SCOPE OF ANESTHESIA MILLER .PRESENTATION

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1. 1 SCOPE OF ANESTHESIA PRACTICE Ronald D. Miller, Tula Gourdin

2. INTRODUCTION 1. When did the specialty of anesthesiology become recognized?

3. In the early 19th century , the concept of providing analgesia and eventually anesthesia became increasingly possible.

4. 2. Initially, how was anesthesia primarily used and how did it evolve?

5. The major emphasis was initially on surgical anesthesia, which evolved into airway management including endotracheal intubation, which led to the development of critical care medicine, regional anesthesia, and pain medicine.

6. 3. Name the two medical organizations whose approval allowed anesthesia to be recognized as a medical specialty.

7. The two organizations whose approval allowed anesthesia to be recognized as a medical specialty are: American Medical Association American Board of Medical Specialties

8. ANESTHESIOLOGY AS A SPECIALTY 4. Besides monitoring and maintenance of normal physiology during the perioperative period, what are some of the areas that define the practice of anesthesia?

9. The American Board of Anesthesiology defines anesthesiology as a discipline within the practice of medicine that deals with: Assessment of, consultation for, and preparation of patients for anesthesia. Relief and prevention of pain during and following surgical, obstetric, therapeutic, and diagnostic procedures. Monitoring and maintenance of normal physiology during the perioperative period. Management of critically ill patients. Diagnosis and treatment of acute, chronic, and cancer-related pain. Clinical management and teaching of cardiac and pulmonary resuscitation. Evaluation of respiratory function and application of respiratory therapy. Conduct of clinical, translational, and basic science research. Supervision, teaching, and evaluation of performance of both medical and paramedical personnel involved in perioperative care. Administrative involvement in health care facilities and organizations, and medical schools necessary to implement these responsibilities.

10. 8. Describe an open versus a closed critical care unit.

11. Regarding critical care units, usually a “closed” system means that full-time critical care physicians take care of the patients . An “open” system means that the patient’s attending physician continues to provide the care in the intensive care unit (ICU).

12. PERIOPERATIVE PATIENT CARE 11. What services are included in perioperative care?

13. Perioperative care includes: Preoperative evaluation, Preparation in the immediate preoperative period, Intraoperative care, Post-anesthesia care unit (PACU), Acute postoperative pain management, and possibly the ICU.

14. 12. What was the impetus behind the creation of preoperative clinics and who generally manages these?

15. Initially preoperative clinics were formed when patients were no longer admitted to the hospital the day before surgery. Also the increased complexity of patient medical risks and surgical procedures prompted the creation of preoperative clinics that allowed patients to be evaluated before the day of surgery. These clinics should be multidisciplinary and lead by anesthesia .

16. 13. Describe the standard perioperative pathway.

17. The perioperative pathway includes: Preoperative evaluation, The accuracy of predicting length and complexity of surgical care, Patient flow in and out of PACUs.

18. 14. What is throughput?

19. Throughput is the term used to describe the efficiency of each patient’s perioperative experience . This can be influenced by the folloing factors: Operating room availability, Length of surgery scheduling times, Availability of beds in the PACU Other issues. At some institutions perioperative or operating room directors are appointed to manage this perioperative process.

20. TRAINING AND CERTIFICATION IN ANESTHESIOLOGY 15. What subspecialties are studied in the clinical anesthesia postgraduate training years (years 1 to 3)?

21. All aspects of clinical anesthesia are covered in postgraduate training for anesthesia, including: Obstetric, Pediatric, Cardiothoracic, Neuroanesthesia , Anesthesia for outpatient surgery, Recovery room care, Regional anesthesia Pain management, Critical care medicine

22. 22. Continuous quality improvement (CQI) programs may focus on both critical incidents and sentinel events. Describe critical incidents versus sentinel events.

23. Critical incidents (e.g., ventilator disconnection) are events that cause or have the potential to cause injury if not noticed and corrected in a timely manner. Measurement of the occurrence rate of important critical incidents may serve as a substitute for rare outcomes in anesthesia and lead to improvement in patient safety. Sentinel events are isolated events that may indicate a systematic problem

24. 23. What are some of the key factors in preventing patient injuries related to anesthesia?

25. Some key factors for the prevention of patient injury in anesthesia are: vigilance, up-to-date knowledge, and adequate monitoring

26. ORGANIZATIONS WITH EMPHASIS ON ANESTHESIA AND SAFETY 25. Anesthesia has the distinction of being the only specialty in medicine with a foundation dedicated to issues of safety in patient care. Name the foundation.

27. The Anesthesia Patient Safety Foundation (APSF) is dedicated to patient safety issues and has a quarterly newsletter that provides discussion on this topic.

28. 27. Which organization investigates legal cases as a vehicle for identifying patient and practice areas of risk?

29. The American Society of Anesthesiology Closed Claims Project is a retrospective analysis of legal cases with adverse outcomes. Its investigations have helped identify patient and practice risk areas that tend to have difficulties and require added attention with regard to quality and safety.

30. PROFESSIONAL LIABILITY 29. This chapter states that 93 claims were filed in the United Kingdom in the years 1995 to 2007. What two areas of patient care and safety did these claims emphasize?

31. The majority of the 93 claims in the United Kingdom from 1995-2007 involved drug administration errors with muscle relaxants being the most common issue . The second area involved being awake and paralyzed .

32. 30. What is the anesthesiologist’s best protection against medicolegal action?

33. Besides continuing medical education, the anesthesiologist should be thoroughly knowledgeable of the patient’s condition and care. This includes preoperative and postoperative visits, as well as detailed records of the course of anesthesia.

34. 31. What actions should the anesthesiologist take in the event of an accident?

35. The anesthesiologist should promptly document the facts on the patient’s medical record and immediately notify the appropriate agencies, particularly one’s own medical center administration and legal office. In addition, the anesthesiologist should provide the hospital and the company that writes the physician’s professional liability insurance with a complete account of the incident.

36. RISKS OF ANESTHESIA 32. What is the estimated mortality rate from anesthesia?

37. Currently, it is estimated that the mortality rate from anesthesia is approximately 1 in 250,000 patients.

38. 33. What are some of the factors that have contributed to the decrease in anesthesia related deaths?

39. The increased safety of anesthesia is presumed to reflect from: Introduction of improved anesthesia drugs and monitoring, Improved training of anesthesiologists. Motivating patients to stop smoking, lose weight, avoid excess intake of alcohol, and achieve optimal medical control of essential hypertension, diabetes mellitus, and asthma before undergoing elective surgery has led to a decrease in anesthesia-related deaths.

40. 34. What is the anesthesiologist’s greatest anesthesia patient safety issue?

41. Difficult airway management is perceived to be the greatest anesthesia patient safety issue. Other examples of possible adverse outcomes besides death include: Peripheral nerve damage, Brain damage, Airway trauma, Intraoperative awareness eye injury, Fetal/newborn injury, Aspiration of gastric contents

42. 35. Vigilance accounts for a large proportion of avoidance of adverse anesthesia events. What are some of the factors in the operating room environment that diminish the anesthesiologist’s ability to perform the task of vigilance?

43. Factors that diminish the anesthesiologist’s vigilance: Sleep loss and fatigue with known detrimental effects on work efficiency and cognitive tasks (monitoring, clinical decision making).

44. HAZARDS OF WORKING IN THE OPERATING ROOM 36. Name some of the most prevalent hazards encountered in the operating room?

45. Anesthesiologists are exposed to vapors from chemicals, ionizing radiation, and infectious agents. There is psychological stress from demands of the constant vigilance required for patients under anesthesia. In addition, interactions with members of the operating team may introduce varying levels of interpersonal stress. Other hazards include latex sensitivity from exposure to latex gloves, substance abuse, mental illness and suicide, and infection control.

46. SUMMARY AND FUTURE OUTLOOK 37. Anesthesiology is constantly evolving and changing. Describe some of the changes the specialty has undergone and the direction it is moving toward.

47. Responsibilities of the anesthesiologist have grown in magnitude, scope, and depth. Anesthesia has become a leading specialty with regard to inpatient medicine, especially in the perioperative period including critical care and pain medicine. The specialty will become more valuable to medicine overall by attempting to anticipate future societal needs and continuing to dedicate its members to the pursuit of excellence.

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