter and using the hashtag #APSFpodcast.

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

© 2020, The Anesthesia Patient Safety Foundation