Standards for Patient Monitoring During Anesthesia at Harvard Medical School

Abstract

As part of a major patient safety/risk management effort, the Department of Anaesthesia of Harvard Medical School, Boston, has devised specific, detailed, mandatory standards for minimal patient monitoring during anesthesia at its nine component teaching hospitals. Such standards have not previously existed, and resistance to the concept was anticipated but not seen. The standards are technically achievable in all settings and affordable in terms of effort and cost. Early detection of untoward trends or events during anesthesia will result in prevention or mitigation of patient injury; this, in turn, may also help counter the explosive increases in anesthesia-related malpractice actions, settlements, judgments, and insurance premiums. The committee process used is applicable to the promulgation of standards of practice for all medical specialties and any organized group of medical practitioners.

Clinical evaluation of the Mapleson theoretical ideal fresh gas flow sequence at the start of low‐flow anaesthesia with isoflurane, sevoflurane and desflurane*

“…Minimal standards monitoring was used throughout [6]. End-expired concentrations of isoflurane, sevoflurane and desflurane were monitored continuously (HewlettPackard Anaesthetic Gas Module M1026A) and recorded for the first 20 min of anaesthesia [7].…”

Physiologic Monitoring: Improving Safety or Increasing Risk?

“…The first publication attempting to mandate minimal standards for monitoring during anesthesia came from Boston in 1986 in a JAMA publica-tion: "Standards for Patient Monitoring During Anesthesia at Harvard Medical School" authored by Eichhorn, Copper, Cullen, and others. 12 This paper was met with scorn and anger by many anesthesia providers; no medical person wants to be told that he/she must change his/her practice. A cardinal requirement of the standards was for continuous monitoring by a trained anesthesia person during every anesthetic.…”

“…12 Over the ensuing years, pulse oximetry became routinely available in operating rooms and later spread to the recovery rooms, ICUs, acute patient wards, and even patient's homes. To reiterate, these minimal required monitoring standards strongly asserted the need for one-on-one presence of a trained individual monitoring the patient and specified several possible ways to achieve the required continuous monitoring of circulation and ventilation.…”

Toxicology in the Service of Patient and Medication Safety: a Selected Glance at Past and Present Innovations

“…The concepts of continuous anesthetist presence, patient cardiopulmonary monitoring, breathing system disconnection detection, and oxygen concentration analysis were elevated to required practice standards in 1986 [8]. A U.S. FDA endorsed document, BAnesthesia Apparatus Checkout Recommendations,f ollowed in 1993 with minimum standards for utilization of pulse oximetry, capnography, and respiratory volume and pressure monitors [9].…”

“…Another study determined an anesthesia-related death rate of 1.1 per million population per year and 8.2 anesthesia-related deaths per million hospital surgical discharges [13]. The concerns that this successful systemic approach to safety in anesthesia would cede undue individual autonomy to external authority went largely unrealized [8]. The systemic focus on safety also permitted rapid introduction in safety innovations, such as a BChecklist for Treatment of Local Anesthetic Systemic Toxicity^ [14], as new threats emerged.…”