Waking Up Costs

Administrators, there are Six Sigma specialists already at your hospital

Clark Venable — Sun, 14 Oct 2007 14:18:23 GMT

Six sigma. Lean six sigma. High reliability organizations. Hospital administrators seem to drool over this stuff. Many are willing to go out and spend lots of money on six sigma consultants to come in to their hospitals and integrate the buzz words.

What many hospital administrators don't realize (or conveniently forget) is that anesthesiology is a six sigma specialty within medicine. That is, there are fewer than six mishaps per million events. That safety attitude is ingrained in us from the first day or residency. We live and breath six sigma and evidence-based medicine.

So, hospital administrator, the next time an endocrinologist comes to you with a plan to give insulin to non-critically ill, non-diabetic patients with a blood glucose over 120 right before their general anesthetic and the entire group of anesthesiologist says 'I don't think that's a very good idea,' pause, take a deep breath, and listen to what they have to say.

Six sigma is a way of thinking. Six sigma trumps three sigma any day of the week.

YouTube: Site-Rite Instructional Video

Clark Venable — Sun, 25 Feb 2007 13:18:12 GMT

The AHRQ published Making Health Care Safer: A Critical Analysis of Patient Safety Practices in 2001. Chapter 21 deals with Ultrasound Guidance of Central Vein Catheterization. I thought I'd include a link to a YouTube video that shows how this device is used:

http://www.youtube.com/watch?v=b2sBcIkcQ1U

Although the device has advance considerably since then (see below), the images it provides are still pretty much the same.

I will often use the device to locate and mark an internal jugular vein before draping the patient as I find the use of the needle guide extremely cumbersome.

[Site-Rite]

(Another Reason Why) I Like Desflurane

Clark Venable — Wed, 21 Feb 2007 21:19:55 GMT

I've posted before on why I think the desflurane Tec 6 vaporizer is a good design (it doesn't need to be turned off to be refilled). I'd like to add another reason to the list: it has alarms.

The Desflurane Tec 6 has a 'low agent' alarm and a 'no output' alarm, in addition to the ability to detect when it has been tipped (and therefore shouldn't be used). The other common agent, Sevoflurane, is delivered via a vaporizer that has none of these things. I am personally aware of two cases where no volatile anesthetic was delivered despite the vaporizer being 'open'. Two cases that would have been uneventful if desflurane and a Tec 6 vaporizer had been used. I'm going to ask the Society for Technology in Anesthesia listserv if there is any reason the Sevoflurane vaporizer couldn't have these features.

In advocating for patient safety, be forceful but not 'disruptive'

Clark Venable — Sat, 21 Jan 2006 12:00:08 GMT

Is whistleblowing worth it?

"What would you do if you discovered that conditions at your hospital posed a threat to patient safety? Let's say you reported the problem to your supervisor, and got no response. Would you then go to the hospital's administrator or CEO? Say you do, but he also refuses to deal with the problem. Then what? Would you file a formal report, or contact state or federal health officials?

If you do decide to blow the whistle, chances are you won't be rewarded for your efforts. In fact, you're more likely to be labeled a troublemaker or "disruptive physician." And if you persist in pursuing your cause, you could risk losing your staff privileges or your job. "

Anesthesia Blood Loss

Clark Venable — Thu, 19 Jan 2006 00:32:39 GMT

Anesthesia-related blood loss almost never exceeds surgical blood loss...but it can. I recently had a case where the IV tubing became disconnected from the IV hub during a case. The blood pressure cuff was on the same arm, and the intermittent tourniquet effect of the cuff cycling served to increase venous pressure sufficiently to cause blood to flow backward and out the now disconnected IV.

But wait, there's more. The patient was receiving the medication that kept her asleep through her IV and the disconnect put her at very real risk of waking up or having awareness in the middle of her surgery. This apparently did not happen in this case based on my interview of the patient in the recovery room, but it surely could have.

This misadventure would have been entirely avoided by the use of IV tubing with a locking hub (often called a Leur-Lock connector) connecting the IV tubing to the IV hub. In our case, someone decided the locking connectors were not worth the extra cost and our connections were just slip fit (no lock). How many times should this happen before the equipment is changed?

This has happened many times to my colleagues and I (though usually not with such blood loss), each time we complained, were told it was being looked in to, but kept getting the same connectors. I took the above rather striking photograph to some clinical managers, who agreed we needed to change, and said that they had already ordered the new tubing. Until it arrives, I'm starting IV's myself so that I can use locking connectors.