September 2002
Volume 66 |
Number 9
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ASA Monitoring Guidelines:
Their Origin and Development
Ellison C. Pierce, Jr., M.D.
Committee on Patient Safety and Risk Management
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On October 21, 1986, the ASA House of Delegates approved the
ASA "Standards for Basic Intraoperative (now "Anesthetic")
Monitoring." How did this come about after a long period
of opposition on the part of most anesthesiologists?
In my view, there were two major factors. Beginning in the mid-1970s,
the first medical malpractice crisis occurred, brought about by
the shrinking availability of insurance as commercial insurers
fled the marketplace. The second crisis concerned decreasing affordability
as premiums rose to several times previous levels. Anesthesiology
premiums were, therefore, among the very highest – in many
areas, two to three times the average cost for all physicians.
By the early 1980s, anesthesiologists recognized that something
drastic had to be done if they were going to be able to continue
to be insured.
The other major factor occurred on April 22, 1982, when ABC broadcast
its 20/20 program titled "The Deep Sleep, 6,000 Will Die
or Suffer Brain Damage." The program described a number of
anesthesia mishaps that appeared to have been preventable. The
reaction of the public was strong; for months after the broadcast,
patients appearing in the operating room for anesthesia had questions
about its safety.
Both of these factors pushed anesthesiologists toward development
of ways to improve anesthesia morbidity and mortality. Thus the
current patient safety campaign was born. As President-Elect of
ASA in 1983, I was able to establish a new committee, the Committee
on Patient Safety and Risk Management. The concept for such a
committee received widespread approval in the Society. One of
the committee's early initiatives was the preparation of a series
of videotapes on patient safety, now totaling 30, available on
the Anesthesia Patient Safety Foundation (APSF) Web site at .
Several other undertakings followed quickly. An International
Symposium on Anesthesia Morbidity and Mortality was held in 1983
in Boston, Massachusetts, which resulted in an increased understanding
of the safety problems facing anesthesiology. Establishment of
APSF was a direct outcome of this meeting. ASA led the medical
community with its support of the ASA Closed Claims Study of liability
cases under the auspices of the Committee on Professional Liability.
In the early 1980s, Boston was by no means exempt from the crisis;
there were a significant number of serious anesthesia mishaps
at several Harvard hospitals. The Harvard self-insurance medical
malpractice carrier, as a result, established a Risk Management
Committee to find solutions. This committee believed that most
of the cases involving major morbidity or death were preventable
and concluded that better intraoperative monitoring of the patient
and the anesthesia delivery systems would give warnings early
enough to allow appropriate responses that might prevent the accident.
Many of the incidents involved inadequate ventilation or oxygenation.
The committee further believed that the use of minimal safety
monitoring requirements as a means of preventing catastrophic
accidents needed to be mandatory. It was obvious to the committee
that there would be objections on the part of many anesthesiologists
to the establishment of standards. It was further recognized that
any published standards would have to be considered and approved
by each of the department heads with agreement by the majority
of their clinicians. After considerable debate, the Harvard Standards
for Minimal Monitoring were adopted in March 1985.
Readers interested in examining in greater detail the ASA and
Harvard developments may find them in the Spring 1987 issue of
the APSF Newsletter on the APSF Web site. The Harvard story is
seen under the section "From the Literature," and the
ASA story can be found under "ASA Adopts Basic Monitoring
Standards."
I have been asked several questions during the preparation of
this short article. Why was I interested in patient safety in
the first place? Well, I would say that from the mid-1960s, when
I started collecting examples of anesthesia mishaps, it became
more and more obvious that something had to be done. It is interesting
that the same was said of the numerous railway accidents in England
in the mid-19th century. If it were your child who died because
of misplacement of the endotracheal tube during surgery for the
extraction of molars, the mortality rate for you was 100 percent.
What were the challenges? Clearly, it was obvious that many,
if not most, physicians resented being told what to do. This,
of course, was true in all of medicine, from the early guidelines
in cardiology concerning emergency treatment of a myocardial infarction
to the listing of indications for carotid artery surgery. It was
assumed by many practitioners that any guidelines or standards
would be fodder for the plaintiff's attorneys. This, of course,
has not been the case.
What were the joys? Certainly, the greatest joy is the knowledge
that our specialty has drastically decreased the incidence of
anesthesia mortality and morbidity. Anesthesia-related deaths
in healthy patients are extraordinarily rare today. It also is
pleasing to all of us that the field of anesthesiology is recognized
worldwide as the leader in patient safety. Praise for our specialty
may be found in numerable publications over the past several years,
from the reports of the Institutes of Medicine to specialty journals
to the Commonwealth Fund Report on Patient Survey of Error and
Quality.
In addition, there is satisfaction in recognizing that anesthesia
medical liability premiums have declined significantly. Even in
the current medical malpractice insurance crisis, anesthesiology
has been less affected than many other specialties. In its dealing
with the media and government entities, ASA has justifiably pointed
to the success of its efforts in promoting anesthesia patient
safety.
Lastly, for the younger anesthesiologists who have not been through
these dramatic changes over two decades, a review is available
in my 1995 Emery A. Rovenstine Memorial Lecture: "The 34th
Rovenstine Lecture – 40 Years Behind the Mask: Safety Revisited,"
which also is available on the APSF Web site at < www.apsf.org/foundation/rovenstine
>.
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Ellison
C. Pierce, Jr., M.D., is Executive Director of the Anesthesia
Patient Safety Foundation. He is currently retired from practice.
Dr. Pierce was ASA President in 1984. |
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