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April
2002
Volume 66 |
Number
4
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| APSF
Research Program: Anesthesiologists Leading the Way |
Sorin
J. Brull, M.D., Chair
Anesthesia Patient Safety Foundation Scientific Evaluation Committee
Past
Patient safety has been a major concern of our specialty long
before the topic became popular as a result of the 1999 Institute
of Medicine report, that praised anesthesiology's patient safety
record.1 In fact, the Anesthesia Patient Safety Foundation (APSF)
was the first organization to sponsor research in patient safety.
APSF was the inspiration of Ellison C. Pierce, Jr., M.D.,
its founding president and current executive director. The other
members of the first APSF executive committee were Jeffrey
B. Cooper, Ph.D., Burton A. Dole, Jr., Joachim S. Gravenstein,
M.D., James Holzer, J.D., Dekyl Rountree and E.S. Siker, M.D.
Prior to the inception of APSF in 1985, there were no defined
sources of research funding for topics that were dedicated specifically
to patient safety. Additionally, studies of safety usually employed
"softer" research methods and were difficult to judge
by the more rigorous criteria used in traditional scientific research.
Recognizing this shortcoming, one of the primary interests of
the APSF founders was to create seed funding for studies related
to patient safety, thus establishing the idea that safety is an
important issue worthy of targeted support.
The APSF Scientific
Evaluation Committee (SEC) was established in 1986 under the leadership
of its chair, Arthur S. Keats, M.D. He created a process
of application review and a standard for excellence that were
modeled on his experience in reviewing grants for the National
Institutes of Health (NIH) and other agencies. Dr. Cooper followed
Dr. Keats as SEC chair for the ensuing 13 years, and under his
able leadership, the amount of support for patient safety increased
from $35,000 to $65,000 per funded project. In 2001, Dr. Cooper
passed the SEC chair "baton" to the undersigned.
APSF has had
as many as 47 applications and as few as 13 each year; most often,
three grants per year are awarded. The first three grants were
selected in 1986 from among a total of 26 applications. The APSF
SEC is now in its 15th cycle of reviews and has awarded more than
50 grants totaling in excess of $2 million from among more than
400 applications from 120 different institutions.
Present
The priorities for funding projects under APSF grants programs
are available at: www.apsf.org.
Although the basic guidelines have remained the same, some important
changes have been made since the first set was established. Recognizing
that the risk of catastrophic events in healthy patients has decreased
significantly in the past 50 years, the priorities were expanded
several years ago to include not only problems related to healthy
patients but also to problems that are more widely applicable
and that affect the safety of critically ill patients. Also, the
areas of interest now include measurement methods of cost-effectiveness
of techniques designed to increase patient safety and innovative
methods of education and training in safety. The guidelines stress
creativity and innovation; for the past two years, they have encouraged
applications related to safety issues in office-based anesthesia,
although no such projects have been awarded thus far.
Although it
is difficult, if not impossible, to measure the direct impact
on patient care or outcome of a research support program such
as APSF, the list of more than 200 publications that have been
derived, at least in part, from APSF sponsorship is significant.
The findings in many of these publications stand out as being
influential in changing clinical and/or educational practice.
The development of realistic, computer-based simulators has clearly
benefited greatly from APSF funding as simulators may not have
gained the current popularity and acceptance without APSF support.
The effect of APSF funding was to seed several groups that worked
independently on this new venture in its early years. The concept
was validated and grew beyond its initial research application
into an educational tool that is rapidly incorporated into medical
education, not only in the United States but around the world.
Another APSF-funded
project led to the publication of a widely quoted paper by Charles
J. Coté, M.D., and his coworkers and was crucial in promoting
the use of capnography in pediatric anesthesia. The work of Richard
E. Moon, M.D., helped to direct more attention to the problem
of carbon monoxide poisoning that may result from an anesthesia
machine's carbon dioxide absorbent. Several other important papers
have evolved from the epidemiological studies of Mark A. Warner,
M.D., and colleagues. They have suggested, for instance, that
adult patients with clinically apparent aspiration who do not
develop symptoms within two hours of the event are unlikely to
have respiratory sequelae. On a broader scale, Dr. Warner and
his group have demonstrated the remarkably low rate of mortality
and morbidity associated with ambulatory surgery.
The importance
of postoperative cognitive dysfunction in the elderly has been
underscored by Terri G. Monk, M.D., through clinical investigative
work sponsored in part by APSF funding and recently resulting
in funding by NIH. Another important finding by Robert C. Morrell,
M.D., and colleagues is that perioperative ulnar neuropathies
are associated with factors other than general anesthesia and
intraoperative positioning. Another grant recipient, Mary E.
Warner, M.D., is performing a large-scale investigation on
the causes of perioperative visual loss, and Charles B. Berde,
M.D., Ph.D., who has received much attention recently for
his efforts in pediatric pain management, cites many of his publications
as having derived in part from his APSF-sponsored project.
Dwayne
R. Westenskow, Ph.D., was the recipient of an APSF grant (which
was also approved and ultimately funded by NIH), which seeks to
enhance the clinician's ability to discover and respond rapidly
to critical events by developing a display that will help visualize
the patient's physiologic state. Another project seeks to identify
patient-based factors that would predict specific adverse outcomes
and may provide clinical guidance to enhance patient safety through
more appropriate choices of anesthetic techniques.
Harvey
J. Woehlck, M.D., is investigating the relationship between
preoperative smoking and perioperative ischemia and may provide
the needed clinical evidence for the use of expired-breath carbon
monoxide as a screen for recent cigarette smoke inhalation. Richard
H. Blum, M.D., is involved in a project that seeks to evaluate
educational interventions aimed at improving team performance,
thus reducing the errors and team failures that lead to adverse
outcomes and patient injuries.
The most recent
awards include a project that proposes to develop a simple, relatively
inexpensive, reliable, less invasive and readily available diagnostic
test for malignant hyperthermia (MH) susceptibility. A study by
W. Andrew Kofke, M.D., will determine whether brain (limbic
system) hypermetabolism, which manifests as hyperemia, occurs
in healthy humans who receive the opioid remifentanil. Finally,
another anesthesia-related proposal will focus on education. Specifically,
a multidisciplinary team of engineers and anesthesiologists will
use a sophisticated "instrumented laryngoscope" to measure
the factors that define expertise in airway management and those
that cause difficulty attaining successful oral endotracheal intubation.
Future
The future of APSF can perhaps be inferred from its past and present
achievements. It is clear that APSF has had a significant impact
on the practice of medicine in this country. A measure of the
success of the APSF grants program is the esteem that it has been
accorded by others. The 1997 creation of the National Patient
Safety Foundation (NPSF) was sponsored by the American Medical
Association and modeled on APSF. NPSF has its own research program,
organized and chaired by Dr. Cooper. The success of the APSF research
program also can be seen in the funding and research achievements
of its investigators. The Agency for Healthcare Research and Quality
(AHRQ), which leads patient safety efforts for the federal government,
recently awarded a large set of patient safety grants [see accompanying
article]. Among those grants is a disproportionate number from
anesthesiology groups and investigators who were previously sponsored
by APSF (e.g., Richard I. Cook, M.D., Colin F. Mackenzie, M.B.,
Stephen D. Small, M.D., and Matthew B. Weinger, M.D.). However,
the most important legacy of the APSF grant program may well be
its creation of leaders in patient safety.
Just as APSF
has been at the forefront of investigations aimed at improving
safety of surgical procedures and anesthesia in office-based settings,
we will continue to target patient-centered areas of clinical
research such as anesthesia in remote locations, moderate sedation
and analgesia, fatigue and production pressure, impact of electronic
medical records, performance evaluation and many other issues
that likely will surface as our specialty continues to evolve.
The members of the APSF SEC are looking for a few (or many) fantastic
research ideas. If you have one of them, we encourage you to apply
for an APSF grant.
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AHRQ
Grants Place Members on Cutting Edge of Safety Research
The
Agency for Healthcare Research and Quality (AHRQ)
recently awarded $50 million in new grants, contracts
and other activities in an effort to reduce medical
errors and improve patient safety. This grant money
represents the single largest investment the federal
government has made so far to combat medical errors
– and many anesthesiologists are at the forefront
of these patient safety studies.
Beginning
in 2001, these projects became part of a multiyear
plan to address key unanswered questions about how
errors occur. It is hoped these investigations also
will provide science-based information on what patients,
clinicians, hospital and other organization leaders,
policymakers and others can do to address these crucial
issues.
AHRQ
funded a three-year grant to the San Diego Center
for Patient Safety, which was established as a collaborative
effort between the Veterans Affairs (VA) San Diego
Healthcare System and the University of California-San
Diego Health Sciences. Directing the program is Matthew
B. Weinger, M.D., whose institutions have already
implemented numerous patient safety initiatives, including
sentinel event analysis, bar coding for medication
administration, computerized medication ordering and
automated pharmacy medication-filling systems. Dr.
Weinger also is the principal investigator for an
AHRQ-supported study titled "Unexpected Clinical
Events: Impact on Patient Safety" that will attempt
to demonstrate the value of studying nonroutine events
during actual patient care in the field of anesthesiology
to improve patient safety.
In
1999, the Department of Veterans Affairs established
four Patient Safety Centers of Inquiry and committed
an initial $6 million to support the centers, the
first of their kind in the United States. Two of the
four centers are headed by ASA members. Research at
the Midwest Patient Safety Center of Inquiry, based
at the VA's Health Care System of Cincinnati, Ohio,
is overseen by Richard I. Cook, M.D., who is
an associate director. The work of the Midwest Center
will centered around gaps in the continuity of care.
"Linking User Error to Lab and Field Study of
Medical Infusion Devices" is another AHRQ project
headed by Dr. Cook at the University of Chicago and
seeks to identify and characterize factors that result
in "user error" associated with the operation
of infusion devices.
The
Patient Safety Center of Inquiry at VA Palo Alto,
California, is directed by David M. Gaba, M.D.,
who has a long history of work in patient safety.
He is collaborating on several projects, including
one with Brian E. Smith, M.D., who is researching
"Simulation-Based Training in Decision Making,
Crisis Management and Teamwork" and "Safety-Related
Event Reporting and Analysis." Dr. Gaba also
serves as a consultant on a Stanford University-based
study, "Transfer of a Novel Pediatric Simulation
Program," which seeks to answer the question
"Do the skills acquired within a simulated delivery
room environment result in improved human performance
and enhanced patient safety in the real delivery room?"
Other
anesthesiologists are playing a major role in the
activities funded by the latest AHRQ grants as well:
"Creating
High-Reliability Health Care Organizations" is
a project by Stephen D. Small, M.D., University
of Chicago, that will study key characteristics of
organizations from other industries that have strong
safety records and utilize that information to improve
the safety of health care delivery systems.
"Development
Center for Patient Safety Research" seeks to
use human factor techniques to improve patient safety
for trauma patients by creating educational programs
and evidence-based guidelines. The project is headed
by Colin F. Mackenzie, M.B., University of
Maryland, Baltimore.
"The
Impact of Intraoperative Monitoring on Patient Safety"
will study the evidence linking monitoring standards
to patient safety. Salim D. Islam, M.D., University
of California-San Francisco School of Medicine/VA
Medical Center, is a principle investigator.
There
may be additional anesthesiologists involved in other
studies not outlined in this article. Please contact
the NEWSLETTER staff at communications@ ASAhq.org
if you are an ASA member who also is currently involved
in an AHRQ patient safety study.
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Sorin
J. Brull, M.D., Chief, Department of Anesthesiology, and Medical
Director, Memorial Health Systems, Ormond Beach, Florida. |
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Reference:
1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building
a Safer Health System. Committee on Quality Health Care in America,
Institute of Medicine. 1999. www.nap.edu/books/030968371/html .
Accessed on March 26, 2002.
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