Pre-use anesthesia machine check; certified anesthesia technician based quality improvement audit

Abstract

Context:

Quality assurance of providing a work ready machine in multiple theatre operating rooms in a tertiary modern medical center in Riyadh.

Aims:

The aim of the following study is to keep high quality environment for workers and patients in surgical operating rooms.

Settings and Design:

Technicians based audit by using key performance indicators to assure inspection, passing test of machine worthiness for use daily and in between cases and in case of unexpected failure to provide quick replacement by ready to use another anesthetic machine.

Materials and Methods:

The anesthetic machines in all operating rooms are daily and continuously inspected and passed as ready by technicians and verified by anesthesiologist consultant or assistant consultant. The daily records of each machines were collected then inspected for data analysis by quality improvement committee department for descriptive analysis and report the degree of staff compliance to daily inspection as “met” items. Replaced machine during use and overall compliance.

Statistical Analysis Used:

Distractive statistic using Microsoft Excel 2003 tables and graphs of sums and percentages of item studied in this audit.

Results:

Audit obtained highest compliance percentage and low rate of replacement of machine which indicate unexpected machine state of use and quick machine switch.

Conclusions:

The authors are able to conclude that following regular inspection and running self-check recommended by the manufacturers can contribute to abort any possibility of hazard of anesthesia machine failure during operation. Furthermore in case of unexpected reason to replace the anesthesia machine in quick maneuver contributes to high assured operative utilization of man machine inter-phase in modern surgical operating rooms.

INTRODUCTION

Daily standard systemic before use, anesthesia machine checking is an essential procedure and it has been discussed in many papers.[1,2,3,4,5] The aim of this paper is to evaluate, through the use of certified privileged anesthesia technicians (CAT), an audit of pre-use check. This audit is based on verifying recording of activities concerning; (1) anesthesia machine inspection. (2) Self-checking part and manual part of anesthesia machines check. These checks are done by CAT and supervised and signed by anesthesiologists. Anesthesia equipment failures may contribute to anesthetic difficulties leading to potentially to operative morbidity and mortality. The recorded case reports may hint to incidents but cannot reflect correctly these problems. There are many reported guidelines by professional organizations advising anesthesiologists; preuse and in-between anesthesia machine check list. Modern anesthesia machine incorporate self-checking program complemented by personnel check to insure operability of these machines. Recording and authentications can be part of the process to improve operative patient safety.

The paper is based on an audit of the process of preuse check of anesthesia machine which is two parts; (1) self-checking part and (2) staff performed anesthesia machine check, in which anesthesia-related data are recorded from all surgical operating areas. The results showed a positive compliance of checking, recording of daily preuse anesthesia machine check. Emergency plan to change any anesthesia machine by another anesthetic machine in working readiness.

MATERIALS AND METHODS

The anesthesia machine, in use in the department has a self-checking part and complementary operator check. Both parts should be recorded as document of auditing performance of our anesthesia practice constitutes a record of safe inter action between man and machine and carried assurance of baseline safety basic use of the machine in OR.

To fulfill the criteria of the checklist over time, we are reporting the last 10 months and present the result of our audit to demonstrate the degree of compliance of our staff with safety measures adopted by our department provide anesthesia machine in working order over the hours of the day.

The anesthesia technician performed the initial checking of the anesthesia machine and sign. The anesthesiologist will come later and do his/her part of checking to determine the machine is ready to be used.

The anesthesia machine is checked through ticking every single component of the machine for every single requirement when it meets the standard of checking. Other criteria of checking include the safety in case of failure or malfunction of the anesthesia machine during the surgical procedure.

The checking of the anesthesia machine is usually done in the early morning of the day prior to the commencement of the scheduled list.

Checking of the anesthesia machine is an essential procedure to confirm the full readiness to start the operative list. Technician: He/she will do the initial checking of the anesthesia machine and signs for that checking.

Anesthesiologist: Will come later and do his/her part of checking and then sign for absulance determination of the machine is ready to be used. Any checking to be ticked will be recorded as 1 when it meets the requirement; if not it will be recorded as 0.

The person in charge of machine reports the machines checking in their areas with filled out checklist forms and send them to the secretary to analyze.

Method: How the check is done? The anesthesia machine is checked through ticking every single component of the machine for every single requirement when it meets the standard of checking. Other criteria of checking include the safety in case of failure or malfunction of the anesthesia machine during the surgical procedures. When it is done? The checking of the anesthesia machine is done in the early morning of the day prior to the commencement of the scheduled list. Why? The checking of the anesthesia machine is an essential procedure to confirm the full readiness to start the operative list. There are eight observation headings and related subheadings and procedures of checking's: (1) Prior usage and appearance. (2) General impression of readiness. (3) Power electricity and anesthetic gases supply. (4) Machine breathing system with its components. (5) Suction unit. (6) Hemodynamic monitoring readiness. (7) Anesthetic machine overlook: Operational or not. (8) Anesthetic machine drawers inspection.

By whom? Technician: He/she will do the initial checking of the anesthesia machine and signs for that checking. Anesthesiologist: Will come later and do his/her part of checking and then sign for absulance determination of the machine is ready to be used. What is recorded? Any checking to be ticked will be recorded as 1 when it meets the requirement; if not it will be recorded as 0. Who does the report? The person in-charge will report the machines checking in their areas with filled out checklist form and send it to the secretary to analyze. Items to be checked are presented in Figure 1.

Figure 1.

Anaesthesia machine checklist

RESULTS

The monthly and year results are numerically, presented in the Table 1 and also presented in the Appendix 1.

Table 1.

Anesthesia machine audit 2011

There were a total of 11,001 checking events during the year under study. There were 10,812 (98.3%) fully met criteria, 189 (1.70%) not-met criteria and 3 (0.03) machine replacement events [Table 1].

This indicates high compliance with required implementation of key performance indicators measured with the audit form as reflected in all theaters in the hospital [Figure 2]. Steps of CAT in watching self checking of the machine and personal check are in [Figure 3]. While Figure 4 show the maneuvere of changing anaesthesia machine connected to system in failure with a new ready to work machine

Figure 2.

Graph showing overwhelming percentage of meeting all quality indicators in machines readiness over the period of study and all theatres in the hospital

Figure 3.

(a) Workstation self check (b) Certified Anaesthesia Technician (CAT) visual check of each machine

Figure 4.

Machine change over in case of failure in use

DISCUSSION

Modern surgery including anesthesia practice demands ultimate safe practice standards.[2] Modern anesthesiology is so safe today due to new advances in developing clean very predictable drugs and inhalational drugs allowed using safe technique but did not reduce dependence on modern anesthesia machines as workstations utilizing gas delivery system, circuits, ventilator and monitoring devices. This introduces new risk factors related to machine failure or human factors.

Many authorities addressed safety issue and variable risk potentials related to it.[2,3,4,5,6,7,8,9,10,11] The issue of anesthetic mishaps during surgery; human error and insufficient pre-anesthetic checking of the anesthesia machine are a recurring theme. Clinical studies[12] also found that human error was responsible for 65% of the incidents “with failure to perform a pre-anesthetic check, the most common associated factor.” Another study[13] noted that 31% of equipment problems involved the anesthesia machine and breathing circuit, with the main cause of human error being insufficient checking of the anesthesia machine before use, especially between cases. They stated, “In our study, human error was the main contributing factor in one-quarter of cases and most of these involved the anesthesia machine. The main cause was insufficient checking of the anesthesia machine before use, especially between cases.” The possibility for error and cause for concern regarding anesthesia machine checks are very clear.

In the issue of checking anesthesia was demonstrated in a conference in (USA) showing that machine checking was demonstrated to be easy and should be methodological.[14] The participants were 190 people attending an anesthesia meeting were given 10 min to detect five created faults in a standard anesthesia machine. The average number of faults that were detected was 2.2. Professional background did not influence the score, although the ability increased with those practitioners with more than 10 year experience. In an effort to reduce or eliminate anesthetic mishaps related to anesthesia machine problems, pre-operative checklists have been developed to assure proper functioning of equipment. The Food and Drug Administration released a checklist in 1986 which it revised in 1992.[15] Professional organizations and anesthesia machine manufacturers have also developed such checklists.[16,17,18,19,20] 


Although few studies have been performed recently, several have suggested that some practitioners are not well able to detect preset anesthesia machine faults.[16,17] About 2% of the closed claims have resulted from gas delivery equipment, with death and permanent damage in 76% of the outcomes. A recent case-control study of anesthesia management characteristics on severe morbidity and mortality demonstrated equipment check with protocol and checklist (odds ratio: 0.64) and documentation of the equipment check (odds ratio: 0.61) was significantly associated with decreased risk.[18] This study was undertaken to see if there has been any improvement in the ability of practitioners to detect preset anesthesia machine faults and if duration of practice is related to the ability to detect such faults.[19,20,21,22,23]

CONCLUSION

Checking the anesthetic machine before daily use and between cases is an essential set up procedures. The aim of our project was to evaluate, through the use of checklist and to record the result of build in, self-checking of the machine. The analysis is built on weekly reports of the result.

This technical report describes the documentation and surveillance of pre-use anesthesia machine self-check process and anesthesia technician's complementary visual inspection performed routinely with readiness of replacing any machine during operation in case of failure. The assurance up set requirement as quality indicators capable of measuring and displaying.

The importance of auditing is to assure and re-assure that the job is done according to the highest standards of patient safety. The achieved results are very encouraging and promising to continue the filling of audit forms to achieve 100% compliance and zero error in safe practice of anesthesia. We demonstrate the improvement of quality is maintained in accordance with the King Fahad Medical City Mission. Our objective in Anesthesia Department is to minimize the risk to patient near zero and not to tolerate mistakes with highly compliant staff by adopting Manufacturer's guidelines.

APPENDIX 1

KING FAHAD MEDICAL CITY

Administration of Anesthesiology and Operating Rooms

Machine Preparation Audit (Primus)

2012 Quarterly and Year-End Reports