Beyond Critical Incidents: The PSH and Patient Safety

  • Levin, Philip, MD
| Oct 27, 2015

Mark Warner, MD, delivered the Ellison C. Pierce Memorial Lecture on the opening day of ANESTHESIOLOGY 2015 in San Diego, speaking on the subject of "Expanding our influence: How the Perioperative Surgical Home will improve patient safety." 

warnerThe ASA and the Anesthesia Patient Safety Foundation (APSF) established this annual honorary lectureship in memory of the founding president of APSF, Ellison Pierce Jr., MD. This year’s honoree, Dr. Warner, is the Annenberg Professor of Anesthesiology at Mayo Clinic, and served as department chair from 1999 to 2005. He is also a past president of the ASA and the American Board of Anesthesiology (ABA).

Dr. Warner emphasized that it is no longer enough for anesthesiologists to be technically good at our work; we also must become true leaders if we want to effect positive change. He echoed the message delivered by retired Navy Commander Michael Abrashoff in his keynote address earlier in the morning. Dr. Warner advised anesthesiologists to expand our patient safety leadership beyond the operating room, and to include the entire perioperative period.

pierce2He quoted Dr. Pierce: "Patient safety is not a fad. It is not a preoccupation of the past. It is not an objective that has been fulfilled or a reflection of a problem that has been solved. Patient safety is an ongoing necessity. It must be sustained by research, training and daily application in the workplace.”

Dr. Warner pointed out that we have definitely improved patient safety in the intraoperative period, but patients still may be harmed during—and by—anesthesia care. Ongoing issues include opioid-induced respiratory failure and inadvertent prolonged neuromuscular blockade.

Perioperative deaths still occur, Dr. Warner said. Anesthesiologists have accepted our responsibility to continually improve intraoperative patient safety, he said. “But we can, we should, and we must improve our patients’ perioperative safety.”

Dr. Warner looked back at the past to emphasize his message. He cited a classic July 1954 article, published by Henry Beecher, MD, and Donald Todd, MD, in the Annals of Surgery, about the significant role of anesthesia errors in morbidity and mortality. They noted then that anesthesia caused one in approximately 2500 surgical deaths.

Preventing critical incidents

Dr. Warner praised Jeffrey Cooper, PhD, for his role as the “father of patient safety research" and a major force in the creation of APSF. A biomedical engineer by training, perhaps his most influential line of research was to lead a team that used the aviation-inspired critical incident analysis technique to understand the causes of anesthesia-related mishaps and injuries. A seminal publication in 1978, with Cooper as first author, provided important data on the human factors of how and why anesthetic mishaps occurred. 

cooperCooper’s work highlighted critical strategies to improve safety:

  • Educate and supervise the workforce
  • Establish protocols
  • Develop standards for anesthesia equipment
  • Act on patient safety incident reports
  • Continuously improve upon safety processes

Dr. Warner noted that even though these concepts are now universally accepted, at the time many anesthesiologists felt threatened, fearing they would only lead to new, cumbersome rules and regulations.

Dr. Warner said he believes that the Perioperative Surgical Home (PSH) concept can improve patient safety and outcomes through better coordination of care, and that physician anesthesiologists are best positioned to lead.

“No patient undergoing an anesthetic should be harmed during the perioperative period,” Dr. Warner said. “Who better than the anesthesiologist to lead patient safety throughout the perioperative period?”

Patient safety beyond the OR

In 2000, leaders from the APSF, ASA, and ABA met in San Francisco at the ASA annual meeting to discuss opportunities to improve patient safety through expansion of safe practices in collaboration with surgeons, other physicians, nurses, and other healthcare practitioners. Clearly, Dr. Warner said, further major advances in patient safety would require multidisciplinary teams working together.

That initial meeting triggered changes over the next decade. Modification of anesthesia training requirements expanded residents’ experiences in general medical and pediatric care, preoperative medicine, critical care, and pain management. Now, Dr. Warner said, our residents are much better prepared to tackle the most difficult patients across the entire perioperative continuum.

Dr. Warner emphasized that we still have much to do to help improve our patients' safety. We need to look intensely into the long-term effects of anesthesia care, he said, especially in the elderly and in children. He recommended more research to assess the effect of blood products on the immune system. What are the long-term effects of pharmacologically and surgically induced inflammation, Dr. Warner asked? Anesthesiologists are best at analyzing and testing these concerns, he said.

As an example of anesthesiologist-led improvement of care, Dr. Warner cited the example of antibiotic administration. Some 90 percent of “penicillin-allergic” surgical patients do not actually have a true allergy. Yet these patients often receive costly third and fourth generation antibiotics, leading to resistant bacteria and other severe complications.

At some institutions, anesthesiologists have developed specific protocols to check for true penicillin allergy. This has led to less need for third and fourth generation antibiotics, saving the hospital money and reducing complications.

Some anesthesia groups have helped develop transfusion protocols that have cut the use of blood products by as much as 40 percent, Dr. Warner said, decreasing the rate of perioperative complications such as acute kidney injury. Since approximately 30-40 percent of all blood products are given in the perioperative period, he noted, our work may significantly reduce patient risk.

Dr. Warner recommended development of more clinical protocols that "pre-habilitate" patients prior to surgery, helping to prevent complications such as venous thrombosis and surgical site infection.

Many anesthesiologists express confusion and concern about payment for the work of a PSH model of care, Dr. Warner said. Yet studies demonstrate reduced expenses when the use of clinical pathways decreases costly complications. As we move toward bundled payment for services rather than fee-for-service payment, he said, we will be properly positioned to take advantage of the new model.

But success depends on sharing the rewards among all who take part in improving the processes, Dr. Warner said. “It will be critical that we are part of the team of leaders who decide how the funds get divided. “

In his closing remarks, Dr. Warner reminded the audience that the APSF mission statement is, “That no patient shall be harmed by anesthesia.” He suggested changing it to read, "That no patient shall be harmed by anesthesia in the perioperative period."

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