Quality control and assurance in anesthesia: A necessity of the modern times

Abstract

The advent of newer developments in anesthesia techniques and current clinical scenario has necessitated assurance of quality anesthesia services delivery. Numerous factors including availability of newer drugs, availability of newer advanced monitoring gadgets, increased awareness among the patient population, implementation of newer medico-legal laws and professional competitiveness has mandated a quality control and assurance in anesthesia. These domains of quality control are adapted from public health and are being incorporated into daily anesthesia practice in a gradual and phased manner. Quality control and assurance can be assessed and measured with certain quality indicators, which are also helpful in determining the perioperative outcome in anesthesia and surgical practice. Patient's perception about various anesthetic procedures, drug effects and recovery state are the prime underlying basis for assessing the quality assurance and control. At the same time, a positive impact of feedback mechanism cannot be under-emphasized while aiming for improvement in delivery of quality anesthesia services. The current review is aimed at highlighting the important aspects associated with quality assurance and quality control in anesthesia practice.

INTRODUCTION

The advancements in anesthesia techniques, availability of newer drugs, availability of newer advanced monitoring gadgets, increased awareness among the patient population, implementation of newer medico-legal laws and professional competitiveness has necessitated assurance of quality anesthesia services delivery. Quality assurance has been defined as an organized process that assesses and evaluates health services to improve practice or quality of care.[1] The objective of quality assurance is to ensure a high standard of anesthetic care with a focus on patient safety during perioperative period, risk reduction and continuous quality improvement through rigorous self-examination.[2] Safety, effectiveness and patient's experience about the whole anesthetic procedure are important indicators to measure the quality of anesthesia in modern clinical practice.[3]

NEED FOR QUALITY ASSURANCE

In recent times, numerous innovative efforts have been made globally by anesthesia specialists in improving the methodology of measuring and reporting the quality of care delivered to patients. One of the important methods involves the feedback from patients and surgeons to improve the quality of anesthesia services.[2] A continuous vigil over the measurement of quality is essential, which can be gauged by an effective monitoring and thus can contribute to maintenance and improvement of standards of care.[4] Monitoring is essential to:

• To identify and understand the factors responsible for a variable level of quality care

• A continuous quest to identify and respond to various potential opportunities so as to improve standards of anesthesia care

• Finally, to measure the significance of changes effected by the concerned anesthesia services.[2]

The process of quality assurance is not complete by merely identifying measurable indicators. To support and improve the standards of quality control, the data collection methods should be meticulous with effective feedback. Transparency, reliability, measurability, flexibility to improvement and above all a scientific platform are the essential parameters for serving as an effective quality indicators.[2]

In 1979, Joint Commission on Accreditation of Hospitals (JCAH) introduced a quality assurance standard aimed at focusing all quality related functions on problem-solving and on their coordination into an organized comprehensive program. The underlying assumption was that if review efforts are focused on identifying problems in patient care and solving these problems, the end result will be that care will improve. The goal of this process is to demonstrate improvement in care or clinical performance through the resolution of important patient care problems.[5]

PERIOPERATIVE OUTCOMES

The process of measuring quality indicators and anesthesia outcomes is highly challenging and difficult in routine daily practice. There is no end to the number of quality indicators has been observed by various literary observations. In one of the systematic reviews, 108 quality indicators have been identified and the majority of them are considered to possibly influence the quality of anesthesia services. The remaining ones are also potentially helpful in measuring surgical and post-operative care.[2]

Indicators for quality of anesthetic care

A lot has been written and observed in routine anesthesia practice related to risks and safety concern in anesthesia practice.[6] The improvement in quality of anesthesia services can be brought about by following measures, which may include but are not limited to.

Adequacy of the pre-anesthesia evaluation

As per the recommendations of JCAH standards, this initial step requires the evaluation to be performed by a physician. This may be assessed through appropriateness of the choice of medication relative to the age of patient or type of procedure being performed.

Perioperative adequacy/quality of anesthesia services

Assessment of quality during perioperative period can be carried out by observing and recording any adverse event such as broken tooth, need for re-intubation and complications during difficult airway management, identification and management of cardiac and other complications related to co-morbid diseases, fluid overload and many others. Further, the quality can be assessed by identifying the timeliness of delivery of anesthesia services or the frequency of line infiltrates.

Post-operative adequacy/quality during recovery and discharge

Quality of the recovery care both in the recovery room and after discharge of patient may be evaluated by assessing post-surgical complications such as hypotensive episodes, arrhythmias, respiratory complications, intake-output ratio, temperature fluctuations or causes for any prolonged stay in the recovery room.

Adequacy/quality in anesthesia documentation and record updating

The quality of anesthesia documentation and record keeping can be measured from the information recorded during the pre-anesthetic visit. This include but is not limited to drug history, history of systemic diseases including allergies, adverse drug reactions, addiction history, previous anesthesia experience, current medications and so on. The adequacy of anesthesia care documentation can also be assessed during the actual surgical procedure and post-operative recovery room.[5]

It is essential to define and delineate the various indicators or parameters of care so that it becomes easy to monitor the quality of anesthesia services at a specified time period, which can be formulated and incorporated in the various standard operating procedures of the department and monitored at intervals specified by the department itself.[5]

It is the evidence and scientific based churning of various procedures and anesthesia techniques over the last few decades, which have brought a substantial improvement in anesthesia delivery systems. It has also enabled a significant reduction in mortality and morbidity associated with anesthesia to such an extent that mortality is considered an obsolete indicator of quality anesthesia care. One of the prime reasons for exclusion of this indicator form measurement of anesthesia quality is that mortality is a rare occurrence in modern day anesthesia practice and is frequently related to factors, which are beyond the control of an Anesthesiologist.[7]

Methods of quality improvement

Methods of quality improvement have also been mentioned in Miller's standard textbook of anesthesiology and can be summarized as.

Voluntary incident reporting

It involves providing means of incident reporting to the health-care providers and is considered to be an excellent method of quality improvement. Reporting of incidents, which might compromise safety of the patients as well as the health-care providers forms the basis of formulating policies and plans for improvement of services.[8]

Multidisciplinary approach

This requires a structured program with a shared goal between multidisciplinary participants within the clinical area, across clinical areas or across multiple health-care organizations to improve care.[8] It involves:

• Identifying evidence-based interventions associated with improved outcome

• Select goal-oriented interventions that have the biggest impact on outcomes

• Develop and implement measures that evaluate either the intervention or the outcomes

• Measure baseline performance

• Administering the required interventions through engagement, education, execution and evaluation.

Comprehensive unit based safety program

It is a six step program to improve the quality in intensive care units by learning from mistakes and improving culture.[8] The steps include:

• Measuring safety culture: Assessing safety culture amongst the staff using the safety attitudes questionnaire

• Presenting educational material: Through lectures and other educational techniques

• Forms to identify patient safety issues using questionnaires

• Assigning a senior executive responsible for a specific area: Who helps prioritize safety efforts, remove barriers for system changes, provide resources and foster relationships with staff

• Implementing projects: With a focus on two to three issues

• Repeat measurement of safety culture.

Quality improvement tools

Including daily goal sheets, briefings and debriefings and checklists.[8]

PERCEPTION OF ANAESTHESIA QUALITY: PATIENT'S PERSPECTIVE

Quality of anesthesia is closely related to the incidences of pain, nausea and vomiting and overall experience during the recovery period after the surgical procedure. Measurement of such attributes and parameters requires evidence based support in the form of objective scales along with subjective perceptions tested on the basis of multiple dimensions by the primary examiner.[9] Globally, numerous attempts have been made at 1 time or the other and in a quest to assess post-operative patient satisfaction; multiple questionnaires have been developed and validated during the course of these scientific studies by the respective researchers.[10,11,12,13,14,15,16] Quality of recovery can be assessed by a nine point scale formulated by Myles et al., which includes items derived from a larger 40-item measure such as: General well-being, support from others, understanding of instructions, respiratory function, bowel function, nausea and pain and many others.[16,17]

Post-operative nausea and vomiting and post-operative pain are considered the two most important parameters for assessment of quality of recovery during the post-operative period. Numerous studies have quoted different techniques for prevention of nausea and vomiting during the post-operative period as well as during the discharge from the hospital in day care surgeries.[18] However, the scientific reliability and validity can be assessed only after examining in a large number of patients as these adverse effects have a strong negative influence on patient satisfaction.[19] Moreover, these adverse outcomes are interrelated and dependent on the balance between analgesic and antiemetic properties of the anesthetic drugs and techniques, patient characteristics and the nature and duration of surgical procedure. Pain in post-anesthesia care unit can be measured by using a variety of scales such as visual analog scale, numerical rating scale, verbal rating scale and behavioral scale, which is a matter of subjective comfort.[20] Post-operative pain relief has been studied extensively in the last two decades resulting in development of newer effective strategies and techniques to relieve the same. The enthusiasm of fighting with this perioperative and post-operative menace can be gauged from the fact that numerous societies of pain relief have come up globally in the last two decades. These societies and associations are working tirelessly in bringing advancements in our understanding of pathophysiologic basis of pain as well as modalities to treat the same in simplest of the manners.

FEEDBACK: AN ESSENTIAL COMPONENT OF ASSURANCE

The information and data obtained from quality indicators is helpful in identifying variations in the quality of care provided. These variations and data have to be converted into suitable tool for further improvement in quality of anesthesia care.[21] The quality of monitoring system related to quality control cannot be improved beyond certain limits if feedback is missing. Providing feedback generally results in small to moderate positive effects on professional practice.[22] The improvement initiatives and measures, which keep the feedback reports out of their domain are usually less effective as compared with those which use feedback reports, regardless of the fact that this is accompanied by an implementation plan or not.[23,24] Certain barriers do exist, which can impede the information available from feedback such as lack of trust in data quality, lack of intensity of feedback and lack of motivation. The success of feedback mechanism is highly dependent upon these factors, which include but are not limited to appropriate timeliness, dissemination of information, trust in data quality and having a confidential or non-judgmental tone.[25]

To bring an organizational behavior change, simple information dissemination alone is rarely effective especially in intense atmosphere of operation theatres and intensive care units. Quality of anesthesia care can be improved by implementation of multifaceted interventions that may involve educational components rather than simple passive interventions. However, vigil should be exercised in identification and removal of barriers to quality improvement that may include unawareness, lack of credible data, lack of supportive local management and lack of hospital resources.[23]

Remedial actions need to be taken once the cause of a problem is identified by the individuals entrusted with the responsibility to take corrective measures. Adjustments in departmental policies and procedures, in service programs, staffing or systems or change in equipment should be carried out as necessary. These indicators can also be helpful in the appraisal of each staff member's performance.

For an effective and sustained quality improvement in anesthesia services, attention should be paid to the problems, which have been identified and addressed so as to make sure they are resolved or reduced permanently. To prevent the recurrence of the problem, follow-up and monitoring the concerned problem is essential as it is considered to be one of the prime indicators of anesthesia care.

This on-going process of monitoring and problem-solving is the nucleus of a hospital quality assurance program. As such enthusiastic and effective efforts should be made to assist each clinical support service and if the relevant information is shared and acted upon among other hospital-wide or medical staff functions, the outcome of better patient care can be achieved.[5] There is an increasing need felt to motivate the fellow colleagues as that can help immensely in bringing about an organizational change. An in-depth analysis of motivational factors in the health industry can also contribute largely in bringing about qualitative changes in the anesthesiology practice.[26]

DISCLOSURE TO PATIENTS AND RELATIVES

Patients or relatives of the patient should be duly informed regarding any untoward perioperative incident, which might have occurred during the conduct of anesthesia, which may result in complications, immediately or at some time in the future or which may cause undue distress to the patient when detected.[27,28] Usually, it is considered to be the primary duty of attending anesthesiologist who is involved in the incident to narrate the entire incident himself rather than prompting others to make a statement or communication. The communication should be made as soon as the incident is recognized and anesthesiologist should ensure that the patient is physiologically and psychologically able to receive information. If it is not possible to communicate with patient, the first communication should be made with the patient's family or caregiver(s) who will be making proxy decisions on behalf of the patient.

CONCLUSION

The concepts of quality assurance and quality control are rapidly gaining popularity in surgical sciences as the society is heading toward social, technical and clinical advancements globally. In coming times, quality of anesthesia services will be largely monitored by quality indicators and will determine the perioperative outcome. A possible change of large magnitude is expected to take place in anesthesia practice for the betterment of humanity in the near future. At present, the need of the hour is to adopt these evolutionary practices aimed at improving anesthesia delivery services.