To Sleep Perchance to Dream - Quality in Pediatric Anesthesia

Author: Dr. Conor McDonnell
Staff Anesthesiologist, The Hospital for Sick Children
Director of Morbidity & Mortality, Patient Safety & Quality Program, Department of Anesthesia & Pain Medicine
Assistant Professor, University of Toronto

Where Am I?

We can usually measure how far we have come by how little we have left to go. While directing the M&M program for the Department of Anesthesia & Pain Medicine at SickKids Hospital in Toronto, Canada, I found myself one day with very little to do, in that regard at least. There had been no mortalities or significant morbidities in the previous three reporting quarters, we had a reliable reporting / data collection system, a timely review process and an institution amenable to change when such change was beneficial to patients.  So what to do next? Wait for the next bad thing to come along or add a fresh challenge to the mix?

Where Are You?

Despite increasingly complex medical care for increasingly fragile patients, pediatric anesthesia continues to ‘measure up’ in terms of safety when compared to other ‘dangerous activities’, lying somewhere between skydiving and airline travel [1]. However, imagine you are talking to a harried air-commuter at the terminal – one who had to wait on standby despite having purchased their ticket months in advance, who subsequently missed their connecting flight due to airline delays, whose baggage was misplaced and who has just come through a less than courteous entry examination into the country. Imagine if you were to say to them that none of that really matters because well, ‘nobody died’. Hmmm. So, if pediatric anesthesia really is that safe then isn’t it time we started looking at (and reporting) the quality of care and service we deliver? Only where to begin?

Is Anyone Else Out There?

Well, you could do a lot worse than Cincinnati, where Dr. Dean Kurth’s group has been observing that particular stream of air traffic for almost a decade now. Reading their descriptive paper on the set up and possibilities of an academic pediatric anesthesia quality program truly opened our eyes and we have barely had time to blink since [2]. Using the Cincinnati group’s program as both a template and springboard we started small in 2010. We learned about phrases like ‘quality indicator’, ‘key performance driver’, ‘Pareto principle’, ‘dashboard report’. We enrolled in certification programs that described Squire guidelines, process control charts, encouraged team-based approaches, knowledge translation, etc etc.

What Can We Do?

We hoped our program would ultimately reflect the six dimensions of Quality as outlined by the Institute of Medicine (i.e. Safety, Effectiveness, Patient / Family Centered, Efficiency, Timeliness, Equity) but what to choose first? Well, how about Safety? It’s pretty close to Morbidity & Mortality so let’s go with what we know. In our ORs we have an emergency alert system whereby every room and clinical area has a ‘panic button’ of sorts. If anyone is getting into difficulties or if someone simply needs help, they press the button. This sets off an audible and visual alarm at a central operations desk and this message is relayed overhead alerting all staff as to the room that requires assistance. It’s a system that works well and help always arrives quickly. However, it also fulfils some of the criteria vital to a quality improvement project: it already exists so there isn’t a lot of set up involved, there is a bottleneck to the system (i.e. the central operations desk) through which all information must flow (therefore, there is a bottleneck to the system where you can reliably capture all data), and it is not manned by physicians (so when you ask the nice people at the desk to help you with data collection they are only too eager to help).

How Can We Do It?

We began by collecting very rudimentary data on the reasons behind such distress calls (‘button presses’ as we call them). After 12 months of data collection we demonstrated that 70% of all ‘button presses’ were respiratory or airway-related and that 80% of these respiratory / airway problems were due to laryngospasm. From these numbers we decided three things: (a) ‘Button presses’ would definitely be our first safety-related Quality Indicator (QI), (b) Unexpected admissions to hospital or ICU would be our effectiveness-related QI, and, (c) Decreasing the amount of times that laryngospasm necessitated an urgent ‘button press’ would be our program’s first Quality Improvement project.

Why Should We Do It?

Figure 1 demonstrates our strategy for decreasing the frequency of urgent calls for help due to laryngospasm by 50% over the following 12 months and sustaining such results into the foreseeable future. Within this strategy, two interventions were vital: (1) the recognition that our residents and fellows represented the greatest opportunity for change in terms of behavior and practice, and, (2) recognizing that these personnel ‘turn over’ completely each and every 12 months, so learning (in terms of maintenance of quality) is finite and must be presented anew to each new arrival to the department.  After the introduction of all measures described in Figure 1, we decreased the frequency of urgent calls for help due to laryngospasm from 2.31 to 1.1 per 1,000 anesthetics delivered (or from 0.25% of all anesthetics delivered to 0.09%). Pre-intervention, 11 patients required escalations in either the type or location of postoperative care as a consequence of intra-operative laryngospasm over a twelve month time period. Post-intervention, three patients required such care over an eighteen-month time period. The results will be published in a special issue of Pediatric Anesthesia later this year [3].

Figure 1.

What Does It All Mean?
Therefore, our first QI gave birth to our first Quality Improvement project (wherein we did improve the quality of care for our patients), we were able to benchmark the incidence of moderate to severe laryngospasm during pediatric anesthesia, and we decreased the burden these patients placed on other clinical locations such as ICU and / or pediatric consultation services.

Where Do We Go From Here?
Since then, we have added quality of induction, incidence of CPR, unanticipated ICU admissions, prolonged postoperative recovery time, and, parental satisfaction to our program as Quality Indicators. Each represents a point in patient care where we hope to positively impact the quality of service we deliver.

How Safe Is Anesthesia?
All About Anesthesia website, accessed January 7th 2013
Quality In Pediatric Anesthesia.
AM Varughese, NS Hagerman, CD Kurth. Pediatric Anesthesia 2010: 20(8); 684-96.
Interventions guided by analysis of quality indicators decrease the frequency of laryngospasm during paediatric anesthesia. C Mc Donnell Pediatric Anesthesia 2013 Early online publication