Remembering the classics: We’ve come a long way! Standards for Basic Anesthetic Monitoring Weren’t Always Our Standard
Alan Jay Schwartz, MD, MSEd and Jayant Deshpande, MD, MPH
Original Articles:
Eichhorn JH. Prevention of intraoperative anesthesia accidents and related severe injury through safety monitoring. Anesthesiology. 1989 Apr;70(4):572-7. doi: 10.1097/00000542-198904000-00002. PMID: 2929993.
Orkin FK. Practice standards: the Midas touch or the emperor's new clothes? Anesthesiology. 1989 Apr;70(4):567-71. PMID: 2929992.
Anesthesiologists’ modern-day clinical practice expectations, designed to assure patient safety and the public trust, require adherence to basic patient monitoring protocols. Without question, we reflexively commence anesthesia patient care by establishing essential minimum basic practices. This was not always the case. Current monitoring standards and technology (capnography and oximetry) did not exist as recently as 40 years ago.
In the early 1970’s we told patients, as part of the preanesthetic visit informed consent, that death during an anesthetic occurred in approximately 1 in 10,00 anesthetics. Today we advise patients that the anesthetic morbidity rate is approximately 1 in 200,000 to 250,000 anesthetics.
Today’s PAAD Remembering the Classics article by John Eichhorn paints the picture of why, how and the benefit that accrued when standards for basic anesthetic monitoring were adopted in 1986.1
“PREVENTION OF SEVERE intraoperative anesthesia-related patient injuries was the primary goal of the ‘Harvard Standards’”2,3
“The standards2,3 mandated the
· continuous presence of an anesthesiologist/anesthetist in the operating room during a case
· determination of blood pressure and heart rate at least every 5 min
· continuous ECG display
· continuous monitoring (by at least one of a variety of means) of ventilation and circulation
· use of an inspired oxygen concentration monitor
· use of a breathing system disconnection monitor during mechanical ventilation
· availability of a means of measuring patient temperature.”2,3
“This is ‘safety monitoring’ as opposed to physiologic monitoring, such as measurements of pulmonary artery pressure. While early warnings generated by safety monitoring do not guarantee a correct response to the alarm, it is reasonable to assume that the earliest possible warning will minimize the probability of damage to the patient.”2
To test this hypothesis Eichhorn and colleagues
· Reviewed, “…1,001,000 ASA Physical Status I and II patients (a subset of the 1,329,000 anesthetics administered from 1976 through mid- 1988 in the nine component hospitals of the Harvard Department of Anaesthesia)…”
· Identified, “…11 major intraoperative accidents solely attributable to anesthesia (five deaths, four cases of permanent CNS damage, and two cardiac arrests with eventual recovery)…”
· Revealed, “…that unrecognized hypoventilation was the most common cause (seven cases)…”
· Concluded, “These seven accidents and one other due to discontinuation of inspired oxygen in all likelihood would have been prevented by appropriate response to earlier warnings generated by the "safety monitoring" principles mandated by the Harvard minimal monitoring standards.
Eichhorn and colleagues’ analysis,
“…reported an “Accident and Death Rate Among ASA Physical Status I and II Patients Before and After Adoption of Monitoring Standards…showing a reduction in the accident rate among ASA physical status 1 and 2 patients from 1/75,700 anesthetics to 1/244,000, a 3.22-fold decrease.”2
Interestingly, in 1989, there was not a unanimous consensus that the risk-benefit ratio of such safety monitoring supported routine application in anesthesia practice. The accompanying editorial published in the same issue of Anesthesiology by Orkin presented a more cautious approach instead of rushing to adopt the monitoring standards.4 Orkin advised that, “Regardless of the motivation, however, the critical need is to learn more about the relationship between what we do and patient outcome. In this context, practice standards must be regarded as just another form of medical technology: each must be shown to produce net benefit before it becomes part of the clinical practice…Until we incorporate the study of patient outcome into our consideration of practice standards, the emperor is naked.”
We are indebted to our forward-looking predecessors who insightfully recognized that we needed to validate and adopt recognized standards of practice to ensure patient safety.
Since the publication of these articles, the tools to improve patient safety and quality have evolved and are broadly available. Current practices to assess practice changes (e.g., implementing practice standards) include setting SMART (specific, measurable, achievable, relevant, time-based) goals and collecting relevant data to assess the impact of the changes. We are fortunate to be in a specialty (anesthesiology) which has long been recognized as a leader in this arena.5
PS from Myron: I don’t know if this anecdote is real or an urban legend and I’m hoping one of our readers from the UK can finally put this tale to rest. You’ll note that one of the safety requirements is for continuous presence of an anesthesiologist/anesthetist in the operating room during a case. The legend goes that once a year, on ether day, a day in which ether was taken out of storage and used throughout the operating rooms in the UK. On what turned out to be the last ether day ever, one of the ORs exploded in flames killing everyone in the OR except for the anesthesiologist who was on his afternoon tea break…
References
1. Eichhorn JH. ASA Adopts Basic Monitoring Standards. APSF Newsletter. Sprimg 1987 (https://www.apsf.org/article/asa-adopts-basic-monitoring-standards/).
2. Eichhorn JH. Prevention of intraoperative anesthesia accidents and related severe injury through safety monitoring. Anesthesiology 1989;70(4):572-7. (In eng). DOI: 10.1097/00000542-198904000-00002.
3. Eichhorn JH, Cooper JB, Cullen DJ, Maier WR, Philip JH, Seeman RG. Standards for patient monitoring during anesthesia at Harvard Medical School. Jama 1986;256(8):1017-20. (In eng).
4. Orkin FK. Practice standards: the Midas touch or the emperor's new clothes? Anesthesiology 1989;70(4):567-71. (In eng).
5. Gaba DM. Anaesthesiology as a model for patient safety in health care. BMJ (Clinical research ed) 2000;320(7237):785-8. (In eng). DOI: 10.1136/bmj.320.7237.785.