Patient safety and quality: can anaesthetists play a greater role?

Patient safety, a major focus for the specialty of anaesthesia for at least 20 years, is now a prominent concept in the whole healthcare system. Anaesthetists almost exclusively focus on safety and quality issues in the operating theatre. Can anaesthetists play an even greater role in patient safety especially outside the operating theatre? Despite the manifold dangers of the operating theatre [1], the risks associated with anaesthesia are low. In the United States, anaesthetic mortality rates have decreased from one death per 5000 administrations of anaesthetics in the late 1970s to fewer than one death per 250 000 [2]. Hospital admission overall is far riskier: up to 16% of hospital admissions have been associated with an adverse event [3] and 81% were complications of surgery. Surgical patients spending more than 48 h in hospital have a 6.5% mortality rate [4]. The US Institute of Medicine recommends the healthcare system should aim for ‘six sigma’ reliability (fewer than 3.4 errors per 1 million events) [5]; these low error rates are achieved by airlines and the nuclear power industry. Most areas of medicine are far from this, but anaesthesia is close [6]. Individual caregivers cannot achieve six sigma reliability without support from organisational systems designed to prevent the consequences of unavoidable human error [6]. Anaesthetists have become focused on the safety of the individual patient during the period of anaesthesia often ignoring other safety and quality considerations. Application of fasting rules is a good example. Fasting of an emergency case can result in wasted operating theatre time, other cases being cancelled and adverse effects for the fasted patient. Despite much research, the very relationship between intragastric volume, regurgitation and actual aspiration remains obscure [7]. The delaying of emergency surgery of a non-life/limb threatening nature to ‘optimise’ gastric emptying was shown to be the practice of two thirds of New Zealand anaesthetists [8]. Lankester et al. [9] showed delay in operating on orthopaedic trauma patients leads to increased morbidity, mortality, hospital stay and cost. Early operation for patients with fractured ankles has been shown to significantly reduce bed stay and improve function [10, 11]. Daytime emergency theatre and orthopaedic trauma lists are now considered best practice [12, 13] and exist at many Australasian and United Kingdom hospitals. Anaesthetists also all ‘know’ that operating after midnight is associated with increased morbidity and mortality (NCEPOD) and that fatigue reduces our ability to be vigilant [14, 15]. The individual patient though, has a personal risk of complications, which increases with delay. Yet how much input do anaesthetists have or seek to have in the timing of surgical procedures and in minimizing surgical risks overall? Anaesthetists must take a wider perspective outside the operating theatre to secure quality outcomes for surgical patients. Lee pointed out that failure to provide an appropriate medical intervention through underuse, overuse or misuse should be considered as ‘error’, that is, such failure is an issue of safety as well as of quality [16]. Anaesthetists do not always act as part of a team working to reduce common causes of morbidity and mortality for surgical patients. For example, the use of thromboprophylaxis, where there are frequent failures by the healthcare team to give the appropriate drugs [17], yet the system change of adding this item to pre-operative check procedures is very simple. Similarly, the place of peri-operative beta blockade is well established [18-20], yet how many anaesthetic departments have any system to ensure the right patients get these drugs? How can the focus on intra-operative safety be moved to quality and safety in the peri-operative period? Major changes need to occur in three areas: journal focus, audit of practice, and involvement in system improvements in health. Our journals could publish more articles concerned with quality. This means more clearly embracing qualitative research methods and making a place in anaesthetic journals for publication of quality improvement projects which can change the practice of others. Runciman [21] recently emphasised that attention to continuous improvements in process, rather than a preoccupation with objective evidence of improvements in outcome, is the key to successful quality improvement. Anaesthetists were leaders in adoption of improvements not always supported by randomised controlled trials (e.g. mandatory monitoring). Audit can improve clinical practice. Intra-operative events are not the ideal focus for audit, because adverse events are rare. The post anaesthesia care unit (PACU) can provide some useful markers of anaesthetic quality, for instance pain and hypertension, but we need to move beyond the PACU to the whole postoperative course. The major surgical adverse events of anastomotic leak and wound infection are surely matters of shared concern [22]. Clinical governance means that anaesthetists must be involved in an organisational commitment to critically appraise the underlying causes of morbidity and postoperative adverse events and to correct the problems identified. What are the system issues within the hospital ensuring oxygen therapy is delivered, or consideration of the contributions of hypertension/hypotension, fluid status, anticoagulation and haematocrit to morbidity and mortality? Detmer points out that: ‘Doctors…see quality as being mainly their own individual responsibility rather than a collective effort encompassing other people, processes, and, especially systems’[23]. We must move beyond this attitude. Anaesthetic simulators provide formal training in teamwork and the nature of error in the operating theatre [24] but we cannot simulate the entire hospital and all our interactions. We can learn to employ a system approach to patient safety, using the study of human factors to reduce errors in patient care throughout the hospital [25, 26]. Anaesthetists as a profession have a huge body of expertise in patient safety and error prevention and can extend their expertise out from the operating theatre to the wards where most adverse events and deaths occur. This would be an advance in the safety of surgical patients and a significant improvement in the quality of health care. I would like to acknowledge the help of: Professor Peter Kam, Professor of Anaesthesia, University of NSW, Sydney; Associate Professor Denis King, Director of the Division of Surgery and Critical Care, St George Hospital, Sydney; Dr Louisa Jorm, Director Epidemiology and Research, NSW Department of Health.