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    Anesthetic Adverse Events Vary Based on Time of Day

    By Jennifer Decker Arevalo, MA,  contributor.   

    A recent study found that patients who have surgery in the morning, beginning from 6:00 am to 9:00 am, are less likely to experience anesthetic adverse events (AEs) than patients whose surgery begins in the afternoon, from 3:00 pm to 6:00 pm.

    This “afternoon effect” was confirmed after researchers in the department of anesthesiology at Duke University Medical Center in North Carolina analyzed over 90,000 cases from their perioperative database over a four-year period. The researchers categorized all AEs pertaining to error, harm or other adverse events.

    According to the retrospective study published in Quality and Safety in Health Care, the Duke researchers found 31 instances of error, such as improper dosing of anesthetic agents and problems inserting respiration tubes. Prolonged sedation, wound infection and postoperative nausea and vomiting (PONV) accounted for 667 instances of harm. The “other AEs” category had 1,995 events, such as changes in blood pressure and operating room equipment and pain management problems. The most common AEs overall were pain management problems (1,102 cases) and PONV (277 cases).

    After matching all of these AEs with the start time for surgery (and controlling for other variables), the researchers found that the probability of harm was three times greater for cases beginning at 3:00 pm than for those starting at 8:00 am.

    Likewise, “other AEs” occurred more frequently for operations starting between 3:00 pm and 4:00 pm, compared with those starting at 7:00 am. The probability of an event in the “other AEs” category increased from one percent at 9:00 am to 4.2 percent at 4:00 pm.

    Additionally, there was a huge increase in administrative delays (9,497 cases) in the late afternoon, suggesting a correlation between delays and AEs.  Delays, due to slow lab results, late doctors, unavailable transporters to move patients or room readiness, appear to increase throughout the workday, from five percent in the morning to about thirty percent in the afternoon.

    “We suspect that these increases in AEs at the end of the day may be attributed to multiple factors, such as sleep deprivation and fatigue, circadian rhythm disruption, and issues related to demand, scheduling and staffing,” said Melanie Wright, Ph.D., lead author of the study and a human factors specialist who studies how people behave physically and psychologically in different environments.

    “There are troughs around 4:00 am and 4:00 pm in a person’s natural circadian rhythm, the internal clock that regulates daily activities, that may affect a person’s cognitive and psychomotor performance,” said Wright. “These lows tend to coincide with changes in anesthesia staff and transfers of patient care from one anesthesia team to another. They may also be related to qualitative changes in operating room performance and the incidence of AEs. Identifying periods of relatively poor OR performance is an important step in applying human factors principles to the improvement of patient care in this environment.”

    In addition, the communication between surgical team members is not always effective during hand-offs and care transitions, and it becomes clear why the Institute for Healthcare Improvement’s Prevent 5 Million Lives from Harm campaign and the Surgical Care Improvement Project are focusing on teamwork and culture as just one of the ways to improve patient safety.

    “Increased case loads, whether they are due to a shortage of CRNAs and anesthesiologists or trouble with scheduling and coverage, also seem to play a part in the rise of late afternoon AEs,” according to Wright. “CRNAs may cover more of the case load than residents during the 3:00 pm to 7:00 pm time frame and attending physicians may see an increase in case load as patient supervision is being transitioned to fewer late-call anesthesiologists. Administrative delays also suggest a potential workload problem at this time.”

    “Since health care is a 24-hour-a-day business, it’s not surprising that certain factors may affect patient care over the course of a day,” Wright said. “Identifying the times when anesthetic AEs are most likely to occur, and then increasing awareness among OR management and staff about these times, are important steps in the overall process of making surgery safer and ensuring that patients have a good experience.”

    “From a standpoint of staffing, planning and scheduling, simulation and modeling techniques for decision makers to use would be helpful. The implementation of health information technology like electronic medical records and computerized physician order entry may also be helpful, if these systems are designed with the needs of the care providers and human capabilities and limitations in mind,” Wright continued. “Hand-offs and transition care might be improved by using shared displays, similar to computerized white boards, that provide data from different sources and are available for exiting and incoming staff to view at all times.”

    “I don’t think there is just one thing out there that will solve the issue of increased AEs in the late afternoon and make it better,” concluded Wright. “We need to look carefully at the problem and consider how any of these technology solutions might fit in with what already exists and ultimately, we have to get better at transitions and smarter at scheduling.”

    Wright also believes that it is important to review the current research indicating how long people can function physically and mentally at their best and then consider what performance levels can be reasonably expected toward the end of a 12-hour work shift.  “We can only work so many hours in a week or day before our performance suffers; residency programs have already recognized this and instituted the 80-hour work-week.”

    Wright sees her team’s research project as just one step in bringing increased attention to safety issues regarding late afternoon surgeries.

    “From our study, we know things don’t go as well in the afternoon as they do in the morning. It will take future research to identify the exact causes before we can begin to develop specific strategies to reduce or eliminate the increase in late afternoon anesthetic AEs. In the meantime, not every surgery can be scheduled in the morning, so we need to begin to compare what happens in the OR during these two times of day and see if we can transfer what works early in the day to the afternoon.”

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