ANZCA position statements & professionalism Flashcards
PG 15: Guideline for the perioperative care of pts selected for day stay procedures- what are the key principles?
-Guidelines apply to facilities providing procedural/diagnostic services where pts are discharged on the same day or within 24hours of anaesthesia/sedation
-Enhanced outcomes dependent on careful pt selection combined with optimised anaesthesia selection for any given procedure in an appropriately resourced facility
-Potential benefits= psychological benefits of limited time in unfamiliar environment (particularly if prone to delirium), pt satisfaction, lower risk of VTE & infection, risks= less monitoring eg. for postop resp failure, bleeding or other surgical/anaesthetic complications.
-The anaesthetist administering the anaesthesia is ultimately responsible for deciding the suitability of a pt for a day stay procedure
-There should be a pre-arranged criteria & mechanisms for patients scheduled for day stay procedures to be admitted to a healthcare facility with inpatient care capability (even with best possible care, some pts need admission)- this mechanism is particularly important in “stand-alone” facilities
-Day stay criteria (consider together):
Appropriate pt selection:
-age
-ASA 1 or 2 or MEDICALLY STABLE ASA 3 or 4 (ie. can’t have any unstable respiratory or cardiac disease, obese with previous VTE or metabolic syndrome)
-BMI criteria set (generally <=35kg/m2- depends on factors including maximal equipment ratings for safe manual handling/pt care/transport)- all facilities require a BMI above which the patient is referred for early consultation with an anaesthetist (*BJA education article: there’s an incr risk of complications for day surgery if BMI >50)
-pts should undergo careful screening for OSA or difficult airway- if pts have confirmed or suspected OSA, minimal post-op opioid should be used & ideally discharge analgesia NOT include opioid
-social considerations: pt must have responsible adult able to understand post-op instructions accompany & transport them in suitable vehicle (NOT bus/train) and stay with them at least overnight (may require an escort + driver) & be physically/mentally able to make decisions for the pts welfare when necessary
Anaesthesia risk factors:
(from BJA article: pt should have PAC review if obese for consideration
pt unsuitable for day case if obese & needs long-acting potent opioids, the anaesthesia should provide rapid cognitive, multimodal analgesia recovery incl consideration of regional/neuraxial)
Appropriately low risk surgery/procedure:
-minimal risk postop haemorrhage or airway compromise
-amenable to outpatient pain management techniques
-post-op care able to be performed by pt/responsible adult & special post-op nursing requirements able to be met by day surgery, home/district nursing facilities
-associated with rapid resumption of normal food/fluid intake
-if longer anticipated recovery, procedure should be scheduled first on list or as close to first as feasible
Appropriate facility/equipment/personnel:
-facility must have adequate numbers of appropriately qualified staff & equipment (incl resus equipment)- as per PS09
-incident/adverse event reporting & management system in place
-infection control policies consistent with PG28
-drug handling standers as per PG51
-emergency & ambulance access must be available along with mechanisms to transfer to higher level of care if required)
-discharge area should be wheel chair accessible & parking facilities located in close proximity to minimise walking
-specific arrangements/equipment/personnel required to facilitate paediatric day stay
-maximal patient weight for the facility determined
-AUDIT system of outcome related to anaesthesia should be in place (eg. audit factors such as delayed discharge, unanticipated pt transfer, failure of pts to comply with discharge instructions). There should be a specific CLINICAL LEAD for each facility with audit, guideline & policy development in their job description.
post-anaesthesia/discharge criteria:
-PACU as per PS4
-2nd stage- comfortable reclining seating- adequately supervised by nursing staff, ready access to resus equipment incl O2 & suction. Pts must not leave 2nd stage unaccompanied.
-discharge planning & suitable arrangements should occur prior to admission & be confirmed on admission.
Criteria for discharge home:
-vitals stable
-conscious state & mobility (considering their surgery/anaesthesia type) similar to pre-anaesthesia levels
-manageable pain, PONV or dizziness
-tolerating PO fluids
-minimal bleeding/wound drainage
-must have passed urine if at significant risk of urinary retention (eg, central neuraxial blockade/pelvic surgery)
-verbal AND WRITTEN instructions for post-anaesthesia & post-surgical care provided to pt/accompanying adult & it should be established that they understand & intend to comply with advice particularly wrt public safety (eg. activities such as driving, decision making)
-emergency contact provided to patient/carer, adequate analgesia (ideally not opioid) with clear written instructions on when to use, advice re: resumption of other medications
-discharge must be authorised by medical team (or trained nurse)
What’s the difference between ANZCA policies (CP), position statements (PS) & guidelines (PG)?
Policies= formally state a principle, plan +/- course of action that’s prescriptive & mandatory
Position statements= describe where the college stands on a particular issue- includes areas with lack of clarity/varying opinions. not definitive/prescriptive/binding.
Guidelines= offer advice which is ideally based on best practice recommendations, may be based on available evidence +/- expert consensus, not prescriptive.
PS53: Position statement on the handover responsibilities of the anaesthetist- key principles
-provide care & be continuously present through anaesthesia/sedation or major regional analgesia
-handover of this responsibility may occur for temporary relief or permanent handover, eg. situations of prolonged anaesthesia (eg. preventing undue fatigue of the primary anaesthetist) or at the end of anaesthetic (eg. to PACU, ICU).
-the primary anaesthetist must be satisfied as to the competence of the relieving anaesthetist & ideally should hand over only at a time when the clinical status of the patient is stable & no foreseen adverse events are likely to occur
-relieving anaesthetist must be willing to accept responsibility for the pt & must have had all facts relevant to safe pt management adequately explained, particularly:
pts health status (PHx, present condition)
description of anaes technique (drugs, IV lines, airway grade & security, fluid management, untoward events & foreseeable problems, their plans for further intra & postop management)
current state of the surgical procedure & its implications for anaesthesia
anaesthetic record with pt observations
check of anaesthesia delivery system, monitors & other equipment
notification of handover to surgeon/proceduralist & to consultant (if trainee)
nature of handover- temporary (expected duration) or permanent
if temporary relief, the relieving anaesthetist shouldn’t change anaesthetic management substantially without conferring with the primary anaesthetist except in an emergency- primary anaesthetist must be available to return at short notice
-The anaesthetist is responsible for recognising, managing & documenting adverse effects that may be related to the anaesthetic technique- including a responsibility to inform pts/caregivers of any future health care matters relevant to the conduct of the technique
-Anaesthetist is responsible for safe transport of pt from OT or procedure room to PACU/HDU/ICU:
may require supplemental O2
appropriate monitoring/equipment/drugs for transport
-formal handover to suitably trained & qualified staff in PACU or ICU must occur- appropriate briefing on relevant aspects of surg & anaesthesia- pt should be cardio-respiratory stable when handover occurs. handover should include specific instructions for issues such as airways, throat packs, IV or intra-arterial devices, epidurals or drug infusions along with:
clinical observations & monitoring & reportable levels
pain relief
management of complications (esp PONV)
fluid & resp therapy
any residual regional block
discharge expectations from PACU
care related to anaesthesia matters
-Anaesthetist is responsible for ensuring the pt recovers safely from anaesthesia in an appropriate area for purpose (as per PS04)- retains responsibility for ensuring safe pt recovery unless formal handover to another suitably qualified & available medical practitioner has occurred. Care & responsibility after sedation/major regional or GA is shared by anaesthetist, nurse & proceduralist. Communication within the team must be effective.
-Anaesthetist retains accountability for the management of the patient recovering from anaesthesia, particularly in the recovery room (& must be readily available to deal with unexpected problems or alternatively ensure that another nominated anaesthetist or suitably qualified medical practitioner is available & has access to the necessary information about the patient)
Must ensure the pt isn’t discharged from recovery facility until discharge criteria satisfied. Ensure plans are in place for adequate post-op care of the pt after discharge from PACU. anaesthetist responsible to be available to provide advice to the primary care team after PACU discharge.
If the pt is discharged from medical care on the same day as sedation/anaesthesia, anaesthetist must ensure the pt/caregivers are provided with protocols for post-anaesthesia care as per PG15
PS64(G): Position statement on environmental sustainability in anaesthesia and pain medicine practice
In Australia, >7% of national carbon emissions is from the healthcare sector.
In the UK, 5% of acute hospital carbon release is estimated to be a direct result of anaesthesia.
Considerations for the impact of Anaesthesia on environment:
- INHALATIONAL ANAESTHETIC AGENTS:
Impact depends on their absorption of IR radiation that would otherwise leave the earth’s atmosphere, the amount used and it’s atmospheric lifetime.
Nitrous oxide and desflurane have high intrinsic impact- at least 10-fold higher than sevo & iso
We can reduce the environmental impact of using inhalational anaesthetics by:
-using low-flow anaesthesia
-using agents with lower environmental impact
-minimising requirement for inhalational (regional, TIVA)- GA with TIVA has much lower carbon footprint than inhalational- from background paper:
life cycle assessment comparing props, sevo, iso & des with or without nitrous (assuming 50% propofol wastage & based on 1 MAC-hour equivalent, assumed disposable plastics & energy required for the delivery pump. Desflurane accounted for the largest life cycle GHG emissions, 15 & 20x those of iso & sevo when oxygen/air co-administered, higher with N2O. The environmental impact of propofol was 4x lower than des or N2O (main environmental impact from propofol= energy to operate syringe pump, minor contributions from manufacturing & waste).
- INFRASTRUCTURE:
-Architectural elements eg., nature light, use of motion-sensitive taps, oppupancy-sensing lighting. - EQUIPMENT & CONSUMABLES:
-operating theatres use large amounts of energy & contribute 25% of all hospital waste & 25% of this comes from anaesthesia specifically.
-participate in product evaluation & consider environmental footprint of equipment & consumables (esp reusable & single use equipment- made from & packaged in recycled & recyclable materials), performing full life cycle assessments
-management of stock volumes to minimise wastage of expired stock.
-consider profiled emergency drug syringes vs drawing up (risks wastage, errors, contamination). - RATIONAL USE OF DIAGNOSTIC TESTS, CLINIC VISITS & PRESCRIPTIONS:
-consider Telehealth where appropriate (reduce unnecessary transport emissions) - WASTE MANAGEMENT:
-recycling program- reduce OT waste to landfill by up to 60%
-can recycle tempered glass (drugs remain in small quantities & glass-making temperatures render drugs inert) if a stream exists
-ensure only needles & non-tempered glass med vials are discarded in sharps bins (reduces frequency of processing)
-discard unused but drawn up drugs into an incinerated stream of waste (clinical waste or sharps) reduces landfill & water contamination. - TRAVEL
-designing education/services to limit “carbon miles” - ADVOCACY
- RESEARCH
PG09: Guideline on sedation and/or analgesia for diagnostic and interventional medical, dental or surgical procedures summary
procedural sedation +/- analgesia= drug-induced tolerance of uncomfortable or painful procedures
conscious sedation= drug-induced depression of consciousness- pt can respond purposefully to verbal command or light tactile stimulation. may require interventions to maintain airway potency, spont vent or CV function in exceptional circumstances. should employ a margin of safety whereby LOC unlikely.
deeper sedation: deeper depression of consciousness- can readily progress to situation where pt only responds to painful stimulus. associated with loss of ability to maintain patent airway, adequate spont vent +/- CV function, has similar risks to GA, requires equivalent level of care.
Analgesia: reduction or elimination of pain perception, locally (interfering with nerve conduction) or generally (depressing pain perception in the CNS). may be achieved by a wide variety of drugs including methoxyflurane & N2O.
general anaesthesia: a drug-induced, reversible state of hypnosis (LOC), amnesia, loss of purposeful response to any stimulus and depending on depth, loss of protective airway reflexes, depression or respiration & disturbance of circulatory reflexes.
Requirements for the safe performance of sedation/analgesia:
PATIENT PREPARATION:
-informed consent
-provide written information including nature & risks of procedure, preparation instructions, what to expect during recovery incl after discharge
PATIENT ASSESSMENT:
-Hx/exam/Ix
-identify pts @ incr risk of airway, resp or CV compromise- in such cases, anaesthetist or trained & credentialed practitioner within their scope of practice should be present to care for the pt. INCLUDING: children <2yo, elderly, those with severely limiting co-morbidities, morbid obesity, significant OSA, known/suspected difficult airway, acute GI bleeding, severe anaemia, aspiration risk, previous adverse events with sedation/analgesia/anaesthesia, higher ASA grades
STAFFING:
-Assistance: except for techniques such as inhaled N2O, inhaled methoxyflurane or low dose PO sedation, there must be at least 3 appropriately-trained staff present: proceduralist, practitioner administering sedation & monitoring the pt & at least one additional person to assist either. The assistant to the practitioner administering sedation must be exclusively available to that practitioner at induction & emergence from sedation & during the procedure as required. For GA, a person to specifically assist the anaesthetist is required throughout the procedure.
-practitioner administering sedation/analgesia must only provide techniques within their scope of practice & must understand the drugs & modify technique based on pt & surg factors, monitor consciousness & cardioresp status, detect & safely manage complications.
-a practitioner skilled in airway management & CPR relevant to the pts age & condition must be present whenever procedural sedation+/- analgesia are administered,
FACILITIES & EQUIPMENT:
-adequate size, equipment & staff for dealing with cardiopulmonary emergency- to provide BLS until more specialised help, equipment & drugs become available.
-must have adequate room, lighting, ideally (but not mandatory) a table/trolley/chair that can be easily tilted head down, suction source, supply of O2 & O2 delivery method, a means of inflating the lungs + equipment for advanced airway management, drugs for CPR, IV equipment & fluids incl drugs for opioid & BZD reversal, pulse ox, BP measure device, device for measuring expired CO2, ready access to ECG & defibrillator, means of summoning emergency assistance, access for easy transport throughout the facility, clinical emergency response plan to manage potential clinical deterioration
SPECIALISED EQUIPMENT FOR INHALATIONAL SEDATION +/- ANALGESIA
-must have capacity to administer 100% O2
-installation & maintenance of piped gas must comply with & be serviced according to relevant standards
-appropriate method of scavenging of expired gases must be in use
-When N2O used: lightweight breathing circuit with low resistance to normal gas flows, reservoir bag for inspired gases, non-return valve or other mechanism (eg. T-piece flow connection) to prevent re-breathing, gas flow rates must be adequate & circuit must have an anti-hypoxic device. Must be a low gas flow alarm except if a demand-flow system is used.
-where methoxyflurane is used: there must be a guideline for recognition & emergency management of MH
TECHNIQUE & MONITORING:
-reliable venous access for all procedural sedation +/- analgesia except if low doses inhaled or oral agents (may not be practical eg, small children, intellectually disabled). Keep all doses to minimum for comfort. monitor depth of sedation (response to commands/stimulation) regularly. continuous pulse ox with alarm in place. regular pulse rate & BP monitoring. consider other monitors according to status of the pt (eg. ecg, capnography)
OXYGEN:
consider & have available- monitor need with pulse ox.
MEDICATIONS:
IV anaesthetics must not be administered by the procedurals.
DOCUMENTATION:
names of staff performing sedation/analgesia, Hx/exam/Ix. dosages & timing of sedative/analgesics. monitor variables including in recovery. any major resus/rescue/complications.
RECOVERY:
-appropriately equipped & staffed area with safe pt transfer facilities available & facility to manage complications.
-discharge authorised by an appropriately qualified practitioner, into care of a responsible adult with written instructions & system for transfer to appropriate medical care if needed.
TRAINING IN PROCEDURAL SEDATION/ANALGESIA FOR NON-ANAESTHETIST MEDICAL OR DENTAL PRACTITIONERS
-minimum 3/12 FTE supervised training in procedural sedation +/- analgesia & anaesthesia or similar. participate in in-training & competency assessment including crisis resource management simulation centre course (longstanding clinical experience is deemed equivalent). Regular CPR & CPD required for credentialing.
AUDIT
each unit have established system for audit of outcomes & include these outcomes, including complications, in QA & peer review processes.
Jurisdictional requirement to report M&M.
PG07: Guideline on pre-anaesthesia consultation & patient preparation
IMPORTANCE:
pre-anaesthesia assessment and consultation integral to improved outcomes.
Anaesthesia-related mortality is higher in older, sicker pts having urgent surgery- appropriate perioperative resources should be provided including appropriate levels of specialist anaesthetic care & supervision & availability of high-dependency facilities for postoperative care. Perioperative medicine should be a focus.
Engage with elderly pts & their families/carers in discussion about potential outcomes & considering advanced care directives, reduce risk of inappropriate interventions.
TIMING & LOCATION:
-Consultation must occur @ a time & place prior to the planned procedure allowing for adequate assessment & optimisation, particularly if significant comorbidity, major surgery, specific anaesthesia or pain management concerns.
-hand washing facilities, equipment, space for privacy & support person.
-NOT appropriate for elective procedures to have pre-anaes consult in the OT.
-emergency surgery consult may occur in holding bay but generally this shouldn’t occur for elective surgery unless practitioner confident there’s been thorough preop assessment & consultation & the pt doesn’t have significant comorbidity or major surgery planned. consult must allow for autonomy, religious/cultural sensitivities & support persons.
-In emergency situations, must not omit pre-anaes consultation unless welfare of pt is at risk.
CONTENT:
-Even if someone else has done a pre-anaes Ax, the practitioner responsible for administering anaesthesia must be satisfied that all elements of the assessment have been adequately addressed & repeat any points of doubt. Procedural anaesthetist must still discuss the proposed treatment with the pt to ensure all appropriate preparation & explanation has occurred.
-confirm pt’s identity, procedure, site.
-relevant Hx (supplemented by R/V of previous anaesthesia records), medication review, clinical exam, results/Ix review
-consider other Ix/interventions to optimise pt & consider that may need to delay/postpone, reappraise or even cancel surgery on the basis of these.
-role in health advocacy: as well as in optimal preparation for surgery, opportunity to educate pts re: modifiable health factors.
-take note of advanced care directives or consideration of developing these, if relevant.
-provide instructions re: medication management.
-Provide fasting instructions: continued consumption of clear fluid, particularly carbohydrate-rich fluid, may improve gastric emptying & mitigate metabolic & psychological impact of fasting. Studies have shown that in adults, it’s safe to administer up to 400mL clear fluids (eg. water, carb-rich fluids designed for perioperative use, pulp-free fruit juice, clear cordial, black tea & coffee, EXCLUDES jelly & drinks containing particles, soluble fibre or milk) 2hrs prior to surgery.
Adults: solid food up to 6hrs, clear fluids up to 2hrs prior to anaesthesia.
children over 6 months: breast milk/formula/limited solid food up to 6hrs & clear fluids (no more than 3mL/kg/hr) up to 1hr pre-anaesthesia.
infants under 6 months: formula up to 4hrs, Breast milk up to 3hrs & clear fluids (no more than 3mL/kg/hr) up to 1hr prior to anaesthesia.
may take prescribed meds with a sip of H2O within 2hrs prior to anaesthesia.
consider agents to decrease gastric secretion & acidity in pts at higher risk gastric regurgitation.
base guidelines on individual risk (eg. Hx bariatric surgery, labour, delayed gastric emptying or oesophageal motility disorders)
chewing gum has not been found to increase acidity or significantly increase the volume of gastric fluid compared to control however chewing gum MUST be discarded prior to induction due to aspiration risk.
Issues relevant to breastfeeding:
Support of the benefits of breastfeeding for women & their babies & the provision of spaces to express, facilities to store expressed milk, access to lactation consultants, limiting periods of separation between mother & infant. Most anaesthetic medications are transferred in small amounts into breastmilk. considerations:
1. amount transferred (relative infant dose, or RID)- considered “safe” if RID is <10% as are most medications used in anaesthesia.
2. oral bioavailability in the infant of the medication or its metabolites, once transferred into the breastmilk
3. metabolism & clearance by the infant- hepatic & renal- influenced by gestational age (*premature neonates may be @ higher risk for apnoeas), postnatal age & BW
4. effects of the medication/metabolites
planning:
feeding/expressing just prior to anaesthesia may help prevent engorgement
having expressed milk for the baby if period of separation is > feed interval
alternate carer for post-op if sedative/hypnotic or opioids anticipated
consideration of techniques aiming to facilitate early return of consciousness, control of pain (multimodal- short courses of opioid preferable to poor analgesia as comfort facilitates breastfeeding)/nausea/vomiting, facilitate same-day discharge if planned
education re: most medication in anaesthesia/analgesia passes in small amounts to breast milk & is unlikely to cause adverse effects to infant- that if repeated doses of opioid administered, hospital staff/carers should monitor infants for signs of sedation & sedation in the parent should prompt assessment of the infant. infants of breastfeeding mothers on long-term opioids as management of opioid-use disorder should be observed for neonatal abstinence syndrome.
-liaise with other disciplines as required.
Benzodiazepines- compatible but short-acting preferred.
There’s little information on volatiles, sux & roc but m relaxants are rapidly metabolised in adults, poor lipid solubility & very little t/f into breastmilk. volatiles have short adult serum half-life. Sugammadex has no info available but it’s a large, highly polar molecule so low transfer into breastmilk is probable.
Morphine is compatible but caution with SR preparations. use oxycodone with caution.
Codeine contraindicated- both codeine & morphine excreted in breastmilk & risk re: mother or baby being ultra-rapid metabolisers.
Although the product info recommends against use in breastfeeding, tramadol is safe; <2.5% of tramadol is excreted into maternal breastmilk, the M1 metabolite is water soluble so less readily excreted in breastmilk. Term neonate’s ability to convert tramadol to M1 by CYP2D6 is 50% cf adult, limiting mu-opioid effects- while renal excretion of M1 is also reduced (30%), this isn’t clinically relevant until after 3 months due to slow maturation of CYP2D6. However, given the small amounts ingested in breastmilk, both newborns & older infants can effectively eliminated the parent drug & its metabolite. Plasma concentrations in breastfed neonates with standard tramadol doses are <5% that administered to neonates for analgesia so sedation or OIVI in breastfed newborn very unlikely. Both tramadol & its M1 (from liver CYP2D6) metabolite provide analgesia- O-desmethyl tramadol is more potent at MOP so poor metabolisers have less analgesic efficacy but need to reduce dose for intermediate & rapid metabolisers- tramadol causes sedation (doesn’t suppress breathing) while M1 may cause both sedation & OIVI.
Fentanyl safe but avoid transcutaneous patch.
paracetamol/ibuprofen/diclofenac/local anaesthetics all compatible as are metoclopramide & ondansetron; dex has lack of data but data on other steroids reassuring.
Dexmedetomidine: no therapeutic guidelines breastfeeding recommendation. Pk study in 2017 suggested a RID of 0.034%, further info is required.
Tapentadol: TGA recommend avoiding it. not converted to active metabolite- further info required.
-providing the pt with information of significance (details of anaesthetic plan, relevant potential complications/risks- provide information & enough time for consideration, opportunity to ask questions & discuss issues of concern- interpreter present if necessary) & obtaining thorough informed consent.
-provide information re: discharge care requirements.
-contemporaneous written notes documenting consultation & informed consent in the pts medical record.
PLANNING:
-ensure facilities, equipment, staffing, services & support appropriate to the pt & their co-morbidities + procedure/recovery & ensure TIMING of surgery appropriate to allow planning/optimisation.
anaesthesia-related deaths per procedure per annum: 1:57000, anaesthesia-related deaths per million population per annum 3.23.
PS26: Informed consent for anaesthesia or sedation
Obtaining informed consent for all medical treatment is a legal requirement.
Also an ethical requirement; respect for autonomy & provision of relevant information= the cornerstones of consent.
A statement re: the necessity for anaesthesia forming part of the consent for an operation doesn’t constitute informed consent for anaesthesia and if there is a signed consent form involved, separate consultation/discussion and signatures are required for each consent; the college encourages obtaining signature as confirmatory in conjunction with documentation of the discussion.
Informed consent must be given voluntarily & without coercion.
Environment (quiet, ideally NOT in the pre-anaesthesia bay), timing (unhurried, time to consider the information provided and seek advice if they wish) and presence of support people are important considerations.
Consent can only be given by persons competent to do so, adults are presumed competent unless there are reasonable grounds for believing otherwise (which must be supported by evidence eg. known dementia, unconscious, under the influence of sedatives)
Persons <18yo may have consent provided on their behalf by a parent or persons with parental responsibility (with sufficient capacity) if the young person does not have capacity to consent & the treatment is in the best interests of the child, however the parent’s authority is not absolute.
A minor may give consent for a procedure if they can demonstrate that they have the understanding, maturity and intelligence to comprehend the proposed medical treatment and its risks/benefits/alternatives including the consequences of non-treatment and if the medical practitioner assessing their competence believes the procedure is in their best interests (ie. demonstrate “Gillick competency”; unlike an adult, a young child is presumed not to have capacity to give consent unless there’s sufficient evidence they have such capacity).
The Dr’s assessment of capacity depends on the seriousness of the proposed treatment and potential side-effects, the child’s age & maturity.
The practitioner must document their assessment of competency- the more serious/complex treatment or consequences, the more evidence is required and in situations of complex high risk medical intervention, the assessment of competence should be corroborated in writing by @ least one other medical practitioner who’s examined the child.
In QLD there’s no fixed lower limit of age to demonstrate Gillick competency.
It is good practice to encourage a child to consider seeking involvement of a parent before reaching a decision and explore reasons if the child does not want them involved, in case the child requires additional support in the area. The wishes of a child with sufficient capacity who doesn’t want their parent involved in decision making are usually protected however this may be overruled in some circumstances (eg. if there is a reasonable suspicion re: child protection concerns, which must be reported to Department of Communities, Child Safety and Disability Services and the HHS child Protection Liaison). Grandparents or other relatives need to produce evidence of a court order or testamentary guardianship to be able to consent on behalf of the child.
Treatment that is urgent or life-saving and in the best interests of the patient can proceed without prospective consent if it is in the patient’s best interests and reasonable steps have been taken within time constraints to obtain the patient’s point of view. Provision of information and discussion of the treatment undertaken with the patient must be obtained as soon as possible.
In the absence of capacity to give consent, another person can give consent on behalf of the patient in legally-defined circumstances, with the hierarchy of:
-Advanced health directive
-Guardian appointed by the Civil & Administrative Tribunal
-Power of Attorney from an Advanced Health Directive
-Statutory Attorney in the following order: spouse (close & continuing relationship), unpaid carer, close adult friend or relative (unpaid)
-Public Guardian
The substitute decision maker should always act in the best interests of the person for whom the consent being given.
A patient’s change of mind or withdrawal consent must be respected at any time.
The consent must be informed and the information provided be rational, that to which a reasonable person in the patient’s position would attach significance- should present the necessary but not excessive information- material risks to the patient must be disclosed, for instance if the patient is on hormonal contraception and sugammadex is to be used, the risk of ineffective contraception & necessity for barrier methods must be discussed with the patient, prospectively.
Basic information should be provided even if the pt requests no information but if they clearly don’t wish for further information & state that, confirmation should be sought & documented without forcing further information on them.
Discussion of risks & benefits includes those of the proposed treatment, alternatives or no treatment. Known risks should be discussed where the outcome is rare but severe or common but minor.
Advantages, risks and alternatives for blood products should be discussed.
If there are financial implications these need to be discussed as part of consent.
Information must be presented in a manner the pt is likely to understand (eg. verbal supported by handouts +/- video) and the consent discussion must be documented. Standard info sheets are not substitute for informed consent as the info provided must be specific to the individual patient. Signatures are encouraged.
Existence of advanced care directives or Power of Attorney (& confirming which is in effect) should be established preoperatively so they can be consulted & incorporated into consent process.
Patients with limited English are actively encouraged to have a qualified interpreter (not a family member) involved.
Ideally, disclosure of information and discussion is best performed by the anaesthetist/sedationist who conducts the treatment as liability for consent lies with the treating doctor- where they can only see the patient immediately prior to anaesthesia/sedation, a separate anaesthetist may consult the patient and provide information for the elements of consent. The procedural anaesthetist should still discuss the proposed treatment with the patient to ensure all appropriate preparation has occurred & the need for this discussion should be considered before sedative premedication is to be given. Those involved in the consent process are individually responsible for documentation.
What’s the order of substitute decision makers if a pt can’t give informed consent?
a valid advance health directive
a guardian appointed by the Queensland Civil and Administrative Tribunal
a health attorney under an advance health directive or enduring power of attorney
a statutory health attorney(s)
the Public Guardian.
Define non-technical skills
the cognitive, social & personal resource skills that complement technical skills & contribute to safe & efficient task performance
Define crew resource management
set of training procedures for environments where human error may have devastating safety outcomes. Focuses on interpersonal communication, leadership and decision-making.
Why are non-technical skills important? how improve?
risk deficiencies/errors/adverse events
incident analysis (routine tasks & emergencies), training (education sessions, simulations), debriefing & ongoing audit of incidents
What’s the TeamSTEPPS approach & the teachable teamwork skills to enhance performance & safety?
A teamwork system developed by department of defence & agency for healthcare research & quality to improve collaboration & communication wrt patient safety
Relates to knowledge (shared mental model), attitudes (mutual trust & team orientation), performance (efficiency, safety)
-team structure
appropriate to skills/resources
-leadership
MRCODERAC:
maximise activities of team members
have necessary resources & utilise appropriately
communicate clearly, calmly in critical situations- articulate goals, team actions understood, share changes in info, brief/debrief
Organised task management (structured & focused approach, patient-centred & maintaining standards, plan/prepare/prioritise, ability to make decisions (identify options, balance risks, select & re-evaluate)
Delegate
Role model- approachable & accountable
conflict resolution abilities
involves pts and families
-communication
clear & accurate, closed-loop, check back, brief/debrief
-mutual support
anticipate & support team members needs (workload & responsibility), advocacy & graded assertiveness, constructive feedback
-situational monitoring & stress/fatigue management
team (skills/performance/fatigue in self & others (IMSAFE illness/meds/stress/ETOH/fatigue/emotion), patient, env’t, progress towards goal, communication for shared mental model
AR_LM 1.2
Discuss the processes of quality assurance and quality improvement, and their application to anaesthesia practice including:
Principles of quality assurance
Quality improvement cycle
Risk management
Nature of error
Relationship between adverse events, system factors and human factors
Incident monitoring
Root cause analysis
(Refer to College professional document: PS58: Guidelines on Quality Assurance in Anaesthesia)
AR_LM 1.3
Outline strategies to identify and manage adverse events and near misses and analyse these to improve future patient care
PS58: guidelines on QA in anaesthesia
PRINCIPLES of QA:
-individual, departmental & institutional responsibility to contribute to assurance & improvement of safety & quality of pt care
-QA= establishing that facilities & processes meet accepted standards: “an organised process designed to ensure the maintenance of a desired level of S&Q”. QI seeks to promote continuous improvement to achieve increasingly better outcomes for pts. ie. QI: “an iterative process to continuously improve safety & quality of care”, elevates standards for ongoing QA.
*key is that expectations of acceptable outcomes should improve continuously, over time
-TRIPLE AIM of QA & QI
1. improve safety, quality & experience of care for individual pts
2. improved health & equity for population
3. best value w avail resources
Achieve Triple Aim by:
Doing the right things (evidence-based, pt-centred)
Doing things right the first time
elements of quality in healthcare:
-safety
-timeliness
-efficiency
-equitability
-patient-centredness
Expertise & competence: achieve through training & CPD, mandated by medical board of Oz for all registered specialist anaesthetists. Also support & facilitation of soundly based & properly conducted research is also integral to QI.
-Clinical guidelines/policies/protocols= key part of QA; development, review & implementation should be linked to audit & ongoing measurement
QI cycle:
-measures providing comparisons against accepted standards or previous outcomes, or btwn institutions.
Involves qual & quant measures, focus on structure, process & outcome (the latter 2 are easier to measure since outcomes are influenced by multiple factors outside practitioner’s control), ideally an element of all.
-should be a systematic process underpinned by science.
-since QA or QI projects involve expense, need to articulate the purpose & value.
QI CYCLE:
-AUDITS are a type of QA project that may also serve purpose of QI: review elements of structure/process/outcome against a standard or other predetermined criteria.
Process may be repeated & certain metrics (w worthy cost/benefit) may be worth collecting on an ongoing basis.
Steps in a QA project:
1. PLANNING (define topic, data to gather, collection/analysis method)
2. IMPLEMENTATION (collect & analyse data, review results, compare w standard, implement action to improve adherence to standards)
3. REVIEW (monitor the outcome of actions taken; “close the loop”)
4. SET (or review) STANDARDS/POLICIES (incorporate improvements achieved into new or reviewed guidelines.
RISK MANAGEMENT:
-An important part of QA programs. Regular, proactive identification of risks, assessment of risk factors, implementation of controls to mitigate identified risks. Identification of locally important risks should inform some of the projects undertaken within a QA/QI program.
NATURE OF ERROR:
each human error must have a preceding cause & the CAUSE of the error leads to productive prevention strategies.
eg. system-induced error may be a step not included in medical procedure, while an at-risk behaviour= doing a task by memory vs following a checklist.
INTERACTION BTWN ADVERSE EVENTS, SYSTEM FACTORS & HUMAN FACTORS:
-most errors involve at least 1 human factor; root cause analysis aims to identify root cause (primary cause) & contributing factors which can become the focus of QI & risk mitigation.
-human errors may be system-induced or contributed by behaviours.
INCIDENT MONITORING:
-Departmental quality & safety coordinator should be allocated & that person should be allocated the time/resources/training for the role (& must ensure that PS58 is implemented!). There may be a team who can be a contact point however for departmental Q&S issues (linked w institution) but all staff members should be encouraged to report & engage in quality improvement & participate at INSTITUTIONAL & EXTERNAL (NATIONAL/STATE) programs eg:
-M&M committees
-adverse reactions committees
-sentinel (unexpected occurrence involving death or serious physical or psych injury or risk thereof; it’s a type of adverse event (adverse occurrence directly associated with care or services within jurisdiction of a medical facility, type of review the event receives determined through the SAC scoring process (severity & probability of the event, there’s some subjectivity but it provides a yardstick for priority from a systems perspective, helping resources to be applied where they have greatest potential to improve safety, from the start of a process)) & serious adverse event reporting & root cause analysis; serious events ass’d w anaesthesia, periop care & pain management should be reported & reviewed w intention of identifying contributory factors, mitigating these & educating team to improve future safety.
-critical incident reviews: critical incident reporting eg. participation in WEBAIRS (web-based incident reporting system, combined initiative of ASA, NZ society of Anaesthetists, ANZCA (tripartite anaesthetic data committee), joint funding. assists anaesthetists to report, evaluate & receive info regarding anaesthetic incidents. results of incident analyses can be fed back into the system (close the loop)).
-ANZCA have a safety & quality committee so reports can be directly made to them, they issue safety alerts or other guidance regarding drugs, devices, equipment.
-ANZCA mortality sub-committee use data reported to department of health (compulsory in some jurisdictions, voluntary in others) re: anaesthesia-related mortality to publish triennial safety of anaesthesia reports.
-mechanism for receiving & managing pt complaints/comments is important element of QA/QI; integrate departmental mechanisms w wider institution. Pt & staff experience surveys (focus on experience & observations vs satisfaction).
ROOT CAUSE ANALYSIS:
-Process to identify basic or contributing causal factors underlying variations in performance associated with adverse events or near misses.
-interdisciplinary, focused on systems & processes vs individual. analysis asks WHAT and WHY until all contributing factors are identified.
an adverse event or near miss rarely has only one underlying cause/contributor.
-the analysis should identify changes in systems & processes (redesign or development of new ones) to improve performance & reduce risk of recurrence.
-to be credible, it must have involvement of leadership of the organisation & individuals most closely involved in the process & systems under review. Must consider relevant literature.
AR_LM 4.5: Outline the rules for formal meetings
-assembly of ppl gathered to discuss & achieve a common goal.
-should be highly structured with rules of order, pre-planned topics & clear objectives. ie. there is an agenda, chairperson, minutes, more thorough decision-making procedures (eg. vote on actions).
-some people may have highly specific roles to help keep things organised.
-typically they are for major actions.
-call to order, roll call, approval of minutes, open issues (review prev discussed items ready for approval, new business, adjournment. follow-up (send out minutes, ensure all attendees know their action tems.
PG 18: monitoring during Anaesthesia
Applies to GA, major regional anaesthesia/analgesia, sedation
Monitoring= clinical observation in conjunction with measurement & recording, with visual & audible alarms enabled.
Recommendations of PG18 may be exceeded depending on pt Ax
Person providing anaesthesia must ensure the required monitors are available
The person doing the procedure can’t be responsible for the provision & monitoring of anaesthesia.
Person with sole responsibility for provision of anaesthesia for the pt must be constantly present from induction of anaesthesia until safe t/f to PACU or ICU (in exceptional circumstances, may be temporarily delegated to a practitioner judged competent for the task. permanent handover must be to an anaesthetist able to accept continued responsibility for the care of the pt).
*MONITORING FOR ANY TYPE OF ANAESTHESIA SHOULD INCLUDE REGULAR Ax & RECORDING OF:
- circulation: detection of arterial pulse, supplemented by BP reading which should be @ least 10-minutely & a range of cuff sizes available. ecg must be available for every anaesthetised pt, should use it for general & major regional anaesthesia as clinically indicated. invasive BP monitoring should be available.
- ventilation: monitored continuously, whenever an automatic ventilator is in use, breathing system disconnection or ventilator failure alarm must be in automatic & continuous operation. monitor of CO2 level in inhaled & exhaled gases must be in use for every pt undergoing GA & be immediately available for every pt undergoing sedation.
- oxygenation: there must be an oxygen analyser incorporating an audible signal to warn of low O2 [], correctly fitted in the breathing system, in continuous operation for every pt when an anaesthesia breathing system is in use. A pulse oximeter MUST be in use for every pt undergoing GA or sedation. A variable pulse tone & low threshold alarm should be appropriately set & audible. Adequate lighting must be available to aid Ax of pt colour.
*visual & audible alarms must be enabled.
- monitoring of anaesthetic effect on the brain should be available when clinically indicated, esp if high risk of awareness, during GA.
- inhaled anaesthetic agent monitor must be used to identify & monitor insp & Et [] of inhaled anaesthetics for every pt undergoing GA with inhalational.
- temp monitor must be available for every pt undergoing GA & used whenever warming devices are used.
- quantitative NM functioning must be available for every pt with NMB & used whenever considering extubation following use of NDNMBa.
- other equipment as clinically indicated.
AR_LM 4.7: process by which new drugs are approved for research & clinical use in Oz
All meds claiming to have a clinical benefit myst be approved by the TGA (division of Aust Govt Dept of Health).
manufacturers of prescription meds can apply for their products to be subsidised.
early experiments on proposed meds in labs +/- w animals.
medicines must undergo phase 1 (small number healthy volunteers) to establish Pd & safe dose. Phase II: 50-100ppl w the target illness, info re: efficacy & dose. phase 3 1000-3000 ppl w target illness. TGA looks @ phase III.
TGA considers evidence from clinical trials to ensure side effects acceptable.
