Sally Rampersad

Risk factors for adverse events in children with colds emerging from anesthesia: a logistic regression.

Background:  Recent upper respiratory infection (URI) in children increases respiratory adverse events following anesthesia for elective surgery. The increased risk continues weeks after resolution of acute URI symptoms. Few systematic analyses have explored specific risk factors. This logistic regression explores the relationship between preoperative URI symptoms and adverse events during emergence from anesthesia.

Two-agent analgesia versus acetaminophen in children having bilateral myringotomies and tubes surgery

Objectives:  The objective of this study was to determine whether the incidence of emergence agitation (EA) can be reduced by adding an additional, faster onset, non‐IV analgesic, intranasal fentanyl or intramuscular (im) ketorolac to rectal acetaminophen.

Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia.

In 2006, the Quality and Safety Committee of the Society for Pediatric Anesthesia initiated a quality improvement project for the specialty of pediatric anesthesiology that ultimately resulted in the development of Wake Up Safe (WUS), a patient safety organization that maintains a registry of de-identified, serious adverse events. The ultimate goal of WUS is to implement change in processes of care that improve the quality and safety of anesthetic care provided to pediatric patients nationwide. Member institutions of WUS submit data regarding the types and numbers of anesthetics performed and information pertaining to serious adverse events. Before a member institution submits data for any serious adverse event, 3 anesthesiologists who were not involved in the event must analyze the event with a root cause analysis (RCA) to identify the causal factor(s). Because institutions across the country use many different RCA methods, WUS educated its members on RCA methods in an effort to standardize the analysis and evaluate each serious adverse event that is submitted. In this review, we summarize the background and development of this patient safety initiative, describe the standardized RCA method used by its members, demonstrate the use of this RCA method to analyze a serious event that was reported, and discuss the ways WUS plans to use the data to promote safer anesthetic practices for children.

Quality and safety in pediatric anesthesia

Health care quality and value are leading issues in medicine today for patients, health care professionals, and policy makers. Outcome, safety, and service—the components of quality—have been used to define value when placed in the context of cost. Health care organizations and professionals are faced with the challenge of improving quality while reducing health care related costs to improve value. Measurement of quality is essential for assessing what is effective and what is not when working toward improving quality and value. However, there are few tools currently for assessing quality of care, and clinicians often lack the resources and skills required to conduct quality improvement work. In this article, we provide a brief review of quality improvement as a discipline and describe these efforts within pediatric anesthesiology.

Modification of anesthesia practice reduces catheter-associated bloodstream infections: a quality improvement initiative.

A major strategic hospital goal is the prevention of catheter associated bloodstream infections (CABSI). In 2009, at our institution, the CABSI rate for patients who traveled out of the ICU to the operating room and other procedural areas under the care of an anesthesiologist was increased compared to patients who remained on the unit.

Assessing the Impact of the Anesthesia Medication Template on Medication Errors During Anesthesia: A Prospective Study.

BACKGROUND: Medication errors continue to be a significant source of patient harm in the operating room with few concrete countermeasures. The organization and identification of medication syringes may have an impact on the commission of medication errors in anesthesia, so a team of physicians and designers at the University of Washington created the Anesthesia Medication Template (AMT) to define a formal way of organizing the anesthesia workspace. The purpose of this study is to assess the ability of the AMT to reduce perioperative medication errors by anesthesia providers. METHODS: This study evaluated the AMT in 2 phases: (1) 41 anesthesia providers administered medications in 2 prospective, randomized operating room simulations with or without the AMT, while medication errors were directly observed; and (2) around 200 providers prospectively self-reported medication errors from all anesthetizing locations during a 2-year period at Seattle Children’s Hospital, an academic, pediatric medical center. RESULTS: In simulated emergencies, the odds of medication dosing errors using the AMT were 0.21 times the odds of medication dosing errors without AMT (95% confidence interval [CI], 0.07, 0.66), controlling for scenario, session, training level, and years at training level. During the year after implementation of the AMT, the mean monthly error rate for all reported medication errors that reached patients decreased from 1.24 (95% CI, 0.85–1.79) to 0.65 (95% CI, 0.39–1.09) errors per 1000 anesthetics. The mean monthly error rate of reported swap, preparation, miscalculation, and timing errors decreased from 0.97 (95% CI, 0.64–1.48) to 0.35 (95% CI, 0.17–0.70) errors per 1000 anesthetics. Medication errors that resulted in patient harm did not change after implementation of the AMT. CONCLUSIONS: Standardizing medication organization with the AMT is an intuitive, low-cost strategy with the potential to improve patient safety through reducing medication errors by anesthesia providers.

Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia.

The Institute of Medicine has called for development of strategies to prevent medication errors, which are one important cause of preventable harm. Although the field of anesthesiology is considered a leader in patient safety, recent data suggest high medication error rates in anesthesia practice. Unfortunately, few error prevention strategies for anesthesia providers have been implemented. Using Toyota Production System quality improvement methodology, a multidisciplinary team observed 133 h of medication practice in the operating room at a tertiary care freestanding childrens hospital. A failure mode and effects analysis was conducted to systematically deconstruct and evaluate each medication handling process step and score possible failure modes to quantify areas of risk. A bundle of five targeted countermeasures were identified and implemented over 12 months. Improvements in syringe labeling (73 to 96%), standardization of medication organization in the anesthesia workspace (0 to 100%), and two‐provider infusion checks (23 to 59%) were observed. Medication error reporting improved during the project and was subsequently maintained. After intervention, the median medication error rate decreased from 1.56 to 0.95 per 1000 anesthetics. The frequency of medication error harm events reaching the patient also decreased. Systematic evaluation and standardization of medication handling processes by anesthesia providers in the operating room can decrease medication errors and improve patient safety.

Video observation of anesthesia practice: a useful and reliable tool for quality improvement initiatives.

Patients with central venous catheters who are transferred out of the Intensive Care Unit to the care of an anesthesiology team for an operation or interventional radiology procedure had excessive rates of catheter associated blood stream infection (CABSI).

Gastric contents in pediatric patients following bone marrow transplantation

Background:  Graft versus host disease (GVHD) of the gut is thought to delay gastric emptying and so may increase the risk of aspirating retained contents while under anesthesia. Knowing that gastric emptying is delayed in patients with GVHD might lead one to choose to intubate the trachea for all patients with suspected GVHD, who present for diagnostic esophagogastricduodenoscopy (EGD). We are not aware of published data that gives specific guidance as to the need for intubation in the pediatric bone marrow or stem cell transplantation (BMT) population. This review was intended to evaluate the gastric contents (pH and volume) in this group of patients, to provide anesthesiologists with data that would inform their decisions about airway management for these patients.

Risk factors for laryngospasm.

response from the Society for Pediatric Sedation in the June edition of this journal. Our purpose in adding to this discussion is to demonstrate a model for the provision of sedation for children that has been extremely successful at Kentucky Children’s Hospital and to show what can be accomplished when groups work together. Dr Cote has been a leader in the development of safe sedation for children for the last twenty years. His vision to provide the safest possible care to all children and his determination to bring all groups that provide sedation to the table are to be applauded. We are cognizant of the fact that the training of anesthesiologists and especially pediatric anesthesiologists is resource intensive. It is probably not reasonable to ever expect that this group will be capable of providing the volume of care that is required for all of the children that should be sedated for medical procedures. There are certainly other professional groups (Pediatric Critical Care, Pediatric Emergency Medicine, Pediatric Hospitalists) that have sufficient training and expertise to develop programs for sedation. These groups will, of course, want to include provisions for quality control, continuing demonstration of competence, as well as discussions about the requirement for more intensive use of resources in patients that have a higher acuity level. The American Society of Anesthesiologists has worked to elevate the level of care for all sedated patients and, through the Committee on Pediatric Anesthesia has worked with the American Academy of Pediatrics and other groups with interests in the medical management of children to develop guidelines for sedation which provide a consistently high level of care to all. At the University of Kentucky Children’s Hospital, faculty and staff in the Heinrich Werner Division of Pediatric Critical Care provide sedation for a large percentage of children that have procedures on a daily basis (2). The development of this service has been accomplished with the assistance and support of the Division of Pediatric Anesthesia, and for the last ten years, there has been continuous communication between the two divisions concerning the disposition of individual patients. In addition, both groups have collaborated on the development of guidelines for which group – Anesthesia or Critical Care should be involved in the care of a patient based on individual circumstance. Involvement of a Pediatric Anesthesiologist (REB) in Morbidity and Mortality conferences, research projects and continuing medical education has made the management of this issue in our medical center safe and seamless. Recently we have brought Pediatric Hospitalists to the table and, it is our expectation that, this effort will be expanded to include all episodes of sedation management in the future. The key feature in the development of this effort was the vision of Heinrich Werner. He realized that there were children in need of care and that were not enough Pediatric Anesthesia resources to provide all of the sedation services that were required. Collaboration between Pediatric Critical Care and Pediatric Anesthesia has produced what I think all of us really want, a safe environment for children to have medical procedures done without pain and anxiety. Raeford E. Brown J R* Carrie E. Makin† Cheri Landers† Dawn Turner† Horacio Zagul† Phillip Bernard† *Department of Anesthesiology, University of Kentucky Medical Center, Kentucky Children’s Hospital, Lexington, KY, USA †Heinrich Werner Division of Critical Care, Department of Pediatrics, Kentucky Children’s Hospital, Lexington, KY, USA