Five-year audit of adherence to an anaesthesia pre-induction checklist

Although patient safety related to airway management has improved substantially over the last few decades, life-threatening events still occur. Technical skills, clinical expertise and human factors contribute to successful airway management. Checklists aim to improve safety by providing a structured approach to equipment, personnel and decision-making. This audit investigates adherence to our institution's airway checklist from 1 June 2016 to 31 May 2021. Inclusion criteria were procedures requiring airway management and we excluded all procedures performed solely under regional anaesthesia, sedation without airway management or paediatric and cardiovascular surgery. The primary outcome was the proportion of wholly performed pre-induction checklists. Secondary outcomes were the pattern of adherence over the 5 years well as details of airway management, including: airway management difficulties; time and location of induction; anaesthesia teams in operating theatres (including teams for different surgical specialities); non-operating theatre and emergency procedures; type of anaesthesia (general or combined); and urgency of the procedure. In total, 95,946 procedures were included. In 57.3%, anaesthesia pre-induction checklists were completed. Over the 5 years after implementation, adherence improved from 48.3% to 66.7% (p < 0.001). Anticipated and unanticipated airway management difficulties (e.g. facemask ventilation, supraglottic airway device or intubation) defined by the handling anaesthetist were encountered in 4.2% of all procedures. Completion of the checklist differed depending on the time of day (61.3% during the day vs. 35.0% during the night, p < 0.001). Completion also differed depending on location (66.8% in operating theatres vs. 41.0% for non-operating theatre anaesthesia, p < 0.001) and urgency of procedure (65.4% in non-emergencies vs. 35.4% in emergencies, p < 0.001). A mixed-effect model indicated that urgency of procedure is a strong predictor for adherence, with emergency cases having lower adherence (OR 0.58, 95%CI 0.49–0.68, p < 0.001). In conclusion, over 5 years, a significant increase in adherence to an anaesthesia pre-induction checklist was found, and areas for further improvement (e.g. emergencies, non-operating room procedures, night-time procedures) were identified.     

The WHO surgical checklist

Following the overwhelming evidence of adverse events in hospital practice, the World Health Organization (WHO)'s World Alliance for Patient Safety has launched the 'Safe Surgery Saves Lives' campaign, which has developed a surgical safety checklist aimed to improve patient safety. The implementation of this checklist has met with mixed reactions in different institutions. Many countries have still not adopted its use. In this article, a brief review is presented regarding the role of the WHO checklist, barriers to its implementation and strategies for successful adoption.     

Effectiveness of interventions to improve therapy adherence in people with upper limb conditions: A systematic review

Study DesignSystematic review.IntroductionPatient adherence to orthosis wear and/or prescribed exercises improves functional outcome after acute injury and can prevent deformities, contractures, and reinjury of tissues. This is the first systematic review to review the evidence of the effectiveness of interventions to improve treatment adherence in children and adults with acute or chronic upper limb injuries or conditions.Purpose of the StudyThe purpose of this study is to establish the effectiveness of interventions to improve hand therapy adherence in people with upper limb conditions and to report on outcome measures used when reporting adherence.MethodsA literature search of MEDLINE (OVID), Embase (OVID), CENTRAL (OVID), CINAHL (EBSCO), and EmCare (OVID) (from inception to March 2017) was undertaken. Studies were selected if they met the following inclusion criteria: clinical trials; in adults or children with any injury or condition affecting the upper limb including acute trauma and injury; chronic and acquired musculoskeletal conditions; and neurological conditions. Two independent assessors rated the study quality and risk of bias using the Cochrane Collaboration tool for assessing the risk of bias.ResultsEight studies met the inclusion criteria. Study quality ranged from 3 to 6 out of 7 points on the Cochrane risk of bias tool. There were 4 categories of intervention for improving adherence: orthosis/cast material/design; orthosis wear schedule; patient education mode for home exercise programs; and behavioral approaches. Due to heterogeneity of condition acuity, interventions, and outcomes reported, it was not possible to pool the results from all studies. Therefore, a narrative best evidence synthesis was undertaken. There is weak evidence from a very small number of trials that orthosis/cast material has no influence on treatment adherence in acute or chronic conditions and mode of patient education (audio-visual vs written) has no effect in acute conditions. There is low-to-moderate quality of evidence in support of behavioral interventions for achieving treatment adherence in chronic rheumatoid arthritis.ConclusionBehavioral approaches that encourage self-efficacy are likely to be useful in achieving treatment adherence in populations with chronic upper limb conditions. There is insufficient evidence for other interventions aimed at improving adherence in acute upper limb injuries and conditions.     

Breaking the adherence barriers: Strategies to improve treatment adherence in dialysis patients

Nonadherence to therapy (dietary/fluid restrictions, medications, and dialysis treatment), is common in patients with end-stage kidney disease (ESKD) undergoing dialysis. It is associated with a higher risk of mortality and adverse outcomes. Clinical trials evaluating adherence improvement interventions have largely addressed patient-related factors by employing educational/cognitive, counselling/behavioral, psychological strategies, or combinations thereof. A major barrier to progress in addressing ESKD-related adherence is the difficulty in comparing these trials due to the highly diverse nature of interventions and adherence outcomes. Surrogate outcomes like changes in inter-dialysis weight gain or phosphate levels are frequently used without adjusting for confounders, with the potential for biased efficacy estimates. A majority of trials reported improvement in some adherence measures, but some of the same studies showed no improvement in other adherence markers, questioning the validity of outcome measurement. Among the interventions, cognitive/behavioral strategies, combination strategies, and individually delivered interventions may have some advantages. Relapse of nonadherence, which is common on follow-up, should be managed to sustain long-term adherence. Technology-based interventions hold great future potential for addressing ESKD nonadherence. Streamlining intervention strategies and standardizing outcome measures in future clinical trials will provide reliable guidance to manage nonadherence effectively, which may improve clinical outcomes in dialysis patients.     

A checklist to improve the quality of central venous catheter tip positioning

Central venous catheter insertion is a routine procedure performed by anaesthetists in the peri-operative setting. Upper body central venous catheters are usually placed such that their tip lies within the superior vena cava or at the cavo-atrial junction. Positioning the tip ‘too low’ in the right atrium has long been argued against on the basis that it increases the risk of perforation, leading to cardiac tamponade. Positioning the tip ‘too high’ in the brachiocephalic vein or above can also be problematic in that proximal migration can result in extravascular placement of the proximal lumen. Such an incident occurred at our hospital in 2016, resulting in extravasation of a vesicant medication causing tissue necrosis. We undertook a quality improvement project involving a standardised bundle of care and a peri-operative central venous catheter insertion checklist with the aim of reducing the risk of such an incident re-occurring. We conducted a three-month pre-intervention audit (n = 84) in 2016 and a post-intervention audit (n = 84) in 2017. Compared with the pre-intervention audit, the post-intervention audit coincided with a lower rate of central venous catheter tip malpositioning (5.6% vs. 9.2%); and a higher rate of ‘optimal’ central venous catheter tip position in the distal superior vena cava or cavo-atrial junction (45.1% vs. 29.2%). The central venous catheter insertion checklist also substantially improved documentation of sterility measures, insertion depth and post-insertional documentation of tip position on chest radiograph.     

Educational interventions aimed at the transition from surgical training to surgical practice

The transition from surgical training to surgical practice is a critical juncture in the career progression of surgeons. This period is associated with myriad challenges that need to be addressed through specific educational interventions to ensure delivery of safe care to patients and to support the career aspirations of junior surgeons entering the practice environment. These interventions should be based on principles of contemporary surgical education and training, and focus on the needs of surgery residents and junior surgeons entering practice. The specific systems of patient care in which the junior surgeons will work should also be considered while planning and implementing such educational interventions. Senior surgeon colleagues within these systems should play key roles in supporting the junior surgeons entering practice, and may require special training to serve as effective mentors, preceptors, and coaches. Professional societies should play a key role in establishing national standards regarding the educational programs aimed at this transition and develop programs to complement local efforts to address various needs. The American College of Surgeons Division of Education has developed a spectrum of innovative programs that are aimed at this important transition.     

Psychosocial interventions to improve outcomes among dialysis patients

Patients with end‐stage renal disease (ESRD ) report high levels of emotional problems and poor compliance with treatment and quality of life. Nevertheless, there are not many studies which examine the effectiveness of different psychosocial interventions in ameliorating these poor outcomes. Theories have been helpful in identifying targets for interventions to improve compliance with treatment, adjustment, and quality of life. However, their effects have been mixed. In particular, interventions incorporating beliefs are promising in improving these outcomes. Moreover, relaxation and imagery techniques have reduced symptoms and have been effective improving adjustment and compliance. Future randomized controlled studies are needed to compare the effects of theory‐based and patient‐derived interventions on compliance with treatment and adjustment.     

Multimodal approaches to improve surgical outcome

In the year 2002, despite an improvement in perioperative care, major and minor surgical procedures may be followed by sequelae such as pain, organ dysfunction, and prolonged recovery. Surgeons and anesthesiologists should recognize that multidisciplinary and multimodal approaches are necessary to improve postoperative outcomes. Some European investigators have designed accelerated perioperative care programs that include features such as preoperative patient instruction, protocols for intraoperative anesthesia and postoperative analgesia, early enteral nutrition, and early enforced mobilization. The relative impact of these techniques on pain, the stress response, and bowel function recovery will be discussed in greater detail in this article. Copyright 2002, Elsevier Science (USA). All rights reserved.     

Multimodal strategies to improve surgical outcome

OBJECTIVE: To evaluate the effect of modifying perioperative care in noncardiac surgical patients on morbidity, mortality, and other outcome measures. BACKGROUND: New approaches in pain control, introduction of techniques that reduce the perioperative stress response, and the more frequent use of minimal invasive surgical access have been introduced over the past decade. The impact of these interventions, either alone or in combination, on perioperative outcome was evaluated.METHODS: We searched Medline for the period of 1980 to the present using the key terms fast track surgery, accelerated care programs, postoperative complications and preoperative patient preparation; and we examined and discussed the articles that were identified to include in this review. This information was supplemented with our own research on the mediators of the stress response in surgical patients, the use of epidural anesthesia in elective operations, and pilot studies of fast track surgical procedures using the multimodality approach. RESULTS: The introduction of newer approaches to perioperative care has reduced both morbidity and mortality in surgical patients. In the future, most elective operations will become day surgical procedures or require only 1 to 2 days of postoperative hospitalization. Reorganization of the perioperative team (anesthesiologists, surgeons, nurses, and physical therapists) will be essential to achieve successful fast track surgical programs. CONCLUSIONS: Understanding perioperative pathophysiology and implementation of care regimes to reduce the stress of an operation, will continue to accelerate rehabilitation associated with decreased hospitalization and increased satisfaction and safety after discharge. Developments and improvements of multimodal interventions within the context of "fast track" surgery programs represents the major challenge for the medical professionals working to achieve a "pain and risk free" perioperative course.