Professor Francois Clergue, director of anesthesia of the University Hospitals of Geneva, challenged attendees of the European Society of Anaesthesiology (ESA) annual meeting here to extend their demonstrated success in improving anesthesia safety to address the entire perioperative period. The goal: Reduce postoperative mortality by 20%.
Dr. Clergue, delivering the Sir Robert Macintosh Lecture, discussed the recent improvements in anesthesia care, which started in the 1980s when a series of surveys on safety were published. These surveys found intraoperative mortality rates of 2 per 10,000 cases in Finland and 1 to 4 instances of death or coma per 10,000 cases in France. Research found similar results across Europe. Analyses showed that equipment failures and disconnection accidents were not rare. “It suggested that with better equipment, we would prevent some of these catastrophes,” said Dr. Clergue, who is also head of Intensive Care Medicine. “Remember, at that time instrumental monitoring was applied to less than 50% of anesthetized patients.”
Epidemiological studies have since found that mortality has plummeted more than 10-fold from 1980 to the end of the 1990s, with current anesthesia-related mortality rates in both Europe and the United States between 4 and 8 deaths per million cases.
How did that happen? “We first had to change the mental model in which we had been educated,” Dr. Clergue said. “We had to admit that these errors are not so rare.” From that admission came a series of improvements that focused on three overall areas: the standardization of training, better medical equipment and drugs, and improved facilities (e.g., the postanesthesia care unit). Training was improved to reflect the new understanding of how errors occurred, and errors in selection, dilution and labeling of drugs were addressed by color-coding the drugs and making labeling easier to read. With the resultant diminution of accidents came reduced insurance premiums for anesthetists and a reduction in their malpractice claims, even in the United States. “I think we can be very proud,” Dr. Clergue said.
Positive Changes Mean Increased Demand
However, since anesthesia has become safer, the demand for anesthesia has increased dramatically. “About 7% of the European population was anesthetized in 1980, which increased to 13.5% in 1996.” The largest percentage increases in anesthetization have occurred in elderly patients, and the number of surgeries per population in many cases has doubled.
The challenge is to manage the explosion in demand for anesthesia. “The population growth over the last 30 years in Europe was about 16%, but during the same time the growth of anesthesia cases was 322%,” Dr. Clergue noted. This represents a staffing challenge. The density of anesthesiologists in Western Europe was 5.1 per 100,000 population in 1980; today, it is 16.2 per 100,000. That sounds good, but baby-boomer anesthesiologists are retiring: “Between 2012 and 2016, 2,000 French anesthesiologists will retire. The growth of the number of anesthesiologists was greater than the growth of the activity between 1980 and 1996, but during the next period, between 1996 and 2010, this was reversed.”
Countries will deal with this problem in different ways. Some European countries now allow nurse anesthetists to work unsupervised by anesthesiologists in the operating room, and this practice will increase as the decade progresses. Dr. Clergue emphasized the connection between staffing and safety. “An important challenge that we have for the next few years will consist of maintaining the present level of safety, but this can be done only if staffing is still growing and adapting to the increasing demand for anesthetics. If this is not the case, in 10 years, our staffing should increase by 50%, and in 20 years our staffing should double. Is that realistic?”
The Perioperative Challenge
For Dr. Clergue, the challenge for anesthesiologists over the next decade will be to tackle the problems of safety within the perioperative period with the same deliberation and success as the problems that were confronted back in the 1980s in intraoperative anesthesia safety.
“With the improvement in anesthesia safety, we have come to the present situation in which the indications for surgery have been extended to more severe patients. The result is that if anesthesia [remains] safer, postoperative mortality will remain unchanged, around 1.5%,” Dr. Clergue said “For the next decade, the major safety challenge of the surgical patient is to reduce postoperative complications. It is known that the first complications to appear postoperatively greatly increase the risk for death. Yet not many complications that begin in the postoperative period are directly related to anesthesia, so anesthesiologists might be wading into an area outside their direct control—perhaps, but not necessarily outside anesthesiologists’ direct influence.”
Anesthesiologists, together with surgeons, can embrace procedures that heighten safety. One such procedure is the implementation of the SURPASS (SURgical Patient Safety System) checklist (de Vries EN, et al. Qual Saf Health Care 2009;18:121-126) which averts preventable adverse events through the implementation of multidisciplinary checklists. In one study (de Vries EN, et al. N Engl J Med 2010;363:1928-1937), infection rates were reduced from 4.8% to 3.3% (P=0.006) and death rates from 1.5% to 0.8% (P=0.003) in hospitals that implemented the SURPASS program.
Dr. Clergue challenged his audience to reduce postoperative mortality by one-fifth by maintaining and improving levels of patient safety, ensuring adequate staffing, controlling demand for anesthetic agents, and embracing the additional oversight of the perioperative period. Anesthesiologists have proved that they are capable of analyzing safety procedures and implementing corrections, he said. The next decade should see those capabilities used to improve the full spectrum of perioperative care.