SEA 32 Unintended Intraoperative Awareness

1
SEA 32 Unintended Intraoperative Awareness

• Finding Your Way Through the New
• JCAHO Sentinel Alert
• ASA Committee on Quality Management and
  Departmental Administration

2
JCAHO standards for CQI Patterns and trends
are identified

• Undesirable patterns or performance trends are
  analyzed
• Elements of performance - analysis is triggered
• When trends exceed acceptable performance limits
• When performance/outcome varies excessively
• For locally chosen topics and those mandated by
  JCAHO
• transfusion reactions
• adverse drug reactions
• adverse events/patterns of events during
  anesthesia and sedation
• hazardous conditions (e.g., frequent electrical
  or monitor failure)
• staffing effectiveness
• sentinel events

3
JCAHO standards for sentinel events Sentinel
events are recognized and managed

• Processes for identifying and managing sentinel
  events are defined and implemented
• Rationale reduces the frequency of catastrophic
  failures
• Elements of Performance
• Review events causing death or loss of function
  not related to disease (suicide, death of term
  infant, infant abduction, assault, homicide,
  rape, major transfusion reaction, surgery on
  wrong site or patient).
• Reporting pathway voluntary to JCAHO and as
  required by law, Note Reporting of awareness
  under anesthesia is not required
• Performance of root cause analysis of process and
  system factors within 45 days of reporting to (or
  notification from) JCAHO
• Risk reduction plan and follow up measurement of
  effectiveness
• Accreditation watch for noncompliance

4
Sentinel Event Alerts from JCAHO

• JCAHO definition - not the systems definition
• An unexpected occurrence involving death or
  serious physical or psychological injury, or the
  risk thereof.
• Source Published by JCAHOs sentinel events
  database
• Examples
• Awareness under anesthesia (32 October, 2004),
  wrong site surgery, medical gas mix-ups,
  medication error , needle sticks
• Alerts are recommendations, not scored standards
  to be implemented and considered in QI planning

5
SEA 32 Awareness/Intraop recall

• Magnitude 40k reported cases a year
• Events reported range from hearing voices to
  experiencing pain
• Sometimes normal during induction, emergence,
  and sedation without GA
• Risk reduction targets are controversial and
  support data for them varies
• TIVA riskier than inhalation?
• Light anesthesia due to hemodynamic instability
  or during emergency C-section
• Premature lightening of anesthesia at end of case
  to facilitate turnover
• Lack indications of awareness by monitoring
  vital signs and movement due to use of beta
  blockers and relaxants
• Need to educate patients that sedation does not
  prevent all awareness
• Issues of brain monitoring

6
SEA 32 Brain monitoring controversies

• Awareness during anesthesia is not necessarily a
  sentinel event
• BIS, etc, may not be sufficiently predictive
  especially with TIVA
• Impact of low BIS on adverse outcome
• Is the increase in death in the elderly within 2
  years caused by deep anesthesia, reflected by a
  low BIS?
• Is the effect of deep anesthesia on BIS in the
  elderly an independent predictor of death in 2
  years
• What can we say now for sure with respect to
  awareness
• More science is needed to allow us to have a
  meaningful brain monitor
• Beta blockers and muscle relaxants are not a
  complete anesthetic
• The patient should not be aware, the
  anesthesiologist should be

7
SEA 32 Reducing risk of awareness

• Pre operative amnestics
• Deeper anesthesia during intubation
• Appropriate use of narcotics to prevent pain
  separate recall of events from pain
• Less profound muscle relaxation
• Appropriate considerations for substance-tolerant
  patients
• Maintain accuracy of anesthesia delivery systems
• Brain monitoring
• Better OR decorum less talking and loud music
  at times of expected light anesthesia
• Post op review and counseling
• Informed consent?

8
SEA 32 ASA Sample Policy Elements Steps to
take after evidence of awareness/recall

• Assure the patient of the credibility of his or
  her account and sympathize with the patients
  experience
• Explain what happened and why, if a reason can be
  given (e.g., the need for lighter anesthesia
  because of cardiovascular instability)
• Offer the patient support, including referral of
  the patient to a psychiatrist or psychologist, if
  appropriate
• Document any referrals or treatment provided to
  the patient
• Notify the patients surgeon and personnel in the
  Department of Risk Management about the incident
  if part of your institutions risk management
  protocol
• Complete an occurrence report concerning the
  event for the purpose of quality management

9
Further reading on SEA 32 and unintended
awareness during anesthesia

• Administrative Update Another side of Awareness,
  ASA Newsletter, February 2005.
• http//www.asahq.org/Newsletters/2005/02-05/admin
  02_05.html
• Sentinel Event Alert Issue 32, October 6, 2004.
  http//www.asahq.org/news/SEAfinal.pdf
• Commentary Awareness monitoring, ASA Newsletter,
  January 2005.
• http//www.asahq.org/Newsletters/2005/01-05/comme
  ntary01_05.html
• JCAHO Sentinel event resource index
  http//www.jcaho.com/accreditedorganizations/sent
  inelevent/se_index.htm
• Sample policy on awareness
• http//www.asawebapps.org/docs/SampleAwarenessPol
  icy.pdf (ASA members site)
• Above also found together at www.asahq.org/clinic
  al/toolkit/sea32.htm