A Proposed Method for the Measurement of Anesthetist Care Variability Paul King.
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Transcript of A Proposed Method for the Measurement of Anesthetist Care Variability Paul King.
A Proposed Method for the Measurement of Anesthetist Care VariabilityPaul King
Definitions:
• Anesthesiology = the practice of medicine dedicated to the relief of pain and total care of the surgical patient during and after surgery.
• Anesthesiologist = MD trained (4+4+4)
• Anesthetist = MD, CRNA (4+3), …
Statistics
• 40 Million + anesthetics/year USA
• 90% by MD Anesthesiologists
Role of Anesthesiologist
• Perioperative care =
• Preop evaluation
• Intraoperative care
• Postoperative care
Intraoperative Role:
• Provide continuous medical assessment
• Monitor & control vital life functions
• Control Pain & level of consciousness
• safe surgery
Intraoperative Role Reworded:
• NO Pain
• NO Memory/Consciousness
• NO Movement
A Proposed Method for the Measurement of Anesthetist Care VariabilityPaul King
Who/Where
• Paul King, PhD, PE. Bme/me/anesth.
• Don Pierce MD, PhD. Anesth. HPS & Pre. OP
• Mike Higgins MD Anesth., Peri. OP
• Charles Beattie PhD, MD Chairman, $
• Russ Waitman, MS PhD candidate, data mining
• … all at Vanderbilt
What? When?
• A Proposed Method (demo/technique) for the Measurement of Anesthetist (resident anesthesiologist– novice to final, faculty, CRNA, others)
Care Variability ( controllability)
• Testing done at VU, ~ 1 year ago, to be published (JOCM).
Why?
• To Err Is Human: Building a Safer Health System (2000) – National Academy Press (anesthetic only)
• ~1 death/2-300,000 v 2/10,000 (80’s) pg 32.
• Human error ~82% of preventable pg 53.
• 72 year lifespan = ~ 1 death/630,720 hours.
How 2/10,000 1/(2-300,000)?
• Technological changes (new dev, std.)
• Guidelines & strategies
• Use of human factors, including simulators
• APSF
• Leaders (Pierce, Cooper, Schwid, …)
Why?
• U. S. Anesthesiologists are ~ 100% certain of at least one major lawsuit during their careers…
Maintain?
• Continue the above…
• Increase/improve training (MD v CRNA).
• Morbidity/Mortality conferences.
• Periodic Reviews of cases & records.
• Test. Test for competency. Test safely. Test in an unbiased fashion. Test.
Hypotheses
• A challenging protocol may be developed using a simulator that tests anesthetists' skills at maintaining patient homeostasis within limits, and
• An analytical technique may be demonstrated that will suggest that "skill level" may be inferred from the data collected from the simulator.
Method: METI Simulator
Method: METI Simulator
Why a simulator?
• Standardization of “cases.”
• Standardization of “patient.”
• Data collection q 5 sec, not circa 5 min. (20+ variables, important HR, BP, pOx)
• Other (biased?) modalities possible – observation, taping, etc.
• Safe, not sorry.
Simulation Method
• Inform examinee who the patient is (Stan, normal young male)
• Operation type: low anterior bowel resection
• SOP please …
• Inform re stage of surgery…
• Start!
And we are off…
The protocol (“Stable Anesthesia”)
• Induction Intubation (epi) Maintenance
Incision (epi) Fluid loss (~ 3L)
Maintenance Ischemia & Desaturation ( & lung changes)
Maintenance Emergence
Extubation ( adequacy)
This Scenario was designed to discriminate between subjects at different levels of anesthesia training• Events range from minor to severe
• Events and responses (drug & gas admin.) are recorded real time
• Maintenance periods for reality
• Instructor available for simple requests only, but does forewarn per real OR
Data Analysis Criteria
• Blood pressure wrt preop. +/- 20%• +/- 20% hypertensive/hypotensive cardiac/renal
disorders.
• HR wrt preop.+/- 20%• Probably need to set +60%/-30%, give me a reference?
• pOx wrt preop. +/- 5%
• Based upon thoughts about significant changes…
Literature re limits & analysis?
• Reich, et al, “Validation of an Algorithm for Assessing Intraoperative Mean Arterial Pressure Lability” Anesthesiology 87:156-161
• … rolling 2 min map values exceeding +/-6% swing
Analysis Method
• Fractional time out of range (King)• +/- 20% BP
• +/- 20% HR
• +/- 5% pOx
Subjects
• First year new student – “novice”
• Second year - “PGY2”
• Graduate/Faculty – “PGA”
• All physician data from outpatient clinic, cases > ~60 samples, 1543 cases
Results: Fraction out of range – Heart Rate
• Simulator: PGA .310
• Simulator: PGY2 .328
• Simulator: Novice .685
• Outpatient data set: .311
Results: Fraction out of range – Systolic Blood Pressure
• Simulator: PGA .036
• Simulator: PGY2 .145
• Simulator: Novice .236
• Outpatient data set: .318
Results: Fraction out of range – Diastolic Blood Pressure
• Simulator: PGA .131
• Simulator: PGY2 .224
• Simulator: Novice .236
• Outpatient data set: .642
Results: Fraction out of range – Pulse Oximeter Data
• Simulator: PGA .158
• Simulator: PGY2 .197
• Simulator: Novice .170
• Outpatient data set: .081
PGA Data
0
50
100
150
2000:
00
0:02
0:04
0:05
0:07
0:09
0:11
0:13
0:15
0:16
0:18
0:20
0:22
0:24
0:26
Time (Minutes)
BP
, H
R,
SaO
2
HR
SBP
DBP
SaO2
PGY2 Data
0
50
100
150
2000:
00
0:02
0:04
0:06
0:07
0:09
0:11
0:13
0:15
0:17
0:19
0:21
0:23
0:25
0:27
Time (Minutes)
BP
, H
R,
SaO
2
HR
SBP
DBP
SaO2
Novice Data
0
50
100
150
2000:
00
0:01
0:03
0:05
0:07
0:09
0:11
0:12
0:14
0:16
0:18
0:20
0:22
0:23
0:25
Time (Minutes)
BP
, H
R,
SaO
2
HR
SBP
DBP
SaO2
Conclusion
• The human patient simulator may be used as a testing device to do inter-individual comparison of anesthetist response to simulated stresses during anesthetic procedures.
• A simple measure of competency of intervention may be derived by a “time out of range” measure as discussed here.
Thank you for your attention, from Dr. King & patient…Questions?