In the September 17, 2024 PAAD entitled Global quality improvement programs and WakeUp Safe® (https://ronlitman.substack.com/p/global-quality-improvement-programs ) Drs. Jay Desphande and Faye Evans reviewed the editorial by Politis et al.1 and original article by Iyer et al.2 describing and comparing perioperative patient safety activities in several high, moderate, and low income countries. There was so much in this themed issue that I didn’t think we did it justice and so I asked Drs. Politis and Raj to expand upon our original PAAD review.
And to our Jewish readers my best wishes for a “Shanah Tova Umetuka” (A Happy and Sweet New Year) Myron Yaster MD
Original article
Iyer RS, Dave N, Du T, Bong CL, Siow YN, Taylor E, Tjia I. Wake Up Safe in the USA & International Patient Safety. Paediatr Anaesth. 2024 Sep;34(9):958-969. doi: 10.1111/pan.14920. Epub 2024 May 29. PMID: 38808685.
The Journal Pediatric Anesthesia’s (PAN) September 2024 themed issue (https://doi.org/10.1111/pan.14975 is on Global Health and includes details on how pediatric anesthesia is practiced and taught around the world. It also discusses worldwide quality improvement and patient safety education, and highlights challenges in achieving timely delivery of safe pediatric anesthesia care and education in high, moderate and low resource settings. Today’s PAAD by Iyer et al.2, titled, Wake Up Safe in the USA & International Patient Safety describes Wake up Safe’s (WUS) patient safety processes in the U.S. and their collaborations 1 with Australia-New Zealand (A-NZ), India, and Singapore, including collaboration benefits and barriers. For brevity’s sake, this PAAD summarizes only their descriptions efforts in the USA, A-NZ, and India.
Most USA based pediatric anesthesiologists, and many others are familiar with Wake Up Safe but may not know WUS’s origins and accomplishments. WUS is an accredited patient safety organization (PSO) established in 2008, with roots in the Pediatric Perioperative Cardiac Arrest Registry (POCA); many of the same individuals who started and ran POCA also founded WUS. It is worth understanding POCA’s origin as a subset of the ASA Committee on Professional Liability’s 1984 initiative, the Closed Claims Database (CCDB).
Dr. Alan Schwartz wrote a detailed description of POCA and CCDB in PAAD’s August 24, 2022 “Remembering the Classics: Pediatric Perioperative Cardiac Arrest-the POCA Data” (https://ronlitman.substack.com/p/remembering-the-classics-pediatric ). POCA involved voluntary enrollment of over 60 institutions and prospectively collected detailed data on every cardiac arrest. POCA’s model improved on that of the CCDB because the CCDB had a bias toward severe outcomes and substandard care, providing a liability profile rather than a safety profile. Both POCA and CCDB produced important findings but both lacked denominator data and therefore could not determine incidence nor perform risk assessment. Neither CCDB nor POCA included a quality improvement arm. WUS planned from its inception to prospectively collect details for numerous serious adverse events (SAEs), not just cardiac arrest, and to collect denominator data by automating input from participating institutions’ computerized medical records (CMR). Most important to those creating WUS, they were going to improve patient safety using quality improvement science to impact the patient safety problems found by analyzing their ever-growing data base.
Iyer et al.2 note, “WUS is a PSO with four main components”, hereafter referred to as WUS’s four pillars. Those pillars are: “a national registry, quality improvement education, quality improvement work, and patient safety communication.” The 1st pillar, their national registry, is a database currently fed by more than 40 partner institutions. Reported SAEs are reviewed and analyzed by three anesthesiologists from the institution where the SAE occurred. Their assessment includes cause, extent of harm, and preventability. Multidisciplinary collaboration is typically involved when assessing individual, team, system, or process flaws, and usually includes root cause analysis. WUS institutions have access to their own data and aggregate data and can therefore benchmark. Iyer, et al note self-reporting as a WUS database limitation and “an intrinsic limitation of any patient safety database.” Surveillance and reporting differ across WUS institutions, hampering the ability to compare their SAE incidences.
WUS’s 2nd pillar, quality improvement (QI) education, requires members to gain QI methodology skill and uses a specific milestone achievement scale. Members are encouraged to climb the milestone ladder by obtaining mentorship from those higher on the ladder. That mentorship strategy keeps all WUS participants’ QI abilities developing. The core elements of WUS’s education process are The Institute for Health Care Improvement (IHI) online modules, WUS monthly conference calls, and WUS bi-annual workshops.
Their 3rd pillar, quality improvement work, involves implementation of QI science to tackle identified patient safety problems and involves both individual and multi-institutional platforms.
And finally, WUS’s 4th pillar, patient safety communication, has included workshops at national meetings, safety alerts, and over 30 peer-reviewed publications leading to recommendations on topics including recall, perioperative aspiration and neurologic SAEs.
A-NZ patient safety initiatives within pediatric institutions have been ad hoc, according to Iyer et al. They note that National anesthesiology societies in Australia and in New Zealand run a SAE database called webAIRS that has, like POCA, collected lots of SAE data but doesn’t input numerator data and therefore cannot determine incidence or risk.3 WebAIRS has produced one pediatric-related and 29 adult-related publications leading to numerous, largely adult-related, patient safety recommendations. Of WUS’s four pillars, A-NZ’s strength is a reasonable national registry and fairly robust patient safety communication. They lack financial support to raise that registry to the required level and to establish QI education and QI work. WUS has assisted with QI education by facilitating a QI workshop at a 2022 national meeting.
India4 faces challenges in improving patient safety in rural areas, according to Iyer et al, They note the huge disparity in availability of equipment, medications and specialized medical personnel across India’s rural population as a major factor. Well-resourced urban areas have “health care comparable to any high-income countries” while poorly resourced rural areas may be experiencing patient safety similar to low-income countries. The care across India is not standardized across urban and rural healthcare organizations, but the National Accreditation Board for Hospitals and other accreditation bodies may be having some positive effect. The Indian government has implemented national frameworks and commissions aimed at improving patient safety. National societies have developed standards of care. The National Medical Commission has mandated that postgraduate programs focus on competency-based education including simulator training for critical events. Specialized pediatric anesthesiology training programs have been introduced and are increasing in numbers. The Indian Association of Pediatric Anesthesiologists (IAPA) has partnered with the World Federation of Societies of Anesthesiologists (WFSA) and others to spread standardized education platforms on pediatric anesthesia and resuscitation, such as the Safer Anesthesia from Education (SAFE) pediatric courses. According to Iyer et al., non-governmental organizations (NGOs) including Operation Smile and Smile Train have “positively contributed to processes, safety, and safety reporting systems”, largely by mandating quality and safety protocols and by analysis of sentinel events. Despite all those achievements, the four pillars of WUS currently exist in a limited way in India; there is “no national registry to report critical perioperative events,” QI education or implementation and patient safety communication are limited to major university hospitals and major for private hospitals spread across India. WUS is currently investigating collaboration with IAPA to establish a sister organization called WUS India that would have similar overarching goals to those of the parent organization. The proposal is for a pilot program incorporating four large Indian pediatric hospitals.
WUS’s quality improvement approach has substantially impacted pediatric patient safety in the USA. Facilitating global quality improvement and patient safety is a laudable and challenging goal.
Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Politis GD, Drum ET, Habre W, Bosenberg AT. Global quality improvement programs: One size doesn't fit all. Pediatric Anesthesia 2024; 34(9): 824-6.
2. Iyer RS, Dave N, Du T, et al. Wake Up Safe in the USA & International Patient Safety. Paediatric anaesthesia 2024; 34(9): 958-69.
3. Waugh E, Thomas J, Anderson BJ, Lee-Archer P. Pediatric anesthesia in Australia and New Zealand and health inequity among First Nations and Māori children. Paediatric anaesthesia 2024; 34(9): 934-40.
4. Rai E, Varghese E, Yaddanapudi S, Iyer RS. Advancing pediatric perioperative care in India: A contemporary overview. Paediatric anaesthesia 2024; 34(9): 875-83.