When he was a resident, said Mark Warner, MD, one attending anesthesiologist announced that calling him during a case would be interpreted as “a sign of weakness”.
But in the years since, Dr. Warner came to believe that it is critical to know when to call for help during any case, and no one should hesitate.
“Call me early!” he told the audience at our department’s Grand Rounds on September 25. “More hands and two brains are better!”
A former President of the American Society of Anesthesiologists and the American Board of Anesthesiology, Dr. Warner became President of the Anesthesia Patient Safety Foundation (APSF) in 2017. He said the Foundation has one primary goal – that no patient should ever be harmed by anesthesia. Each year APSF highlights a list of patient safety initiatives.
Topping the 2019 list is “preventing, detecting, and mitigating clinical deterioration in the perioperative period,” Dr. Warner said. This goal has three major components:
• Implementing early-warning systems such as end-tidal CO2 in monitoring all perioperative patients;
• Monitoring for patient deterioration due to treatable causes such as opioid-induced ventilatory impairment and early sepsis;
• Early recognition of and response to the decompensating patient.
Avoiding distraction in the operating room – staying off your cell phone – is one key to early recognition of problems, Dr. Warner said. “Don’t think that anything you touch electronically in an OR can’t be traced back to you!”
He said there are anesthesiologists in prison right now who were convicted of negligence because patients were harmed while they were distracted by devices during clinical care.
Medication safety is another top APSF priority, Dr. Warner explained. Giving “the wrong dose of the wrong drug at the wrong time” is at the heart of the problem, he said. “There is too much individual discretion.”
Consistency of practice – including consistent use of standardized concentrations and consistent labeling of medications by everyone – can help prevent errors, Dr. Warner said. New technology can help to solve some of these problems, he believes, such as the implementation of bar-coding and radiofrequency ID to avoid the simple error of picking up the wrong syringe from among several others.
Dr. Warner told the story of how he once picked up a 10-cc syringe thinking it contained 1% lidocaine and instead administered 1 mg of epinephrine into a patient’s IV tubing. The arrhythmias and hypertension that followed were short-lived but impressive, he said, remembering how horrified he felt about the error. “It didn’t hurt the patient, but it hurt me!” Drug shortages are an ongoing issue that in some cases can be traced back to the problem of having only a single source for the medication, Dr. Warner said. Sometimes 90 percent of the supply of one medication comes from only one manufacturer, which may be located as far away as China. Disruption due to any cause – work stoppage or natural disaster such as the hurricane in Puerto Rico – can lead to severe shortages. Substitution of an unfamiliar new medication may be a source of dosing error.
“We don’t have the best drugs yet!”
The long, complex process of getting a new medication approved is another problem, Dr. Warner said. Sevoflurane, for example, has caused the deaths of 38 people in America from hepatitis, he said, by an immune-related reaction similar to halothane-induced hepatitis.
“We don’t have the best drugs yet! There are better drugs available!” Dr. Warner said. “Why are they using xenon in Europe and we’re not?”
There is a new formulation of propofol that causes neither hypotension nor pain on injection, Dr. Warner said, but it’s “sitting on the shelf” for lack of FDA approval. “How do we push to get that done – get a drug introduced and get going?”
Dr. Warner sees the role of the APSF as getting people together in the same room to talk about drug issues. “We’re a convener,” he said. Representatives from the FDA, manufacturers, anesthesiologists, hospitals, and nurses need to agree on ways to standardize processes and improve drugs to reduce adverse medication effects systemwide.
“There are so many people that need input, but they never get together,” Dr. Warner said. The APSF will convene a meeting in January where the FDA, Joint Commission, Institute for Safe Medication Practices, American Society of Health-System Pharmacists, and manufacturers will aim to achieve consensus on vials and labels, among other issues.
Dr. Warner said APSF is focusing attention on a number of other problems, including:
• Opioid-induced respiratory depression: “The fact that you’re giving supplemental O2 hides respiratory depression. If you’re giving supplemental O2, you need to monitor for effective air exchange.”
• Intraoperative fires: “There’s still room for improvement. Most surgical fires involve electrosurgical equipment as the ignition source in airway, head, neck, and upper chest cases. If you have to use open delivery of oxygen, keep the FiO2 at 30 percent or less.”
• Handoffs: “Miscommunication is the highest cause of sentinel events, and is involved in 80 percent of serious errors.” Dr. Warner cited evidence that complete transfer of a case from one anesthesiologist to another is associated with worse outcomes, though breaks and meal relief improve alertness during a long case.
• Perioperative delirium, cognitive function, and brain health: Dr. Warner praised Dan Cole, MD, FASA, of our faculty for his dedicated work spearheading ASA’s Brain Health Initiative in 2015 during his term as ASA President.
Though APSF doesn’t create “standards”, Dr. Warner said, it plans to be increasingly aggressive in publishing recommendations and advocating for appropriate regulations and practice guidelines. He noted that APSF recommendations have been cited as evidence in at least two anesthesia cases where no neuromuscular function monitoring was in use and the patient subsequently suffered harm from residual blockade and hypoventilation.
Dr. Warner commended our department’s quality improvement program and singled out Emily Methangkool, MD, MPH, for congratulations on her leadership at UCLA and her contributions as the Social Media Ambassador Program Director on the APSF communications team.
“I wish I was getting started in anesthesiology right now, because it is just incredibly fascinating,” he said. There are great discoveries yet to come, he predicts, such as new research that will help us understand how the metabolism of drugs differs in patients of different ages and populations, and help us deliver more precisely targeted care.
In response to a question about using different-sized syringe connectors for epidural catheters so that IV medications could not be given into the epidural by mistake, Dr. Warner said that in this case the real question is, “How do you get that done?” The manufacturers haven’t yet caught up with the demand for different interlocking mechanisms, he said, though he expects eventual success.
What does Dr. Warner think about the electronic health record (EHR) from the perspective of patient safety?
“I like Epic,” Dr. Warner said. “I like the ‘Care Everywhere’ aspect.” He said he anticipates that technology eventually will link drug delivery to the intraoperative record by means of wearable technology on the arm that can identify which syringe was actually picked up and ask for confirmation that it contains the drug intended for use.
What about the safety of anesthesia in free-standing ambulatory surgery centers?
“We know there are higher rates of airway complications in free-standing facilities,” Dr. Warner said, even though patients are healthier. He cited the case of comedian Joan Rivers’ death in a free-standing endoscopy center as an example.
There is disagreement over whether dantrolene must be available in free-standing ambulatory centers, Dr. Warner said. There is also a “huge controversy” over whether oral surgeons and endoscopists should be permitted to direct sedation as well as do the procedure without an qualified anesthesia professional in attendance – the so-called “single operator-anesthetist model” which has been cited as a factor contributing to many adverse patient outcomes.
Dr. Warner’s career since medical school has been spent at the Mayo Clinic, where he is currently the Annenberg Professor in Anesthesiology and emeritus Executive Dean of the Mayo Clinic College of Medicine.
By Karen Sibert, MD, FASA