AA Blog Post 9

FMEA Table

The group worked on a preliminary Failure Mode and Effect Analysis (FMEA) table, to minimize process based failures and variation on design specifics due to the process. We focused on on failures that could result from the process. We took into consideration the basic steps required to use the device, and found potential failure modes associated with those steps. An RPN value of 175 was calculated, and these failure modes will be taken into consideration to be worked on later.

Killer Experiment

Our killer experiment is still being discussed and improved up on. However, based on recent interviews, we have decided that our biggest weakness at the moment is with the training program we suggested. We have not provided enough training time for nurses to learn how to deliver and monitor anesthesia. This could make or break our entire project. These professionals need more training to become proficient in anatomy and physiology and also get technical practice. This will decrease risks and hazards with the patients.

Interview Transcript 1

Name Sarah Smolik

Contact info Phone Number, email: sarahsmolik@yahoo.com

Short bio/background

American grad, educated on west coast and then trained in anesthesia on east coast. Graduated in 2006 and have done 2 one-year fellowships in neuroanesthesia and regional anesthesia. Have worked in university and community hospitals anesthesia average of 55 hours a week for 14 years in Philadelphia, Pittsburgh, Steubenville, New Castle, Greenville, and Hermitage.

Interview questions

What is a typical day like for you? How many patients do you usually see/ procedures do you usually do?

I arrive at the hospital after 1 hour and 15 minute commute at 6:30am. I start by reviewing my patient’s records on computer. Then I meet them in the holding area. Then I start rooms with the CRNAs. Usually I supervise 3 rooms and the cases are short. So as soon as the operations start I go back to the holding area to see the next wave of patients. When the operations are complete I see the patients in the recovery area and place PACU orders. I see about 20 patients a day.

I do mostly paperwork and computer charting. While the ORs are running and in between seeing patients in pre-op and recovery, I review patient charts for patient’s getting surgery in the days to come. Sometimes I see patients in the preoperative clinic as well.

The number of procedures that I do varies widely. Many days I do no procedures. Some days I do as many as 10 procedures including intubations, spinal taps, nerve blocks, epidurals, iv starts, and central line placements.

How many other professionals do you usually work with during a procedure?

I usually work with at least one other healthcare provider, sometimes two.

How do you prepare for the procedure?

I explain the procedure and get consent and then I wash my hands and position the patient. Then I collect my materials and do a time out.

Have you practiced in a city hospital? If so, what are the differences between rural and city hospitals?

Yes. My exposure to city hospitals was early in my career circa 2000-2009. After that I worked in community and then in rural hospitals. The patient in city hospitals suffer the ailments of poverty and drug abuse. I found them to be thinner and to have scarred veins. The HIV epidemic peaked just before my residency and HCV did not have a cure. There was a lot of fear about getting needle sticks while trying to gain iv access in these patients. There was a lot of animosity between the doctors and the nurses. I also perceived also of anger in the patients in the hospitals of Philadelphia. The physical characteristics and quality of the hospitals themselves were not very different except that the city hospitals were larger and served a larger population and received referrals. Therefore they could offer a wider variety of services and have more subspecialized venues. So the expertise there was better, but because of the volume issue the personal concern for each patient was reduced.

Have you practiced in a different country? If so, could you elaborate on the experience and the differences between practicing in that country versus the United States? N/A

How do you deliver and monitor anesthesia depth currently, and what features do you prefer in the methods you use?

We use the age old methods of giving the patient doses that historically have been adequate, while continuously visualizing the patient and monitoring their vital signs either continuously or intermittently. In the last decade a monitor called BIS was promoted. It is a processed simplified EEG. The early literature indicated that it may reduce awareness. My understanding is that the latest research refutes this claim. In any case, the incidence of true intraoperative awareness is so low that it is difficult to study and reach a conclusion to this question. In the last couple years the BIS has gone from being mandatory to being considered optional. I use it about 50% of the time.

What I don’t like about the BIS is that the probe is expensive per patient and it hurts their skin when it is applied. It cannot be applied to a patient who must be positioned prone. Further, the validity of the BIS is questionable if it is not applied prior to anesthesia to get a baseline reading or if the patient has had a stroke or frontal lobe/temporal lobe resection.

In your time being an anesthesiologist, have you had a patient experience intraoperative awareness?

Yes. A cardiac patient had intraoperative awareness. They recollected voices and some sensation from the surgery. However, they did not experience pain or trauma from the event. I attribute this to the fact that in that era we were administering a large amount of narcotic during heart surgery. In fact, due to the limited capacity or cardiac patients to tolerate anesthesia physiologically, intraoperative awareness continues to have a higher incidence in this population.

What special conditions do you look for when giving anesthesia to a patient? For example, if the patient has a history of using opiates or alcohol, does that change the dose?

If a patient is chronically taking opioids then they will have a baseline tolerance to them and they may need more than the average patient to treat their postoperative pain. However, it does not necessarily increase the amount of anesthesia that they require. Chronic alcohol use is known to increase the anesthetic dose that is required to achieve operative conditions. I have found this to be true. However, there is no linear relationship and one cannot extrapolate from the drinks per week how much more the patient will need. Therefore, there is always a process of titrating the medication to effect.

What is the procedure when too much anesthesia is delivered? What are the steps to correct it?

That really depends on precisely what medication is given. If the over dose is narcotic, then Narcan is the remedy. If the overdose one of the non-depolarizing muscle relaxants, then there are specific reversals for those. If the overdose is the hypnotic agent then the only remedy is support of the vital signs until the effects of the medication wear off. In fact, the tincture of time, rather than a specific reversal drug can be used for all the anesthetics so long as the vital functions are supported and the patient is comprehensively cared for while the overdosed medication wears off.

Exceptions to this that I can think of insulin and medication that either make blook thin or too thick. Overdosing these lead to fatal consequences that cannot be reversed even if the patient's vital functions are supported.

What is the procedure to follow when any of the vitals go out of range of what is normal?

Unfortunately, this is not the kind of thing that can be encapsulated into one protocol. Not only does it depend on which vital sign we are dealing with, but it also depends on the characteristics of the patient and the procedure that is being performed. For instance, a change in breathing often, but not always, requires a different initial reflex than a change in heart rate. And the initial response depends on the severity of the change. At the same time there are a multitude of patient factors that will guide ones response: are they old or young? Are they sick, or healthy? Fat or skinny? Smoker? Drinker? Exercise enthusiast? Even race may impact how a change in vital sign is treated. And there can be surgical reasons that need to be considered as a cause. This question is really the meat of my four year medical degree and four year residency.

I guess I would have to say that the unifying approach to a change in a vital sign is to ask myself why is this occurring. Then I will use my informed mind to begin evaluating the patient and the situation. Then I exercise my judgement to arrive at the most likely diagnosis and to administer a proper treatment. Now judgement is something that involves logic and pattern recognition. Over time pattern recognition is improved and therefore judgement is improved with experience. In anesthesia time is of the essence and we often have to diagnose and treat with little certainty because of the limited time to gather data, process ones thoughts, and consult colleagues. Therefore, even the best of us still misdiagnose from time to time. It has been my own experience that over the course of years my pattern recognition as well as my anesthetic dose estimation have gotten better and my adverse events have become rarer.

What are your thoughts on Ketamine being used as an alternative anesthesia in low resource settings?

Ketamine is a great thing to use in the field, in the OR, in the ED. In fact, my son had pure ketamine when his broken arm was set. He told me months after the procedure that he remembered how scary we looked to him while he was “anesthetized” with Ketamine. It can cause some weird physiological reactions. Ketamine causes the BP and heart rate to go up and it causes the patient to salivate. So in the context of surgery, if you bolus with Ketamine and then the heart rate goes up, is it because you gave ketamine, or is it because they are experiencing discomfort? If you erroneously give more, they will aspirate their secretions and stop breathing. If you give to little then they may move during incision. You should also know that Ketamine does not produce amnesia. It causes dissociation. So a patient, like my son, who gets only Ketamine will be awake and aware during surgery and may likely recall their surgery, even though they will not experience it as painful.

My concern is that the anesthetist needs to look at the patient and the surgery and make the final decision as to whether or not giving more or giving less Ketamine is the correct thing to do. I also think that it is kind to premedicate with benzodiazepine to reduce the risk of hallucinations, bad dreams, and disturbing recollections that occur after Ketamine anesthetics. This is not always wise however, and will lead to increased risk of apnea and airway obstruction so constant surveillance is required.

Also, premedication with glycopyrrolate will reduce the salivation. It will also cause the heart rate to increase.

Is it feasible for a nurse to go through a few months’ worth of training to learn how to deliver and monitor anesthesia, and help with the procedure with the help of guides?

Administering anesthesia requires more than a basic knowledge and understanding of physiology, anatomy, pharmacology, and the ability to make quick calculations and estimates. In our country four year nursing degrees require a lot of education in these areas. Nevertheless some nurses will not have the attributes to use this education in the setting of providing anesthesia. So I would subscribe that at least the equivalent of a 4 year RN degree would be necessary. Anything less than that would compromise patient safety too much. In this country the standards and resources are different and a four year RN degree is not adequate. We require a select group of seasoned ICU nurses to get 2-4 more years of experience, essentially putting them at the level of an MD. I am not aware of any data that can demonstrate that CRNAs are inferior or superior to MDs in terms of the anesthesia outcomes. Presently, there is an anesthesia training program for people with various bachelor degrees to get trained as and anesthesia assistant in just one year. So that is a total of 5 years of intense higher education. I think that is probably the minimum education required to give anesthesia and still have acceptable anesthesia morbidity and mortality. Sure you can train a tech, but there ill be a price paid in terms of patient safety.

I have used references while administering anesthesia, and I still do that from time to time. But the difference is that I am doing that for items that don’t require immediate answers and I already have all the knowledge I need to keep the patient alive. The anesthetist must be able to deal with a situation during surgery and anesthesia without consulting a written document or video. It is not feasible to be administering anesthesia and reading about the problems that are arising during the case.

Interview Transcript 2

What type of operation did you go for? How long was the surgery?

Heart Stent; Two hours

Do you remember what questions you were asked by the anesthesiologist pre-operation?

Asked if he had any allergies, mainly concerned with shellfish allergies. Ask if he had ever been under anesthesia before.

How did they administer the anesthetic? Did they tell you what kind it was?

It was through the IV in the arm; wasn’t sure about the type of drug

During the operation, do you remember experiencing any sort of sensation, pain or awareness?

No

After you woke up, did you experience any immediate side effects? Did you feel any side effects over the course of the next few days?

Just grogginess, took a couple of hours to wear off; no side effects from the anesthesia after that

What did you postoperative recovery look like?

Told him to just take it easy for a couple days, don’t exert himself, keep an eye on the place where they inserted the IV (they said it was a direct line to your heart so need to make sure it didn't start bleeding

Is there anything about the anesthesia process that you wish could have been done differently or better? Did anything stand out as being particularly bad or good?

No complaints with the procedure