The Anesthesia Patient Safety Foundation (APSF) is pleased to report that it continues to attract outstanding applications for funding. The educational focus of APSF includes innovative methods of education and training to improve patient safety, development of educational content with application to patient safety, and development of testing of educational content to measure and improve safe delivery of perioperative anesthetic care.
The application process continues with an electronic, on-line submission format that was introduced in 2005. The applications, as well as all the required attachments, are uploaded to the new APSF redesigned website (dev2.apsf.org), a process that facilitates the application review by members of the Scientific Evaluation Committee, improves the timeliness of responses to queries, and facilitates transmission of reviewer feedback to the applicants. The Scientific Evaluation Committee members continue to modify and perfect the electronic application and review process.
This year, the Scientific Evaluation Committee is very pleased to report on several significant developments in, and achievements of, the APSF Grant Program. The first is the total amount of funding that APSF continues to award; this year, APSF is committing a total of $661,326 to support research and educational projects dedicated to patient safety. In addition, this year the APSF Executive Committee developed a Request for Proposals (RFP) process that was the direct result of recommendations developed during the APSF Board of Directors Workshop. The RFP for this new, $200,000 grant was entitled, “Neurocognitive Effects in Patients Undergoing General Anesthesia during Surgery in the Head-Up (“Beach Chair”) Position.” Last, APSF is proud to announce the continued funding of named awards, including the APSF / American Society of Anesthesiologists (ASA) President’s Endowed Research Award, utilizing funds from the APSF endowment account that was made possible by the generous financial support from ASA over the past 25 years; the APSF / American Society of Anesthesiologists (ASA) Endowed Research Award ($150,000); the APSF / Covidien Research Award, supported by a generous partial ($100,000) grant from Covidien; and the APSF / Research Award, sponsored entirely by a grant from APSF.
In addition to the Clinical Research and Education and Training content that is the major focus of the funding program, APSF continues to recognize the patriarch of what has become a patient safety culture in the United States and internationally, and one of the founding members of the foundation—Ellison C. “Jeep” Pierce, Jr., MD. The APSF Scientific Evaluation Committee continues to designate each year one of the funded proposals as the recipient of this prestigious nomination, the Ellison C. “Jeep” Pierce, Jr., MD, Merit Award. The selected nomination carries with it an additional, unrestricted award of $5,000.
APSF also has awarded The Doctors Company Foundation Ann S. Lofsky, MD, Research Award. This award is made possible by a $5,000 grant from The Doctors Company Foundation that will be awarded annually for a total of 5 years to a research project deemed worthy of the ideals and dedication exemplified by Dr. Ann S. Lofsky. Dr. Lofsky was a regular contributor to the APSF Newsletter, a special consultant to the APSF Executive Committee, and a member of the APSF Board of Directors. Her untimely passing cut short a much-valued and meaningful career as an anesthesiologist and as a dedicated contributor to anesthesia patient safety. It is the hope of APSF that this award will inspire others toward her ideals and honor her memory.
For the year 2010 (projects to be funded starting January 1, 2011), 3 grants were selected for funding by the APSF Scientific Evaluation Committee (for names of committee members, please refer to the list in this issue). The APSF Scientific Evaluation Committee members were pleased to note that they reviewed a total of 42 applications in the first round, 12 of which were selected for final review at the American Society of Anesthesiologists’ (ASA) Annual Meeting in San Diego, CA. As in previous years, the grant submissions addressed areas of high priority in clinical anesthesia. The major goal of APSF funding is to stimulate the performance of studies that lead to prevention of mortality and morbidity due to anesthesia mishaps. A particular priority continues to be given to studies that address anesthetic problems in healthy patients, and to those studies that are broadly applicable and promise improved methods of patient safety with a defined and direct path to implementation into clinical care. Additionally, APSF is encouraging the study of innovative methods of education and training to improve patient safety, and methods for the detection and prevention of medication errors.
The APSF Scientific Evaluation Committee convened during the ASA Annual Meeting on October 16, 2010 in San Diego for evaluation and final selection of the proposals. Of the 12 finalists, the members of the APSF Scientific Evaluation Committee selected the following 3 applications:
Andreas Taenzer, MD
Assistant Professor of Anesthesiology and Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, NH.
Dr. Taenzer’s Clinical Research submission is entitled, “Examination of Respiratory Rate Monitoring as a Patient Surveillance Parameter for In-Patient Populations.”
Background: In-hospital general ward patients are having preventable deaths while under anesthesia care because of unrecognized changes in their physiologic state. Unrecognized physiologic deterioration is a significant precursor to morbidity and mortality for in-hospital postoperative patients. Consequently, the authors’ multidisciplinary team has been studying patient surveillance methods to detect deterioration, increase patient safety, and prevent adverse events. The author and his colleagues implemented a Patient Surveillance System on several wards at Dartmouth-Hitchcock Medical Center, where patients’ vital signs are continuously monitored and stored in a clinical archival system. This automated approach is unique in that it provides continuous surveillance (1-second intervals), as compared with intermittent nursing checks, intermittent data sampling, or averaging via an electronic medical record system. To date, only hard limits on heart rate and oxygen saturation have been used as a threshold to detect deterioration using continuous surveillance methods. These limits are set to minimize nuisance and false alarms, which can overburden clinical staff.
Aims: In this study, the authors will add a third variable for deterioration detection using continuous surveillance: respiratory rate. Respiratory rate is one of the most sensitive parameters to track respiratory status, and new technology (using acoustic sensors) makes it possible to use respiratory rate as a continuous monitor. In contrast to other respiratory rate monitors such as chest straps or nasal carbon dioxide cannulae, previous pilot studies have shown acoustic respiratory rate monitoring to be well tolerated by patients as continuous monitors.
Implications: The proposed research encompasses a) collection of an unprecedented volume of physiological data (heart and respiratory rate, oxygen saturation) from non-ICU postoperative inpatients; b) analysis of these data to determine the normal distribution of respiratory rate among a postsurgical population; c) establishment of static deterioration alarm thresholds for respiratory rate that optimize specificity and sensitivity; d) retrograde testing of these settings on an existing physiologic database (with several thousand patient-days and over 400 million data points) to determine whether adverse events would have been prevented; e) development of optimized settings for all 3 variables (heart rate, oxygen saturation and respiration) when used jointly to detect deterioration; and f) forward analysis of the addition of acoustic respiratory rate monitoring (to the existing monitoring of heart rate and oxygen saturation) using a before-and-after study design by deployment on 1 postsurgical unit while using 2 other postsurgical units as controls.
In addition to receiving the requested funding of $149,875 for his project, Dr. Taenzer’s application was designated as the APSF / American Society of Anesthesiologists (ASA) President’s Endowed Research Award. Dr. Taenzer is also the recipient of the Ellison C. “Jeep” Pierce, Jr., MD, Merit Award, which consists of an additional, unrestricted amount of $5,000.
Eric You-Ten, MD, PhD.
Assistant Professor, Department of Anesthesia, Mount Sinai Hospital—University Health Network, Toronto, ON, Canada.
Dr. You-Ten’s Clinical Research project is entitled “A Prospective Observational Study to Determine the Prognostic Value of Noninvasive Computed Tomography Coronary Angiogram for Cardiac Risk Stratification in Noncardiac Surgery – Role of the 320-Row Multidetector Computed Tomography.”
Background: Perioperative major adverse cardiac events (pMACE) remain the major cause of mortality and morbidity in patients undergoing noncardiac surgery. Clinical experts and opinions have long advocated the inclusion of preoperative noninvasive tests with patient clinical characteristics to further delineate the cardiac risk. However, the optimal noninvasive test remains elusive, since the added value of our current best-practice cardiac test to predict pMACE is questionable. This is important, because an accurate cardiac risk stratification model can identify patients at increased cardiac risk who will benefit from medical treatments/interventions, as opposed to low risk patients who can suffer from significant adverse effects from these interventions.
Hypothesis: The authors hypothesize that computed tomography coronary angiogram (CTCA) can improve the ability to predict perioperative major adverse cardiac events and may become an important noninvasive preoperative test for cardiac risk stratification. Preliminary data from the authors’ pilot study demonstrated a potential role for preoperative CTCA in cardiac risk stratification.
Aims of the proposed study are (i) to conduct a prospective nonrandomized observational study to determine the prognostic value of CTCA as a preoperative diagnostic test for cardiac risk stratification in noncardiac surgery; (ii) to determine whether this knowledge will increase our clinical ability to predict perioperative cardiac complications to improve outcome and patient safety.
Implications: This proposal plans to improve cardiac risk stratification by assessing the degree of coronary artery stenosis with noninvasive CTCA, since the severity of coronary luminal stenosis puts patients at increased risk of suffering from pMACE. At present, invasive conventional coronary angiography (CCA) is reserved for a limited patient population. Therefore, alternative methods for assessing the coronary artery anatomy must be validated, and any such method should be accurate enough to enable therapeutic treatments and interventions to be targeted specifically to patients at risk. Only in this way can patient safety and outcome be improved. With improved CT technology that is nearly as accurate as invasive CCA, the authors propose that significant improvement in image quality with the state of the art 320-row CTCA can provide an accurate assessment of coronary luminal disease by determining the severity of coronary stenosis and plaque formation burden. At present, the prognostic value of CTCA to predict pMACE in noncardiac surgery is not known.
In addition to receiving the requested funding of $149,586 for the project, Dr. You-Ten’s application was designated as the APSF / American Society of Anesthesiologists (ASA) Endowed Research Award, made possible by an unrestricted, $150,000 grant from the American Society of Anesthesiologists. Dr. You-Ten is also the recipient of The Doctor’s Company Foundation Ann S. Lofsky, MD, Research Award, which consists of an additional, unrestricted grant of $5,000.
Anne Miller, PhD (Psychology)
Assistant Professor of Nursing (Human Factors), Vanderbilt University Medical Center, Nashville, TN.
Dr. Miller’s Clinical Research project is entitled “Embedding Safety-Related Evidence-Based Protocols into Routine Clinical Practice.”
Background: In High Reliability Organizations (HROs), work units establish performance goals that guide the development and evolution of standardized work processes. Methods for implementing and evaluating such HRO processes in health care have not been well studied. This 18-month feasibility study will use a quasi-experimental design to evaluate whether standardized goal-directed inter-disciplinary processes and tools directed at safety-related evidence-based practices (SREBP) reduce patient length of stay in a cardiovascular intensive care unit (CVICU).
Goal-directed processes will focus on SREBP in post-cardiovascular surgery patients. The SREBP will target ventilator-acquired pneumonia, ICU delirium, and catheter-associated bloodstream and urinary tract infections. SREBP goals will include early tracheal extubation, cessation of vasopressors, sedatives, and parenteral analgesics, mobilization, enteral nutrition, intravascular and urinary catheter removal, and ICU discharge. Despite the published benefits of SREBP, sustained decreases in preventable complications have been difficult to achieve, suggesting that SREBP are not being effectively integrated into everyday practice.
Aims: 1. Develop and integrate SREBP goal-directed interdisciplinary care processes and tools into post-cardiovascular (CV) surgery ICU patient management practices; 2. Evaluate the effects of SREBP goal-directed processes and tools on CVICU and hospital length of stay (LOS); and 3. Describe factors contributing to SREBP goal (non)-compliance and patient LOS. The authors hypothesize that increased SREBP goal attainment (and, by direct intent, increased SREBP compliance) will decrease ICU and hospital LOS.
Implications: Goal-directed structured checklists will first be assessed for accuracy and reliability. After HRO process/tool implementation, the authors will collect data for 1 year to demonstrate sustained practice change. Daily global and goal specific SREBP compliance scores will be calculated from a goal-tool for each study patient, while length of stay and other patient variables will be queried from the hospital’s comprehensive electronic medical record. A piecewise linear regression model of SREBP compliance against ICU or hospital LOS, adjusting for patient pre-existing condition, surgical procedure, ICU admission acuity, and time from study start, will be used to test the primary hypothesis that there is an the association between SREBP compliance and ICU and hospital length of stay. The results will inform the conduct of a planned RCT to evaluate the effect of an HRO-based goal-directed intervention on short- and long-term ICU patient outcomes and on cost of care.
In addition to receiving the requested funding of $149,865 for her project, Dr. Miller’s application was designated as the APSF / Covidien Research Award, made possible by an unrestricted, partial $100,000 grant from Covidien.
Charles W. Hogue, Jr., MD
Associate Professor, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD
Dr. Hogue’s Research project is entitled “Assessing Cerebral Blood Flow Autoregulation in the Head-Up versus Supine Position during General Anesthesia and its Relationship with Postoperative Neurocognitive Changes and Serum Biomarkers of Brain Injury.”
Background: Neurologic injury under general anesthesia in the beach chair position is believed to result from cerebral hypoperfusion. The authors hypothesize that brain hypoperfusion in this circumstance is caused by blood pressure monitoring that is not reflective of cerebral perfusion pressure. Maintenance of arterial blood pressure (ABP) above an individual’s lower limit of cerebral blood flow (CBF) autoregulation would prevent hypoperfusion and brain injury complications. Near infrared spectroscopy (NIRS) can be used to continuously monitor autoregulation with the cerebral oximetry index (COx), a moving linear correlation coefficient between cortical tissue oxygen saturation and ABP. The authors hypothesize that subjects in the beach chair position have impaired CBF autoregulation compared with subjects undergoing surgery in the lateral decubitus supine position.
Aims: 1) To compare the average COx and the percentage of time with abnormal COx between subjects in the head-up or supine position during surgery under general anesthesia; 2) To compare the range of ABP required for a normal COx between subjects anesthetized in the head-up or supine position; 3) To assess the association between impaired CBF autoregulation and postoperative neurocognitive decline and elevation of serum glial fibrillary acid protein. The authors will test their hypothesis by comparing CBF autoregulation data, including the percentage of time that patients undergoing elective surgery have abnormal autoregulation, in the beach chair position versus supine position.
Implications: The authors plan to establish the range of ABP required to maintain autoregulation in the 2 groups. CBF autoregulation results will be assessed for a relationship with postoperative neurocognitive dysfunction and with serum glial fibrillary acid protein levels, a biomarker of brain injury. Monitoring autoregulation non-invasively with COx has the potential to improve patient safety by delineating individualized limits of safe ABP for patients at risk of neurologic injury.
In addition to receiving the requested funding of $212,000 for his RFP project, Dr. Hogue’s application was designated as the APSF Research Award, made possible by an unrestricted grant from APSF.
On behalf of APSF, the members of the Scientific Evaluation Committee wish to congratulate all of the investigators who submitted their work to APSF, whether or not their proposals were funded. The Committee members hope that the high quality of the proposals, the significant amount of resources offered by APSF, and the important findings that will undoubtedly result from completion of these projects will serve as a stimulus for other investigators to submit research grants that will benefit all patients and our specialty.