Service pressures and the role of anaesthetists in training – joint RCoA & AAGBI statement

Service pressures and the role of anaesthetists in training – joint RCoA & AAGBI statement
The Royal College of Anaesthetists (RCoA) and the Association of Anaesthetists of Great Britain & Ireland (AAGBI) have issued the following statement in light of some anaesthetists in training being asked to work outside of their usual scope of practice due to recent unprecedented demands on clinical services:

Patient safety should be the first priority of all NHS staff at all times. To support the needs of patients, and their safety, we believe the following principles are important when redeployment of trainees in our specialty is being considered although some of the points made would be equally applicable to non-trainee colleagues:

  • Trainee anaesthetists should be redeployed from their normal duties only in exceptional circumstances, and for the shortest possible length of time. The decision to do so should be made only by the Medical Director or deputy taking account of all service pressures and the clinical environment pertaining at that time.
  • Trainee anaesthetists should never practice beyond their competence. Trainees working in unfamiliar environments must have clear lines of supervision and responsibility established, and they must always receive adequate induction and be familiar with local governance arrangements.
  • It is important that those trainees asked to help support a part of the service under pressure are selected equitably from all of the medical staff competent to contribute to that aspect of the hospital’s clinical activity and that the number of sessions each redeployed trainee spends in another clinical service is closely monitored. 
  • If as a result of a change in duties an anaesthetic trainee misses an important training opportunity, it should be clearly outlined how this training will be accessed in a timely manner once the crisis has passed. We would encourage trainees to reflect on their experiences of working under these circumstances with their educational supervisors so that trainers can fully understand the problems trainees face and the potential for learning in these unfamiliar environments.

The decision to alter a trainee anaesthetist’s duties should be communicated by the Medical Director to the local Guardian of safe working, the trainee’s educational supervisor, RCoA Tutor (who should inform the relevant RCoA Regional Advisor) and Postgraduate Dean at the earliest opportunity. This should outline the circumstances that led to the redeployment being necessary; how long it will last for and the actions that will be put in place to avoid a recurrence in the future”.

 

 

 

Emergency Manual Uses During Actual Critical Events and Changes in Safety Culture From the Perspective of Anesthesia Residents: A Pilot Study

Goldhaber-Fiebert, S. et al. Anesthesia & Analgesia. 123(3) pp. 641–649

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Background: Emergency manuals (EMs), context-relevant sets of cognitive aids or crisis checklists, have been used in high-hazard industries for decades, although this is a nascent field in health care. In the fall of 2012, Stanford clinically implemented EMs, including hanging physical copies in all Stanford operating rooms (ORs) and training OR clinicians on the use of, and rationale for, EMs. Although simulation studies have shown the effectiveness of EMs and similar tools when used by OR teams during crises, there are little data on clinical implementations and uses. In a subset of clinical users (ie, anesthesia residents), the objectives of this pilot study were to (1) assess perspectives on local OR safety culture regarding cognitive aid use before and after a systematic clinical implementation of EMs, although in the context of long-standing resident simulation trainings; and (2) to describe early clinical uses of EMs during critical events.

Methods: Surveys collecting both quantitative and qualitative data were used to assess clinical adoption of EMs in the OR. A pre-implementation survey was e-mailed to Stanford anesthesia residents in mid-2011, followed by a post-implementation survey to a new cohort of residents in early 2014. The post-implementation survey included pre-implementation survey questions for exploratory comparison and additional questions for mixed-methods descriptive analyses regarding EM implementation, training, and clinical use during critical events since implementation.

Results: Response rates were similar for the pre- and post-implementation surveys, 52% and 57%, respectively. Comparing post- versus pre-implementation surveys in this pilot study, more residents: agreed or strongly agreed “the culture in the ORs where I work supports consulting a cognitive aid when appropriate” (73.8%, n = 31 vs 52.9%, n = 18, P = .0017) and chose more types of anesthesia professionals that “should use cognitive aids in some way,” including fully trained anesthesiologists (z = −2.151, P = .0315). Fifteen months after clinical implementation of EMs, 19 respondents (45%) had used an EM during an actual critical event and 15 (78.9% of these) agreed or strongly agreed “the EM helped the team deliver better care to the patient” during that event, with the rest neutral. We present qualitative data for 16 of the 19 EM clinical use reports from free-text responses within the following domains: (1) triggering EM use, (2) reader role, (3) diagnosis and treatment, (4) patient care impact, and (5) barriers to EM use.

Conclusions: Since Stanford’s clinical implementation of EMs in 2012, many residents’ self-report successful use of EMs during clinical critical events. Although these reports all come from a pilot study at a single institution, they serve as an early proof of concept for feasibility of clinical EM implementation and use. Larger, mixed-methods studies will be needed to better understand emerging facilitators and barriers and to determine generalizability.

Read the abstract here

Using educational video to enhance protocol adherence for medical procedures

Kandler, L. et al. British Journal of  Anaesthesia. 2016. 116 (5): pp.662-669.

Background: Better education of clinicians is expected to enhance patient safety. An important component of education is adherence to standard protocols, which are mainly available in written form. Believing in the potential power of videos, we hypothesized that the introduction of an educational video, based on an institutional standard protocol, would foster adherence to the protocol.

Methods: We conducted a prospective intervention study of 425 anaesthesia procedures and teams (202 pre-video and 223 post-video) involving 1091 team members (516 pre-video and 575 post-video) in seven individual operating areas (with a total of 30 operating rooms) in a university hospital. Failure of adherence to safety-critical tasks during rapid sequence anaesthesia inductions was assessed during systematic on-site observations pre- and post-introduction of an educational video demonstrating evidence-based and best practice guidelines.

Results: The odds for failure of adherence to safety-critical tasks between the pre- and post-intervention period were reduced, odds ratio 0.34 (95% confidence interval 0.27–0.42, P<0.001). The risk for failure of adherence was reduced significantly for eight of the 14 safety-critical tasks (allP<0.001).

Conclusions: This study provides empirical evidence for the effectiveness of an educational video to enhance adherence to a standard protocol during complex medical procedures. The introduction of a video can reduce failure of adherence to safety-critical tasks and contribute to patient safety. We recommend the introduction of videos to improve protocol adherence.

Read the abstract here

Health risk factors in the anesthesia population

  • The prevalence of lifestyle risk factors in perioperative patients is high.
  • A total of 30.1% of patients had no lifestyle risk factor.
  • The most prevalent health risk factors were overweight, smoking, and hypertension.
  • Overweight and hypertension are frequently underreported by patients.
  • Patient self-reports require critical appraisal.

Study objective

We investigated the prevalence of lifestyle risk factors in patients admitted to our preoperative assessment outpatient clinic, and compared patient self-reports and anesthetist reports of health risk factors to evaluate the patient self-image of preoperative health status.

Design

Cross-sectional survey.

Setting

The study was performed in an academic teaching hospital in Amsterdam, the Netherlands, during 3 consecutive months at the preoperative screening clinic.

Patients

A total of 1227 adult patients scheduled for surgery were screened, and 1111 were included (patients being excluded where data were incomplete).

Interventions and measurements

Before health risk screening by an anesthetist, patients filled out a lifestyle risk factor questionnaire including overweight, hypertension, diabetes mellitus, smoking, physical activity, and alcohol use. These were compared with risk factors stated in the preoperative assessment report of the anesthetist.

Main results

The study population was aged 51 ± 17 years with a body mass index of 25.6 ± 4.7 kg/m2. The most frequent lifestyle risk factors reported by the anesthetist were overweight and obesity (47.5%), smoking (25.3%), and hypertension (23.7%). The prevalence of no, 1, or 2 lifestyle risk factors in the preoperative assessment outpatient clinic population was, respectively, 30.1%, 35.6%, and 18.5% reported by the anesthetist and 36.4%, 36.7%, and 18.6% reported by the patients. Patients with more lifestyle risk factors were older with a higher body mass index and American Society of Anesthesiologists classification. Differences in reporting of lifestyle risk factors between patients and anesthetist occurred especially with overweight (26.5% vs 47.5%).

Conclusions

The prevalence of lifestyle risk factors in perioperative patients is high, and differences in reporting between patients and anesthetists may suggest that patients are unaware of or ignore their unhealthy state. Further studies are warranted to investigate the association between the lifestyle risk factors and outcome in the anesthesiology setting.

Full reference: Scharwächter, W.H. et al. Health risk factors in the anesthesia population Journal of Clinical Anesthesia. Volume 32, Pages 33–39

Psychological distress, burnout and personality traits in Dutch anaesthesiologists: A survey

van der Wal, R. et al. European Journal of Anaesthesiology: March 2016 – Volume 33 – Issue 3 – p 179–186

Background: The practice of anaesthesia comes with stress. If the demands of a stressful job exceed the resources of an individual, that person may develop burnout. Burnout poses a threat to the mental and physical health of the anaesthesiologist and therefore also to patient safety.

Objectives: Individual differences in stress appraisal (perceived demands) are an important factor in the risk of developing burnout. To explore this possible relationship, we assessed the prevalence of psychological distress and burnout in the Dutch anaesthesiologist population and investigated the influence of personality traits.

Results: Respectively, psychological distress and burnout were prevalent in 39.4 and 18% of all respondents. The prevalence of burnout was significantly different in resident and consultant anaesthesiologists: 11.3% vs. 19.8% (χ2 5.4; P < 0.02). The most important personality trait influencing psychological distress and burnout was neuroticism: adjusted odds ratio 6.22 (95% confidence interval 4.35 to 8.90) and 6.40 (95% confidence interval 3.98 to 10.3), respectively.

Conclusion: The results of this study show that psychological distress and burnout have a high prevalence in residents and consultant anaesthesiologists and that both are strongly related to personality traits, especially the trait of neuroticism. This suggests that strategies to address the problem of burnout would do well to focus on competence in coping skills and staying resilient. Personality traits could be taken into consideration during the selection of residents. In future longitudinal studies the question of how personal and situational factors interact in the development of burnout should be addressed.

Read the article abstract here

The effect of a standardised source of divided attention in airway management: A randomised, crossover, interventional manikin study

Prottengeier, J. European Journal of Anaesthesiology: March 2016 – Volume 33 – Issue 3 – p 195–203

Background: Dual-tasking, the need to divide attention between concurrent tasks, causes a severe increase in workload in emergency situations and yet there is no standardised training simulation scenario for this key difficulty.

Objectives: We introduced and validated a quantifiable source of divided attention and investigated its effects on performance and workload in airway management.

Participant: One hundred and fifty volunteer medical students, paramedics and anaesthesiologists of all levels of training.

Interventions: Participants secured the airway of a manikin using a supraglottic airway, conventional endotracheal intubation and video-assisted endotracheal intubation with and without the Paced Auditory Serial Addition Test (PASAT), which served as a quantifiable source of divided attention.

Results: All 150 participants completed the tests. Volunteers perceived our test to be challenging (99%) and the experience of stress and distraction true to an emergency situation (80%), but still fair (98%) and entertaining (95%). The negative effects of divided attention were reproducible in participants of all levels of expertise. Time consumption and perceived workload increased and almost half the participants make procedural mistakes under divided attention. The supraglottic airway technique was least affected by divided attention.

Conclusion: The scenario was effective for simulation training involving divided attention in acute care medicine. The significant effects on performance and perceived workload demonstrate the validity of the model, which was also characterised by high acceptability, technical simplicity and a novel degree of standardisation.

View the abstract here

Rota gaps causing ‘significant problems for patient safety’

Anaesthesia UK: 2nd February 2016

The latest census of consultant physicians and higher specialty trainees in the UK (2014/15) produced by the Royal College of Physicians, Royal College of Physicians of Edinburgh and the Royal College of Physicians and Surgeons of Glasgow, highlights significant concerns around filling gaps in trainee rotas.

Published in full today, the annual census measures the number of UK consultants and higher specialty trainees in all medical specialties, as well as capturing the views of those in the profession.

As part of the census, consultant physicians were asked about the gaps they face in their trainees’ rotas and their concerns. The findings from the consultant census show that trainee rota gaps were reported by 21% of respondents as, ‘frequent, such that they cause significant problems for patient safety’. This problem is reported more among consultants who have an acute or general medical commitment (28%). A further 48% stated rota gaps happened ‘often, but usually with a workaround solution such that patient safety is not compromised’.

The consultant census also notes, along with previous years, the growing need for consultants who can meet the needs of frail older patients. Following trends noted in last year’s census, the greatest increase in consultant jobs advertised have been in acute medicine and geriatric medicine, suggesting a move away from specialist working to more generalist roles treating acutely ill patients.

The nature of patients coming to hospital is changing. Sixty-five per cent of people admitted to hospital are over 65 years old and many have multiple complex conditions – often such patients require increased generalist input, as highlighted by the RCP’s Future Hospital Commission report.