Chapter 1 Scope of Anesthesia Practice
Evolution of anesthesia as a multidisciplinary medical specialty
6. Name the four subspecialties of anesthesiology that require an additional certification process from the American Board of Anesthesiology (ABA).
7. In pain management, anesthesiologists are usually part of a multidisciplinary team. Name some of the other specialties that provide services that support pain management.
8. Describe an open versus a closed critical care unit.
9. Which other anesthesia subspecialties are evolving toward a separate certification process?
10. What factor dictates whether some institutions have subspecialized anesthesia teams? Give an example of two such teams.
Training and certification in anesthesiology
15. What subspecialties are studied in the clinical anesthesia postgraduate training years (years 1 to 3)?
16. Describe the fundamental steps that lead to being a “board-certified anesthesiologist.”
17. What is the emphasis of the Maintenance of Certification in Anesthesiology (MOCA)?
18. What are other anesthesia specialties that the ABA certifies?
19. Name the three new professional performance concepts developed by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties.
Quality of care and safety in anesthesia
21. The Joint Commission provides quality improvement guidelines in anesthesia for health care organizations. What three fundamental areas do these guidelines address?
22. Continuous quality improvement (CQI) programs may focus on both critical incidents and sentinel events. Describe critical incidents versus sentinel events.
23. What are some of the key factors in preventing patient injuries related to anesthesia?
24. Provide two examples of Patient Safety Practices and the Suggested Penalties for Failure to Adhere to the Practice as published in the New England Journal of Medicine.
Organizations with emphasis on anesthesia and safety
25. Anesthesia has the distinction of being the only specialty in medicine with a foundation dedicated to issues of safety in patient care. Name the foundation.
26. Which organization provides a retrospective database of patient and safety data that can be used to assess and improve patient care?
27. Which organization investigates legal cases as a vehicle for identifying patient and practice areas of risk?
28. Name the foundation that provides research support in anesthesia.
Professional liability
29. This chapter states that 93 claims were filed in the United Kingdom in the years 1995 to 2007. What two areas of patient care and safety did these claims emphasize?
30. What is the anesthesiologist’s best protection against medicolegal action?
31. What actions should the anesthesiologist take in the event of an accident?
Risks of anesthesia
32. What is the estimated mortality rate from anesthesia?
33. What are some of the factors that have contributed to the decrease in anesthesia-related deaths?
34. What is the anesthesiologist’s greatest anesthesia patient safety issue?
35. Vigilance accounts for a large proportion of avoidance of adverse anesthesia events. What are some of the factors in the operating room environment that diminish the anesthesiologist’s ability to perform the task of vigilance?
Answers*
Introduction
1. In the early 19th century, the concept of providing analgesia and eventually anesthesia became increasingly possible. (11)
2. The major emphasis was initially on surgical anesthesia, which evolved into airway management including endotracheal intubation, which led to the development of critical care medicine, regional anesthesia, and pain medicine. (11)
3. The The two organizations whose approval allowed anesthesia to be recognized as a medical specialty are the American Medical Association and the American Board of Medical Specialties. (11)
Definition of anesthesiology as a specialty
4. The American Board of Anesthesiology defines anesthesiology as a discipline within the practice of medicine that deals with:
5. As with other medical specialties, anesthesiology is represented by professional societies (American Society of Anesthesiologists, International Anesthesia Research Society), scientific journals (Anesthesiology, Anesthesia and Analgesia), a residency review committee with delegated authority from the Accreditation Council for Graduate Medical Education to establish and ensure compliance of anesthesia residency training programs with published standards, and a medical specialty board, the American Board of Anesthesiology, which establishes criteria for becoming a certified specialist in anesthesiology. Other countries have comparable systems of training and certifying mechanisms. (12)
Evolution of anesthesia as a multidisciplinary medical specialty
6. In addition to board certification in anesthesiology, the American Board of Anesthesiology has an additional certification process for pain management, critical care medicine, hospice and palliative medicine, and sleep medicine. (12)
7. Many other supportive services are involved in the pain management specialty of anesthesia, including neurology, medicine, psychiatry, and physical therapy. (12)
8. Regarding critical care units, usually a “closed” system means that full-time critical care physicians take care of the patients. An “open” system means that the patient’s attending physician continues to provide the care in the intensive care unit (ICU). (12)
9. The American Board of Pediatrics and the American Board of Anesthesiology have commenced a combined integrated training program in both pediatrics and anesthesiology that would take 5 years instead of the traditional 6. In addition, cardiac anesthesiologists who now serve both pediatric and adult cardiac patients may move toward a separate certification process. (12)
10. Institutional patient volume in a given specialty often dictates whether only subspecialized anesthesia teams can administer anesthesia to these patients. Two examples may be obstetric or neurosurgical anesthesia teams. (13)
Perioperative patient care
11. Preoperative care includes preoperative evaluation, preparation in the immediate preoperative period, intraoperative care, postanesthesia care unit (PACU), acute postoperative pain management, and possibly the ICU. (13)
12. Initially preoperative clinics were formed when patients were no longer admitted to the hospital the day before surgery. Also the increased complexity of patient medical risks and surgical procedures prompted the creation of preoperative clinics that allowed patients to be evaluated before the day of surgery. These clinics should be multidisciplinary and lead by anesthesia. (13)
13. The pathway includes preoperative evaluation, the accuracy of predicting length and complexity of surgical care, and patient flow in and out of PACUs. (13)
14. Throughput is the term used to describe the efficiency of each patient’s perioperative experience. This can be influenced by such things as operating room availability, length of surgery scheduling times, availability of beds in the PACU, and many other issues. At some institutions perioperative or operating room directors are appointed to manage this perioperative process. (13)
Training and certification in anesthesiology
15. All aspects of clinical anesthesia are covered in postgraduate training for anesthesia, including obstetric, pediatric, cardiothoracic, neuroanesthesia, anesthesia for outpatient surgery, recovery room care, regional anesthesia and pain management, as well as training in critical care medicine. (13)
16. To become a certified diplomate of the American Board of Anesthesiology, one must complete an accredited postgraduate training program, pass a written and oral examination, and meet licensure and credentialing requirements. (14)
17. MOCA emphasizes continuous self-improvement and evaluation of clinical skills and practice performance to ensure quality and public accountability. In 2000, board certification became a 10-year, time-limited certificate that emphasizes participation in MOCA. (14)
18. Pain Management, Critical Care Medicine, Hospice and Palliative Medicine, and Sleep Medicine are issued to diplomats who have completed 1 year of additional postgraduate training in the respective subspecialty, meet licensure and credentialing requirements, and pass a written examination. (14)
19. Evaluation of a clinician’s professional performance now includes data regarding General Competences, Focused Professional Practice Evaluation, and Ongoing Professional Practice Evaluation. (14)
Other anesthetic providers
20. The certified registered nurse anesthetist (CRNA) must first be a registered nurse, spend 1 year as a critical care nurse, and then complete 2 to 3 years of didactic and clinical training in the techniques of administration of anesthetics in an approved nursing training program. The anesthesiologist assistant completes a graduate level 27-month program leading to a master of science degree in anesthesia. (14-15)
Quality of care and safety in anesthesia
21. The Joint Commission guidelines evaluate quality of care based on the measurement and improvement of these areas:
22. Critical incidents (e.g., ventilator disconnection) are events that cause or have the potential to cause injury if not noticed and corrected in a timely manner. Measurement of the occurrence rate of important critical incidents may serve as a substitute for rare outcomes in anesthesia and lead to improvement in patient safety. Sentinel events are isolated events that may indicate a systematic problem (e.g., syringe swap because of poor labeling, drug administration error related to keeping unneeded medications on the anesthetic cart). (15)
23. Some key factors for the prevention of patient injury in anesthesia are vigilance, up-to-date knowledge, and adequate monitoring. (15)
24. The following examples of patient safety practices and suggested penalties are from Table 2-1, page 16. The Patient Safety Practice is listed first, followed by the suggested initial penalty.
Organizations with emphasis on anesthesia and safety
25. The Anesthesia Patient Safety Foundation (APSF) is dedicated to patient safety issues and has a quarterly newsletter that provides discussion on this topic. (15)
26. The Anesthesia Quality Institute (AQI) is the primary source of information for quality improvement in the practice of anesthesiology. AQI provides the National Anesthesia Clinical Outcomes Registry (NACOR) on its website. (16)
27. The American Society of Anesthesiology Closed Claims Project is a retrospective analysis of legal cases with adverse outcomes. Its investigations have helped identify patient and practice risk areas that tend to have difficulties and require added attention with regard to quality and safety. (16)
28. The Foundation for Anesthesia Education and Research (FAER) encourages research, education, and scientific innovation in anesthesiology, perioperative medicine, and pain management. (16)
Professional liability
29. The majority of the 93 claims in the United Kingdom from 1995-2007 involved drug administration errors with muscle relaxants being the most common issue. The second area involved being awake and paralyzed. (16)
30. Besides continuing medical education, the anesthesiologist should be thoroughly knowledgeable of the patient’s condition and care. This includes preoperative and postoperative visits, as well as detailed records of the course of anesthesia. (17)
31. The anesthesiologist should promptly document the facts on the patient’s medical record and immediately notify the appropriate agencies, particularly one’s own medical center administration and legal office. In addition, the anesthesiologist should provide the hospital and the company that writes the physician’s professional liability insurance with a complete account of the incident. (17)
Risks of anesthesia
32. Currently, it is estimated that the mortality rate from anesthesia is approximately 1 in 250,000 patients. (17)
33. The increased safety of anesthesia is presumed to reflect the introduction of improved anesthesia drugs and monitoring, as well as the training of anesthesiologists. In addition, motivating patients to stop smoking, lose weight, avoid excess intake of alcohol, and achieve optimal medical control of essential hypertension, diabetes mellitus, and asthma before undergoing elective surgery has led to a decrease in anesthesia-related deaths. (17)
34. Difficult airway management is perceived to be the greatest anesthesia patient safety issue. Other examples of possible adverse outcomes besides death include peripheral nerve damage, brain damage, airway trauma, intraoperative awareness, eye injury, fetal/newborn injury, and aspiration of gastric contents. (17)
35. Prominent among the factors are sleep loss and fatigue with known detrimental effects on work efficiency and cognitive tasks (monitoring, clinical decision making). (17)
Hazards of working in the operating room
36. Anesthesiologists are exposed to vapors from chemicals, ionizing radiation, and infectious agents. There is psychological stress from demands of the constant vigilance required for patients under anesthesia. In addition, interactions with members of the operating team may introduce varying levels of interpersonal stress. Other hazards include latex sensitivity from exposure to latex gloves, substance abuse, mental illness and suicide, and infection control. (18)
Summary and future outlook
37. Responsibilities of the anesthesiologist have grown in magnitude, scope, and depth. Anesthesia has become a leading specialty with regard to inpatient medicine, especially in the perioperative period including critical care and pain medicine. The specialty will become more valuable to medicine overall by attempting to anticipate future societal needs and continuing to dedicate its members to the pursuit of excellence. (18)
