Pediatric anesthesiology 2016 reviews

Saturday Session I: Quality and Safety Panel

Dr. LaochamroonvorapongseReviewed by Dean Laochamroonvorapongse, MD, MPH
OHSU Doernbecher Children’s Hospital

This session was moderated by Lynn Martin, MD, MBA (Seattle Children’s Hospital) and featured two very different presentations with the shared goal of improving safety in the operating room.

The first presentation was “Types of Cognitive Errors” by Marjorie Stiegler, MD (University of North Carolina, Chapel Hill) and gave a broad overview of the difference between evidence-based decision making and the nuanced decision making that actually occurs in medicine.  Dr. Stiegler began her presentation by polling the audience to see who had been involved in a real code; not surprisingly, nearly everyone in the audience had participated in a code.  In high stress situations like a code, we cannot access all the knowledge in our minds.  Additionally, humans are not always rational and oftentimes do not make the statistically “right” decision, or the one with the highest expected value.  Dr. Stiegler emphasized that in medicine, knowledge about an individual patient and the expected outcome of their therapy is nearly always incomplete.  This combined with inconsistent patient preferences (regarding DNR, blood transfusion, etc.) means that decision making is rarely ever dichotomous.

Dr. Stiegler further explained that clinical decision making is influenced by one's personal, vicarious (i.e., learning about clinical scenarios from colleagues via their stories), and semantic (i.e., keeping up with the medical literature) experiences as well as evidence-based guidelines and risk calculators.  She then projected a slide with two rashes; on the left was a “classic” vesicular rash in a dermatomal distribution that the audience correctly identified as zoster.  This served as an example of intuition, the under the surface awareness that is “thinking without thinking.”  Intuition occurs when one has learned something early and often that it becomes obvious.  This acquisition of expertise through pattern learning/recognition is called heuristics, which are used on a daily basis in order to avoid analyzing everything we do.  In contrast, the rash on the right was less obvious, with many differing opinions as to the diagnosis.  Analytical thinking is required here, with further questioning regarding occupational exposures, travel history, and pets needed to narrow the possibilities. 

Dr. Stiegler then discussed the many reasons for cognitive errors.  Overconfidence, emotions, and stress (from taking care of VIP patients, etc.) all increase our likelihood of making mistakes.  Under periods of stress and uncertainty, availability bias can lead to cognitive errors.  Each individual anesthesiologist has been exposed to a different variety cases during their training.  Our minds pull forth the experiences that are most memorable and available, which influences our decision making during patient care.  According to Dr. Stiegler, memorable experiences include those that are novel, clinical scenarios told as a story and those cases with a surprise twist. 

As an example of how framing can lead to mistakes, Dr. Stiegler described the case of a woman with a history of multiple ED visits for panic attacks, who presented to the ED with shortness of breath in the context of her brother’s recent death.  She later died of a massive pulmonary embolism that developed during the long flight to her brother’s funeral.  Through the frame of this “frequent flyer” (pun intended) with panic attacks, her clinicians made a cognitive error and overlooked her recent travel history, which was a clear risk factor for PE.  Framing occurs every time one hands off a patient to a colleague in that we provide him or her with a small selection of data we believe is important in order to convince them about what is happening clinically.
Outcome bias is also a source of cognitive errors.  As an illustration of how favorable outcomes do not necessarily equate to high quality, Dr. Stiegler cited the fact that on average, drunk drivers make it home safely eighty times before finally getting arrested.  Like a roulette wheel, future probability for adverse outcomes is usually not influenced by past events.   As our profession moves increasingly outside of the OR to locations with less safety infrastructure in place, Dr. Stiegler emphasized need to be cautious in applying the same anesthetic practices to remote locations simply because "we've been doing things this way all along and nothing bad has happened."

Dr. Stiegler noted that failure to speak up when something potentially unsafe is occurring is a huge root cause for medical errors; this failure to speak up during potential errors is due to loss aversion, or the tendency for people to strongly prefer avoiding losses than acquiring gains.  In this situation, there is no public reward for medical personnel to speak up about potential errors, yet there is a huge loss of reputation for speaking up erroneously.  Dr. Stiegler suggested that hospitals change their internal culture into one where identifying and verbalizing potential errors and near-misses is encouraged and rewarded, even if it turns out in hindsight that no error was actually committed.

As OR based physicians, we are susceptible to feedback bias, which occurs when adverse outcomes (e.g., corneal abrasions, infiltrated IVs, central line infections) are never reported back to the anesthesiologist.  Dr. Stiegler explained that this leads us to believe that "no news is good news" and prevents future improvement in our individual anesthetic practice.  Despite this tendency, we are also influenced by recent negative experiences and alter our decision making and adherence to evidence-based during similar future events.  As an example of this, Dr. Stiegler cited a paper (J Am Geriatr Soc. 2012 Oct;60(10):1889-94) where surgeons' recent computer-simulated encounters of having a patient die of AAA rupture during a period of watchful waiting led them to operate sooner on subsequent patients despite the operative mortality risk being higher than the known risk of rupture.

To conclude her fascinating presentation, Dr. Stiegler provided the audience with tips on how to avoid committing cognitive errors.  Individuals with higher IQs (i.e., anesthesiologists) are less likely to recognize their own biases, thus creating a "bias blind spot."  She implored the audience to stop and think more during our routine clinical practices, and verify, for instance, that the anticipated hypotension after an induction dose of propofol is not actually due to myocardial ischemia or anaphylaxis.  In addition to this, imagining that the patient we are currently anesthetizing is being presented at a future M and M conference is a form of "prospective hindsight" that can help us discover clinical clues that were previously overlooked.  Cognitive aids and counterbalancing algorithms (e.g., the secondary survey in trauma, pediatric critical events checklist, MH poster in OR) can allow us to perform the way we intend to during high stress situations.  Finally, Dr. Stiegler advocated for the "nudge," which means structurally changing the clinical environment and workflow such that the safest decision is the easiest to perform and becomes the default.

"Making Connections in the OR," the second presentation, was given by Ron Litman, DO (Children's Hospital of Philadelphia).  He also serves as medical director for the Institute of Safe Medication Practices (ISMP).  Dr. Litman began his talk with a historical overview of the ubiquitous Luer lock syringe, which was created in Germany in 1896 by Karl Schneider and Hermann Adolf Wulfing-Luer.  In 1897, Luer traveled to the US and met Maximillian Becton and Fairleigh Dickinson (founders of BD), who commercialized his device and made the Luer the universal connection for many types of medical tubing. 

Dr. Litman then showed the audience a video of the 1988 Ramstein Air Show disaster, which killed 70 people.  The handling of this large-scale medical emergency was hampered by, among other things, incompatibility between syringes used by the American military and German paramedics (the tips had a 6% vs. 10% taper).  Despite this tragedy, the universality of the Luer connection and its ability to connect disparate types of tubing has proven to be a much greater problem.  For example, in 2011 there were 116 reported cases where enteral feeds were connected to intravenous lines.  Since no mandatory reporting guidelines exist, this is likely an underestimate.  Other misconnection examples include IV gadolinium contrast for MRI being injected into an external ventricular drain, IV phenylephrine injected into the epidural space, enteral feeds connected to tracheostomy suction tubing, and the connection of NIBP tubing to the needleless injection port of an IV line, leading to a fatal venous air embolus.

In 2006, the World Health Organization recognized this as a global public health issue and requested an industry standard from ISO; at the same time, The Joint Commission issued a Sentinel Event Alert entitled "Tubing connections- a persistent and potentially deadly occurrence."  In 2012, California passed Assembly Bill No. 1867 (CA 1867), which states that by January 2017, epidural and enteral connections are prohibited to fit into vascular connections.  Manufacturers such as Braun and BD are currently rushing to produce new products that adhere to this new standard.  Transitional connectors are also being temporarily produced so that existing hospital supplies can still be used until their stock is exhausted.

ISO 80369 is the standard for all small bore connectors 2-8.5mm wide.  The new ISO 80369 classification is as follows:

  • 80369-3: Enteral connectors (now called ENfit)
  • 80369-5: Limb cuff inflation connectors
  • 80369-6: Neuraxial connectors (now called NRfit)
  • 80369-7: Luer 6% taper 

Dr. Litman explained the many new safety features have been incorporated into these connectors.  For instance, ENfit connectors will be purple and ENfit syringes will have a purple barrel, whereas NRfit connectors will be yellow and NRfit syringes will have a yellow barrel.  Additionally, ENfit connectors are now rigid locking connectors, as opposed to the current "Christmas tree" type connectors, and the male NRfit syringe has a smaller tip that is very distinct from the male Luer syringe.  The NRfit syringe also has an outside cuff with prevents accidental IV injection into a female Luer connector.

Despite the huge improvement in patient safety resulting from the creation of the ENfit and NRfit connectors, there are many unresolved issues that remain.  At the beginning of his presentation, Dr. Litman polled the audience about their preferred technique for placing a single shot caudal block, and two-thirds of the audience routinely inject local anesthetic through an angiocath, which will not be acceptable starting in January.  New NRfit catheters may need to be created for caudal blocks.  Other unresolved issues include the need to reengineer syringes used for intrathecal chemotherapy, epidural blood patches, and Omaya reservoirs. 

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