STAT Calls: Real Data Could Improve Anesthesia Staffing Models

With advances in monitoring and the relative safety of anesthetics, focus has shifted to early warning and crisis prevention through the utilization of “big data.” In the past 2 decades, numerous larger data sets on perioperative adverse events have been presented, each adding new variables to expound on the knowledge behind these events.1,2 Vlassakova et al3 present an excellent review of the patient demographics and procedural characteristics surrounding “STAT calls” for help within the Department of Anesthesiology at Boston Children’s Hospital (BCH) main campus. Congruent with previously published data sets, respiratory events, younger age at surgery, and higher American Society of Anesthesiologists (ASA) status were associated with a greater likelihood of STAT calls. In addition, this study encompasses the additional characteristics of recent upper respiratory infections, history of prematurity, and anesthetic phase, as well as inclusion of patients with cardiovascular disease. Similar to the data from Children’s Hospital of Philadelphia, laryngospasm proved to be a common cause for STAT call initiation.2 These airway events, which occur most frequently at the time of emergence and in the postanesthesia care unit, highlight the importance of the anesthesiologists’ presence at the time of extubation and during the first phase of recovery. The authors also examined the data based on the provider initiating the STAT call (attending/fellow versus certified registered nurse anesthetist/resident) and, secondarily, whether the STAT call was deemed complicated or uncomplicated (by nature of the ensuing patient disposition).3 Building on the data from Children’s Hospital of Philadelphia, which established that physicians with less experience were more likely to call for help, the authors of this study also found that STAT calls initiated by more experienced providers were more likely to be “complicated” and potentially require additional care and management beyond the immediate period of crisis management.2 There are a few theoretical reasons for these differences. Advanced practitioners (ie, attending and fellow physicians) are more likely to care for more complex and high-acuity patients. This may be due to individual comfort level or case selection bias because fellow physicians are generally graduated based on completion of a certain number of index cases that are of greater complexity, and therefore have higher morbidity and mortality by default. Also, given the supervision principle that is at play, the physician practitioners are more likely to work deeper into the therapeutic algorithm before calling for help, even with problems of significant complexity. For example, during a routine laryngospasm, it may be less likely for an attending physician to initiate a STAT call. However, when he or she does, it is more likely that the situation is critical. The need to call for help is sometimes unrecognized by providers in training.4,5 Unfortunately, these more complex cases may have already been planned for admission to the medical floor or especially the intensive care unit, which would not have been captured by the present study as an upgrade of care level. Similarly, direct calls to providers outside the STAT system may also go unrecorded. However, considering the acuity at BCH, it is likely that the numbers here underestimate the degree of complicated STAT calls because presumably, many of these patients were either already in the intensive care unit or slated to recover there. The BCH data invite questions on how we can incorporate deliberate practice models when it comes to staffing our pediatric anesthetizing locations, especially with respect to resource mobilization during crisis situations. While overall, staff reported a lower number of STAT calls in nonoperating room anesthesia (NORA) locations, the number of these that were complicated was actually higher. Certainly, as the number of NORA anesthetics continues its upward trajectory, we must use the authors’ conclusions regarding the nature of offsite procedures and their inescapably higher risk to inform our practices.6 The nature of NORA procedures dictates that patients, no matter how complex and critical, travel to these remotely located regions of the hospital (eg, interventional radiology, magnetic resonance imaging, and nuclear medicine), often directly from the intensive care unit. While these locations are more commonly staffed solely by attending anesthesiologists (making the likelihood of STAT calls less), we have noticed in our institution a growing number of situations in which crisis resource management and help in the “wilderness” can be difficult.7 Nationally, the percentage, variety, and acuity (by ASA classification) of cases being done in NORA sites have continued to increase and even surpass those in operating rooms (by ASA classification).6 This study has clearly demonstrated the increased complexity and urgency of STAT calls generated from offsite locations and the need for faculty to be available and ready to assist colleagues in those situations. As we move toward expansion at Texas Children’s Hospital, the information presented here will allow us to consider staffing, especially for the remote site locations. As our practices and hospitals continue to grow, it is crucial to consider crisis resource management in the design of new anesthetizing locations for which anesthesia will be required, the potential for crisis resource management. Given that NORA sites are often on different floors or even in different buildings in the same facility, it behooves groups to find solutions like those that BCH has admirably implemented to take care of their sickest NORA patients. At the same time, we must also interpret STAT calls from all perioperative team members with the same level of urgency. If nothing else, when your offsite colleague calls, run! DISCLOSURES Name: Adam C. Adler, MS, MD, FAAP, FASE. Contribution: This author helped prepare the manuscript. Name: Arvind Chandrakantan, MD, MBA, FAAP, FASA. Contribution: This author helped prepare the manuscript. This manuscript was handled by: Richard C. Prielipp, MD.