APSF Conducts a Conference on Technology Training

he topic for the Anesthesia Patient Safety Foundation (APSF) Board of Directors’ workshop to be held on Friday, October 13, 2007, at the San Francisco Parc 55 Hotel from 1 p.m. to 5 p.m. will be “Formal Training Before Using Advanced Medical Devices in the Operating Room — Voluntary or Mandatory for the Anesthesiologist?” The conference has been organized by Michael A. Olympio, M.D., chair of the APSF Committee on Technology, and will include speakers representing clinical anesthesia, equipment manufacturing, hospital administration, the airline industry and the legal profession. ASA Annual Meeting attendees are welcome to attend this conference.

APSF envisions that all anesthesiologists who apply advanced medical devices, which directly affect a patient’s vital functions and immediate safety, will be certifiably trained prior to such clinical application. The manner in which such training is applied or successfully accomplished is not known and requires deliberate investigation. For example the most effective method of introducing a new anesthesia machine (“workstation”) into the operating room has not been thoroughly investigated despite recent and dramatic increases in the complexity of these machines.^1,2

New anesthesia machines often introduce unique and subtle variations in breathing circuit design, automated checkout, volatile drug delivery, hidden piston ventilators, fresh gas delivery and ventilation modes. New designs intended to enhance patient safety can actually have unintended and adverse consequences, particularly in stressful clinical situations. Despite conventional pre-use instruction with or without simulation, anesthesiologists may not be able to reliably assess their ability to safely use new equipment in clinical practice.³ Anesthesiologists who received additional simulation training with the equipment were more likely to correctly apply anesthesia machine features during a simulated anesthesia emergency.³

Although the incidence of equipment-related critical events is infrequent, morbidity associated with these events may be catastrophic.^4-6 Human error is the leading contributor to equipment-related problems. Logic would suggest that anesthesiologists need directed training with new and complex anesthesia equipment prior to its clinical use. The question is: “Should this training be voluntary or mandatory?”

Current Practice
Conventional “in-service” programs are often recognized as superficial and inadequate because they do not require advanced preparation, are not mandated, do not allow individual practice, do not test for learning or application skills and are frequently abandoned for lack of time on the part of the anesthesiologist.² These programs typically occur only once when new equipment is installed, do not account for personnel who are away from work that day, and do not accommodate new personnel.

Experience With an APSF Pilot Program
Members of the APSF Committee on Technology designed a training program for clinicians who would be using newly purchased anesthesia machines.² Although all the clinical leaders agreed that additional anesthesia machine training would be valuable, it was difficult to reach a consensus on issues such as 1) requests for proof that training was necessary, 2) convincing anesthesiologists that the program was necessary, 3) providing time and resources for those being asked to take the training, 4) measuring the outcome and value of the training process and 5) determining the consequences of refusal or failure to participate.

Results of the APSF Pilot Program
The effort to justify, organize and accomplish a comprehensive technology training program prior to the installation of new and unfamiliar anesthesia machines proved to be an intimidating challenge.² In retrospect the greatest mistake was to not mandate the program for all categories of clinicians (residents, student nurse anesthetists, nurse anesthetists and staff anesthesiologists) who would be responsible for using the equipment upon installation.

The chair of the department where the pilot program was conducted endorsed the training but did not mandate it.⁷ Perhaps not surprising, participation by staff anesthesiologists in all phases of the training was disappointing. In retrospect this chair would now view the program not as a clinical study but as a major departmental safety initiative. Buy-in from faculty would be prospectively sought, and faculty members who failed to complete the training course would not be assigned clinically until they did so. The chair asked, “What private or academic anesthesia group wants to recruit an anesthesiologist … who declined to participate in a mutually agreed-upon safety initiative?”⁷

Conclusion
How would a patient likely respond if asked whether training before using complex anesthesia equipment in the operating room should be voluntary or mandatory?

References:
1. Olympio MA. Modern anesthesia machines: What you should know. American Society of Anesthesiologists Refresher Course Lectures. Park Ridge, IL: American Society of Anesthesiologists. 2005:501.
2. Olympio MA, Reinke B, Abramovich A. Challenges ahead in technology training: A report on the training initiative of the Committee on Technology. APSF Newsletter. Fall 2006:43-48.
3. Dalley P, Robinson B, Weller J, Caldwell C. The use of high-fidelity human patient simulation and the introduction of new anesthesia delivery systems. Anesth Analg. 2004; 99:1737-1741.
4. Caplan RA, Vistica MF, Posner KL, Cheney FW. Adverse anesthetic outcomes arising from gas delivery equipment: A closed claims analysis. Anesthesiology. 1997; 87:741-748.
5. Weinger MB. Anesthesia equipment and human error. J Clin Monit Comput. 1999; 15:319-323.
6. Eisenkraft JB. A commentary on anesthesia gas delivery equipment and adverse outcomes. Anesthesiology. 1997; 87:731-733.
7. Roy RR. Commentary pertaining to the decision not to mandate faculty participation. APSF Newsletter. Fall 2006:47.

Robert K. Stoelting, M.D., is President of the Anesthesia Patient Safety Foundation, Indianapolis, Indiana.