A Proposed Method for the Measurement of Anesthetist Care Variability Paul 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 Variability Paul 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 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

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: … 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

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?