Important and urgent issues in perioperative patient safety – a second expert panel perspective

Important and urgent issues in perioperative patient safety – a second expert panel perspective

  • Issue 75

Johannes Wacker, Sven Staender
jwac@gmx.net

A conference that convenes experienced experts is a unique opportunity to learn from the merged wisdom of participants.1Euroanaesthesia is such a conference: Participating experts accumulate wisdom about the scientific, professional, practical, and patient safety dimensions of all fields of anaesthesiology and perioperative medicine. Accordingly, the ESA PSQC organizes the Patient Safety Expert Meeting, a World Café2style invitational and moderated group discussion with the purpose of exploring the most important and most urgent current issues in perioperative patient safety. After the successful start during Euroanaesthesia 2016 in London,3a second edition of the meeting was held during Euroanaesthesia 2017 in Geneva. This summary highlights the bottom line of the meeting’s engaged and lively debate. Some literature references were added as suggestions for further reading.

The initial debate centered on the need for an official document definingminimum patient safety standards. The Helsinki Declaration on Patient Safety in Anaesthesiology4(HD) provides a fundamental framework of guiding ideas and of principal requirements for anaesthesia departments – but it is not a detailed practice manual. The discussion disclosed a desire for enhancing the HD by a document containing such instructions for clinical practice – detailed definitions of safety requirements including minimum required equipment and minimum organisational standards (including staffing requirements) related to anaesthesia, intensive care, perioperative medicine, and critical emergency medicine. The desired document could be drafted as part of the “HD Follow Up Project5that has recently been started by the PSQC with the aim to assess and improve the adoption of the HD. The optimal format should then be based on a consensus of all parties involved, and consider the pros and cons of different formats ranging from a basic recommendation to a formal guideline developed in line with established ESA standards.

A second line of the discussion explored the particular importance of communication for patient safety, and a need for communication standards in clinical practice, in particular during transitions of care. Associations between anaesthesia handovers and perioperative patient mortality have been reported.6,7Several tools are available that may help to improve communication in general, and particularly during handover processes: Besides the structure provided by the WHO Surgical Safety Checklist, tools and resources are provided by the Joint Commission’s “Transitions of Care (ToC) Portal”, or by the Health and Safety Executive Human Factors Website (UK Government). It was emphasised, however, that standard communication tools that cover every situation may never be feasible – the point is to hand over responsibility. A concern is that human factors are not taken seriously – sometimes even by seniors.

As a third major subject, perioperative organizational structures and resource allocation were discussed:Who is admitted to ICU, PACU, or to the ward after surgery? Judicious use of these resources would require early and factual communication, yet final patient admissions often result from less factual fights. Despite preoperative evaluation and risk calculation tools (e.g., the ACS risk calculator), predictability of postoperative complications remains limited. It is not easy to objectify the gut feeling that organizational structures may contribute to patient mortality: More ICU beds do not appear to save more lives8– are more PACU beds needed, or more resources for early warning score monitoring and outreach teams on the wards?9Indeed, manpower represents a patient safety priority:10increasing evidence supports the contribution of adequate staffing on patient outcomes.11,12We need a better understanding of these factors, and of the long-term consequences of surgery. Analysing routine data bases and linked clinical registries13would contribute to this, but meets many obstacles.

Inevitably, these major topics overlapped during the moderated discussion. They have been compiled for this summary based on the meeting minutes. All individuals listed below have approved the final summary, and agreed to be listed as participants. The dynamic debate touched many other patient safety issues, among them the impact of different national legal backgrounds on safety practices, the challenge to demonstrate the value provided to patients by safety interventions, and the need for an anaesthesiology-specific patient safety curriculum. Many patient safety issues remain highly important, or as Robert K. Stoelting remarked: “If you want to have a hot topic – take OR fires!”

Participants: Daniel Arnal, Paolo Pelosi, Dan Longrois, Robert K. Stoelting, Beverly K. Philip, Jannicke Mellin-Olsen, Gabriel M. Gurman, Daniela Filipescu, Filippo Bressan, Karen Domino, Cor Kalkman, Leif Saager, David Whitaker, Flavia Petrini, Doris Østergaard, Jan Hendrickx, Paraskevi Matsota, Frank Wappler; Josef I. Wichelewski; Mark Coburn; Tino Münster. Moderation: Johannes Wacker, Sven Staender. Organisation: Mirka Cikkelova.

 

References

  1. Cosby Karen S, Zipperer L, Balik B. Diagnosis 2015;2(3):189-93.
  2. MacFarlane A, Galvin R, O’Sullivan M, et al. Fam Pract 2016;pii: cmw104 [Epub ahead of print].
  3. Wacker J. ESA Newsletter 2017(68). http://newsletter.esahq.org/important-and-urgent-issues-in-perioperative-patient-safety-views-of-an-expert-panel/
  4. Mellin-Olsen J, Staender S, Whitaker DK, Smith AF. Eur J Anaesthesiol 2010;27(7):592-7.
  5. Wacker J. ESA Newsletter 2017;69. http://newsletter.esahq.org/revisiting-the-helsinki-declaration-on-patient-safety-in-anaesthesiology-a-project-to-assess-and-improve-implementation-into-practice/
  6. Hyder JA, Bohman JK, Kor DJ, et al. Anesth Analg 2016;122(1):134-44.
  7. Saager L, Hesler BD, You J, et al. Anesthesiology 2014;121(4):695-706.
  8. Kahan BC, Koulenti D, Arvaniti K, et al. Intensive Care Med 2017;43(7):971-9.
  9. Hollis RH, Graham LA, Lazenby JP, et al. Ann Surg 2016;263(5):918-23.
  10. UEMS Section & European Board of Anaesthesiology. EBA recommendations for Assistance for the Anaesthesiologist. 2016. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwj5uv3Y8IrbAhUhG5oKHfnCAioQFgg2MAA&url=http%3A%2F%2Fwww.eba-uems.eu%2Fresources%2FPDFS%2Fsafety-guidelines%2FEBA-recommendations-for-Assistance-for-the-Anaesthesiologist-2016.pdf&usg=AOvVaw0-vXCulgNbF7qhAaerLvZx
  11. Aiken LH, Sloane DM, Bruyneel L, et al. Lancet 2014;383(9931):1824-30.
  12. Cho E, Sloane DM, Kim EY, et al. Int J Nurs Stud 2015;52(2):535-42.
  13. Glance LG, Wanderer JP, Dick AW, Dutton RP. Anesth Analg 2017;125(2):689-91.