Anaesthetic machine checking practices. A survey

[Prevention of medical device-related adverse events in hospitals: Specifying the recommendations of the German Coalition for Patient Safety (APS) for users and operators of anaesthesia equipment]

BACKGROUND

The use and organisation of medical technology has an important role to play for patient and user safety in anaesthesia.

OBJECTIVES

Specification of the recommendations of the German Coalition for Patient Safety (APS) for users and operators of anaesthesia equipment, explore opportunities and challenges for the safe use and organisation of anaesthesia devices.

METHODS

We conducted a literature search in Medline/PubMed for studies dealing with the APS recommendations for the prevention of medical device-related risks in the context of anaesthesia. In addition, we performed an internet search for reports and recommendations focusing on the use and organisation of medical devices in anaesthesia. Identified studies were grouped and assigned to the recommendations. The division into users and operators was maintained.

RESULTS

Instruction and training in anaesthesia machines is sometimes of minor importance. Failure to perform functional testing seems to be a common cause of critical incidents in anaesthesia. There is a potential for reporting to the federal authority. Starting points for the safe operation of anaesthetic devices can be identified, in particular, at the interface of staff, organisation, and (anaesthesia) technology.

CONCLUSIONS

The APS recommendations provide valuable information on promoting the safe use of medical devices and organisation in anaesthesia. The focus will be on risks relating to the application as well as on principles and materials for the safe operation of anaesthesia equipment.

Anaesthetic machine checking guidelines: have we improved our practice?

BACKGROUND AND OBJECTIVES

This study follows up an initial audit in 1992 indicating that anaesthetic machine checking practices were often incomplete. The aims were to ascertain if there has been any improvement during this period with special reference to the latest guidelines.

METHODS

Following the Association of Anaesthetists of Great Britain and Ireland machine checking guidelines, a structured questionnaire, was used to interview 41 anaesthetists in the South West region on one particular day.

RESULTS

Despite 80% of subjects stating that they had read the latest guidelines recently, only one undertook a complete check and 39/41 (95%) performed partial checks (omitting one or more steps in the guidelines). Steps most commonly omitted were additional monitoring, ventilator function, availability of an alternative means of ventilation and function of ancillary equipment such as laryngoscopes. Only 5/41 subjects performed any check between cases. Several of these checks have been introduced in the 2004 guidelines.

CONCLUSIONS

Although there has been a significant increase in the proportion of anaesthetists undertaking machine checks since 1992 (P = 0.0007), we conclude that machine checking guidelines are still poorly followed, with checks specific to the latest guidelines most likely to be omitted.

Inadequate preanesthesia equipment checks in a simulator

PURPOSE

To assess how completely anesthesiologists check their machinery and equipment before use, and to determine what influence seniority, age and type of practice may have on checking practices.

METHODS

One hundred and twenty anesthesiologists were videotaped during a simulated anesthesia session. Each participant was scored by an assessor according to the number of items checked prior to the induction of anesthesia. A checklist of 20 items derived from well-publicized, international standards was used.

RESULTS

Participants were grouped according to their type of practice. Overall, mean scores were low. The ideal score was 20. There were no differences among university anesthesiologists (mean score 10.1, standard deviation 4.3), community anesthesiologists (7.5 +/- 4.3) and anesthesia residents (9.0 +/- 3.8). Each of these groups scored, on average, better than medical students (3.6 +/- 3.7) (P < 0.05). Neither age (r = 0.15, P > 0.1) nor number of years in practice (r = -0.18, P > 0.1) correlated with score.

CONCLUSIONS

Our study suggests that the equipment-checking practices of anesthesiologists require considerable improvement when compared with national and international standards. Possible reasons for this are discussed and some remedial suggestions are made.

Procedures and the professional: the case of the British NHS

The introduction of procedures to guide medical practice is a growing phenomenon in the British National Health Service. It is thought to be a useful way of managing risk, standardising practice and ensuring that research evidence is incorporated into patient care. However, the mere development and introduction of procedures does not ensure that they are actually followed. In the research reported here focus group methodology was used to investigate the perceptions and opinions of doctors, nurses, midwives and health service managers. Twenty-four focus groups were convened across three hospitals, with discussion focusing on the purpose, development and implementation of clinical protocols. The effect of proceduralisation on professional autonomy and on the working relationships among professional groups also emerged as important themes. The paper concludes that successful implementation of protocols or guidelines in the NHS depends on achieving the right balance between standardising practice and allowing professionals to use clinical judgement. Successful implementation of clinical guidelines also requires that the culture of the health service and the beliefs, attitudes and norms of its employees are taken into account.

Revised checklist for anaesthetic machines

A revised edition of the guidelines of the Association of Anaesthetists of Great Britain and Ireland, for the pre-operative check of anaesthetic machines, was published in March 1997. A checklist based on the revised guidelines was used for the routine pre-operative checks of anaesthetic machines over a 6-week period in a district general hospital. One hundred and thirty-two checklists were completed. These were analysed for the time taken to complete the check and for the faults found in the anaesthetic machines. The mean time taken to complete a check was 6.8 min and the mean time taken to complete two consecutive checks, in the anaesthetic room and operating theatre, was 12.7 min. Carbon dioxide cylinders were present on the machines in 99 checks (75%), contrary to Association guidelines. Other faults were found in 40 checks (30.3%). The most frequent cause of faults was the oxygen analyser, faults being found in 15 checks. Other frequent faults were due to empty vaporisers or spare gas cylinders and the emergency oxygen bypass control.

A simplified concept for controlling oxygen mixtures in the anaesthetic machine--better, cheaper and more user-friendly?

Modern anaesthetic machines are equipped with several safety components to prevent delivery of hypoxic mixtures. However, such a technical development has increased the complexity of the equipment. We report a reconstructed anaesthetic machine in which a paramagnetic oxygen analyzer has provided the means to simplify the apparatus. The new machine is devoid of several components conventionally included to prevent hypoxic mixtures: oxygen failure protection device, reservoir O2 alarm, N2O/air selector, and proportioning system for oxygen/nitrous oxide delivery. These devices have been replaced by a simple safety system using a paramagnetic oxygen analyzer at the common gas outlet, which in a feed-back system cuts off the supply of nitrous oxide whenever the oxygen concentration falls below 25%. The simplified construction of the anaesthetic machine has important consequences for safety, cost and user-friendliness. Reducing the complexity of the construction also simplifies the pre-use checkout procedure, and an efficient 5-point check list is presented for the new machine.

The use of a visual aid to check anaesthetic machines. Is performance improved?

We asked 20 anaesthetists and seven operating department assistants to check three anaesthetic machines 'doctored' to contain errors of varying seriousness, and recorded their performances. Two weeks later we asked the same group to repeat the test. On the second occasion they followed a visual aid and filled in a questionnaire about the test. Participants showed a significant improvement in the rate of fault detection when using the aid (p < 0.05). The visual aid was most useful at increasing the detection rate of machine leaks. Of the participants, 60% considered that the visual aid was helpful and 74% thought that such an aid should be available in our theatre complex. Sixty-six percent of those questioned felt that a formal check list would be of use.