Author: Robert D’Angelo, M.D.
ASA Monitor 03 2017, Vol.81, 20-21.
Robert D’Angelo, M.D., is Section Head and Vice Chair, Obstetric Anesthesia, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
Initiatives in recent decades to improve quality in medicine have and will continue to significantly impact anesthesia practice. In order to assess and improve quality, metrics must be identified, tracked and reported. This was particularly problematic in anesthesia in that, until recently,there were no clearly identified anesthesia metrics. Faced with this reality, the specialty either had to define metrics or they would be defined for us by forces outside of anesthesiology. In response to this challenge, the Anesthesia Quality Institute (AQI) was created in 2008. To achieve its vision of quality improvement of the clinical practice of anesthesiology by improving quality care of patients, lowering anesthesia mortality and lowering anesthesia incidents, AQI created a database in 2010, the National Anesthesia Clinical Outcomes Registry (NACOR). NACOR is currently capturing data from an ever-increasing number of anesthesiology practices and currently reports on 26 Physician Quality Reporting System (PQRS) and 19 ASA Quality Clinical Data Registry (ASA QCDR) metrics. Each of these 45 metrics can be categorized as “big data” by capturing and reporting data on population-level statistics. Examples include perioperative mortality (ASA QCDR #12), unplanned transfer or admission (ASA QCDR #37), pain brought under control within 48 hours (PQRS #342) and prevention of postoperative nausea and vomiting with combination therapy (PQRS #430). Although designed to improve outcomes on a global level, the registry fails to capture detailed data at the individual patient level.
Similar problems have been encountered in quality improvement anesthesia initiatives at the subspecialty level. For example, the Society for Obstetric Anesthesia and Perinatology (SOAP) created the Serious Complication Repository (SCORE) in 2004 to establish the incidence of serious obstetric anesthesia-related complications and to identify variables that contribute to each serious complication. Over a five-year period, 30 institutions reported 85 anesthesia-related serious complications in more than 165,000 vaginal and 95,000 cesarean deliveries.1 Although an attempt was made to capture data on individual adverse events, the project failed to capture large enough numbers of each complication to identify contributing factors. Because of the limited number of participating institutions, data was captured on only 1.5 percent of the nearly 20 million U.S. births that occurred during the five-year project study period. Extrapolating SCORE findings suggest there are approximately 1,300 serious adverse events related to obstetric anesthesia each year in the U.S. alone, including as many as 43 epidural abscesses, 83 serious neurologic complications, 105 failed intubations during general anesthesia for cesarean delivery and 750 high spinals. This amounts to an incredible amount of morbidity that is not being captured by existing databases. Capturing detailed information on a significant number of these adverse events is a goal established by both AQI and SOAP.
Unfortunately, it is currently difficult, if not impossible, to capture detailed information on adverse events at the patient level, and this problem is not unique to anesthesia. Not only are the quality metrics and data capture systems outlined in the first paragraph designed to capture population-level data, electronic medical records (EMR) are designed to integrate extremely complex information systems. The current focus of EMR quality assessment is to stream quality metrics in compliance with national initiatives such as QCDR and PQRS. They have not been designed to easily capture patient-centric quality metrics.
In response to these limitations, AQI created the Anesthesia Incident Reporting System (AIRS) for collecting individual adverse events with the purpose of improving anesthesia care nationwide. AQI is also partnering with subspecialty organizations, including SOAP, to develop subspecialty AIRS reporting modules. Currently there are four active AIRS modules: Respiratory Depression, Drug Shortage, Pediatric Anesthesia and Obstetric Anesthesia. The obstetric anesthesia module includes 13 serious complications: maternal death, cardiac arrest, failed intubation, high spinal requiring respiratory assistance or intubation, respiratory arrest in L&D, aspiration, neuraxial infection, neuraxial hematoma, serious neurologic injury, injury related to blood patch, anaphylaxis, undesired intraoperative awareness and blood transfusion reaction. The website can be accessed through the AQI homepage at www.aqihq.org or directly at www.aqihq.org/airs/airsIntro.aspx. Links will soon also be included on additional anesthesia society homepages. The AIRS website was designed to be user-friendly, is easy to navigate and maximizes the use of drop-down menus. In addition to drop-down menus, there are areas for free texting additional details. Adverse events can be reported anonymously or confidentially, and it takes only minutes to report each adverse event. AQI’s standing as a Patient Safety Organization confers legal protection from discovery, and institutional IRB approval is not required for anyone to provide information into the AIRS database as no patient identifiers are collected.
The goal of the AIRS OB Anesthesia module is to obtain high-quality, detailed information on large numbers of each type of serious complication. Data will be collated looking for patterns or variables that contribute to each of the 13 complications. If found, educational practice bulletins or guidelines will be created with the intent of altering anesthesia practice to hopefully reduce the incidence of future complications. For the first time, a quality improvement tool can theoretically be used to improve patient safety at the level of the individual. However, this cannot happen without your help! Information on each adverse event must be entered manually into the database. It will be easier to identify contributing factors with larger numbers of reported adverse events or to determine that the incidence of serious complications related to obstetric anesthesia cannot be reduced below current levels.
Please review the list of serious obstetric anesthesia complications outlined above, post them in your departments and labor wards along with the AIRS homepage address, educate members of your department about the project and promptly report details of serious adverse events into the AIRS database whenever they occur. It might also be useful to designate a specific person responsible for making it so. Please feel free to contact me with questions at email@example.com or AIRS at firstname.lastname@example.org. In my opinion, this is a wonderful opportunity to work together as an anesthesia community to achieve the goal of improving patient safety in obstetric anesthesia.
D’Angelo R, Smiley RM, Riley ET, Segal S . Serious complications related to obstetric anesthesia: the serious complication repository project of the Society for Obstetric Anesthesia and Perinatology. Anesthesiology. 2014;120(6):1505–1512.