Jane Torrie

Safety assessment of postoperative pain management by an acute pain service

While there are increasing demands for improved post-operative analgesia and the implementation of Acute Pain Services (APS), the safety of such an approach remains under discussion. This paper analyses the safety outcome of 3016 consecutive post-operative patients treated under the care of a formalised Acute Pain Service. No serious complication resulting in morbidity or mortality occurred. Potentially severe complications without sequelae were discovered in 16 patients (0.53%); this incidence was similar for techniques of systemic opioid administration and continuous regional analgesia. Patient-controlled analgesia (PCA) alone had a significantly lower rate of respiratory depression than PCA with a background infusion or continuous morphine infusion. In 1069 patients receiving continuous regional analgesia (epidural, interpleural, peripheral) no trauma to nervous structures, no infection and no local anaesthetic toxicity occurred. In conclusion, an anaesthesiology-based APS can provide postoperative pain relief using a wide range of relatively invasive techniques without endangering patient safety.

The effect of a simulation-based training intervention on the performance of established critical care unit teams

Objective:We evaluated the effectiveness of a simulation-based intervention on improving teamwork in multidisciplinary critical care teams managing airway and cardiac crises and compared simulation-based learning and case-based learning on scores for performance. Design:Self-controlled randomized crossover study design with blinded assessors. Setting:A simulated critical care ward, using a high-fidelity patient simulator, in a university simulation center. Subjects:Forty teams from critical care units within the region comprising one doctor and three nurses. Intervention:At the beginning and end of the 10-hr study day, each team undertook two preintervention and two postintervention assessment simulations (one airway, one cardiac on both occasions). The study day included presentations and discussions on human factors and crisis management, and airway and cardiac skills stations. For the intervention, teams were randomized to case-based learning or simulation-based learning for cardiac or airway scenarios. Measurements and Main Results:Each simulation was recorded and independently rated by three blinded expert assessors using a structured rating tool with technical and behavioral components. Participants were surveyed 3 months later. We demonstrated significant improvements in scores for overall teamwork (p ≤ .002) and the two behavioral factors, “Leadership and Team Coordination” (p ≤ .002) and “Verbalizing Situational Information” (p ≤ .02). Scores for clinical management also improved significantly (p ≤ .003). We found no significant difference between simulation-based learning and case-based learning in the context of this study. Survey data supported the effectiveness of study day with responders reporting retention of learning and changes made to patient management. Conclusions:A simulation-based study day can improve teamwork in multidisciplinary critical care unit teams as measured in pre- and postcourse simulations with some evidence of subsequent changes to patient management. In the context of a full-day course, using a mix of simulation-based learning and case-based learnings seems to be an effective teaching strategy.

Building the evidence on simulation validity: comparison of anesthesiologists' communication patterns in real and simulated cases.

Background:Effective teamwork is important for patient safety, and verbal communication underpins many dimensions of teamwork. The validity of the simulated environment would be supported if it elicited similar verbal communications to the real setting. The authors hypothesized that anesthesiologists would exhibit similar verbal communication patterns in routine operating room (OR) cases and routine simulated cases. The authors further hypothesized that anesthesiologists would exhibit different communication patterns in routine cases (real or simulated) and simulated cases involving a crisis. Methods:Key communications relevant to teamwork were coded from video recordings of anesthesiologists in the OR, routine simulation and crisis simulation and percentages were compared. Results:The authors recorded comparable videos of 20 anesthesiologists in the two simulations, and 17 of these anesthesiologists in the OR, generating 400 coded events in the OR, 683 in the routine simulation, and 1,419 in the crisis simulation. The authors found no significant differences in communication patterns in the OR and the routine simulations. The authors did find significant differences in communication patterns between the crisis simulation and both the OR and the routine simulations. Participants rated team communication as realistic and considered their communications occurred with a similar frequency in the simulations as in comparable cases in the OR. Conclusion:The similarity of teamwork-related communications elicited from anesthesiologists in simulated cases and the real setting lends support for the ecological validity of the simulation environment and its value in teamwork training. Different communication patterns and frequencies under the challenge of a crisis support the use of simulation to assess crisis management skills.

Anaesthetic drug administration as a potential contributor to healthcare-associated infections: a prospective simulation-based evaluation of aseptic techniques in the administration of anaesthetic drugs

Objective To evaluate the possibility that anaesthetists are administering potentially pathogenic micro-organisms to their patients. Design Prospective microbiological and observational study in a realistic simulated setting. Participants Ten anaesthetists supported by 10 anaesthetic technicians. Primary outcome measure The presence or absence of organisms cultured from sterile intravenous bags used to collect drugs injected during the simulated cases and from the needles and the contents of the syringes used. The authors also observed the aseptic techniques used. Results Organisms were isolated from five of 38 (13%) bags from five of 20 simulated cases anaesthetised by four of 10 anaesthetists, 10 of 197 (5%) syringes and six of 17 (35%) needles. None of the anaesthetists washed their hands prior to entry, used the hand gel provided, disinfected the phial septa before drawing up drugs or disinfected the intravenous ports on the intravenous administration set before use. One was seen to recap a needle left on a syringe for possible reuse. Three participants were observed to place equipment such as stethoscopes, drug charts and pens on top of their inuse drug trays. Conclusion The administration of intravenous drugs during anaesthesia may be an important factor in the genesis (or potentially the prevention) of healthcare-associated infection. These observations suggest room for improvement in the aseptic techniques of at least some anaesthetists when preparing and administering intravenous drugs. Confirmation of these findings in clinical settings is needed. Study registry number (for the VASER study) Australian New Zealand Clinical Trials Registry: Ref: ACTRN 12609000530224, https://www.anzctr.org.au/registry/trial_review.aspx?ID=308128; note that the work presented here is a subset of the registered trial and its outcomes were not included in this registration.

Microbiological Contamination of Drugs during Their Administration for Anesthesia in the Operating Room

Background:The aseptic techniques of anesthesiologists in the preparation and administration of injected medications have not been extensively investigated, but emerging data demonstrate that inadvertent lapses in aseptic technique may be an important contributor to surgical site and other postoperative infections. Methods:A prospective, open, microbiological audit of 303 cases in which anesthesiologists were asked to inject all bolus drugs, except propofol and antibiotics, through a 0.2-µm filter was performed. The authors cultured microorganisms, if present, from the 0.2-µm filter unit and from the residual contents of the syringes used for drawing up or administering drugs. Participating anesthesiologists rated ease of use of the filters after each case. Results:Twenty-three anesthesiologists each anesthetized up to 25 adult patients. The authors isolated microorganisms from filter units in 19 (6.3%) of 300 cases (3 cases were excluded), including Staphylococcus capitis, Staphylococcus warneri, Staphylococcus epidermidis, Staphylococcus haemolyticus, Micrococcus luteus/lylae, Corynebacterium, and Bacillus species. The authors collected used syringes at the end of each case and grew microorganisms from residual drug in 55 of these 2,318 (2.4%) syringes including all the aforementioned microorganisms and also Kocuria kristinae, Staphylococcus aureus, and Staphylococcus hominus. Participants’ average rating of ease of use of the filter units was 3.5 out of 10 (0 being very easy and 10 being very difficult). Conclusions:Microorganisms with the potential to cause infection are being injected (presumably inadvertently) into some patients during the administration of intravenous drugs by bolus during anesthesia. The relevance of this finding to postoperative infections warrants further investigation.

Read-back improves information transfer in simulated clinical crises

Background Safe and effective healthcare is frustrated by failures in communication. Repeating back important information (read-back) is thought to enhance the effectiveness of communication across many industries. However, formal communication protocols are uncommon in healthcare teams. Aims We aimed to quantify the effect of read-back on the transfer of information between members of a healthcare team during a simulated clinical crisis. We hypothesised that reading back information provided by other team members would result in better knowledge of that information by the receiver than verbal response without read-back or no verbal response. Method Postanaesthesia care unit nurses and anaesthetic assistants were given clinically relevant items of information at the start of 88 simulations. A clinical crisis prompted calling an anaesthetist, with no prior knowledge of the patient. Using video recordings of the simulations, we noted each time a piece of information was mentioned to the anaesthetist. Their response was coded as read-back, verbal response without read-back or no verbal response. Results If the anaesthetists read back the item of information, or otherwise verbally responded, they were, respectively, 8.27 (p<0.001) or 3.16 (p=0.03) times more likely to know the information compared with no verbal response. Conclusions Our results suggest that training healthcare teams to use read-back techniques could increase information transfer between team members with the potential for improved patient safety. More work is needed to confirm these findings.

A behaviourally anchored rating scale for evaluating the use of the WHO surgical safety checklist: development and initial evaluation of the WHOBARS

Background Realising the full potential of the WHO Surgical Safety Checklist (SSC) to reduce perioperative harm requires the constructive engagement of all operating room (OR) team members during its administration. To facilitate research on SSC implementation, a valid and reliable instrument is needed for measuring OR team behaviours during its administration. We developed a behaviourally anchored rating scale (BARS) for this purpose. Methods We used a modified Delphi process, involving 16 subject matter experts, to compile a BARS with behavioural domains applicable to all three phases of the SSC. We evaluated the instrument in 80 adult OR cases and 30 simulated cases using two medical student raters and seven expert raters, respectively. Intraclass correlation coefficients were calculated to assess inter-rater reliability. Internal consistency and instrument discrimination were explored. Sample size estimates for potential study designs using the instrument were calculated. Results The Delphi process resulted in a BARS instrument (the WHOBARS) with five behavioural domains. Intraclass correlation coefficients calculated from the OR cases exceeded 0.80 for 80% of the instruments domains across the SSC phases. The WHOBARS showed high internal consistency across the three phases of the SSC and ability to discriminate among surgical cases in both clinical and simulated settings. Fewer than 20 cases per group would be required to show a difference of 1 point between groups in studies of the SSC, where α=0.05 and β=0.8. Conclusion We have developed a generic instrument for comprehensively rating the administration of the SSC and informing initiatives to realise its full potential. We have provided data supporting its capacity for discrimination, internal consistency and inter-rater reliability. Further psychometric evaluation is warranted.

Crisis Management in Anesthesiology, 2nd Edition

The first edition of this book was novel at the time of publication in 1994. It not only listed the practical actions to undertake in anesthetic crises, but in the introductory section, it also described the cognitive and behavioural skills needed for effective crisis management. Recognition of the importance of these ‘‘soft skills’’ in healthcare is illustrated in Miller’s Anesthesia. In 2015, this topic is promoted to Chapter 7, whereas in 2000, it was buried far back in Chapter 80. Gaba et al. have been influential in translating certain concepts from the highly reliable aviation world into anesthesia practice, and they created simulation-based courses in the process. Their term ‘‘Anesthesia Crisis Resource Management’’ (ACRM) is still used as shorthand to indicate courses that contain such content. Twenty years later and with a fourth editor, Gaba et al. have compiled a second edition. How has this publication adapted to the changing anesthesia world? The presentation is almost identical. This paperback is portable but not pocket size with font and formatting that are adequate though not particularly noteworthy. The e-book simply replicates the print version, but I personally found the e-version more convenient to search and navigate. As with the first edition, this current publication is divided into two sections, ‘‘Basic Principles of Crisis Management’’ and ‘‘Catalog of Critical Events’’. In the first section, the original two chapters on dynamic decision-making and the principles of ACRM are supplemented by two chapters, a chapter on teaching ACRM that concentrates on the use of simulation techniques and a chapter that focuses specifically on debriefing. All of the above chapters offer good reading, although the first chapter seems less current with most references well prior to 2000. The second chapter appropriately has a larger section on cognitive aids in crises, including the Stanford Emergency Manual for Anesthesia produced by a group with contributors to this book. The added chapters serve as a general introduction to their topics and are slanted towards the personal opinions and practices of the authors, which they explicitly acknowledge. Overall, I consider this an invaluable approach; although more focus was devoted to individual cognition and behaviours in the simulation lab than to full integration of all team members into teams. The book’s comprehensive second section comprises 99 critical events, up from the original 80. Certain generic crises, e.g., hypotension, are presented first, and then specific events are arbitrarily yet reasonably grouped (e.g., cardiovascular, obstetric, equipment). In my view, some of these events should be rated as non-emergent complications rather than as critical events (e.g., moderate hypothermia or peripheral nerve injury), whereas I did not find inadvertent intra-arterial injection in either edition. Each event is presented under standard headings of definition, etiology, typical situations, prevention, manifestations, similar events, management, and complications. Under the management heading is a list of actions which are ‘‘described approximately in the order of things an experienced healthcare professional might check or do’’. This (lack of) structure was intentionally chosen by the authors and helps to ensure that the reader avoids inadvertently focusing on one action to the exclusion of others. On the other hand, this approach also makes some complex sections less easy to follow (e.g., ‘‘Management J. Torrie, MBChB (&) Department of Anaesthesiology, Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand e-mail: j.torrie@auckland.ac.nz

Fake and expired medications in simulation-based education: an underappreciated risk to patient safety

In January 2015, the US Food and Drug Administration (FDA) reported that at least 40 patients had received non-sterile intravenous fluids, resulting in associated adverse events and one death. The offending products were produced for educational purposes by a company supplying the growing healthcare simulation market, and were not intended for patients. The plastic bags, labelled to mimic sterile 0.9% saline solution, contaminated the medication supply chain in 22 locations.1 Although the sequence of events is not yet clear, the supply shortage of 0.9% saline in the USA2 may have been a contributory factor. The presence of fake products was a latent condition or ‘resident pathogen’3 which in certain circumstances led to error and patient harm. Harbingers of the tragic events above have been reported, such as the discovery of demonstration adrenaline syringes on an emergency trolley for clinical use and the treatment of anaphylaxis with an Epipen subsequently found to be an inactive training device.4 An editorial on unintended consequences of simulation5 highlighted administration of fake medications as a potential hazard to patients, and simulating medications has been an active topic in the simulation community, for example on the Society For Simulation in Healthcare Listserve. Simulation-based activities are common in healthcare education and an expanding evidence base suggests they are also useful for improving patient safety6 ,7 and for detecting latent safety threats in new products.8 Debate continues on how accurately the clinical environment should be recreated to achieve educational objectives and to enable transfer of learning to the workplace.9 One approach is to use clinical areas for simulation activities (in situ) as opposed to using separate, dedicated simulation spaces.10 Medication errors are a persistent and important problem in healthcare.11 Simulation-based education in any location often incorporates medication, …

Ward calls not so scary for medical students after interprofessional simulation course: a mixed-methods cohort evaluation study

Background An interprofessional simulation ‘ward call’ course—WardSim—was designed and implemented for medical, pharmacy and nursing students. We evaluated this intervention and also explored students’ experiences and ideas of both the course and of ward calls. Methods We used a mixed-methods cohort study design including survey and focus groups. Descriptive statistical analysis and general purpose thematic analysis were undertaken. Results Survey respondents who participated in WardSim subsequently attended more ward calls and took a more active role than the control cohort, with 34% of the intervention cohort attending ward calls under indirect supervision, compared with 15% from the control cohort (P=0.004). Focus group participants indicated that the situation they were most anxious about facing in the future was attending a ward call. They reported that their collective experiences on WardSim alleviated such anxiety because it offered them experiential learning that they could then apply in real-life situations. They said they had learnt how to work effectively with other team members, to take on a leadership role, to make differential diagnoses under pressure and to effectively communicate and seek help. Conclusions An interprofessional, simulated ward call course increased medical students’ sense of preparedness for and participation in ward calls in the next calendar year.