The Anesthesia Patient Safety Foundation (APSF) is pleased to report that it continues to attract outstanding applications for funding. The educational focus of the 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, online submission format that was introduced in 2005. The applications, as well as all the required attachments, are uploaded to the new redesigned APSF 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.
The Scientific Evaluation Committee is very pleased to report that the APSF Executive Committee developed a Request for Application (RFA) for Patient Safety Investigator Career Development Award (see: dev2.apsf.org) that seeks to develop the next generation of patient safety scientists. Additionally, the APSF is proud to announce the continued funding of named awards, including the APSF/American Society of Anesthesiologists (ASA) Endowed Research Award ($150,000), utilizing funds from the APSF endowment account that was made possible by the generous financial support from ASA over the past 25 years; and the APSF/Covidien Research Award, supported by a generous ($150,000) grant from Covidien.
In addition to the Clinical Research and Education and Training content that is the major focus of the funding program, the 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.
The 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 the APSF that this award will inspire others toward her ideals and honor her memory.
For the year 2011 (projects to be funded starting January 1, 2012), 2 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 17 applications in the first round, 8 of which were selected for final review at the American Society of Anesthesiologists’ (ASA) Annual Meeting in Chicago, IL. 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, the 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 15, 2011, in Chicago for evaluation and final selection of the proposals. Of the 8 finalists, the members of the APSF Scientific Evaluation Committee selected the following applications:
Jesse M. Ehrenfeld, MD, MPH
Assistant Professor of Anesthesiology and Biomedical Informatics, Vanderbilt University, Nashville, TN.
Dr. Ehrenfeld’s Clinical Research submission is entitled “Enhancing Perioperative Safety Through the Determination of Intraoperative Predictors of Post-Operative Deterioration.”
Background: Post-surgical deterioration necessitating unanticipated ICU transfer is common and is associated with worse patient outcomes. Although the morbidity and mortality attributed to anesthesia is low, large numbers of patients experience adverse postoperative events in spite of the availability of advanced monitoring technologies. In fact, 7-27% of post-surgical and trauma patients have inpatient clinical deterioration that is specifically associated with adverse events and worse outcomes, including pulmonary complications, shock, cardiac failure, and hemorrhage. In a recent national survey of surgical Medicare inpatients with serious treatable complications, “failure-to-rescue” occurred in 9.6% of patients and was an independent predictor of death. Suboptimal management of airway, breathing, circulation, oxygen therapy and monitoring occurred in a majority of severely ill patients prior to their transfer to an intensive care unit (ICU). However, failure to rescue really consists of 3 parts: failure to anticipate [increased risk of deterioration], failure to detect [an evolving problem], and failure to treat. This proposal addresses the first of these elements required to prevent harm to post-surgical patients.
Aims: The overall goal is to identify intraoperative risk factors for clinical deterioration in the immediate postoperative period defined as transfer to an ICU within 48 hours of admission to a post-surgical floor after a surgical procedure. Relatively healthy, post-surgical and trauma patients continue to suffer potentially preventable adverse events, in spite of the availability of advanced monitoring technologies. The investigators hypothesize that certain intraoperative physiologic markers (e.g., heart rate variability, vasoactive drug use patterns) portend poor outcomes in the immediate postoperative period. Pilot data from Vanderbilt identified 422 surgical patients who were discharged from the PACU to a surgical floor, and then transferred to the ICU within 48 hours of their departure from the operating room (OR). These patients had a 50% increased relative risk of death at 30 days compared to a matched group of patients who did not have postoperative deterioration. Having previously validated a risk-stratification score for major complications or death within 30 days (the Surgical Apgar Score), the investigators now propose to identify risk factors for deterioration in the immediate postoperative period. This work is enabled by the availability of high-resolution physiologic data and new advanced pattern recognition algorithms.
Implications: A validated risk score will ultimately allow the investigators to: 1) identify patients who are at risk for postoperative deterioration; and 2) design and evaluate both intraoperative and postoperative interventions to decrease the incidence of postoperative deterioration and prevent harm to post-surgical patients.
In addition to receiving the requested funding of $149,357 for his project, Dr. Ehrenfeld’s application was designated as the APSF/Covidien Research Award.
Dr. Ehrenfeld is also the recipient of The Doctors’ Company Foundation Ann S. Lofsky, MD Research Award, which consists of an additional, unrestricted grant of $5,000.
Miriam M. Treggiari, MD, PhD, MPH
Associate Professor, Department of Anesthesiology, Adjunct Associate Professor of Neurological Surgery and Epidemiology, University of Washington, Seattle, WA.
Dr. Treggiari’s Clinical Research project is entitled “Extubation Safety Quality Initiative Project˛- ESQIP.”
Background: Patient safety surrounding tracheal extubation represents an area for significant practice improvement in the intensive care unit (ICU). In a cohort study, the investigators have previously observed that nearly 20% of mechanically ventilated, critically ill patients required reintubation during their hospitalization, and the need for tracheal reintubation was associated with higher mortality, length of stay, and higher hospital costs compared with those patients who never required tracheal reintubation. While the occurrence of difficult intubation and airway-attributed complications were similar for initial and subsequent intubation, airway difficulty encountered during reintubation was associated with higher mortality. With appropriate planning, the majority of tracheal extubations can be carried out in a fashion that maximizes the safety of the procedure and prevents adverse events. Recently, the use of a pre-intubation checklist consisting of 10 bundle components significantly reduced the occurrence of cardiac arrest or death, severe cardiovascular collapse, and hypoxemia occurring within 60 minutes of emergency intubation in the ICU. The logical next step to improve the safety of tracheal extubation is to implement a planned extubation strategy in the context of a quality improvement initiative.
Aims: The purpose of this proposal is to determine if the use of a standardized airway management algorithm at the time of tracheal extubation reduces the occurrence of serious complications, improves patient outcomes, and reduces the incremental cost incurred in the event of failed extubation.
Implications: Few recommendations are available on the approach to tracheal extubation in spite of the observed high frequency of potential complications. An important step in the understanding of these adverse events is to evaluate a systematic approach to tracheal extubation. This strategy has the potential to greatly improve airway management, resulting in improved patient outcome and safety.
In addition to receiving the requested funding of $149,997 for the project, Dr. Treggiari’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. Treggiari is also the recipient of the Ellison C. “Jeep” Pierce, Jr., MD, Merit Award, which consists of an additional, unrestricted amount of $5,000.
On behalf of the APSF, the members of the Scientific Evaluation Committee wish to congratulate all of the investigators who submitted their work to the 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 the 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.
Sorin J. Brull, MD, FCARCSI (Hon)
Chair, APSF Scientific Evaluation Committee