Anaesthesia
-
Observational Study
The effects of an aviation-style computerised pre-induction anaesthesia checklist on pre-anaesthetic set-up and non-routine events.
There is ever greater interest in mitigating medical errors, particularly through cognitive aids and checklist-system long-used in the aviation industry.
Jelacic and team instituted a computerised pre-induction checklist, using an observational before-and-after study design across 1,570 cases. This is the first study of a computerised anaesthesia checklist in a real clinical environment.
They found an absolute risk reduction of almost 4% of failure-to-perform critical pre-induction steps, along with reduction in non-routine events and several examples of pre-induction mistake identification through checklist use.
Although the researchers claim the results “strongly argue for the routine use of a pre-induction anaesthesia checklist” this overstates the case a little. This study, like many similar, struggles with confounder effects on anaesthesia vigilance that may explain some of the results, particularly as arising from observational, non-randomised, non-blinded research.
Be careful
The challenge for cognitive aid research is that commonly it must use surrogate markers (workflow step failure; behavioural deviations; efficiency; time spent on task etc.) rather than the safety outcomes that actually matter to patients: death and injury.
There is no easy way around this other than large multi-center studies focusing on outcomes, such as the WHO surgical safety checklist study – which even then, has not escaped criticism!
Thinking deeper...
There will continue to be tension between those pro-checklist and those against. The irony is that both camps share a similar rationale for their position: the advocates for routine checklists point to the safety benefits of reducing cognitive load, whereas those opposing argue that enforced use is anti-individual and itself adds additional task and cognitive burden for clinicians.
summary -
Multicenter Study
A survey of antenatal and peripartum provision of information on analgesia and anaesthesia.
Why is this relevant?
Anaesthetists and anesthesiologists have long worried about the recall of labouring women when presented with risk-benefit discussions prior to epidural analgesia or receiving anaesthesia for cesarean section.
This UK survey of over 900 women across 28 Greater London hospitals explored recall of this antenatal and intrapartum information, along with maternal satisfaction.
What did they find?
There was very little recall of receiving either thorough labour analgesia information (9%) or anaesthesia for CS (12%) provided during the antenatal period.
During the interpartum period, fewer than two-thirds (62%) recalled receiving thorough information during labour before insertion, and less than one-third (28%) before Caesarean section anaesthesia.
13% of women did not recall receiving any information before epidural insertion.
These are concerning findings in a modern era where patient autonomy and informed consent are prioritised, and more so where informed decision making may contribute to a positive birth experience.
Interestingly, verbal information appeared best recalled (OR 5.9 to 20.7 across different categories), although this is counter to past studies showing superiority of written information.
Be clear
Because the 28 hospitals contributing to the survey had large practice differences in how antenatal anaesthetic information was provided, it is difficult to determine whether the provision of information or recall itself is the problem.
Take-home...
Regardless of the cause, a large proportion of pregnant women did not recall being adequately informed before epidural analgesia or caesarean anaesthesia. This needs to be improved.
summary