Reengineering Intravenous Drug and Fluid Administration Processes in the Operating Room

Reengineering Intravenous Drug and Fluid Administration Processes in the Operating Room Step One: Task Analysis of Existing Processes Deborah B Fraind, B.S *; Jason M Slagle, M.S.†; Victor A Tubbesing, B.S.‡; Samuel A Hughes, Ph.D.†; Matthew B Weinger, M.D.§ Presented in part at the 74th Annual Congress of the International Anesthesia Research Society, Honolulu, Hawaii, March 13, 2000 Dr Weinger was a paid consultant of, and held a small equity stake in, FluidSense Corporation (Newburyport, Massachusetts), a manufacturer of intravenous infusion therapy products ANESTHESIOLOGY 2002;97:139-147 Background: A reengineering approach to intravenous drug and fluid administration processes could improve anesthesia care In this initial study, current intravenous administration tasks were examined to identify opportunities for improved design Methods: After institutional review board approval was obtained, an observer sat in the operating room and categorized, in real time, anesthesia providers’ activities during 35 cases ( 90 h) into 66 task categories focused on drug/fluid tasks Both initial room setup at the beginning of a typical workday and cardiac and noncardiac general anesthesia cases were studied User errors and inefficiencies were noted The time required to prepare de novo a syringe containing a mock emergency drug was measured using a standard protocol Results: Drug/fluid tasks consumed almost 50 and 75%, respectively, of the set-up time for noncardiac and cardiac cases In cardiac anesthetics, drug/fluid tasks comprised 27 ± 6% (mean ± SD) of all prebypass clinical activities During 20 noncardiac cases, drug/fluid tasks comprised 20 ± 8% of induction and 15 ± 7% of maintenance Drug preparation far outweighed drug administration tasks Inefficient or error prone tasks were observed during drug/fluid preparation (e.g., supply acquisition, waste disposal, syringe labeling), administration (infusion device failure, leaking stopcock), and organization (workspace organization and navigation, untangling of intravenous lines) Anesthesia providers (n = 21) required 35 ± s to prepare a mock emergency drug Conclusions Intravenous drug and fluid administration tasks account for a significant proportion of anesthesia care, especially in complex cases Current processes are inefficient and may predispose to medical error There appears to be substantial opportunity to improve quality and cost of care through the reengineering of anesthesia intravenous drug and fluid administration processes General design requirements are proposed * Medical Student, University of California-San Diego † Senior Research Associate, University of California-San Diego and Veterans Medical Research Foundation ‡ Research Assistant, Department of Anesthesiology, University of California-San Diego and VA San Diego Healthcare System § Director, San Diego Center for Patient Safety, Staff Physician, VA San Diego Healthcare System, and Professor of Anesthesiology, University of California-San Diego Received from the Anesthesiology Ergonomics Research Laboratory, Health Services Research Service, VA San Diego Healthcare System, San Diego, California; the San Diego Center for Patient Safety, La Jolla, California; and the Department of Anesthesiology, University of California-San Diego, La Jolla, California Submitted for publication August 6, 2001 Accepted for publication February 18, 2002 Address correspondence to Dr Weinger: VA Medical Center (125A), 3350 La Jolla Village Drive, San Diego, California 92161-5085 Address electronic mail to: mweinger@ucsd.edu Individual article reprints may be purchased through the Journal Web site, www.anesthesiology.org Supported by grants from the Anesthesia Patient Safety Foundation, Pittsburgh, Pennsylvania, the National Patient Safety Foundation, Chicago, Illinois, a Howard Hughes Summer Research Scholarship, La Jolla, California (to Dr Fraind); grant No HSR&D IIR 20-0066 from the Department of Veterans Affairs, Washington, DC; and grant Nos R01-HS11375 and P20-HS11521 from the Agency for Healthcare Research and Quality, Rockville, Maryland Impact of Unplanned Extubation and Reintubation after Weaning on Nosocomial Pneumonia Risk in the Intensive Care Unit A Prospective Multicenter Study Arnaud de Lassence, M.D *; Corinne Alberti, M.D.†; Élie Azoulay, M.D.‡; Eric Le Miere, M.D.§; Christine Cheval, M.D.||; Franỗois Vincent, M.D.#; Yves Cohen, M.D.**; Maùtộ Garrouste-Orgeas, M.D.; Christophe Adrie, M.D.; Gilles Troche, M.D.ĐĐ; Jean-Franỗois Timsit, M.D.||||; for the OUTCOMEREA Study Group## ANESTHESIOLOGY 2002;97:148-156 Background: The authors prospectively evaluated the occurrence and outcomes of unplanned extubations (self-extubation and accidental extubation) and reintubation after weaning, and examined the hypothesis that these events may differ regarding their influence on the risk of nosocomial pneumonia Methods: Data were taken from a prospective, 2-yr database including 750 mechanically ventilated patients from six intensive care units Results: One hundred five patients (14%) experienced at least one episode of these events; 51 self-extubations occurred in 38 patients, 24 accidental extubations in 22 patients, and 56 reintubations after weaning in 45 patients The incidence density of these events was 16.4 per 1,000 mechanical ventilation days Reintubation within 48 h was needed consistently after accidental extubation but was unnecessary in 37% of selfextubated patients Unplanned extubation and reintubation after weaning were associated with longer total mechanical ventilation (17 vs days; P < 0.0001), intensive care unit stay (22 vs days; P < 0.0001), and hospital stay (34 vs 18 days; P < 0.0001) than in control group, but did not influence intensive care unit or hospital mortality The incidence of nosocomial pneumonia was significantly higher in patients with unplanned extubation or reintubation after weaning (27.6% vs 13.8%; P = 0.002) In a Cox model adjusting on severity at admission, unplanned extubation and reintubation after weaning increased the risk of nosocomial pneumonia (relative risk, 1.80; 95% confidence interval, 1.15–2.80; P = 0.009) This risk increase was entirely ascribable to accidental extubation (relative risk, 5.3; 95% confidence interval, 2.8–9.9; P < 0.001) Conclusion: Accidental extubation but not self-extubation or reintubation after weaning increased the risk of nosocomial pneumonia These events may deserve evaluation as an indicator for quality-of-care studies *Staff Physician, §Attending Physician, Medical ICU, Louis Mourier Teaching Hospital †Staff Physician, Department of Biostatistics, U444-INSERM, Paris University, Paris France ‡Staff Physician, ICU, Saint Louis Teaching Hospital ||Staff Physician, Vascular Surgical ICU, ††Staff Physician, Polyvalent ICU, Saint Joseph Teaching Hospital #Staff Physician, Renal ICU, Tenon Teaching Hospital, Paris, France **Professor, Medical-surgical ICU, Avicenne Teaching Hospital ‡‡Staff Physician, Polyvalent ICU, Delafontaine Hospital, Saint Denis, France §§Staff Physician, Surgical ICU, Antoine Béclère Teaching Hospital ||||Staff Physician, Medical ICU, Bichat-Claude Bernard Teaching Hospital, Paris, France ##Individuals participating in the OUTCOMEREA Study Group are listed in the Appendix Received from the Medical ICU, Avicenne Hospital, Bobigny, France; Surgical ICU, Antoine Béclère Hospital, Clamart, France; Medical and Surgical ICUs, Saint Joseph Hospital, Paris, France; Medical ICU, Louis Mourier Hospital, Colombes, France; and the Medical ICU, Saint-Louis Hospital, Paris, France Submitted for publication October 22, 2001 Accepted for publication February 27, 2002 OUTCOMEREA® is supported by nonexclusive educational grants from Aventis Pharma France, Paris, France, Wyeth-Lederle, Puteaux-Paris la Défense, France, and Centre National de Recherche Scientifique, Paris, France Adress reprint requests to Dr de Lassence: Service de Réanimation Médicale, Hôpital Louis Mourier, 92701 Colombes Cedex, France Address electronic mail to: arnaud.de-lassence@outcomerea.org Individual article reprints may be purchased through the Journal Web site, www.anesthesiology.org Anaesthesia Type Brings on Temporarily Twitchy Legs Wed Jun 26, 5:30 PM ET By Hannah Cleaver BERLIN (Reuters Health) - People who have spinal anaesthesia should be warned that they may experience restless legs syndrome afterwards, but that this restlessness will disappear on its own within a few months This is the conclusion of a study on possible triggers for the condition, which often robs sufferers of their sleep as severe discomfort in their legs can only be reduced by walking around or at least moving the legs Dr Birgit Hoegl, head of the sleep laboratory at Innsbruck University, Austria, said there also seemed to be a link between low blood iron levels and the onset of the syndrome after a spinal anaesthetic In spinal anaesthesia, drugs are injected into the spinal area, resulting in numbness of the body below the injection point Presenting her paper at the 12th Meeting of the European Neurological Society here Wednesday, Hoegl said her study looked at 161 patients who had never experienced restless legs syndrome (RLS) Many were pregnant women who received spinal anaesthesia while undergoing C-sections Fourteen of the patients developed RLS after anaesthesia Four had mild RLS, five had a moderate form of the condition, and five had severe RLS Among an additional 41 patients who already had RLS, four experienced a marked worsening of the condition Hoegl told Reuters Health that all those who developed the condition saw it disappear again, generally within about a month, while all were free of it after months She said, "We ruled out gender, age, type of anaesthetic and dose as factors, but there does seem to be a correlation between low iron levels and development of RLS The iron factor seems to be a susceptibility factor "The condition is not so bad, nor so long-lasting that one would recommend using a different anaesthetic But the patient needs to know that it is a possible side-effect of spinal anaesthetic and doctors treating them should also be aware so that if need be, treatment can be offered It also looks as if preoperative anaemia increases the risk of developing RLS after the operation." Hoegl and her colleagues, chaired by Werner Poewe, now plan another study to investigate whether RLS appears after other types of anaesthesia Anesthestic-related Cardiac Arrest and Its Mortality A Report Covering 72,959 Anesthetics over 10 Years from a US Teaching Hospital Myrna C Newland, M.D *; Sheila J Ellis, M.D.†; Carol A Lydiatt, M.D.‡; K Reed Peters, M.D.‡; John H Tinker, M.D.§; Debra J Romberger, M.D.||; Fred A Ullrich, B.S.#; James R Anderson, Ph.D.** This article is featured in “This Month in Anesthesiology.” Please see this issue of A NESTHESIOLOGY, page 5A Presented in part at the annual meeting of the American Society of Anesthesiologists, San Francisco, California, October 14–18, 2000 ANESTHESIOLOGY 2002;97:108-115 Background: A prospective and retrospective case analysis study of all perioperative cardiac arrests occurring during a 10-yr period from 1989 to 1999 was done to determine the incidence, cause, and outcome of cardiac arrests attributable to anesthesia Methods: One hundred forty-four cases of cardiac arrest within 24 h of surgery were identified over a 10-yr period from an anesthesia database of 72,959 anesthetics Case abstracts were reviewed by a Study Commission composed of external and internal members in order to judge which cardiac arrests were anesthesia-attributable and which were anesthesia-contributory The rates of anesthesia-attributable and anesthesiacontributory cardiac arrest were estimated Results: Fifteen cardiac arrests out of a total number of 144 were judged to be related to anesthesia Five cardiac arrests were anesthesia-attributable, resulting in an anesthesiaattributable cardiac arrest rate of 0.69 per 10,000 anesthetics (95% confidence interval, 0.085–1.29) Ten cardiac arrests were found to be anesthesia-contributory, resulting in an anesthesia-contributory rate of 1.37 per 10,000 anesthetics (95% confidence interval, 0.52–2.22) Causes of the cardiac arrests included medication-related events (40%), complications associated with central venous access (20%), problems in airway management (20%), unknown or possible vagal reaction in (13%), and one perioperative myocardial infarction The risk of death related to anesthesia-attributable perioperative cardiac arrest was 0.55 per 10,000 anesthetics (95% confidence interval, 0.011–1.09) Conclusions: Most perioperative cardiac arrests were related to medication administration, airway management, and technical problems of central venous access Improvements focused on these three areas may result in better outcomes * Professor, † Assistant Professor, ‡ Associate Professor, § Professor and Chair, Department of Anesthesiology, || Associate Professor, Internal Medicine and Pulmonology, # Senior Programmer Analyst, ** Professor and Chair, Preventive and Societal Medicine Received from the Departments of Anesthesiology, Internal Medicine and Pulmonology, and Preventive and Societal Medicine, University of Nebraska Medical Center, Omaha, Nebraska Submitted for publication February 19, 2001 Accepted for publication February 13, 2002 Support was provided solely from institutional and/or departmental sources Address reprint requests to Dr Newland: Department of Anesthesiology, 984455 Nebraska Medical Center, Omaha, Nebraska 68198-4455 Address electronic mail to: mnewland@unmc.edu Individual article reprints may be purchased through the Journal Web site, www.anesthesiology.org Eliminating Intensive Postoperative Care in Same-day Surgery Patients Using Short-acting Anesthetics Jeffrey L Apfelbaum, M.D *; Cynthia A Walawander, M.A.†; Thaddeus H Grasela, Pharm.D., Ph.D.‡; Phillip Wise, B.S., M.B.A.§; Charles McLeskey, M.D.||; Michael F Roizen, M.D.#; Bernard V Wetchler, M.D.**; Kari Korttila, M.D., Ph.D., F.R.C.A.†† For the list of study sites, please see Appendix This article is featured in “This Month in Anesthesiology.” Please see this issue of A NESTHESIOLOGY, page 5A Presented in part at the annual meeting of the American Society of Anesthesiologists, San Diego, California, October 21, 1997 ANESTHESIOLOGY 2002;97:66-74 Background: A multidisciplinary effort was undertaken to determine whether patients could safely bypass the postanesthesia care unit (PACU) after same-day surgery by moving to an earlier time point evaluation of recovery criteria Methods: A prospective, outcomes research study with a baseline month, an intervention month, and a follow-up month was designed Five surgical centers (three communitybased hospitals and two freestanding ambulatory surgical centers) were utilized Two thousand five hundred eight patients were involved in the baseline period, and 2,354 were involved in the follow-up period Outcome measures included PACU bypass rates and adverse events Intervention consisted of a multidisciplinary educational program and routine feedback reports Results: The overall PACU bypass rate (58%) was significantly different from baseline (15.9%, P < 0.001), for patients to whom a general anesthetic was administered (0.4– 31.8%, P < 0.001), and for those given other anesthetic techniques (monitored anesthesia care, regional or local anesthetics; 29.1–84.2%, P < 0.001) During the follow-up period, the average (SD) recovery duration for patients who bypassed the PACU was significantly shorter compared to that for patients who did not bypass, 84.6 (61.5) versus 175.1 (98.8) min, P < 0.001, with no change in patient outcome Patients receiving only short-acting anesthetics were 78% more likely (P < 0.002) to bypass the PACU after adjusting for various surgical procedures Conclusions: This study represents a substantial change in clinical practice in the perioperative setting Same-day surgical patients given short-acting anesthetic agents and who are awake, alert, and mobile requiring no parenteral pain medications and with no bleeding or nausea at the end of an operative procedure can safely bypass the PACU * Professor and Chair, Department of Anesthesia and Critical Care, University of Chicago Hospitals and Clinics, Chicago, Illinois † Executive Vice President, ‡ President and CEO, Cognigen Corporation, Williamsville, New York § Former: Glaxo Wellcome, Incorporated, Research Triangle Park, North Carolina Current: Vice President, Commercial and Business Development, Ardent Pharmaceuticals, Durham, North Carolina || Former: Professor and Chair, Department of Anesthesiology, Scott & White Hospital and Clinic, Texas A&M College of Medicine, Temple, Texas Current: Senior Director, Clinical Development, Hospital Products Division, Abbott Laboratories, Abbott Park, Illinois # Former: Professor and Chair, Department of Anesthesia and Critical Care, University of Chicago Hospitals and Clinics, Chicago, Illinois Current: Dean and Vice President of Biomedical Sciences, College of Medicine, State University of New York of Upstate Medical University, Syracuse, New York ** Clinical Professor, University of Illinois College of Medicine, Chicago, Illinois †† Professor, Department of Anesthesia and Intensive Care, University of Helsinki, Women’s Hospital, Helsinki, Finland Submitted for publication July 25, 2001 Accepted for publication January 2, 2002 Supported in part by a grant from Glaxo Wellcome, Incorporated, Research Triangle Park, North Carolina Address reprint requests to Dr Apfelbaum: Department of Anesthesia & Critical Care, The University of Chicago Hospitals and Clinics, 5841 South Maryland Avenue MC4028, Chicago, Illinois 60637 Address electronic mail to: jeffa@airway.uchicago.edu Individual article reprints may be purchased through the Journal Web site, www.anesthesiology.org OBSTETRIC ANESTHESIA Intrathecal Versus Intravenous Fentanyl for Supplementation of Subarachnoid Block During Cesarean Delivery Sahar M Siddik-Sayyid, MD, FRCA, Marie T Aouad, MD, Maya I Jalbout, MD, Mirna I Zalaket, MD, Carina E Berzina, MD, and Anis S Baraka, MD, FRCA Department of Anesthesiology, American University of Beirut, Medical Center, Beirut, Lebanon Address correspondence and reprint requests to Anis Baraka, MD, FRCA, Department of Anesthesiology, American University of Beirut, PO Box 11-0236, Beirut, Lebanon Address e-mail to abaraka@aub.edu.lb Forty-eight healthy parturients scheduled for elective cesarean delivery were randomly allocated to receive intrathecally either 12 mg of hyperbaric bupivacaine plus 12.5 µg of fentanyl (n = 23) or bupivacaine alone (n = 25) In the latter group, IV 12.5 µg of fentanyl was administered immediately after spinal anesthesia We compared the amount of IV fentanyl required for supplementation of the spinal anesthesia during surgery, the intraoperative visual analog scale, the time to the first request for postoperative analgesia, and the incidence of adverse effects Additional IV fentanyl supplementation amounting to a mean of 32 ± 35 µg was required in the IV Fentanyl group, whereas no supplementation was required in the Intrathecal Fentanyl group (P = 0.009) The time to the first request for postoperative analgesia was significantly longer in the Intrathecal Fentanyl group than in the IV Fentanyl group (159 ± 39 versus 119 ± 44 min; P = 0.003) The incidence of systolic blood pressure