Commentary
The Evolution of Safety in Anesthesiology
Standardized anesthesia care and patient monitoring have made surgery safer. The next step is for anesthesiologists, surgeons, and hospital staff to work together on pre- and postoperative care.
By Mark A. Warner, M.D.
When I first started in medicine during the mid-1970s, the risk of a relatively healthy patient dying within 24 hours of a surgical procedure was approximately one in 10,000.1 That risk has since decreased at least 12-fold; the best estimates now suggest that the frequency is one in 120,000 or better.2 In fact, a large Minnesota study published in the Journal of the American Medical Association in 1993 found that it was safer to undergo outpatient anesthesia and surgery than it was to travel to and from the surgical center by car.3 I believe the increased safety of anesthesia and surgery during this period is one of the great achievements in modern medicine.
There are many reasons why safety has improved so steadily. Surgical procedures have become less invasive, and many surgical techniques now result in much less blood loss and tissue trauma and fewer postoperative complications. The drugs used intraoperatively for anesthesia, postoperatively for analgesia, and perioperatively for infection prevention and treatment also have improved remarkably. However, one significant effort stands out for its contribution to better patient safety—the work of the American Society of Anesthesiologists (ASA) to standardize anesthesia care and patient monitoring. The society’s contributions were noted by the Institute of Medicine (IOM) in its 2000 treatise “To Err is Human: Building a Safer Health System.”4 In fact, the ASA was the only specialty organization recognized by the IOM for its success in improving patient safety.
In 1985, the ASA instituted the Anesthesia Patient Safety Foundation (APSF). The work of the foundation and the ASA has resulted in a number of standardized practices, including the use of pulse oximetry and end-tidal carbon dioxide monitoring for anesthetized patients. These now-required practices have markedly reduced the frequency of anoxic brain injury and other major complications.
The APSF is now in its 25th year and continues to sponsor workshops in which key stakeholders meet to share ideas on topics such as medication errors and fire safety. Through the APSF, government agencies, equipment and pharmaceutical manufacturers, surgeons, anesthesiologists, other anesthesia providers, nurses, and patients work together to review problems, develop innovative processes, and make recommendations that will likely result in safety improvements.
Unfinished Business
With all of these efforts and the resulting improvements, why do we continue to focus on patient safety? Because we still have a ways to go. For example, each year, hundreds of patients in the United States either die or suffer anoxic brain injury from opioid-related postoperative respiratory depression. This is a problem we can solve: 1) We know many of the patient characteristics and surgical and anesthetic risk factors associated with postoperative respiratory depression; 2) we know that opioid analgesics play a role in nearly all instances of postoperative respiratory arrest; and 3) we have equipment and systems that can detect postoperative respiratory depression. Despite our knowledge and the availability of needed technology, we still have patients dying from or significantly impaired as a result of this problem. Sadly, we are missing the union of forces that is necessary to address it.
Resolution of postoperative respiratory depression will require anesthesiologists to work with surgeons, nurses, pharmacists, and health care facility administrators, as each group is responsible for overlapping pieces of the process. Anesthesiologists often use opioid analgesics intraoperatively while closely monitoring patients but then do not insist on similar postoperative monitoring for patients who continue to receive these analgesics. Surgeons often provide oversight of postoperative analgesia, frequently using delivery systems such as patient-controlled pumps, but they do not require the use of technologies to monitor respiration. Administrators may not support the purchase, deployment, and upkeep of the number and array of monitors that would detect early respiratory depression. The problem is that no single group owns the entire perioperative period or is responsible for the entire set of steps associated with preventing postoperative respiratory depression.
We need to change that for a number of compelling reasons. First, it will prevent injuries and save lives. Second, it will save money. Complications are costly. A simple case of postoperative pneumonia has recently been estimated to cost the health care system more than $25,000 on average.5 Care for a patient who survives a pulmonary embolism has been projected to cost more than $80,000 in the first year.6
And complications matter to facilities and health systems. It is estimated that there are now more than 1,000 online health care quality or safety rating sites. Although the validity of many of these sites is questionable, and it appears that anyone who can afford a website can establish a rating system for physicians and health care facilities and systems, there is no doubt that the public reads and uses this information. Publicly reported rates of complications are significant components of many rating systems—and they do influence patients’ perception of physicians, hospitals, and clinics.
Minnesota anesthesiologists are committed to furthering efforts to reduce the complications of surgery and improve patient safety. The 350 practicing members of the Minnesota Society of Anesthesiologists strongly support the discovery of novel therapies, improvements in perioperative care, and studies that will allow the prediction of postoperative complications and development of effective interventions. They are also applying their expertise in new ways. At our major academic centers and some community hospitals, anesthesiologists are now involved in preoperative and postoperative care and work in intensive care units, hospice medicine, and palliative care programs. For example, at Mayo Clinic, 17 anesthesiologists provide primary intensive care for more than 100 patients daily. These same anesthesiologists also respond to all rapid response requests and cardiac arrests, 24 hours a day, seven days a week. Over the next several years, additional anesthesiology intensivists will begin to provide electronic oversight of critical care services throughout Mayo Health System’s hospitals. This new service will provide continuous expertise in the care of critically ill patients, even in rural hospitals. Initial studies of this remote oversight model suggest that the frequency of death and severe complications such as ventilator-associated pneumonia and sepsis can be reduced by more than half.7
In addition, the ASA and APSF have made perioperative safety a priority and will start a three-year initiative this year to reduce—or, even better, eliminate—postoperative respiratory depression, surgical site infections, postoperative thromboembolism, and medication errors. Eliminating these preventable complications will require nurses, surgeons, anesthesiologists, and others to work together in ways they have not before. No one wants patients to develop disabling or life-threatening complications. That’s why we can, and we must, do better. MM
Mark Warner is a professor of anesthesiology at Mayo Medical School and dean of the Mayo School of Graduate Medical Education. He also is president of the American Society of Anesthesiologists.
References
1. Tiret L, Desmonts JM, Hatton F, Vourc’h G: Complications associated with anaesthesia—a prospective survey in France. Can Anaesth Soc J. 1986;33: 336-44.
2. Liu G, Warner M, Lang B, Huang L, Sun L: Epidemiology of anesthesia-related mortality in the United States, 1999-2005. Anesthesiology. 2009;110:759-65.
3. Warner MA, Shields SE, Chute CG: Morbidity and mortality after ambulatory surgery. JAMA. 1993;270:1437-41.
4. Kohn L, Corrigan JM, Donaldson MS (eds): To Err Is Human: Building a Safer Health System. Institute of Medicine, National Academy Press, Washington, DC, 2000.
5. Thompson DA, Makary MA, Dorman T, Pronovost PJ: Clinical and economic outcomes of hospital-acquired pneumonia in intra-abdominal surgery patients. Ann Surg. 2006;243:547-52.
6. MacDougall DA, Feliu AL, Boccuzzi SJ, Lin J: Economic burden of deep-vein thrombosis, pulmonary embolism, and post-thrombotic syndrome. Am J Health System Pharmacy. 2006;63:S5-15.
7. Groves RH, Holcomb BW, Smith ML: Intensive care telemedicine: evaluating a model for proactive remote monitoring and intervention in the critical care setting. Stud Health Technol Inform 2008;131:131-46