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43The Royal College of Anaesthetists nRaising the Standard: a compendium of audit recipes

Section 2: Intraoperative care

Availability and accuracy of operating lists

Pre-anaesthesia equipment checks

Adequacy and location of advanced airwaymanagement equipment

Anaesthetic records

Monitoring

Management of diabetes mellitus

Perioperative temperature management

Awareness and general anaesthesia

Safe red cell transfusion

Blood conservation strategies

Breathing system failures

2.1

2.2

2.3

2.4

2.5

2.6

2.7

2.8

2.9

2.10

2.11

Edited byDr Alex MacLeod


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44

2 Intraoperative care

The Royal College of Anaesthetists nRaising the Standard: a compendium of audit recipes

2.1

Availability and accuracy of

operating listsDr A F Naylor, Dr L Anderson

Why do this

audit?

Best practice:

research evidence

or authoritative

opinion

Suggested

indicators

Proper and safe patient care may be compromised if operating lists are published verylate.1 If the patient is in hospital on the previous day, the anaesthetist should have accessto the list, including its proposed order, in good time so that the patient may be visited andarrangements made for preoperative care. This may include requesting food/fluids be givento patients scheduled for surgery later on the list, organising diabetic care, organising additionalpreoperative tests or arranging availability of specific equipment.

Anaesthetic time may be wasted trying to find the list and its order, and patients may notreceive appropriate care.

The operating list must be accurate. The patients full name, hospital number and date of birthshould be included, as should the proposed procedure (including the side to be operated onwhere appropriate) abbreviations should be avoided. Date and start time should also benoted as should the names of the operating surgeon and anaesthetist.

Errors on the list may lead to delays in theatre, e.g. theatre may require a different setof sterilised equipment for a procedure which differs from that stated on the list. Moreimportantly, there are significant implications both for the patient and medico-legally where aprocedure is performed inappropriately or on the wrong limb or organ.

A number of reports suggest that early communication is the key to optimal preparation of thepatient and provision of appropriately skilled and experienced anaesthetists for the list.17

The medical defence societies, in conjunction with the nursing profession, have producedrecommendations to reduce the risk of errors in operating theatres;8 incorrect details onoperating lists increase the risk of such errors.

% lists where the list was published by 1600 h on the previous day or 0800 h the same day forafternoon lists. Different deadlines may be chosen.

% lists where changes were made to the published list. Genuine emergencies are excluded although irritating, this may be unavoidable.

% difficult cases notified to the anaesthetist at least 7 days prior to surgery. This includesplanned ITU admissions or cases requiring special skills (such as fibreoptic intubation or wherea history of anaesthetic complications exists, e.g. malignant hyperpyrexia). However, this is onlypossible if the surgical team are aware of likely difficulties

% lists where errors have been made in patient details or proposed procedure.

% patients cancelled due to immediate preoperative reassessment by surgeon different fromthe one that listed them.


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2

45

2.1


Intraoperative care

Suggested data to

be collected

Common reasons

for failure to

reach standards

References

All lists or those from a suspected problem specialty should be audited over a period of 13months.

The theatre administrator may be asked to record the time the list was received and anychanges that were made after receiving it.

The anaesthetist may be asked what time he/she looked for and found the list and whetherthey made changes to it and why, and whether problem cases were previously discussed andwhen.

Theatre staff may be asked to verify the accuracy of the published list with the regard to

complete and accurate details on patient identification, proposed procedure, correct side stated,correct date and time.

The anaesthetist, the Operating Department Assistant (ODA) and theatre staff may be askedwhat problems arose from late changes.

Junior medical staff disorganised or too busy.

Non-availability of beds or urgent cases requiring last-minute changes.

1 Buck N, Devlin HB, Lunn JN. A confidential enquiry into perioperative deaths. Nuffield Provincial

Hospitals Trust, London 1987.

2 The use of operating theatres in the National Health Service (HC 143). National Audit Office, London1987.

3 The use of operating theatres in the National Health Service. Committee of Public Accounts, London50th Report, 14 November 1988.

4 Campling EA, Devlin HB, Lunn JN. The report of the National Confidential Enquiry into Perioperative

Deaths 1990. NCEPOD, London 1990 (see: http://www.ncepod.org.uk/).

5 Campling EA et al. The report of the National Confidential Enquiry into Perioperative Deaths

1991/1992. NCEPOD, London 1993 (see: http://www.ncepod.org.uk/).

6 Campling EA et al. The report of the National Confidential Enquiry into Perioperative Deaths1993/1994. NCEPOD, London 1996 (see: http://www.ncepod.org.uk/).

7 Gray AJG et al. The report of the National Confidential Enquiry into Perioperative Deaths 1996/7.NCEPOD, London 1998 (see: http://www.ncepod.org.uk/).

8 The National Association of Theatre Nurses. Safeguards for invasive procedures: The managementof risks. NATN, Harrogate 1998.

Proposed

standard or target

for best practice

100% of elective operating lists should be available as above.

0% lists should be changed after the time chosen as the deadline.

100% of problem cases should be notified to the anaesthetic department at least 7 days priorto surgery.

100% of lists should be accurate with complete patient and procedure details.

0% patients should be cancelled due to immediate preoperative reassessment by differentsurgeon.


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Suggested data to

be collected

As above

Grade of anaesthetist.

The auditor would need to observe checks being made.

46



Pre-anaesthesia equipment checksDr J Mackay

Why do this

audit?

Best practice:

research evidence

or authoritative

opinion

Suggested

indicators

Proposed

standard or target

for best practice

2.2

A correctly functioning anaesthetic machine is vital for safe anaesthesia. New anaestheticmachines are becoming more sophisticated and many have self-testing programmes. It is theduty of the anaesthetist to ensure that anaesthetic equipment in the anaesthetic room andthe operating theatre is working properly before starting an operating list.1 Failure to do somay result in a critical incident. Equipment failure may be responsible for up to 10% of criticalincidents.2 Evidence exists that faults on machines are not always detected even if checks areperformed.3,4

The Association of Anaesthetists has published guidelines for checking anaesthetic machines.1This document includes a new procedure for checking patency of single use filters, angle piecesand catheter mounts which may be specifically included in this audit.5

Existence of a locally agreed list of recommended checks which reflects national publishedstandards and is situated adjacent to all anaesthetic machines

% anaesthetists who know how to perform an adequate check of equipment.

% lists at which a check of the anaesthetic equipment by the anaesthetist is made prior to thefirst case.

% lists at which an adequate check is made in the opinion of the auditor.

Evidence of documentation of checks.

100% of anaesthetic machines should have check-list immediately available.

100% anaesthetists should be able to perform adequate checks.

100% of lists a check of anaesthetic equipment should be made and documented appropriately.

At 100% of lists an adequate check should be made in the opinion of the auditor.


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2

47

2.2


Intraoperative care

Common reasons

for failure to

reach standards

References

Lack of communication between anaesthetists when more than one anaesthetist is covering alist.

Checks not regarded as important.

Inadequate resources for supervision of checking process in trainees.

Inappropriate delegation of equipment checking.

1 Association of Anaesthetists of Great Britain and Ireland. Checking anaesthetic equipment 3. AAGBI,

London January 2004 (see: www.aagbi.org/pdf/Check_Anae_Equip.pdf).

2 Webb RK et al. The Australian incident monitoring study. An analysis of 2000 incident reports.

Anaesthesia and Intensive Care 1993;21:520528.

3 March MG, Crowley JJ. An evaluation of anesthesiologists; present checkout method and validity ofFDA checklist. Anesthesiology1991;75:724729.

4 Kimmer M, Lake AP, Wrav I. Covers for anaesthetic machines: an audit and standard.

Euro J Anaesthesiology1997;14:505513.

5 Department of Health. Protecting the breathing circuit in anaesthesia. Report to the Chief

Medical Officer. DH, London May 2004 (see: www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4081825&chk=rFCDhz).


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Proposed

standard or target

for best practice

A named consultant should be responsible for the AA set.

100% of areas where anaesthesia is administered should have AA set immediately available.

100% AA sets should include a list of contents and an algorithm flow chart of advanced airwaymanagement.

100% AA sets should include evidence of regular maintenance.

100% of anaesthetists should be familiar with the location and contents of the AA set.

100% anaesthetists should have had training in the use of the equipment in the AA set.

48



2.3

Adequacy and location of advanced

airway management equipmentDr B E McGuire

Why do this

audit?

Best practice:

research evidence

or authoritative

opinion

Suggested

indicators

Difficulty or failure in airway management is a significant factor in much anaesthesia-relatedmorbidity and mortality.1,2 Rapid access to advanced airway equipment is essential for theprovision of safe anaesthesia.

Knowledge among UK anaesthetists of the location and contents of the advanced airway set ispoor.3

Excluding routine airway equipment, the advanced airway set should include equipment for themanagement of both the anticipated and the unanticipated difficult airway (the latter equipmentmust be immediately available).

Stipulation of the ideal contents of the Advanced Airway (AA) equipment set is very difficultas evidence is limited, but certain principles of advanced airway management are generally heldin the UK and elsewhere in the world.46 There has been no attempt to recommend specificadvanced airway equipment in this document, but there may be need to do so in the future ifthere is more consensus on best practice.

The Difficult Airway Society has published guidelines for the management of the unanticipateddifficult intubation6 and has a list of recommended airway equipment available on its website. 7

Existence of a named consultant responsible for the AA set.

Immediate availability of an AA set in all areas where anaesthesia is administered.

Each AA set includes a list of contents and an algorithm flow chart of advanced airwaymanagement.

There is documentation of regular maintenance and stocking of each AA set.

Existence of training in the use of the equipment in the AA set.

% anaesthetists familiar with the location and contents of the AA set.% anaesthetists with formal training in use of AA set.


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49

2.3


Intraoperative care

Suggested data to

be collected

Common reasons

for failure to

reach standards

References

As above.

Inadequate awareness of advanced airway management issues or a lack of agreement as towhich equipment and techniques represent best practice.

Inadequate documentation accompanying AA sets.Lack of a leader to take responsibility for the provision, maintenance and education of advancedairway equipment/techniques.

Resource limitation or lack of prioritisation with regards to the purchase of advanced airwayequipment.

Lack of facilities for training in advanced airways management.

Some locations may be forgotten, especially isolated ones. Consider A&E, X-ray, and obstetrics.

1 Gannon K. Mortality associated with anaesthesia. A case review study. Anaesthesia 1991;46:962

966.

2 Domino KB et al. Airway injury during anaesthesia: a closed claims analysis. Anesthesiology

1999;91:17031711.

3 Green L. Cant intubate, cant ventilate! Can you do it? Manual from annual meeting of the DifficultAirway Society, Lille November 2005. DAS, London 2005: pp 71.

4 American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practiceguidelines for the management of the difficult airway. Anesthesiology1993;78:597602.

5 Crosby ET et al. The unanticipated difficult airway with recommendations for management. Can JAnaesth 1998;45:757776.

6 Henderson JJ et al. Difficult Airway Society guidelines for the management of the unanticipated

difficult intubation. Anaesthesia 2004;59:675684.

7 Difficult Airway Society. Recommended equipment list for the management of the unanticipated

difficult intubation. DAS, London July 2005 (see: www.das.uk.com/DASequipmentJuly2005.doc).


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Proposed

standard or target

for best practice

There are two areas to consider: structure and content of the anaesthetic record and adequacyof data entry on the anaesthetic record.

100% anaesthetic records used within the hospital/trust/health board or strategic healthauthority area provide space to record the data listed in the minimum data set.

The standard for completion will depend on the form being used and on the complexity of thecase. A minimum acceptable data set should be prepared locally in consultation with colleaguesin relation to case type. A suggested minimum data set is given below.

50



Anaesthetic recordsDr I Quasim

Why do this

audit?

Best practice:

research evidence

or authoritative

opinion

Suggested

indicators

The anaesthetic record provides several important functions: a record of preoperativeinformation about clinical and laboratory findings; discussion of techniques/risks of anaesthesia; 1record of completion of equipment checking; documentation of drug/fluid therapy givenduring the anaesthetic; and record of relevant physiological variables. The anaesthetic recordshould also provide information about the postoperative management of the patient. It is alsoimportant that any untoward event, which may have a bearing on future anaesthetics, is clearlydocumented.

An accurate anaesthetic record enables the patient to receive effective continuing care, enablesthe healthcare team to communicate effectively, allows another doctor or professional memberof staff to assume care of the patient at any time, and enables the patient to be identifiedwithout risk or error.

The record is also useful retrospectively for a future anaesthetist to establish events or for usein medico-legal defence.

A recommended data set was published by the Royal College of Anaesthetists (RCoA) in2002.2 NHS Quality Improvement Scotland assessed hospital performance using clinicalstandards for anaesthesia including complying with the RCoA minimum data set. 3 At presentvery few anaesthetic records comply with all the RCoA recommendations.

% Anaesthetic records:

n containing RCoA recommended data set

n containing locally agreed minimum data set

n signed by the anaesthetist

n for trainee anaesthetists and non-consultant career grade anaesthetists name of supervisingconsultant3,4

n assessed as complete

n legible.

2.4


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51

2.4


Intraoperative care

Suggested data to

be collected

Common reasons

for failure to

reach standards

References

Ten cases per anaesthetist should be reviewed, chosen to cover all areas of practice.

A suggested minimum data set is:

n Patient identification, date, operation, names of surgeon(s) and anaesthetist(s), including anamed consultant, documentation of preoperative visit and relevant findings,pre-medication, cannulation, equipment and monitoring used including completion of AAGBIequipment check, drugs and fluids administered, record of relevant physiological variables,postoperative instructions including analgesia, anti-emetics, fluid and oxygen therapy. There

should also be space available for documenting adverse events/critical incidents and consentto anaesthetic procedures.

The record should be assessed as adequate, inadequate or cause for concern according to thestandards above.

Record has not been updated to take account of recent standards.

Recommended RCoA data set contains a large amount of information to be recorded whichcan be difficult during short routine cases or when there is a lack of assistance with paperworkduring theatre.

1 Association of Anaesthetists of Great Britain and Ireland. Consent for anaesthesia. Revised edition.

AAGBI, London 2006 (see: www.aagbi.org/pdf/Consent.pdf).

2 Royal College of Anaesthetists and Association of Anaesthetists of Great Britain and Ireland. Goodpractice: a guide for departments of anaesthesia. RCoA/AAGBI, London 2002 (see: www.rcoa.ac.uk/

docs/goodpractice(july02).pdf).

3 NHS Quality Improvement Scotland, Anaesthesia Project Group. Anaesthesia Care before, during

and after anaesthesia. NHS QIS, Edinburgh July 2003 (see: www.nhshealthquality.org/nhsqis/files/Anaesthesia.pdf).

4 Chambers WA. Message from the Honorary Secretary: The named consultant.Anaesthesia News.2004;209:16.


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Suggested data to

be collected

Anaesthetist, theatre, list, time of day, anaesthetic technique (e.g. regional or general anaesthetic,ventilated or spontaneously breathing), monitoring used.

Monitors immediately available, monitors available elsewhere.

Reason for not monitoring. Details of any critical incident that occurred.

Where a new type of monitor is being introduced there is an opportunity to monitor criticalincidents before and after the introduction of the monitor.

52



MonitoringDr J Fielden , Dr J Rechner

Why do this

audit?

Best practice:

research evidence

or authoritative

opinion

Suggested

indicators

Proposedstandard or target

for best practice

Many international bodies now recommend minimum standards of monitoring for anaesthesiaaiming to reduce critical incidents and patient harm.13 This is backed by studies showing thehigh contribution of human error to these events,2 and the inability to detect some problemsclinically without significant delay.1,4 As a risk management issue, it is important to meet thesestandards and show that the cost and effort of monitoring is justified by reduced frequencyof critical incidents and patient morbidity.5 There is also some evidence that inappropriatemonitoring may cause harm and thus it needs to be applied appropriately. 5

Minimum standards of monitoring for anaesthesia have been described in the UK by theAssociation of Anaesthetists of Great Britain and Ireland (AAGBI).2 They state that thefollowing are essential to the safe conduct of anaesthesia: pulse oximeter, non-invasive bloodpressure monitor, electrocardiograph and capnograph. There is evidence to suggest that useof non-invasive blood pressure, ECG, pulse oximetry and clinical observation will detect 90%of all critical incidents.4 Capnography must be available in all locations where anaesthesia isadministered and used in all instances of tracheal intubation.2,6

Guidelines for sedation suggest a lower standard of monitoring may be appropriate for casessolely receiving sedation and/or local anaesthesia.7,8

Using the AAGBI minimum monitoring standards:2

n % patients adequately monitored prior to and during induction

n % patients adequately monitored during anaesthesia

n % patients adequately monitored in recovery.

In the absence of absolute standards of frequency for intermittent monitoring, for example ofnon-invasive blood pressure, consideration should be given to defining targets for specific clinicalsituations in advance of data collection.

100% of patients should receive minimum standards of monitoring prior to and during inductionof anaesthesia, through the anaesthetic and in the recovery area. This may include locally settargets for frequency of intermittent measurements.

2.5


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53

2.5


Intraoperative care

References 1 Winter A, Spence AA. An international consensus on monitoring? Br J Anaesth, 1989;64:263266.

2 Association of Anaesthetists of Great Britain and Ireland. Recommendations for standards ofmonitoring during anaesthesia and recovery 3. AAGBI, London 2000 (see: www.aagbi.org/pdf/Absolute.pdf).

3 Kluger MT, Bullock MFM. Recovery room incidents: a review of 419 reports from the Anaesthetic

Incident Monitoring Study (AIMS). Anaesthesia 2002;57:10601066.

4 Findlay GP, Spittal MJ, Radcliffe JJ. The recognition of critical incidents: quantification of monitoring

effectiveness. Anaesthesia 1998;53:595598.

5 Saunders DA. On the dangers of monitoring. Or primum non nocere revisited. Anaesthesia,1997;52:399400.

6 Royal College of Anaesthetists. Guidance on the provision of anaesthetic services for intra-operativecare. RCoA, London 2004 (see: www.rcoa.ac.uk/docs/GPAS-Intra.pdf).

7 Academy of Medical Royal Colleges. Implementing and ensuring safe sedation practice in adults.

AoMRC, London November 2001 (see: www.rcoa.ac.uk/docs/safesedationpractice.pdf).8 Royal College of Anaesthetists and Royal College of Ophthalmologists. Local anaesthesia for

intraocular surgery. RCoA/RCOphth, London July 2001 (see www.rcoa.ac.uk/docs/rcarcoguidelines.pdf).

Common reasons

for failure to

reach standards

Lack of perceived benefit.

Monitors not immediately available or not working.

Monitors not available.


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54



Management of diabetes mellitusDr D Lomax

Why do this

audit?

Best practice:

research evidenceor authoritative

opinion

Suggested

indicators

Proposed

standard or target

for best practice

Diabetes mellitus is the most common endocrine disorder encountered in anaesthesia1 andcan have many adverse effects especially on the cardiovascular and renal systems. Severalfactors complicate the metabolic management of the surgical, diabetic patient. These includestarvation, the endocrine and consequent metabolic response to surgery and immobilisation.2Poor control can lead to significant morbidity and increased hospital stay.

There is no consensus as to the best way of managing diabetic patients but evidence is

accumulating that intensive glycaemic control is associated with improvement of perioperativemorbidity and mortality.3 Variables that will affect the method of management include whetherthe patient is insulin dependent or not, the level of control preoperatively and the extent of thesurgery. For those patients who require insulin perioperatively,4 methods have been described:

1 separate, variable rate, IV glucose and insulin infusions4

2 combined IV infusion of glucose and insulin5

3 IV bolus insulin6 although not recommended by some7

4 S/C bolus insulin.8

Regular measurement and correct interpretation of blood sugar levels may be more importantthan the regimen used.9

Bedside blood ketone monitoring may be useful for unstable diabetics.10

The National Institute for Health aand Clinical Excellence (NICE) recommend that perioperativepatients with type I diabetes are managed using a local protocol. 11

An up to date local protocol is routinely used to guide perioperative diabetic management.

% diabetic patients in whom efforts have been made to keep starvation time to a minimum.This would usually be by placing them first on the morning operating list.

% patients in whom the blood sugar is measured hourly for 4 h postoperatively, then 2 hourlyfor 4 h, then 4 hourly thereafter. This should be until oral food and fluid intake is resumed and

the usual diabetic treatment regimen recommenced.% patients in whom regular urinalysis for ketones is performed during this period.

% patients in whom > 90% of their blood sugar measurements fall between 5.5 mmol/l and11.1 mmol/l during this period.

100% of relevant clinical staff should be aware of and should use the local protocol.

100% patients should have:

n efforts made to keep starvation time to a minimum

n hourly blood sugar measurements as above

n regular urinalysis as above

n blood sugar control as above.

2.6


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55

2.6


Intraoperative care

Suggested data to

be collected

Common reasons

for failure to

reach standards

References

Usual diabetic treatment regimen.

Level of preoperative control.

Extent of surgery.

Position on operating list and starvation time.

Perioperative regimen used.

Frequency of blood sugar checks and urine testing.

Results of blood sugar and urine tests.

Evidence that blood-testing equipment is being properly calibrated and used correctly.

Adverse cardiovascular or renal sequelae.

List order changes and/or long starvation time.

IV not sited preoperatively when required.

Blood sugars not measured or incorrect interpretation of results.

Inaccurate measurements of blood sugars because of failure to calibrate measuring devices.

Inadequate preoperative control of diabetes.

Local regimens and guidelines not able to deal with all diabetic states encountered.

1 Raucolles-Aim M, Grimaud D. Diabetes mellitus: implications for the anaesthesiologist. Curr Opin

Anaesth 1996;9:247253.

2 McAnulty GR, Hall GM. Anaesthesia for the diabetic patient. Br J Anaesth 2003;90:428429.

3 Robertshaw HJ, McAnulty GR, Hall GM. Strategies for managing diabetic patients. Best Prac Res Cl

Anaesth 2004;18:631643.

4 Watts NB et al. Perioperative management of diabetes mellitus: steady state glucose control withbedside algorithm for insulin adjustment. Diabetes Care 1987;10:722728.

5 Alberti KGMM, Thomas DJB. The management of diabetes during surgery. Br JAnaesth 1979;51:693

710.

6 Watts LF et al. Perioperative management in diabetes mellitus. Anesthesiology1981;55:104109.

7 Hall GM. Insulin administration in diabetic patients return of the bolus? Br J Anaesth 1994;72:12.

8 Christiansen CL et al. Insulin treatment of the insulin-dependent patient undergoing minorsurgery. Continuous intravenous infusion compared with subcutaneous administration. Anaesthesia1988;43:533537.

9 Milaskiewicz RM, Hall GM. Diabetes and anaesthesia: the past decade. Br JAnaesth 1992;68:198206.

10 Mc Bride MO et al. Bedside blood ketone monitoring. Diabetic Medicine 1991;8:688690.

11 National Insititue for Clinical Excellence. Type 1 diabetes in children, young people and adults. NICE

CG15, London July 2004 Section 1.12.3.4, p67 (see: www.nice.org.uk/pdf/CG015NICEguideline.pdf).


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56



Perioperative temperature management

Dr M Harper

Why do this

audit?

Best practice:

research evidence

or authoritative

opinion

Temperature monitoring is essential during induction and maintenance of anaesthesia andshould be available during recovery from surgery.1 Both hypothermia and hyperthermia(including malignant hyperthermia) can complicate anaesthesia.

There are a number of reviews of the adverse effects of inadvertent peri-operative hypothermia(IPH) in the literature.24 Research has shown that IPH can lead to morbidity includingprolonged recovery and hospital stay,5 increased blood loss and transfusion and an increasedincidence of pressure sores,6 wound infections7 and morbid cardiac events.8 Reducing theincidence of IPH through appropriate peri-operative care can reduce the incidence of thesecomplications

In hyperthermia the margin between temperatures for normal cellular processes and celldamage from high temperature is very small compared with hypothermia. Hyperthermia can becorrected by cooling.

This audit reflects the recommendations of the NICE guideline Perioperative hypothermia(inadvertent): The management of inadvertent perioperative hypothermia in adults.9

Best practice is to prevent IPH rather than have to treat it. The NICE postoperative treatmentreview9 found that the rate of rewarming is very slow (0.21C per hour) in hypothermic patients.

Patients are at higher risk of hypothermia and its consequences if any two of the following apply:n ASA grade 25 (the risk at 5 is greater than the risk at 2)

n

pre-operative temperature below 36.0

Cn combined regional and general anaesthesia

n intermediate or major surgery

n at risk of cardiac complications

n extremes of age.

Care should be taken to ensure that patients are adequately covered on the ward and duringtransfer to the operating theatres. Unless surgery is life or limb saving, patients should beactively warmed to a temperature 36.0C or above before being anaesthetised. Otherwise,active warming should be initiated in the anaesthetic room for all procedures where the totaloperative time (from first anaesthetic intervention to arrival in recovery) is greater than 30minutes. For total operative times less than 30 minutes, only higher risk patients should be

actively warmed. All intravenous infusions of greater than 500 ml (and all blood products andirrigation fluids) should be warmed.

Care should also be taken to keep the patient warm between the end of surgery and their arrivalin the PACU as there is evidence that their temperature can fall significantly during this time.10

Body temperature is as vital a clinical sign as the pulse or blood pressure and should berecorded in the hour prior to the patient coming to theatre. It should be measured throughoutthe operation and in recovery until such time as it reaches 36.0C. It should be recorded at thesame frequency as other vital sign measurements for the first 24 postoperative hours.

NICE have recently published a guideline on the management of IPH which details appropriateperi-operative thermal management.9 Although it recommends the use of forced-air warming,there is some preliminary evidence that other forms of active warming may be equally

effective11,12 and that combining two methods can improve outcome.13

The ultimate aim is for all patients to be kept comfortably warm at all times and that theirtemperature should be measured regularly to ensure that it remains in the range of 3637.5 C.

2.7
http://www.rcoa.ac.uk/docs/ARB_2.7-appendix.dochttp://www.rcoa.ac.uk/docs/ARB_2.7-appendix.dochttp://www.rcoa.ac.uk/docs/ARB_2.7-appendix.dochttp://www.rcoa.ac.uk/docs/ARB_2.7-appendix.dochttp://www.rcoa.ac.uk/docs/ARB_2.7-appendix.doc


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1 Recommendations for standards of monitoring during anaesthesia and recovery, 3rd Edition.AAGBI London,2000 (see: www.aagbi.org/publications/guidelines/docs/standardsofmonitoring07.pdf).

2 Harper CM, Andrzejowski J, Alexander R. NICE and warm. Br J Anaesth 2008;101:293295 (see: http://bja.oxfordjournals.org/cgi/content/full/101/3/293).

3 Sessler DI. Perioperative heat balance. Anesthesiology2000;92:578596.

4 Harper CM, McNicholas T, Gowrie-Mohan S. Maintaining perioperative normothermia. BMJ 2003;326:721722.

5 Lenhardt R et al. Mild intraoperative hypothermia prolongs postanesthetic recovery. Anesthesiology

1997;87:13181323.

6 Scott EM et al. Effects of warming therapy on pressure ulcers a randomized trial. Aorn J 2001;73:921927, 929933, 936938.

7 Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-woundinfection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med1996;334:12091215.

8 Frank SM et al. Perioperative maintenance of normothermia reduces the incidence of morbid cardiacevents. A randomized clinical trial. JAMA 1997;277:11271134.

9 Perioperative hypothermia (inadvertent). NICE clinical guideline 29. National Institute for Health and ClinicalExcellence London, 2008 (see: www.nice.org.uk/CG065).

10 Holdcroft A, Hall GM. Heat loss during anaesthesia. Br J Anaesth 1978;50:157164.

11 Wadhwa A et al. new circulating-water devices warm more quickly than forced-air in volunteers.AnesthAnalg2007;105:1681.

12 Harper CM. Is a warming mattress as effective as forced-air warming in preventing peri-operativehypothermia. Anesthesiology2007;107:A92.

13 Wong PF et al. Randomized clinical trial of perioperative systemic warming in major elective abdominalsurgery. Br J Surg2007;94:421426.

2

57

2.7


Intraoperative care

Common reasons

for failure to

reach standards

References

Failure to follow NICE guidelines in terms of warming patients. This stems in particular frompatients not receiving warming from the first anaesthetic intervention to the start of surgery andfailure to monitor patients temperatures in the pre-operative period.

Suggested data to

be collected

Refer to the NICE guideline Perioperative hypothermia (inadvertent): The management ofinadvertent perioperative hypothermia in adults.9

(See also the audit data collection form for this audit)

Suggested

indicators

Proposed

standard or target

for best practice

Frequency of temperature measurement

Temperature < 36.0C at any time

Use of body and fluid warming techniques

Key outcome 1: All patients admitted to recovery should have core body temperature of

36.0C or above.

Key outcome 2: 100% patients should not be discharged from recovery until their

temperature is above 36.0C.

100% patients should have their temperature recorded in the hour prior to their arrival in theatres.

100% patients should arrive in theatres covered with 2 blankets or duvet

100% patients should be comfortably warm throughout.

100% patients scheduled for non-urgent surgery should have a core temperature of 36.0C orabove before the start of anaesthesia.

100% of at-risk patients should, where possible, have active warming from the first anaestheticintervention unless their temperature is greater than 37.5C.

100% intravenous infusions greater than 500ml and all blood products should be warmed.

100% patients receiving active warming should have their core temperature recorded everyhalf-hour during anaesthesia.

100% patients should have their temperature recorded in recovery or on the ward at samefrequency as other vital signs.

100% patients whose temperature drops below 36.0C in recovery or on the ward shouldreceive active warming until this is rectified.
http://www.rcoa.ac.uk/docs/ARB_2.7-appendix.dochttp://www.rcoa.ac.uk/docs/ARB_2.7-appendix.dochttp://www.rcoa.ac.uk/docs/ARB_2.7-appendix.dochttp://www.rcoa.ac.uk/docs/ARB_2.7-appendix.dochttp://www.rcoa.ac.uk/docs/ARB_2.7-appendix.dochttp://www.rcoa.ac.uk/docs/ARB_2.7-appendix.doc


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Awareness and general anaesthesiaDr B Walton, Dr M Kinsella

Why do this

audit?

Best practice:

research evidenceor authoritative

opinion

Suggested

indicators

Proposed

standard or target

for best practice

Patient recall of awareness during surgery is rare. However, particularly if associated withsensation of pain during surgery, it is unpleasant and potentially psychologically damaging. In theUSA awareness under anaesthesia accounted for 2% of all claims from the American Society ofAnesthesiologists Closed Claims Project.1

Using the isolated forearm technique, response to command during surgery was found in 0%

of patients anaesthetised with a volatile anaesthetic agent,

2

16% of patients having propofol-alfentanil total intravenous anaesthesia (TIVA)3 and 72% having midazolam-alfentanil TIVA.4This responsiveness is usually not remembered. As the isolated forearm technique is not usedroutinely, we depend on the patient remembering a period of intraoperative consciousness inorder to gauge the incidence.

Intraoperative awareness with recall (hereafter awareness) is usually associated with one ofthree situations:5

n light anaesthesia (either intentionally or due to drug administration error)

n increased anaesthetic requirement (e.g. drug interaction, alcoholism)

n machine malfunction or misuse resulting in inadequate delivery of anaesthetic.

The incidence of awareness depends on the structure and timing of the postoperative interviewmaking accurate incidence even more difficult to quantify.6 Two recent large studies suggestedan incidence of 0.13%6 and 0.16%7 both in a general patient population. Higher rates of recallhave been reported in major trauma (1143%),8 cardiac (11.5%)9 and obstetric anaesthesia(0.4%).10 Risk of awareness increases with increasing ASA status6 and in the presence ofneuromuscular blockade.7 While some authors have advocated that the use of an objectivecentral nervous system depth of anaesthesia monitor reduces this risk,7 evidence for this is weakand it is by no means standard practice.

% of patients having a general anaesthetic who, on postoperative questioning, complain ofdefinite intraoperative awareness or symptoms suggestive of a high probability of intraoperativeawareness.

The ideal standard is that 0% of patients undergoing general anaesthesia should have awareness.However in line with published data:

For general surgical cases:

n < 0.2% should have intraoperative awareness.

For obstetric anaesthesia:

n < 0.4% of women should have intraoperative awareness.

For cardiac anaesthesia:

n

< 1% should have intraoperative awareness.

2.8


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2.8


Intraoperative care

Common reasons

for failure to

reach standards

Related audits

References

Type of surgery and anaesthetic; use of neuromuscular blockade.

Perception of the need for a light anaesthetic.

Drug labelling error.

TIVA equipment or administration problem.

Lack of appropriate and accurate end tidal anaesthetic agent monitoring.

Inexperience of the anaesthetist.

13.14 Audit of critical incident reporting

13.15 Audit of complications of anaesthesia

1 Domino K et al. Awareness during anesthesia: a closed claims analysis. Anesthesiology1999;90:10531061.

2 Russell IF, Wang M. Absence of memory for intraoperative information during surgery under

adequate general anaesthesia. Br J Anaesth 1997;78:39.

3 Russell IF, Wang M. Absence of memory for intraoperative information during surgery with total

intravenous anaesthesia. Br J Anaesth 2001;86:196202.

4 Russell IF. Midazolam-alfentanil an anaesthetic? An investigation using the isolated forearmtechnique. Br J Anaesth 1993;70:4246.

5 Ghoneim M. Awareness during anesthesia. Anesthesiology2000;92:597602.

6 Sebel P et al. The incidence of awareness during anesthesia: a multicentre United States study.

Anesth Analg. 2004;99:833839.

7 Sandin R et al. Awareness during anaesthesia: a prospective case study. Lancet2000;355:707711.

8 Bogetz M, Katz J. Recall of surgery for major trauma. Anesthesiology1984;61:69.

9 Phillips A et al. Recall of intraoperative events after general anaesthesia and cardiopulmonary bypass.

Can J Anaesth 1993;40:922926.

10 Lyons G, Macdonald R. Awareness during caesarean section. Anaesthesia 1991;46:6264.

Suggested data to

be collected

Incidence of definite or probable awareness.

For cases where it occurred the following should be documented.

n ASA of patient and specific pre-existing patient conditions that may have influenced depthof anaesthesia, type of surgery, induction agent and dose, grade and difficulty of intubation,use of hypnotic agents, type of anaesthetic agent (inhalational or intravenous) and expiredpercentage/dose, use of N

2O, use of muscle relaxant, breathing system and fresh gas flow

used, use of syringe labelling.

n Use of an objective central nervous system depth of anaesthesia monitor (e.g. BispectralIndex (BIS) monitor).

Recommended audit frequency: continuous data collection.


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60



Safe red cell transfusionDr C Brydon

Why do this

audit?

Best practice:

research evidence

or authoritative

opinion

Suggested

indicators

Proposed

standard or target

for best practice

The decision to transfuse red cells is a complex one and depends upon multiple factors. Therisks of transfusion need to be balanced against the perceived benefits for each individualpatient.1

It is now generally accepted that we should avoid unnecessary transfusion of blood wherepossible by adopting appropriate transfusion triggers to reduce the risk to patients, conservescarce resources and avoid unnecessary expense.

In addition to the well-established risks of red cell transfusion there is now the theoretical riskof transmission of variant Creutzfeld-Jakob disease by transfusion.

The introduction of more stringent safety requirements including leucocyte depletion hasincreased the cost of producing each unit of blood.

It is recognised that the most common adverse event relating to blood transfusion is incorrectadministration of cross-matched blood.2,3

It is accepted that most people, including the critically ill will tolerate a much lower haemoglobinthan previously thought. National guidelines based on various levels of published evidencesuggest that a haemoglobin of 7 g/dl may be adopted as an acceptable transfusion triggerin most patients. In some patients in whom anaemia is poorly tolerated, e.g. the elderly orthose with cardiovascular disease, a haemoglobin of 8 g/dl may be more appropriate. It is alsoaccepted patients with a haemoglobin level > 10 g/dl should generally not receive red celltransfusion.1,4,5 On-going active bleeding may modify application of these thresholds in individualpatients.

Red cell use should be audited regularly and departmental guidelines should be drawn up jointlywith the hospital transfusion committee.2,4

Existence and use of local guidelines based on national standards including transfusionthresholds and safe procedure for administration of blood.24

% patients receiving a blood transfusion in whom the reason for transfusion is documented andthe pre-transfusion haemoglobin threshold is recorded.

% transfusions where guidelines on safe administration of blood are followed.

Any adverse events as a result of receiving red cells should be documented and reported viathe transfusion nurse specialist to the Serious Hazards of Transfusion group. 3

100% patients given blood transfusion have transfusion threshold documented.

100% patients with Hb > 7 g/dl given red cells have reason documented.

0% patients with Hb >10 g/dl receive red cell transfusion unless reasons documented.

100% transfusions should demonstrate evidence to support safe administration of blood.

2.9


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2.9


Intraoperative care

Suggested data to

be collected

Common reasons

for failure toreach standards

References

This audit should be carried out jointly with the Haematology department and transfusion nursespecialist. They should be able to provide the information regarding which patients receivedred cells during their hospital stay.

For each patient who received red cells:

n type of operation

n elective or emergency procedure

n preop Hb and its timing

n postop and discharge Hb

n time to discharge

n evidence of safe procedure in administration

n documentation of transfusion including the indication and pretransfusion Hb in the patientsnotes

n any adverse events.

Variations between clinicians may be due to differences in surgical and anaesthetic techniquesor case mix or differences in awareness and use of national standards.

Staff may be unaware of the national guidelines.

Lack of education or training in transfusion.

1 British Committee for Standards in Haematology (BCSH). Guidelines for the clinical use of red cell

transfusions. Br J Haematol 2001;113:2431.

2 NHS Quality Improvement Scotland, Anaesthesia Project Group. Anaesthesia Care before, during

and after anaesthesia. NHS QIS, Edinburgh July 2003 (see: www.nhshealthquality.org/nhsqis/files/Anaesthesia.pdf).

3 National comparative audit of blood transfusion. National Blood Service July 2005 (see: www.blood.co.uk/hospitals/services/ClinAud/comp_aud_05/NATION~0.pdf).

4 Scottish Intercollegiate Guidelines Network. Perioperative blood transfusion for elective surgery:a national clinical guideline (SIGN Guideline No. 54). SIGN, Edinburgh October 2001 (updated

September 2004) (see: www.sign.ac.uk/guidelines/fulltext/54/index.html).

5 Association of Anaesthetists of Great Britain and Ireland. Blood transfusion and the anaesthetist. Redcell transfusion. AAGBI, London September 2001 (see: www.aagbi.org/pdf/blood_tran.pdf).

Related audits 1.10 Preoperative cross-matching of blood

2.10 Blood conservation strategies


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Blood conservation strategiesDr C Brydon

Why do this

audit?

Best practice:

research evidence

or authoritative

opinion

Suggested

indicators

Proposed

standard or target

for best practice

There are well-documented risks and hazards of transfusion which should be minimised byreducing where possible the use of allogeneic blood.1

In addition, recent thinking has emphasised the safety of lower haemoglobin levels and the valueof identifying individual patient thresholds thus shifting considerably the risk benefit balance ofintraoperative red cell transfusion.1,2 (See also audit 2.9).

Blood is a scarce and expensive resource, likely to become even more so due to the

restrictions on the donor population and increasing demand. A high proportion, approximately50%, of all red cell transfusions are given to surgical patients.

The use of a protocol based system such as a maximum surgical blood ordering schedule(MSBOS) for ordering blood prior to elective surgery increases efficiency.

Options to conserve blood stocks and reduce allogeneic red cell transfusions include:14

n use of a maximum surgical blood ordering schedule (MSBOS)

n preoperative assessment and optimisation of haemoglobin with iron therapy or EPO ifrequired 46 weeks prior to surgery

n accepting lower transfusion trigger

n preoperative autologous donation

n isovolaemic haemodilution

n intraoperative cell salvage

n postoperative cell salvage

n staff training and education.

Existence and use of up to date MSBOS.

% units of crossmatched blood which are transfused. This is the cross-match to transfusionratio.

% of patients who receive > 2 units of blood in whom cell salvage or other forms ofautologous transfusion are not considered and reasons for this.

Evidence of anaesthetic staff training in transfusion and its alternatives.

MSBOS is used in 100% of relevant procedures.

A cross-match to transfusion ratio at least 2:1 or better for all procedures. This means thatat least 50% of units cross-matched for elective surgery are actually transfused or reasons forvariance explored and documented. The hospital MSBOS is thus subject to continuing scrutinyand adaptation.

Use of cell salvage or other forms of autologous transfusion should be considered in 100% ofpatients where blood loss is anticipated to be at least 1000 ml.4

100% anaesthetists are trained in transfusion and blood conservation.

2.10


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63

2.10


Intraoperative care

Common reasons

for failure to

reach standards

Related audits

References

Lack of equipment.

Lack of staff training.

Lack of preoperative facilities/co-ordination to allow advance haemoglobin optimisation or pre-donation.

Inability to guarantee date for surgery.

1.10 Preoperative cross-matching of blood

2.9 Safe red cell transfusion

1 Thomas D, Thompson J, Ridler B (Eds). A manual for blood conservation. TFM PublishingMay, 2004.

2 Scottish Intercollegiate Guidelines Network. Perioperative blood transfusion for elective surgery.

A national clinical guideline (SIGN Guideline No. 54). SIGN, Edinburgh October 2001 (updatedSeptember 2004) (see: www.sign.ac.uk/guidelines/fulltext/54/index.html).

3 Royal College of Anaesthetists. The CCST in anaesthesia II: Competency based Senior House Officertraining and assessment. RCoA, London April 2003 (see: www.rcoa.ac.uk/docs/ccstptiied2.pdf).

4 British Orthopaedic Association. Blood conservation in elective orthopaedic surgery. BOA, LondonApril 2005 (see: www.boa.ac.uk/).

Suggested data to

be collected

This audit may be carried out jointly with the Haematology Department and the hospitaltransfusion nurse specialist in order to identify those surgical procedures which use two ormore units of red blood cells.

Use of cell salvage or not and reasons for this.

Evidence of any other blood conservation methods employed.

Evidence for use and appropriateness of MSBOS. This aspect should be audited frequently ormay be continuously evaluated.


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64



Breathing system failuresDr J Mackay

Why do this

audit?

Best practice:

research evidence

or authoritative

opinion

Suggested

indicators

Proposed

standard or target

for best practice

Failure of the breathing system including disconnection must be regarded as a critical incidentas hypoxia or awareness may result.1 Modern monitoring usually allows failures to be detectedbefore any harm comes to a patient. However, such failures remain an important potentialhazard to the patient and should be avoided. Reporting of recurrent faults is vital as it mayreveal a fault in equipment or lead to a change in anaesthetic practice.2 Measures may beintroduced to reduce the risk of accidental disconnections.3

All breathing system failures including disconnections are critical incidents. A means for criticalincident reporting should be up and running in all anaesthetic departments. The Royal Collegeof Anaesthetists has piloted a critical incident study.4 The use of a mandatory system forreporting adverse events, mishaps and errors was recommended by the Department of HealthinAn organisation with a memory5 and Building a safer NHS for patients.6

It is suggested that an audit is performed for one month during which the anaesthetist isrequired to confirm that there was not a disconnection or other breathing system failure duringeach case.

% cases at which a disconnection or other breathing system failure occurs.

% cases of breathing system failure with critical incident severity. The Salisbury Severity Score7can be used, as follows.

1 Transient abnormality unnoticed by patient.

2 Transient abnormality with full recovery.

3 Potentially permanent but not disabling damage.

4 Potentially permanent disabling damage.

5 Death.

% recurrent failures on repeat audit where measures aimed at prevention have been put inplace. This may include education of clinicians, change in practice or change in equipment.

A disconnection or other failure should occur in 0% cases.

Where a failure occurs, 0% should lead to a critical incident with severity 35.

100% of recurrent failures should be assessed for potential for prevention.

2.11


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65

2.11


Intraoperative care

Suggested data to

be collected

Common reasons

for failure to

reach standards

References

It is known that there is widespread under-reporting, it is therefore suggested that an audit isperformed over one month during which the anaesthetist is required to confirm that there isnot a disconnection or other breathing system failure during a case.

Where a failure did occur the exact circumstances and outcome should be noted. Actiontaken to prevent recurrent failures should be noted.

Lack of care in making connections in the breathing system.

Unnecessary connections, poor equipment.

Failure to use or interpret monitors correctly.

Lack of clinical observation.

1 Cooper JB, Couvillon LA Jr. Accidental breathing systems disconnections. HMS publication FDA

86-4205 US Department of Health and Human Services. Public Health Service; Food & Drug

Administration, January 1986.

2 Medical Device Reporting. 21 CFR Part 803, 49 Fed Reg 36326-51 September 14, 1984.

3 Adams AP. Breathing system disconnections. Br J Anaesth 1994;73:4654.

4 Royal College of Anaesthetists Critical Incident Pilot Study. Further details can be obtained from theRoyal College of Anaesthetists website (see: www.rcoa.ac.uk).

5 Department of Health. An organisation with a memory. DH, London June 2000. (see:www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/

PublicationsPAmpGBrowsableDocument/fs/en?CONTENT_ID=4098184&chk=u1I0ex)

6 Department of Health. Building a safer NHS for patients: Implementing an organisation with a

memory. DH, London April 2001. (see: www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPAmpGBrowsableDocument/fs/en?CONTENT_

ID=4097460&chk=gngr/O).

7 Lack JA. Perioperative anaesthetic audit. In Kenny GNC et al. Automated anaesthesia records.

Balliere Tindall, London 1990: pp 171184.


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Documents