POSTER DISCUSSION 1 Patient Safety. DISCUSSION DES AFFICHES 1 Sécurité des patients

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1 CAS 2013 Abstracts supplement POSTER DISCUSSION 1 Patient Safety Chair: Dr Daniel Chartrand, Department of Anesthesia, McGill University, Montreal, QC Sunday June 23 09:00 10:45 Chinook 1 Supplément des résumés 2013 de la SCA DISCUSSION DES AFFICHES 1 Sécurité des patients Président : Dr Daniel Chartrand, Département d anesthésie, Université McGill, Montréal, QC Dimanche 23 juin 9 h à 10 h 45 Chinook IMPROVING CLINICAL PERFORMANCE USING REHEARSAL AND WARM-UP: A SYSTEMATIC REVIEW OF RANDOMIZED AND OBSERVATIONAL STUDIES Presenter: James O'Leary, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON Co-authors: Owen O'Sullivan, Paul Barach, George D Shorten OBSTRUCTIVE SLEEP APNEA AND POSTOPERATIVE COMPLICATIONS Presenter: Thomas Mutter, University of Manitoba, Winnipeg, MB Co-authors: Dan Chateau, Michael Moffatt, Clare Ramsey, Leslie Roos, Meir Kryger THE IMPACT OF SHORTAGES ON DRUG UTILIZATION AND OUTCOME Presenter: Gregory Bryson, Anesthesiology, The Ottawa Hospital, Ottawa, ON Co-authors: Alan D Baxter, Alan J Chaput, Christopher L Pysyk, Alan J Forster IMPROVING THE DOCUMENTATION OF CENTRAL VENOUS CATHETERS USING A QUALITY IMPROVEMENT APPROACH. Presenter: Paul Korchinski, Anesthesiology, University of Saskatchewan, Saskatoon, SK Co-author: Joann Kawchuk THE STERILITY OF PHENYLEPHERINE HYDROCHLORIDE SOLUTIONS AS PREPARED BY ANESTHESIOLOGISTS Presenter: Shahdi Henein, University of Calgary, Calgary, AB Co-authors: Alexander J Gregory, Jan Davies 3

2 IMPROVING CLINICAL PERFORMANCE USING REHEARSAL AND WARM-UP: A SYSTEMATIC REVIEW OF RANDOMIZED AND OBSERVATIONAL STUDIES James O'Leary 1, Owen O'Sullivan 2, Paul Barach 3, George D. Shorten 2 1. Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada 2. Department of Anaesthesia, University College Cork, Cork, Ireland 3. Department of Perioperative Care and Emergency Medicine, University Medical Center Utrecht, Utrecht, Netherlands Introduction: Deficiencies in patient safety and quality improvement have become an increasing concern with growing complexity of patient care. Safe medical care requires that patient interventions be performed by highly skilled operators supported by engaged teams. There is considerable evidence for the contribution of simulation training to quality and impact of team performance (1). Preoperative rehearsal and warm-up, however, have only recently been investigated as potential methods of improving operator and team performance. The purpose of this systematic review is to determine if rehearsal or warm-up prior to performing complex clinical procedures on patients can improve task performance as measured by assessing the technical and non-technical skills of the operators and teams. Methods: We performed an electronic literature search of MEDLINE (via OVID), EMBASE, Cochrane Controlled Trials Register, ISI Web of Knowledge and for published and unpublished studies between 1975 and October Titles and abstracts were reviewed, followed by a full-text review where appropriate, to identify randomized controlled or observational trials that evaluated the effect of formal rehearsal or warm-up on task performance immediately prior to performing complex clinical procedures. Two reviewers used a standardized form to independently abstract data. Differences between reviewers were reconciled by consensus. Results: The potential benefits and optimal methods for performing rehearsal and warm-up have not been established. Our search identified 1886 citations, of which 20 articles were initially considered for eligibility and underwent a full-text review. All included studies (n = 7) reported that rehearsal and warm-up by operators or teams performing endovascular and laparoscopic surgeries is feasible. Only two RCTs, Calatayud et al. and Lee et al. objectively demonstrate that warm-up prior to laparoscopic surgery improves technical performance (2, 3). There were no objective estimates of the effect of rehearsal on operator, team or patient outcomes in the reviewed studies. Discussion: Our review demonstrates that rehearsal practiced by operators and teams performing endovascular and laparoscopic surgeries is feasible. However, the potential benefits related to the quality of performance, improved patient safety and optimal methods of performing rehearsal and warm-up prior to performing procedures on patients remain unknown. There is insufficient evidence to support the routine use of rehearsal or warm-up by operators prior to performing complex clinical procedures. Future research should aim to provide evidence for both low- and high- fidelity rehearsal and warm-up, in distinct domains of mental agility, technical skills and non-technical skills. References: 1.Ann Surg : Ann Surg : J Endourol :

3 OBSTRUCTIVE SLEEP APNEA AND POSTOPERATIVE COMPLICATIONS Thomas C. Mutter 1, Dan Chateau 1, Michael Moffatt 1, Clare Ramsey 1, Leslie Roos 1, Meir Kryger 2 1. University of Manitoba, Winnipeg, MB, Canada 2. Yale University School of Medicine, New Haven, CT, United States Introduction: Importance: Obstructive sleep apnea (OSA) is common in surgical patients and may increase the risk of postoperative complications, especially when undiagnosed and untreated (1). Objective: To better inform the perioperative management of OSA patients by determining the relative importance of undiagnosed OSA, diagnosed OSA, OSA severity, medical comorbidities and the type of surgery in predicting clinically important postoperative cardiovascular and respiratory complications. Methods: Design, Setting and Participants: Local research ethics board approval was obtained. Matched cohort study with analysis of health administrative data and polysomnography data from a clinical database. Postoperative outcomes in OSA patients up to 5 years before (undiagnosed OSA, n = 1,571) and any time after (diagnosed OSA, n = 2,640) polysomnography were compared to controls without an administrative data diagnosis of sleep apnea (n = 16,277). Controls were matched by exact procedure, indication and approximate date of surgery. All surgical procedures on patients at least 18 years old between April 1, 1987 (at which time the recording of complications on hospital discharge abstracts began) and March 31, 2008 (the last fiscal year of data before routine postoperative monitoring for OSA patients was widely adopted locally). Follow up was at least 7 postoperative days. Main outcome measures: Respiratory complications (adult respiratory distress syndrome, respiratory failure or pneumonia) and cardiovascular complications (cerebrovascular accident, acute coronary syndrome, atrial fibrillation or shock and cardiac arrest), were reported as odds ratio [95% confidence interval] for OSA or subgroup versus controls. Results: Results: In multivariate analyses, OSA predicted increased risk of respiratory complications (2.08 [ ], p <0.001), with no significant difference between diagnosed and undiagnosed OSA (p = 0.41). The risk of cardiovascular complications, primarily cardiac arrest and shock, was significantly different (p = 0.004) between undiagnosed OSA (2.20 [ ], p = 0.02) and DOSA patients (0.75 [ ], p = 0.29). For both outcomes, more severe OSA was associated with increased risk (p < 0.05 for trends). Finally, the type of surgery (major (2), emergency, associated with respiratory failure (3)) and patient characteristics (age, Charlson comorbidity index score (4), revised cardiac risk index score (5), chronic obstructive pulmonary disease) were also important independent predictors. Discussion: Multivariate models developed here should guide future research, improve preoperative risk stratification and assist in clinical decision making in patients with UOSA and DOSA presenting for surgery. Age, comorbid disease, the type of surgery and the severity of OSA are inadequately represented in current perioperative management guidelines(6,7) for OSA patients. Unless high-level evidence to the contrary emerges, it may be beneficial to preoperatively diagnose and initiate CPAP therapy in patients with more severe UOSA, in order to prevent significant cardiovascular complications. References: 1. Anesth Analg 2008;107: J Am Coll Cardiol 2007;50:e Ann Surg 2000;232: Circulation 1999;100: J Chronic Dis 1987;40: Anesthesiology 2006;104: Anesth Analg 2012;115:

4 THE IMPACT OF SHORTAGES ON DRUG UTILIZATION AND OUTCOME Gregory L. Bryson 1, Alan D. Baxter 1, Alan J. Chaput 1, Christopher L. Pysyk 1, Alan J. Forster 2 1. Anesthesiology, The Ottawa Hospital, Ottawa, ON, Canada 2. Performance Measurement, The Ottawa Hospital, Ottawa, ON, Canada Introduction: Canadians have struggled with shortages of prescription drugs over the past decade (1). This problem was compounded in the first quarter of 2012 by slowdowns and eventual closure of the Sandoz production facility in Boucherville, QC. The purpose of this study was to evaluate the influence of this event on intaoperative injectable drug use and patient outcomes at a single academic health sciences centre. Methods: Following research ethics board approval, drug utilization and patient outcome data were extracted from our electronic health record (Anesthesia and PACU Manager, Picis, Inc. Wakefield MA). Data were extracted from Feb 1, 2011 to January 31, 2012 to provide a detailed assessment of baseline drug exposure and outcome. Data from February 1 to August 31, 2012 were extracted to capture the impact of the Sandoz closure on perioperative care. Extraction of de-identified patient data was performed by trained analysts. Data was cut into monthly intervals to evaluate trends over time. Drug consumption was described as both categorical (proportion of patients exposed per time interval) and quantitative (total dose of drug administered per case) variables. Rates of nausea, vomiting, mean pain scores and PACU length of stay) were described as rates and proportions. Data was plotted graphically, and inspected visually for trends. Results: In the 12 months preceding the Sandoz closure 25,709 eligible surgeries were performed; 14,804 procedures were performed in the seven months that followed. Distribution of age, route of admission, day of week, and hour of surgery were similar in both time periods. Transient decreases in the quantity of fentanyl administered and the proportion of patients given ondansetron was observed (Figure). Rates and quantities of other analgesics, analgesic adjuncts, and antiemetics were largely unchanged despite decreases in fentanyl dose. Rates of postoperative nausea and vomiting and mean verbal analogue pain scores and were unchanged (Figure). Discussion: Our institution s multidisciplinary response to drug shortages included regular communication regarding drugs in short supply, repackaging of multidose vials, and the encouragement of alternate drugs or routes of administration. These efforts effectively isolated intraoperative practice from shortages experienced elsewhere. Clinician prescribing practices were largely unchanged because drugs of choice continued to be available. Patient outcomes were not significantly influenced by the Sandoz closure. References: 1. issues/drugshortagesreport.pdf.

5 IMPROVING THE DOCUMENTATION OF CENTRAL VENOUS CATHETERS USING A QUALITY IMPROVEMENT APPROACH Paul D. Korchinski 1, Joann Kawchuk 2 1. Anesthesiology, University of Saskatchewan, Saskatoon, SK, Canada 2. Anesthesiology & Adult Critical Care, University of Saskatchewan, Saskatoon, SK, Canada Introduction: Central venous catheter (CVC) infection prevention guidelines suggest: (1) Auditing CVC complications to develop preventative measures 1 ; (2) recording the operator, date, and time of catheter insertion and removal; (3) monitoring trends in Catheter Related Blood Stream Infection (CR-BSI) rates; and (4) expressing these rates as the number of CR-BSIs per 1,000 catheter-days 2. A recent update suggests improvement initiatives in which strategies are "bundled" to improve compliance with recommended practices 3. Our purpose was to improve the quality of and accessibility to data on inpatient CVCs at a 230 bed teaching hospital to include accurate catheter days, complications rates and CR-BSI rates. We hypothesized that the study hospital s current documentation system misses a number of patient populations with CVCs, provides an inaccurate estimate of catheter days and will be improved with the introduction of a standardized CVC record. Methods: This project was exempt from research ethics review by the institutional research ethics office based on its continuing quality improvement design (Plan, Do, Study, Act). The Plan phase involved an audit of inpatient adult CVC documentation and a baseline chart review of CVCs inserted over a one-month period (April 2011) using the existing ICU system and Health Records International Classification of Diseases(ICD)-10 codes. The Do phase introduced a standardized insertion and removal of CVC form with appropriate ICD10 coding. The Study phase will involve an observational cohort study using the new system to capture all CVCs inserted over one month (November 2012) and compare the quality of documentation to that of the baseline chart review. The Act phase may involve expanding, adjusting or limiting the system and form. Results: The Plan phase chart review examined 57 CVCs in 47 patient records. No CRBSIs were identified in 420 catheter-days. Four complications were identified (2 arterial punctures, 1 arterial cannulation and 1 tip malposition). Of the 47 patient records captured in the chart review, 55% (n=26) were identified by the ICU s existing CVC record system and 38% (n=18) were identified by hospital-wide ICD10 coding. Only 6% (n=3) were recognized by both systems. Peripherally Inserted Central Catheters (PICCs) accounted for 65% of CVCs identified by ICD10 codes but only 28% of the CVCs identified by the ICU. 47% of CVCs had both date and time of insertion recorded. 50% had no recorded time of insertion. 54% had both date and time of removal recorded. 25% had no date or time of removal. The operator s name was not recorded or was illegible in 12% of CVC insertions. Discussion: The Plan phase has highlighted: (1) higher PICC numbers in ICD10 identified records, suggesting non-picc CVCs trigger ICD10 coding less frequently and may be missed in non-icu patients; (2) overall low ICD10 capture rates of CVC insertions, suggesting calculated catheter days or complication rates based on these records are erroneous; and (3) a low incidence of properly recorded operator, date and time for insertion and removal. This project should proceed with the Study phase to assess any improvements since introduction of the standardized CVC record. References: 1 Int J Lab Haematol 2007, 29: ; 2 MMWR Recomm Rep 2002, 51:1-29; 3 Clin Infect Dis 2011, 52:

6 THE STERILITY OF PHENYLEPHERINE HYDROCHLORIDE SOLUTIONS AS PREPARED BY ANESTHESIOLOGISTS Shahdi Henein 1, Alexander J. Gregory 1, Jan Davies 1 1. University of Calgary, Calgary, AB, Canada Introduction: Hospital acquired infections have been shown to affect approximately 10% of patients, contributing to the mortality of 90,000 hospitalized patients and costing as much as $4.5 billion per year (US data).1 Possible anesthesiologist related sources of contamination include sub-optimal sterility practices, invasive devices such as endotracheal tubes or intravenous catheters, and medication contamination. Intravenous medications can be stored in single-dose vials (SDV) or multi-dose vials (MDV). Bacterial growth in anesthetic MDV s requires two conditions: 1) Introduction of bacterial contamination and 2) ability of the organism to survive in the drug medium. Large scale studies on MDV s from hospital wards, emergency departments, intensive care units and operating rooms have shown contamination rates of %.2,3 Meanwhile, studies focusing on medications used exclusively by anesthesiologists have shown rates of 0-5%.4-6 Anesthesiologists often compound phenylephrine solutions by diluting an SDV into a saline bag. This solution, which may be used for multiple patients, has to date not had its sterility profile assessed. Our objective was to determine the bacterial contamination rate of phenylephrine solutions compounded by anesthesiologists at our institution as well as the potential contribution of individual sterility practices. Methods: Local ethics committee approval was obtained. Samples of anesthesiologists phenylephrine solutions were collected over a 6 month period by the investigators and sent to a local laboratory where they were cultured for bacterial growth. The data on individual sterility practices was collected with an anonymous self-reported questionnaire. It included hand washing and wearing of a mask during compounding and syringe withdrawals, number of syringe withdrawals prior to sample acquisition, cleaning of the saline bag port with alcohol prior to syringe withdrawals, and solution storage greater than 24 hours. The impact of individual sterility practices on bacterial contamination rates were analyzed using Fisher s Exact Test. Results: A total of 104 samples were collected with a resulting contamination rate of 1.92% (95% CI= 0-4.6%). No sterility practices were found to significantly increase the rate of contamination, however there was a trend towards a higher contamination rate in solutions kept longer than 24 hours (1.2% vs 4.8%, p=0.37). Discussion: Our results show that dilute solutions of phenylephrine can become contaminated and will support bacterial growth. Our rate of bacterial contamination appears to be consistent with prior studies of medications used by anesthesiologist. Although individual sterility practices cannot be definitively associated with contamination reduction, limiting the use of a compounded phenylephrine solution to less than 24 hours may be beneficial. References: 1. Am J Infect Control 2002; 30: Infect Control 1984; 5(4): Am J Infect Control 2004; 32: Anesthesiology 1985; 62: Anesth Analg 1998; 86: Eur J Anaesth (Suppl) 1995; 12: 41-3