ASA NEWSLETTER

June 1996
Volume 60, Number 6

Copyright (c) 1996 American Society of Anesthesiologists. All rights reserved. Contents may not be reproduced without prior written permission of the publisher.

The views expressed herein are those of the authors and do not necessarily represent or reflect the veiws, policies or actions of the American Society of Anesthesiologists.

Editorial Board

FEATURES: Examining the Scope of Professional Liability

Professional Liability: What's Ahead?
Robert A. Caplan, M.D.
The Changing Pattern of Anesthesia-Related Adverse Events
Frederick W. Cheney, M.D.
Closed Malpractice Claims for Awareness During Anesthesia
Karen B. Domino, M.D.
Anesthesia and Surgery: Not Always a One-Sided Affair
Stephen R. Strelec, M.D.
Central Line Complications From the ASA Closed Claims Project
T. Andrew Bowdle, M.D., Ph.D.
Pediatric Perioperative Cardiac Arrest Registry: An Update
Jeffrey P. Morray, M.D.

ARTICLES

ASA Publishes 1996 Manual for Anesthesia Department Organization and Management
J. Kent Garman, M.D.
'The Anesthesia Care Team' Statement Revised
ASA at a Glance
Jack Moyers, M.D., 1921-1996

DEPARTMENTS

To the Membership

President's Page

Washington Report

Practice Management
The Minnesota Lawsuits: HCFA's Reimbursement Policy
Residents' Review

ASA News
Nominations Sought for Media Award
1995 PBLD Case Book Still Available
ABA to Conduct Recertification Exam
Sedation and Analgesia Workshop Scheduled in Seattle
Letters to the Editor
Misrepresented Comments Corrected
An Answer: Good 'Outcome' Sense
Malignant Hyperthermia Support Acknowledged
FAER Report

TO THE MEMBERSHIP
Predictions?

As a medical student in the 1950s, I learned from my professor of bacteriology that if one looked at the overall incidence of infectious disease, there was actually a long-term downward trend. He intimated that this downward trend predated the availability of drugs such as sulfa, penicillin and streptomycin. Who were we to question?

In the article on page 10, Frederick W. Cheney, M.D., cites a decreasing trend in claims related to severe injury (brain damage or death). The downward trend appears to have commenced in the 1970s and continues in the 1990s. Since the prevalent use of pulse oximetry and capnography monitoring did not occur until the mid-1980s, one might cast about for other contributory factors.

The mid-1970s witnessed a significant increased interest in anesthesiology by graduating medical students, a trend that has continued until recently. The infusion of highly motivated physicians into the specialty elevated the quality of care. In the early 1990s, health care costs gained national prominence and resulted in a concerted effort to reduce costs by stifling specialists and elevating primary care to Olympian heights. A chance article in the print media by one of our colleagues signaled the demise of anesthesiology as a career choice. Literally overnight, medical students reset their sights.

Whether this forebodes future changes in the positive closed claims trends is a matter for conjecture.

Erwin Lear, M.D.
Editor

PRESIDENT'S PAGE
The 11th World Congress of Anaesthesiologists:
'The Olympics of Anesthesia,' A Challenge Is Issued

Norig Ellison, M.D., President

The modern era of the Olympic games began in Athens in 1896, and the 23rd Summer Olympics (none were held in 1916, 1940 or 1944) will be held in Atlanta, Georgia, from July 19 to August 4, with the 24th Summer Olympics taking place in Sydney, Australia, in the year 2000. This year, Sydney also provided the venue for "The Olympics of Anesthesia" on April 14-20, when the 11th World Congress of Anaesthesiologists met there. This was the largest medical meeting ever held on that continent. More than 6,000 anesthesiologists, 1,100 accompanying guests and 2,500 exhibitors from 87 countries were in attendance.

The World Federation

When the General Assembly of the World Federation of Societies of Anaesthesiologists (WFSA) convened, the 94 member societies included two newly admitted societies, Myanmar (formerly called Burma) and Saudi Arabia. ASA's active membership of 21,599 makes us by far the largest member society of the WFSA, followed by Germany (5,095), Brazil (4,472) and the United Kingdom (3,507). WFSA dues are $1.25 per member per annum, and so ASA contributes approximately $27,000 to WFSA annually. Papua New Guinea, with 12 anesthesiologists (and 40 nurse anesthetists in a nation of 40 million) is the smallest member society.

Although this meeting was smaller than an ASA Annual Meeting (in 1995, there were 14,784 attendees at the ASA Annual Meeting in Atlanta, composed of 6,707 anesthesiologists, 2,160 guests, 1,826 spouses and 4,091 exhibitors), the quadrennial scheduling and the international emphasis justify the "Olympic" descriptor for the World Congress. Two examples of international emphasis will be cited:

* Equipment. In the United States, new anesthesia machines are routinely equipped with ventilators and capnographs, the latter being required to meet the ASA Standards for Basic Anesthetic Monitoring. These machines were very much in evidence in the exhibit area, but so were machines that were no more than sources of compressed gas, reducing valves and flow meters (similar to what I used during training 30 years ago).

* Presentations. Just after a speaker from Uganda presented with justifiable pride the steps taken in that country to decrease the incidence of transfusion-associated acquired immunodeficiency syndrome (AIDS) from 1 in 4 to 1 in 400 (20-percent HIV seropositivity in Uganda) over five years, a speaker from Australia stated there had not been a documented case of transfusion-associated AIDS in Australia since the start of HIV testing in 1985.

An emphasis on broad geographic representation also was placed in soliciting abstracts and speakers; $150,000 of the World Congress' proceeds were used to fund travel for anesthesiologists from less-developed countries.

A highlight of the 11th World Congress was the address at the opening ceremony by the Governor-General of the Commonwealth of Australia, Sir William Hayden. Provocative, on target, challenging and even inspiring are apt descriptors of his presentation, and many other anesthesiologists with whom I spoke agreed. For that reason, I will borrow heavily from Sir William's remarks for this column.

The Congress' Theme

The theme of the Congress, "Anaesthesiology -- Coming Together 150 Years On," is most apt since the sesquicentennial of William T.G. Morton's demonstration of the use of ether anesthesia is only four months away. Gwenifer Wilson, M.B., who will be the first recipient of the Wood Library-Museum of Anesthesiology Laureate of the History of Anesthesia at the 1996 ASA Annual Meeting in New Orleans, spoke at the opening ceremony about the introduction of anesthesia to Australia nine months after Morton's demonstration on October 16, 1846. She was connected by television satellite to Bucknam McPeek, M.D., who spoke from the Ether Dome at Massachusetts General Hospital (4 a.m. EST and 6 p.m. Sydney time!). Clearly, communication as well as anesthesia have come a long way in 150 years.

The Challenge

Sir William's main theme was the need to increase "the awareness and understanding by patients, the general public and those exercising governmental authority of the nature and scope of the role of anaesthesiology in modern medicine." He went on to point out that over the years, anesthesiologists -- whom he constantly referred to as "anaesthetists" with an extra "a," further emphasizing the international flavor of this meeting -- "by and large have been content to provide their services to patients effectively but unobtrusively."

In the March 1995 ASA NEWSLETTER "President's Page," I made an analogy between our work and electricity; i.e., no one turns on a light switch and exclaims what great electricity we have; only when there is a power failure is comment made. Similarly, and unfortunately, only at times of mishap is there comment made regarding anesthesia. Sir William stated:

"The recipients of anesthesia understand little of what is being done for them by those who neither seek nor obtain star billing. Indeed, it is only if something goes wrong or there is some perceived cause of complaint that the ordinary patient is likely to be really conscious of the importance of the work of such medical practitioners and the degree of expertise which that work involves.
"Be that as it may, the past tendency of the anaesthetist to remain unassertive has been conducive to a situation in which the true scope and full significance of the work of the modern anaesthetist is insufficiently understood and commonly discounted. That is a situation which is undesirable from the point of view of both medical science and the health care system. It is also undesirable from the point of view of the public in general and the individual patient in particular."

Sir William has challenged us not to be so self-effacing but to let our light shine for patients, professional colleagues and government officials alike. In this way, anesthesiologists will be better recognized and their value more appreciated.

I especially appreciated that Sir William recognizes that the role of anesthesia is not limited to the prevention and relief of surgical pain. Resuscitation, life support, principles of critical care, and treatment of benign and terminal pain were also cited as falling within the purview of the modern anesthesiologist.

The Next World Congress

Finally, I conclude with the observation that the 12th World Congress of Anaesthesiologists will be held in Montreal, Quebec, Canada, on June 4-9, 2000. I am sure that our Canadian colleagues will provide a delightful educational, social and cultural experience for all who attend.

The 11th World Congress set a new standard for international meetings in our specialty. The 11th World Congress President, Richard G. Walsh, the Congress Organizing Committee and all members of the Australian Society of Anaesthetists (which is also known as the ASA) can be justifiably proud of the 11th World Congress.

WASHINGTON REPORT
'Insurance Portability' Bill Goes to Conference; Provisions Remain Controversial

Michael Scott, Director
Governmental and Legal Affairs

On April 25, by a remarkable unanimous vote, the Senate passed and sent to conference the "insurance portability" bill (S. 1028) sponsored by Sens. Nancy Kassebaum (R-KS) and Edward M. Kennedy (D-MA), by which workers would be able to change jobs without losing health coverage. The bill would also forbid denial of coverage to new enrollees based on pre-existing medical conditions. Similar legislation (H.R. 3103) has already passed the House by a wide margin.

Despite their core similarities, the two bills contain markedly different additional provisions, many of which are controversial. The Senate bill, for example, includes an amendment sponsored by Sen. Pete V. Domenici (R-NM) that requires insurers to treat mental illness on the same terms as physical illness -- a provision regarded by many as controversial because of the added expense that would be involved.

Perhaps the most controversial provision, however, is the authorization for medical savings accounts (MSA) contained in the House bill. This concept was rejected by the Senate when, by a dramatic 52-46 vote, it stripped the MSA provision from a broad amendment to the bill offered by Senate Majority Leader Robert Dole (R-KS). Five Republicans, including Sen. Kassebaum, joined all of the Democrats in voting to remove the MSA provision.

Other provisions of the Dole amendment found their way into the final bill, however, including those gradually increasing the amount of health insurance costs that are deductible by self-insured persons from the present 30 percent to 80 percent (the House bill would increase deductibility to 50 percent), permitting deduction of long-term health care insurance and expenses and allowing the terminally ill to cash out life insurance without tax penalty.

The two bills now go to conference, where House Republican leaders and Sen. Dole are expected to make a major push for including MSA provisions in the final bill. Whether they will be as generous as those found in the House bill is open to question, but ASA expects to support this MSA-related effort along with the American Medical Association and many other medical specialty organizations.

Also requiring resolution in conference are the provisions of the House bill limiting professional liability awards and authorizing small businesses to create insurance pools designed to permit them to obtain health insurance at rates comparable to large companies. The date for the conference had not been set by press time, but it should have occurred by the time this column appears.

President, Congress Agree on Spending for FY 1996

Ending a struggle that involved the passage of 13 temporary spending bills and closing of the federal government for 27 days, the President signed the FY 1996 spending bill on April 26, some seven months after the fiscal year began. Both the President and the Republican leadership claimed victory. As a result of apparently acrimonious negotiation over the past several days, the Administration was able to gain an additional $5 billion in spending on job-related assistance, environmental protection and education. The Republicans, on the other hand, could point to the fact that overall domestic spending had been cut by $23 billion compared with FY 1995.

The terms of the budget compromise do not impact the issue of future Medicare and Medicaid spending cuts, which would be necessary to balance the budget by the year 2002, as proposed by the GOP in the budget legislation vetoed by the President four months ago. Whether or not some effort will be made to achieve compromise on this issue before the fall elections is presently unknown, but so few days remain on the congressional calendar that the task would be difficult. Inevitably, negotiations also would be complicated by politics involved in the race for the White House between President Clinton and Senate Majority Leader Dole.

HCFA Issues Proposed Rule on Physician Work Values

Consistent with its announced schedule, HCFA in early May released its proposed rule on the congressionally mandated five-year review of physician work values under the Medicare Fee Schedule (MFS).

As readers of this column are aware, last February, the RUC voted to recommend to HCFA an increase of almost 24 percent in anesthesiology work values, but that recommendation was developed too late to be considered by HCFA for inclusion in the proposed rule. Action on anesthesiology work values will occur in connection with HCFA's development of its final rule, due to be published in November or December and take effect January 1, 1997.

The HCFA proposed rule does contain a rather lengthy and accurate discussion of ASA's efforts to gain an increase in anesthesiology work values, in connection with the five-year review, up through the August 1995 RUC meeting. ASA will submit comments on the proposed rule, amplifying on this discussion and explaining the basis for its view that anesthesiology services are significantly undervalued in the MFS.

The RUC staff has reported that HCFA in its proposed rule accepted about 93 percent of the earlier RUC recommendations for refinement of work values for other specialties. This acceptance rate is consistent with HCFA action on RUC recommendations in prior years.

HCFA Action on Teaching Instructions Due Soon

HCFA is expected, by early June, to issue instructions to its carriers with respect to implementation of the new teaching reimbursement rules that were published in December and will take effect July 1. ASA has determined that HCFA's requirement that the teaching anesthesiologist participate in the postanesthesia visit, contained in the December rule-making, was an error and that a correction notice will be published in the Federal Register.

ASA representatives are currently discussing with HCFA the additional terms of the instructions as they apply to anesthesiology and as the anesthesiology requirements relate to those for surgery. Leaders of all the academic anesthesia organizations are participating in those discussions.

Send e-mail to Mr. Scott

Professional Liability: What's Ahead?

Robert A. Caplan, M.D., Chair
Committee on Professional Liability

Historians tell us that the future is best understood by studying the past. This may be good advice when it comes to understanding the challenges that lie ahead of us in professional liability.

The insurance industry provides a good barometer for recent trends. In the early 1980s, the relative risk rating for anesthesiology was in the range of 4 to 6, which is comparable to ratings for neurosurgery and cardiovascular surgery. (The relative risk rating is used to apportion insurance premiums according to the magnitude of loss in each specialty -- the higher the relative rating, the higher the cost of the insurance premium.)

Beginning in the late 1980s, insurance losses associated with anesthesia care showed such a significant and persistent decrease that the relative risk rating for anesthesiology was lowered. These trends have been sustained, and today, the relative risk rating for anesthesiology is in the range of 2 to 3, which is comparable to ratings for nonsurgical specialties. Such changes translate into substantial savings for the practitioner. In Washington state, the premium for a standard "claims made" policy in 1984 was about $27,000. Today, a comparable premium (without adjusting for inflation) costs about $11,000.

What set these changes in motion? In the early 1980s, ASA adopted a simple but far-reaching philosophy: the best method for controlling the cost of professional liability is the prevention of injuries. The reasoning behind this philosophy is straightforward. If injuries are fewer and less severe, then there will be fewer claims and malpractice lawsuits. If there are fewer claims and malpractice lawsuits, insurance losses will be lower and premiums will decrease. Because the expense of premiums and adverse outcomes is passed along, at least in part, to the consumer and third-party payer, this strategy has the potential to make a broad contribution to the cost-effectiveness of anesthesia care.

To put this philosophy to work, ASA initiated a variety of projects. The general goal was to find ways to promote and improve the safety of anesthesia. In aggregate, these efforts are sometimes called "the anesthesia patient safety movement." One of the most important leaders of this movement, Ellison C. Pierce, Jr., M.D., reviewed the history of anesthesia patient safety in the 34th Annual Rovenstine Memorial Lecture at the 1995 ASA Annual Meeting. This lecture will be published in a forthcoming issue of the journal Anesthesiology, and it is sure to make fascinating reading.

For the past decade, the Committee on Professional Liability has been an active participant in the patient safety movement. This role takes the form of the ASA Closed Claims Project. In keeping with the basic philosophy that prevention of adverse outcomes is the best method for controlling the costs of professional liability, the goal of the Closed Claims Project is to discover unappreciated patterns in anesthesia care that may contribute to patient injury and subsequent litigation. The detection of such patterns can serve as an effective tool for directing patient safety research and devising new preventive strategies.

The usefulness of closed claims data was first appreciated in the early 1980s by Richard J. Ward, M.D., Professor of Anesthesiology, University of Washington, and Richard J. Solazzi, M.D., then an anesthesiology resident at the University of Washington, Seattle. In the process of studying closed malpractice claims against anesthesiologists in Washington state, Drs. Ward and Solazzi realized that these cases provided an enriched environment for collecting detailed information about rare but often catastrophic events. They also realized that the opportunity to collect a relatively large set of rare events might reveal recurring themes and insights that would be difficult to discern by the practitioners who experienced the cases as isolated events.

In 1984, Dr. Ward convinced Dr. Pierce, who was then the President of ASA, that a nationwide effort would be the best way to realize the potential benefits of closed claims analysis. Dr. Pierce agreed, and the Closed Claims Project was assigned in 1985 to Frederick W. Cheney, M.D., then Chair of the Committee on Professional Liability.

Insurance companies were initially reluctant to have closed claims reviewed by outside physicians. After a slow start in the mid-1980s, the project gained wider acceptance, and the number of participants steadily increased. Today, closed claims are obtained from 35 U.S. insurance carriers. On aggregate, these carriers provide coverage for approximately 50 percent of practicing anesthesiologists in the United States. The current database contains more than 3,500 claims and represents the world's largest single resource for the in-depth study of major adverse outcomes related to anesthetic practice.

Since the inception of the Closed Claims Project, 13 papers have been published in peer-reviewed literature. Most of the publications have appeared in the journal Anesthesiology. Four papers have been accompanied by editorials. The papers cover a broad range of topics, including new mechanisms of anesthesia-related injury, liability patterns and how anesthesiologists make decisions about the standard of care.

Findings from the Closed Claims Project have played an important role in shaping the features of ASA standards and guidelines, particularly those that relate to the use of pulse oximetry in the operating room and recovery room, the use of capnography for verification of endotracheal tube location and the role of guidelines in the management of the difficult airway.^1-3

Sixty-one ASA members currently serve as reviewers for the Closed Claims Project. The Society owes a great deal of thanks to these members, who devote many long hours to the task of claims review, often at sites distant from home. Current reviewers are acknowledged on the Committee on Professional Liability membership list.

Leadership of the Closed Claims Project remains with Dr. Cheney at the University of Washington. As Director, Dr. Cheney is assisted by Associate Directors Robert A. Caplan, M.D., and Karen B. Domino, M.D.; Project Coordinator Karen L. Posner, Ph.D.; a research assistant; and a secretary.

Although the project has grown considerably in size, it remains efficient and cost-effective. Funding for the project is provided entirely by the ASA membership. Expenses in 1995 were $124,928. Most operating costs are associated with salaries for nonphysician support staff, database management and reimbursement for reviewers' travel to insurance companies. Physician participation remains entirely voluntary and uncompensated.

What's Ahead?

The recent stream of cases entering the Closed Claims Project suggests that the landscape of liability in anesthesiology is changing. Happily, the change continues in a favorable direction. As reported by Dr. Cheney in this issue of the NEWSLETTER [see page 10], the percentage of claims for death and brain damage continues to decrease -- from 56 percent in the 1970s, to 45 percent in the 1980s, to 31 percent thus far in the 1990s. A similar pattern emerges for claims involving adverse respiratory events. These and other patterns described by Dr. Cheney suggest that the Closed Claims Project may offer a valuable way to assess the impact of changes in practice such as monitoring standards and guidelines. In this way, the Closed Claims Project may be able to serve as an ongoing nationwide monitor of quality assurance in anesthesiology.

Under the direction of Dr. Posner, the scientific and technical aspects of data collection and analysis continue to evolve. The resources of the Closed Claims Project are now developed well enough that they can be "exported" for use in related areas of inquiry. The articles in this issue of the NEWSLETTER by T. Andrew Bowdle, M.D., Ph.D., [see page 22] and Karen B. Domino, M.D., [see page 14] provide excellent examples of how the database of the Closed Claims Project can be used to explore a specific area of clinical concern. In particular, these articles demonstrate how closed claims data can be used to support and extend observations from conventional sources such as case reports and clinical reviews.

Another example of an "export product" from the Closed Claims Project is the Pediatric Perioperative Cardiac Arrest (POCA) Registry. This registry is directed by Jeffrey P. Morray, M.D., and Jeremy M. Geiduschek, M.D., of the Children's Hospital and Medical Center, Seattle, Washington. Support and guidance for the POCA Registry is provided by the staff of the Closed Claims Project.

Preliminary findings from the POCA Registry are described in this issue of the NEWSLETTER by Dr. Morray [see page 26]. Unlike the Closed Claims Project, the POCA Registry obtains cases directly from anesthesiologists associated with the practice settings where the adverse events actually occur. This means that there is less likelihood that data of interest will be inaccessible. In addition, there may be relatively little delay between the occurrence of an adverse event and its entry into the POCA database. (In contrast, the legal process often interposes a delay of several years between the occurrence of an adverse outcome and its "availability" as a closed claim.) Of special interest, the POCA Registry includes a mechanism for follow-up reports and retrieval of missing information; thus, the POCA Registry incorporates innovations in data collection that may lead to insights that cannot be discerned from closed claims data.

The POCA registry provides groundwork for applying the techniques of closed claims analysis to the study of insurance company incident reports. Incident reports may be an important resource for the future study and management of professional liability because this type of information is much more contemporaneous than closed claims data. In this way, the study of insurance company incident reports may provide a means for the Closed Claims Project to act as an "early warning system" that can improve our ability to identify emerging problems and implement timely remedies. Early warning systems may be especially important as we enter an era of health care that is increasingly dependent upon cost controls.

What lies ahead for the Committee on Professional Liability? If the past does indeed provide us with clues, then the future directions are not too difficult to identify. First, we must maintain and strengthen the Closed Claims Project, which serves as our core resource for studying and improving professional liability in anesthesiology. Second, we need to channel creative efforts into developing methods that will give us a more timely view of changing trends in liability. Third, and perhaps most importantly, we need to sustain our commitment to the basic philosophy that the prevention of injury is the best strategy for management of professional liability.

References:

1. Tinker JH, Dull DL, Caplan RA, et al. Role of monitoring devices in prevention of anesthetic mishaps: A closed claims analysis. Anesthesiology. 1989; 71:541-546.

2. Caplan RA, Posner KL, Ward RJ, et al. Adverse respiratory events in anesthesia: A closed claims analysis. Anesthesiology. 1990; 72:828-833.

3. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway. Anesthesiology. 1993; 78:597-602.

A list of peer-reviewed publications from the ASA Closed Claims Project is available upon request from the author.

Robert A. Caplan, M.D., is Staff Anesthesiologist at the Virginia Mason Medical Center and Clinical Professor of Anesthesiology at the University of Washington School of Medicine, Seattle, Washington.

Send e-mail to Dr. Caplan

The Changing Pattern of Anesthesia-Related Adverse Events

Frederick W. Cheney, M.D., Director
ASA Closed Claims Project

The ASA Closed Claims Project database is a standardized collection of case summaries of adverse anesthesia-related outcomes derived from professional liability closed claims files. This project, which has been ongoing since 1985, reflects to some extent the safety of anesthesia practice in the United States.

Presently, there are 3,533 closed claims collected from 35 insurance organizations that insure approximately 14,500 anesthesiologists.

Claims for Death, Brain Damage and Nerve Injury [Figure 1]

In the overall database, the most frequent complications are death (34 percent), nerve damage (16 percent) and patient brain damage (12 percent). If claims for death and brain damage are taken as an indication of the severity of injury, analysis of the data by the year the adverse outcome occurred makes it apparent that the severity of injury has been decreasing over time. In the 1970s, 56 percent of claims were for death and brain damage as compared to only 45 percent in the 1980s and 31 percent in the 1990s. The incidence of nerve injury, a far less serious complication than the other two, has remained relatively constant over the years.

Claims for Respiratory System Damaging Events [Figure 2]

The most common damaging events or mechanisms of injury are those involving the respiratory system. These data are also changing over time. In the 1970s, 36 percent of the injuries were respiratory in nature. The incidence of respiratory-related damaging events decreased to 27 percent in the 1980s and 15 percent in the 1990s.

Since pulse oximetry (SpO₂) and capnography (ETCO₂) have been in use since the mid-1980s, we further analyzed the data to determine if we could identify an early trend of the impact of these monitoring modalities on the decrease in respiratory system damaging events. In order to focus on circumstances where SpO₂ and ETCO₂ would be expected to have the most impact, we examined only 1,729 claims in which the adverse event occurred intraoperatively during general anesthesia. In 8 percent (n=138) of these 1,729 claims, SpO₂ (without ETCO₂) was in use, and in another 8.2 percent (n=142), both SpO₂ and ETCO₂ were in use. In the remainder of the claims (83.8 percent), neither monitor was in use.

Claims Related to Respiratory, Cardiovascular and Equipment Damaging Events [Figure 3]

Respiratory-related damaging events led to the injuries in 42 percent of the no SpO₂/ETCO₂ claims, 29 percent of the SpO₂ claims and 20 percent of the SpO₂ + ETCO₂ claims. The next most frequent but far less common damaging events in the no SpO₂/ETCO₂ claims were cardiovascular- and equipment-related. Cardiovascular damaging events were more common in both the SpO₂ and SpO₂ + ETCO₂ groups, compared with those claims in which neither monitor was in use. In the 142 claims in which both monitors were in use, respiratory and cardiovascular damaging events each represented 20 percent of claims, compared with 42 percent for respiratory claims and 9 percent for cardiovascular claims in the no SpO₂/ETCO₂group. The occurrence of equipment-related damaging events was not influenced by the use of SpO₂ and ETCO₂ monitoring.

Claims Involving Inadequate Ventilation, Esophageal Intubation, Difficult Intubation [Figure 4]

Among the claims in the respiratory system category in which SpO₂ and ETCO₂ were not monitored, the most common specific damaging events were inadequate ventilation, esophageal intubation and difficult intubation. These three damaging events combined to represent 71 percent of the claims in that group. In the SpO₂ group, there were 40 respiratory-related damaging events, most of which were due to difficult intubation and esophageal intubation. Of the 12 esophageal intubations in the SpO₂ group, hypoxemia was apparent in most cases, but the correct diagnosis was made too late to prevent brain damage or death.

In most cases, over-reliance on auscultation of the lungs, disregard of the SpO₂ values or failure to observe the pulse oximeter with the alarms turned off were the reasons for the adverse outcome. There were only two damaging events attributed to inadequate ventilation in the SpO₂ group.

Of the 28 respiratory-related damaging events in the SpO₂ + ETCO₂ group, there were six esophageal intubations and one claim due to inadequate ventilation. In the SpO₂ + ETCO₂ group, as in the SpO₂ group, difficult intubation was the most common damaging event. The esophageal intubations in the claims in which ETCO₂ was in use were due to a combination of factors, including misinterpretation of an ETCO₂ reading of zero as machine failure or disregard of the capnographic readings.

The incidence of severe injury (brain damage and death) in the three most frequent respiratory system damaging events was comparable between the no SpO₂/ETCO₂ group (83 percent) and the two groups in which some combination of these monitors was in use (77 percent). Therefore, when adverse outcomes occurred with these monitors in use, the monitor did not seem to reduce the severity of injury.

The almost total lack of inadequate ventilation damaging events in claims in which either SpO₂ or SpO₂ + ETCO₂ were in use suggests that these two monitors may have an impact on this mechanism of patient injury. The near absence of any inadequate ventilation claims in the SpO₂ group suggests that most of the adverse outcomes attributed to inadequate ventilation in the group with no SpO₂ monitoring may have been due to inadequate "oxygenation."

The relative increase in cardiovascular system damaging events and decrease in inadequate ventilation damaging events in the groups where SpO₂ or SpO₂ + ETCO₂ were in use also suggests that many of the adverse events attributed to inadequate ventilation in the no SpO₂/ETCO₂ group may well have been cardiovascular in origin. The fact that difficult intubation is still a frequently cited respiratory damaging event in a group of claims where SpO₂and/orETCO₂ monitors were in use is not surprising since the monitors themselves do not intubate tracheas.

Conclusion

The preliminary data presented may reflect a changing profile of anesthesia-related injury due to adverse respiratory events. This profile may change as more claims for injuries occurring in the 1990s are processed. From the data available to date, it is obvious that in order to be effective, the monitors must be properly used and interpreted. Utilization of the ASA Practice Guidelines for Management of the Difficult Airway may lead to a reduction in patient injury due to this mechanism of injury.

Whatever the reason, it is encouraging that severe-injury claims for death or brain damage seem to be decreasing. Because of this, nerve injury may well assume the position as the leading cause of anesthesia-related injury for which a malpractice claim is made. Since preventative strategies for nerve injury are not apparent, claims for this injury may be expected to remain constant while those for death and brain damage are concurrently decreasing.

Frederick W. Cheney, M.D., is Professor and Chair, Department of Anesthesiology, University of Washington School of Medicine, Seattle, Washington.

Send e-mail to Dr. Cheney

Closed Malpractice Claims for Awareness During Anesthesia

Karen B. Domino, M.D.

"I remember feeling the cold plastic tube being inserted down the back of my throat. I remember trying to cough, talk, open my eyes and do anything to signal that I was still awake. At that point, I began to panic, and I could feel my heart racing. I was crying inside, but no one noticed my tears. The sensation and memory were similar to what I have read about people being buried alive."¹

As is vividly described here, awareness under general anesthesia is a terrifying experience. However, by virtue of its nonphysical nature, awareness is not as easily recognizable or quantifiable as are other anesthesia-related injuries. While it is often assumed that the emotional sequelae of awareness are transient in nature, permanent disability due to recurrent nightmares, sleep disturbances, impaired social interactions, difficulties at work and post-traumatic stress disorder may occur.

The true incidence of intraoperative awareness and recall is poorly documented but varies according to the type and depth of the anesthetic technique. High rates of recall have been reported in major trauma (11 percent to 43 percent)² and obstetric anesthesia (2.5 percent to 4 percent).³ The overall incidence of awareness (0.2 percent for all general anesthesia cases)⁴has decreased during the past 10 years, coincident with increased perception of the problem by anesthesiologists.⁵ At the same time, patient concern with the possibility of intraoperative awareness has also increased, with up to 50 percent of patients expressing anxiety over intraoperative awareness.⁶

The patient profile for malpractice claims for intraoperative awareness and whether the rate of claims is changing are unknown. We therefore examined closed claims maintained by the ASA Closed Claims Project database. The database contains a standardized collection of case summaries of adverse anesthesia-related outcomes, obtained from 35 insurance carriers throughout the United States. The data represents closed malpractice claims and does not provide overall incidence statistics for intraoperative awareness.

Closed Claims Analysis

Out of 3,533 claims in the ASA Closed Claims Project database, there were 69 claims for awareness (2 percent), including 54 claims for patient recall of events under general anesthesia (1.5 percent) and 15 claims for inadvertent paralysis of awake patients (0.4 percent). The rate of claims for awareness and awake paralysis was similar to rates of claims for myocardial infarction, aspiration pneumonia, back pain and hepatic dysfunction following anesthesia [see Figure 1]. These rates suggest that intraoperative awareness is a significant source of lawsuits against anesthesiologists. Although the public's and anesthesiologists' concerns about awareness have increased, the proportion of awareness claims has remained relatively stable during the years of the ASA Closed Claims Project.

The rate of payment for awareness claims was the same as for other claims (57 percent). However, the severity of injury in awareness claims (temporary, minor, etc.) was usually lower than the severity of other claims in the database (generally permanent and disability). Awareness claims resulted in a lower payment than other anesthesia malpractice claims, with a median payment of $18,000 for recall during general anesthesia, compared to a median payment of $100,000 for nonawareness claims [see Table 1]. However, substantial sums of money were recorded in awareness claims, with highest payments awarded for awareness complicated by other anesthetic complications (e.g., $600,000 for a case complicated by aspiration pneumonitis) or severe permanent disability (e.g., $125,000 for post-traumatic stress disorder).

Awake Paralysis

Most cases of awake paralysis were related to intravenous infusion errors or syringe swaps. Infusion errors included the use of nonlabeled succinylcholine bags (two cases), mislabeled succinylcholine bags (two cases) and failure to check the label on unintended succinylcholine drips (six cases), accounting for two-thirds of the claims for awake paralysis. Syringe swaps occurred with properly labeled drugs in three cases and mislabeled syringes in two cases. Reviewers considered most cases of awake paralysis to be examples of substandard anesthesia care, even though the paralysis was promptly recognized and appropriately managed.

Recall During General Anesthesia

In contrast to the awake paralysis claims, most of which were secondary to vigilance errors, recall under general anesthesia had a variety of etiologies. The anesthetic care was classified as substandard in 42 percent of cases, which is similar to classification for all other claims in the database but less than the percentage for awake paralysis claims (substandard in 93 percent of cases). In substandard cases, recall occurred as a result of failure to turn on a halogenated agent vaporizer, vaporizer malfunction or failure to administer appropriate amounts of anesthetic agents during induction; however, recall often occurred in the presence of an anesthetic that met the standard of care such as with use of amnestic agents or during a period of hemodynamic instability. Hypertension and tachycardia were occasionally clinical cues for awareness, although these signs were absent in most cases.

In order to determine risk factors for claims for recall during general anesthesia compared to other types of malpractice closed claims, 52 recall claims and 2,072 other general anesthesia claims, which had sufficient detail concerning anesthetic agents, were compared using logistic regression analysis. Five factors were significantly associated with recall under general anesthesia claims: female gender, gynecological/obstetrical procedures, use of opioids, use of muscle relaxants and lack of use of a volatile anesthetic agent [see Table 2].

Female gender tripled the risk of an awareness claim, compared with other general anesthesia malpractice claims. Gynecological/obstetrical procedures and anesthetic techniques involving use of muscle relaxants and/or opioids doubled the risk of malpractice claims for recall. In contrast, use of a volatile anesthetic agent reduced the risk of recall claims by one half. After adjusting for the other risk factors using multiple logistic regression analysis, female gender, gynecological/obstetrical procedures and anesthetic techniques involving muscle relaxants remained as independent risk factors for malpractice claims for recall during general anesthesia.

The increased risk of recall claims arising from anesthetic techniques that use opioids, use muscle relaxants and do not use volatile anesthetics is logical and predict-able. Likewise, an association of recall with gynecological/obstetrical procedures is not surprising because of the common use of light anesthetic techniques during these procedures.

Unfortunately, the number of recall claims in the database was too small to allow a more detailed examination of risk with different surgical procedures. The increased propensity for women to file suit for recall during general anesthesia is somewhat surprising. In general, women are not more likely than men to sue for minor adverse outcomes, according to the ASA Closed Claims Project. However, women may be more likely than men to sue for emotional injury.

Conclusion

Recall during general anesthesia or awake paralysis is a frightening experience, which may lead to serious emotional injury. The ASA Closed Claims Project analysis of awareness claims suggests that deficiencies of labeling and vigilance are common etiologies for awake paralysis. Claims for recall during general anesthesia represent a more diverse group. Risk factors for claims for recall under general anesthesia include female gender, gynecological/obstetrical procedures and anesthetic techniques using muscle relaxants and opioids without volatile anesthetic agents.

References:

1. Personal communication with a patient who experienced intraoperative awareness.

2. Bogetz MS, Katz JA. Recall of surgery for major trauma. Anesthesiology. 1984; 61:6-9.

3. Crawford JS. Awareness during operative obstetrics under general anesthesia. Br J Anaesth. 1971; 43:179-182.

4. Liu WHD, Thorp TAS, Graham SG, et al. Incidence of awareness with recall during general anesthesia. Anaesthesia. 1991; 46:435-437.

5. Ghoneim MM, Block RI. Learning and consciousness during general anesthesia. Anesthesiology. 1992; 76:279-305.

6. McCleane GJ, Cooper R. The nature of preoperative anxiety. Anaesthesia. 1990; 45:153-155.

Karen B. Domino, M.D., is Associate Professor of Anesthesiology at the University of Washington School of Medicine, Seattle, Washington.

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Anesthesia and Surgery:
Not Always a One-Sided Affair

Stephen R. Strelec, M.D.
Committee on Professional Liability

Wrong-sided surgery has found wide exposure in the lay press in the past year due primarily to a few sensational examples, including a craniotomy in New York1 and a foot amputation in Florida.2,3 The result can be serious permanent disability or death, which was the case in Texas when a 59-year-old patient had his healthy right lung removed rather than the cancerous left lung.4 The $9 million settlement of the wrongful-death lawsuit following this error of laterality speaks to the financial toll extracted.

Professional careers have been seriously disrupted as well. In the instance of the wrong-sided craniotomy reported recently at a large New York City hospital, the chair of the Department of Neurosurgery was dismissed for his part in the affair.⁵

Hospitals themselves are also susceptible to severe sanctions. The hospital in Tampa, Florida, where the wrong foot was mistakenly amputated, was told to halt all elective surgery until better procedures were established to prevent such an occurrence.⁶ In addition, that same institution was stripped of its accreditation from the Joint Commission on Accreditation of Healthcare Organizations, and consequently, Medicare funding was threatened.⁷

While generally not as serious, errors of laterality can occur in the administration of anesthesia as well. An informal survey via the Global Anesthesiology Server Network (GASNet) forum and a mailing to ASA state component societies revealed anecdotes of wrong-sided axillary blocks, unilateral spinal blocks and the like. Recent correspondence by a nurse anesthetist on GASNet asked if there were "any new and foolproof ideas" out there to prevent such an occurrence.

Adherence to strict policies and procedures for patient identification and surgical consent are essential elements of any preventative solution, but no simple, fail-safe measures have come to light. The issue of right versus left becomes much more complicated, for example, when internal paired organs are involved.

Analysis of numerous instances of wrong-sided surgery reveals a myriad of ways in which errors of laterality can occur.

Legal Aspects

The issue of whether or not the anesthesiologist bears responsibility for a surgical error of laterality is controversial at best, as was addressed in the June 1991 ASA NEWSLETTER.⁸ William M. Gild, M.D., J.D., an anesthesiologist and attorney, opined that an expert witness who testified to the responsibility of the anesthesiologist to ensure correct-sided surgery was "articulating an expanded role for the anesthesiologist in the O.R. [operating room] ... and setting a new standard for our specialty."

Like it or not, some states may hold the anesthesiologist responsible for ensuring that the correct operation is done on the correct side through regulatory law emanating from each state's health department, which is the case in California and Hawaii. Moreover, several institutions have adopted policies and procedures that directly involve the anesthesiologist or anesthesia care team in ensuring correct-sided surgery.

A computer search via the LEXIS-NEXIS service yielded little additional information on the subject but did include a description of an interesting case in which a group of 14 anesthesiologists were sued by a plaintiff neurosurgeon for refusing to provide anesthesia services after a series of surgical misadventures, including several wrong-sided craniotomies.⁹ The defendant anesthesiologists prevailed up to and including an appeal to the Iowa State Supreme Court.

Interesting Accounts

Analysis of several surgical errors of laterality can yield insight into how procedures and policies fail and how we might better prevent such occurrences. Poor communication due to a language barrier played a significant role in the wrong-sided craniotomy that occurred in New York City. Failure to crosscheck computerized tomography films with the patient's identification band was a compounding factor.

A wrong-sided emergency craniotomy at another institution resulted from poor communication of a different nature. The attending neurosurgeon had requested that the patient be positioned "supine, head turned, left side." The anesthesiologist and the neurosurgical fellow hearing this request began the procedure with the patient's head turned to the patient's left side, and therefore, a right craniotomy was begun when in fact the staff surgeon thought he was indicating a left craniotomy approach.

Poor communication can also lead to consequences besides wrong-sided surgery. An aphasic stroke patient underwent a bilateral orchiectomy rather than the indicated circumcision because of the way he responded when addressed by the wrong patient's name, leading all to believe he was the intended orchiectomy patient. Notably, his identification band was removed prior to starting an intravenous line.

Failure to compare operating room schedules with surgical consents led to the wrong-sided foot amputation that occurred in Florida. Reliance on the patient's verbal information and failure to crosscheck the information with respect to side of surgery is often a contributing factor. One such case involved a bilateral renal transplant patient who had the one functioning kidney removed because he incorrectly stated the side of surgery.

Even when all communications and paperwork appear in order, mistakes can occur. An unfortunate patient had the wrong leg amputated because the attending surgeon positioned the patient prone for better exposure to the leg vessels and then developed right/left confusion due to the prone position of the patient.

One final anecdote of wrong-sided surgery, according to the New York State Society of Anesthesiologists, involved a surgeon in New York who operated on the wrong knee and subsequently stated, "My mind was clouded by nitrous oxide in the room."

Preventative Measures

No uniformity exists as to how to best document the correct side of surgery and prevent the confusion of this issue. Several institutions insist on the presence of the attending surgeon for induction and positioning, in recognition of the surgeon's key role in determining surgical site and side. This policy is flawed by the problems of significant surgical delays and selective enforcement of policy.

Some institutions advocate marking the patient preoperatively with an indelible marking pencil, using an arrow or other descriptor to indicate the correct side of surgery. The practice of writing "NO" on the nonoperative side may be flawed by a few factors; i.e., smudging of the word "NO" may make it look like a mark indicating the designated surgical site, and the word "NO" viewed upside-down appears to be the word "ON." This second scenario resulted in at least one instance of a wrong-sided hypobaric spinal block being performed.

Critics of the marking of patients before surgery include surgeons and hospital administrators alike, the complaint being that they don't like the message (presumed incompetence?) it sends to their patients. One institution obviates this concern by flagging the patient's chart with a bright red face sheet labeled with an "R" for a right-sided procedure or a green face sheet labeled with an "L" for a left-sided procedure.

Many institutions have adopted policies and procedures necessitating several layers of crosschecking of surgical consents, patient X-rays and chart records and direct patient questioning about surgical procedure and side. These procedures often require verbal agreement and signature documentation by the circulating nurse, surgeon and anesthesiologist. Allegheny General Hospital in Pittsburgh, Pennsylvania, requires crosschecking of consents, X-rays and the patient's chart for correct laterality of surgery. Then, before the scalpel is handed to the operating surgeon, a final verbal agreement between all members of the surgical team, including the anesthesiologist, is necessary to corroborate that the correct procedure is being done.

Conclusion

No perfect solution exists to prevent errors of laterality. Each institution's policy for dealing with this difficult issue will have its own inherent bias. Some anesthesiologists will take exception to the prospect of being held liable for ensuring that the surgeon operates on the correct side. Many anesthesiologists already take on this responsibility but are not aware of it. Heightened awareness on the part of all operating room personnel as to the possibility of such an error and rigid adherence to established procedures for patient identification will minimize the likelihood of such an occurrence.

Redundancy of crosschecking is desirable, and patients' concerns about repeated questioning with respect to surgical procedure and side should be deflected by the reassurance that "we are all just making absolutely certain that no mistake will occur." Care should be taken, however, to avoid confusion due to patient sedation, age, organic disease or language barriers.

As in all other aspects of the practice of anesthesiology, vigilance is paramount to preventing such an error.

References:

1. Altman LK. State issues seething report on error at Sloan-Kettering. The New York Times. November 16, 1995:l.

2. Miller S. Two feet of mistakes. Newsweek. March 27, 1995:60.

3. Gauzer B. When doctors are the problem. Parade Magazine. April 14, 1996:1-6.

4. National briefs: Wrongful death suit. Pittsburgh Post Gazette. April 2, 1995.

5. Bloom M. Scrambled surgery. Physicians Weekly. December 25, 1995; 12(8):1.

6. Martinez J. Tampa hospital loses accreditation. Pittsburgh Post Gazette. April 12, 1995.

7. Ryan M. Series of human errors threatens Medicare funding. Biomedical Safety and Standards. May 1, 1995; 25(8).

8. Gild WM. Expert witness sets new standards for anesthesia practice. ASA NEWSLETTER. June 1991; 55(6):13.

9. Locksley v. Anesthesiologists of Cedar Rapids, #51/66316 (Iowa, 1983).

Stephen R. Strelec, M.D., is Senior Attending Staff Anesthesiologist, Department of Anesthesiology, Allegheny General Hospital, and Assistant Professor of Anesthesiology, Medical College of Pennsylvania and Hahnemann University-Allegheny Campus, Pittsburgh, Pennsylvania.

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Central Line Complications From the ASA Closed Claims Project

T. Andrew Bowdle, M.D., Ph.D.

Among the 3,533 claims in the ASA Closed Claims Project database, there are 48 claims involving problems with central venous catheters or pulmonary artery catheters. Eighteen of the claims involved fatalities. Despite the widespread perception that pulmonary artery catheters are more dangerous than central venous catheters, only two of the 48 claims were explicitly related to pulmonary artery catheters.

A variety of technical misadventures resulted in injuries or deaths [Table 1]. Some of the complications may have been unavoidable, but most appear to be the result of operator errors. Presumably, we can learn from these mistakes and reduce the occurrence of morbidity in the future.

The majority of the 48 claims were accounted for by three classes of problems: perforation of the heart with pericardial tamponade (11 claims), catheter or wire embolism (12 claims) and injury to veins or arteries other than the pulmonary artery (13 claims). These problems are preventable in most cases by paying meticulous attention to technique.

The Food and Drug Administration (FDA) and various manufacturers have expressed their concern for the incidence of complications from central lines and have promoted educational messages to practitioners;¹ for example, the FDA, in cooperation with various private organizations, recently released a series of three educational videotapes titled "Central Venous Catheter Complications" (available from the National Audiovisual Center, 8700 Edgeworth Drive, Capitol Heights, MD 20743-3701; telephone: (800) 788-6282).

In addition, manufacturers provide a variety of "package inserts" in central line kits, containing warnings and recommendations for avoiding complications. Judging from the explicit and detailed warnings in package inserts, manufacturers consider perforation of the heart and pericardial tamponade to be a major problem.

Interestingly, this complication was the most common cause of death in the central line-related claims from the ASA Closed Claims Project. Of the 11 patients with cardiac tamponade, 10 died. Numerous reports in the literature confirm the seriousness of the problem.^1-8 The scenario usually involves a central venous catheter with the tip inside the right atrium or abutting the wall of the superior vena cava at an acute angle. With repeated motion of the catheter tip against the heart or vena cava, perforation may eventually occur. Blood or intravenous fluid can then enter the mediastinum or pericardium, depending upon the location of the perforation. Blood or intravenous fluid in the pericardium may result in pericardial tamponade. This complication usually presents postoperatively, after the catheter has been in place for hours or days, although it may occur immediately following catheter placement.⁸

The key to prevention of pericardial tamponade is to keep the central venous catheter outside of the heart. Chest X-rays should be obtained and carefully reviewed as soon as possible following placement of the catheter.^5,7 For catheters placed in the operating room, X-rays are usually obtained postoperatively in the recovery room or intensive care unit.

When reviewing the chest X-ray, three key features should be assessed. First, the catheter should lie in the vena cava, outside of the cardiac silhouette. Second, the catheter should be relatively parallel to the walls of the vena cava. Third, the catheter tip should not abut the wall of the vena cava.⁷ An example of the use of chest X-rays to detect potential problems is shown in Figure 1, taken from the author's practice.

A central venous catheter placed via the right internal jugular vein was found initially not to lie parallel to the walls of the superior vena cava. Advancement of the catheter by a few centimeters resulted in a safer placement. Continuous monitoring of the pressure waveform may also be useful; while the waveforms obtained in the superior vena cava and right atrium are indistinguishable, the waveform from the right ventricle can be identified easily.

An exception to the rule of keeping the catheter out of the heart may reasonably be made for aspiration of air emboli during sitting neurosurgical procedures or other procedures prone to venous air embolism.⁹ However, such catheters should be placed very carefully and should be withdrawn from the right atrium at the earliest possible time.

The 12 claims involving catheter or wire embolism were not as serious as cardiac perforation, since no deaths were recorded. Although it was impossible to know the precise cause of each of these events from the information in the ASA Closed Claims Project database, the usual causes of these problems are well-known and avoidable. Wires or catheters should virtually never be withdrawn through a needle because of the risk of shearing. The proximal end of a wire should always be under the control of the operator in order to prevent the entire wire from entering the blood vessel while the catheter is being advanced.

Of the 13 claims involving injuries to veins or arteries (other than the pulmonary artery), the most serious problems resulted in hemothorax or hydrothorax; of the nine patients affected, five died. Although the exact cause of these complications was not evident in every case, in some of the cases, the apparent cause was the inadvertent insertion of an introducer sheath or large bore catheter into an artery instead of a vein, resulting in injury to the artery. This problem should be avoidable. After placement of a needle in the blood vessel, the vessel should be positively identified as a vein prior to cannulation. Numerous methods have been used for this purpose, including the subjective evaluation of the force with which blood appears to spurt from the needle, the color of the blood, assessment of blood gases and transduction of a pressure waveform.

Of these methods, the author strongly prefers the transduction of a pressure waveform as the most convenient and reliable technique.¹⁰ Many central line kits are now supplied with tubing and connections designed specifically for transducing a waveform prior to cannulation of the vein, and package inserts describe this procedure.

There are two take-home messages from this review of central line complications in the ASA Closed Claims Project database. The first lesson pertains to the positioning of central venous lines. Unless clinical needs dictate the placement of a catheter tip in the right atrium or ventricle, the tip of the central venous catheter should be located in the superior vena cava with the catheter oriented parallel to the vessel walls. The chest X-ray is the key to making this assessment; monitoring the pressure waveform will identify a catheter that has entered the right ventricle. The second lesson pertains to inadvertent cannulation of an artery. The vein should be positively identified prior to cannulation; the author recommends examination of the pressure waveform as the most convenient and reliable method for distinguishing between the venous and arterial systems.

References:

1. Scott WL. Complications associated with central venous catheters. A survey. Chest. 1988; 94:1221-1224.

2. Brandt RL, Foley WJ, Fink GH, et al. Mechanism of perforation of the heart with production of hydropericardium by a venous catheter and its prevention. Am J Surg. 1970; 119:311-316.

3. Sheep RE, Guiney WB. Fatal cardiac tamponade: Occurrence with other complications after left internal jugular vein catheterization. JAMA. 1982; 248:1632-1635.

4. Bar-Joseph G, Galvis AG. Perforation of the heart by central venous catheters in infants: Guidelines to diagnosis and management. J Ped Surg. 1983; 18:284-287.

5. Collier PE, Ryan JJ, Diamond DL. Cardiac tamponade from central venous catheters -- A report of a case and review of the English literature. Angiology. 1984; 35:595-600.

6. Maschke SP, Rogove HJ. Cardiac tamponade associated with a multilumen central venous catheter. Crit Care Med. 1984; 12:611-613.

7. Tocino IM, Watanabe A. Impending catheter perforation of superior vena cava: Radiographic recognition. Am J Roentgenol. 1986; 146:487-490.

8. Jiha JG, Weinberg GL, Laurito CE. Intraoperative cardiac tamponade after central venous cannulation. Anesth Analg. 1996; 82:664-665.

9. Bunegin L, Albin MS, Helsel PE, et al. Positioning the right atrial catheter: A model for reappraisal. Anesthesiology. 1981; 55:343-348.

10. Jobes DR, Schwartz AJ, Greenhow DE, et al. Safer jugular vein cannulation: Recognition of arterial puncture and preferential use of the external jugular route. Anesthesiology. 1983; 59:353-355.

T. Andrew Bowdle, M.D., Ph.D., is Associate Professor of Anesthesiology and Pharmaceutics, University of Washington School of Medicine, Seattle, Washington.

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Pediatric Perioperative Cardiac
Arrest Registry: An Update

Jeffrey P. Morray, M.D., Director
Pediatric Perioperative Cardiac Arrest Registry

The Pediatric Perioperative Cardiac Arrest (POCA) Registry has completed its second year of data collection. Formed in 1994 under the combined auspices of the ASA Committee on Professional Liability and the American Academy of Pediatrics Section on Anesthesiology, the registry was designed to provide an in-depth examination of cardiac arrests in anesthetized children and provide an estimate of incidence.

All cardiac arrests that are defined as the need for cardiopulmonary resuscitation in children 18 years of age or younger during induction or maintenance of anesthesia or in the postanesthesia care unit are eligible for inclusion. For each case that qualifies, participating institutions are asked to complete and submit a standardized data form to the data bank maintained by the University of Washington School of Medicine Department of Anesthesiology as a component of the ASA Closed Claims Project. Anonymity is maintained so that the patient, physician and submitting institution cannot be identified.

As of March 1, 1996, 52 institutions are participating in the registry. They include 43 university-affiliated hospitals (87 percent) and/or 24 pediatric hospitals (46 percent). In 1995, these 52 institutions administered approximately 272,777 anesthetics to children and reported 63 cases of cardiac arrest.

A total of 132 cases have been submitted since the registry's inception. In contrast to the pediatric component of the ASA Closed Claims Project, in which 43 percent of cardiac arrests and adverse outcomes in children were attributed to respiratory events,¹ only 10 percent of cases submitted to the POCA Registry had respiratory causes of cardiac arrest, while 56 percent had cardiovascular causes.

The predominance of cardiovascular events compared to respiratory events in the POCA registry may have some relationship to the frequent use of pulse oximetry (98 percent) and capnography (86 percent). This relationship has been noted recently in the overall database of the ASA Closed Claims Project. Specifically, the relative frequency of respiratory events was higher and that of cardiovascular events was lower in claims in which neither pulse oximetry nor capnography were used, compared with claims in which pulse oximetry and capnography were used alone or in combination (see the accompanying NEWSLETTER article by Frederick W. Cheney, M.D.).

One explanation for this relationship is the possibility that pulse oximetry and capnography are more effective in preventing respiratory events than preventing cardiovascular events. However, it is also possible that some events previously categorized as respiratory, in the absence of pulse oximetry and capnography, were actually cardiovascular in origin.

Age was correlated with ASA physical status and outcome of cardiac arrest [Table 1]. Children under 1 month of age accounted for 24 percent of all cardiac arrests and had a mortality rate of 72 percent, which is much higher than for any other age group. In this youngest group, both incidence and outcome of cardiac arrest were probably influenced by underlying patient condition; 97 percent were classified as ASA physical status P3-P5, significantly more than expected by chance alone.

Children from 1 to 5 months of age accounted for an additional 19 percent of arrests and also included significantly more ASA physical status P3-P5 patients than expected by chance alone. Interestingly, the mortality rate (36 percent) in this group was less than the mortality rate for children under 1 month of age. Collectively, children under 6 months of age and 1 year of age accounted for 43 percent and 58 percent of all arrests, respectively.

Several previous studies have suggested that children under 1 year of age have the highest risk during anesthesia.^2,3 The POCA Registry data further define this; even within the group under 1 year of age, mortality is inversely proportional to age, with the highest risk in the group of children less than 1 month old. This finding is consistent with data from Cohen.⁴

ASA physical status P1 and P2 patients accounted for 26 (20 percent) of all cases. Although cardiac arrest in this group was frequently ascribed also to cardiovascular causes (50 percent), problems with drug administration (i.e., relative anesthetic overdose, wrong dose, or wrong drug and allergic reaction) were seen in 27 percent of cases compared to 8 percent in ASA physical status P3-P5 patients. The impact of anesthesia was described by the institutional reviewers as a major or total cause of cardiac arrest in 81 percent of ASA physical status P1 and P2 patients, compared to only 29 percent of ASA physical status P3-P5 patients. Outcome was excellent, with no mortality, compared with a 53-percent mortality in ASA physical status P3-P5 patients.

The POCA Registry Director is Jeffrey P. Morray, M.D. Other members of the Registry Steering Committee include Robert A. Caplan, M.D., Frederick W. Cheney, M.D., Karen B. Domino, M.D., Jeremy M. Geiduschek, M.D., Alvin Hackel, M.D., Chandra Ramamoorthy, M.D., and Karen S. Posner, Ph.D.

The Steering Committee would like to increase the size of the registry as well as the participation of community-based hospitals. All university-affiliated and community-based anesthesia departments that care for children and would like to participate in the registry are encouraged to do so.

All necessary information can be obtained by contacting Karen S. Posner, Ph.D., POCA Registry, Department of Anesthesiology, University of Washington School of Medicine, Box 356540, Seattle, WA 98195-6540; telephone: (206) 543-2476; e-mail: <posner@u.washington.edu>.

References:

1. Morray JP, Geiduschek JM, Caplan RA, et al. A comparison of pediatric and adult anesthesia closed malpractice claims. Anesthesiology. 1993; 78:461-467.

2. Olsson GL, Hallén B. Cardiac arrest during anesthesia. A computer-aided study in 250,543 anaesthetics. Acta Anaesthesiol Scand. 1988; 32:653-664.

3. Tiret L, Nivoche Y, Hatton F, et al. Complications related to anaesthesia in infants and children. Br J Anaesth. 1988; 61:263-269.

4. Cohen MM, Cameron CB, Duncan PG. Pediatric anesthesia morbidity and mortality in the perioperative period. Anesth Analg. 1990; 70:160-167.

Jeffrey P. Morray, M.D., is Professor of Anesthesiology and Pediatrics at the University of Washington School of Medicine and Director of the Department of Anesthesia and Critical Care at Children's Hospital and Medical Center, Seattle, Washington.

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ASA Publishes 1996 Manual for Anesthesia Department Organization and Management

J. Kent Garman, M.D., M.S., Chair
Committee on Quality Improvement and Practice Management

The 1996 Manual for Anesthesia Department Organization and Management is now available from the ASA Executive Office. This comprehensive manual contains excerpts from recent publications of the Joint Commission on Accreditation of Healthcare Organizations and the Accreditation Association for Ambulatory Health Care (AAAHC).

Reprinted with permission from the Joint Commission is a crosswalk that connects the contents of the Surgical and Anesthesia Services section of the 1993 Accreditation Manual for Hospitals (AMH) to corresponding language in the current AMH. Also included is a crosswalk between the 1994 and 1996 standards contained in the Accreditation Manual for Ambulatory Health Care. In addition, the Anesthesia Services and Surgical Services sections of the current AAAHC Accreditation Handbook for Ambulatory Health Care is included in this department manual.

Other topics appearing in the manual include departmental leadership, administrative manuals, model anesthesia records, informed consent, equipment standards and maintenance, infection control in anesthesia practice, delineation of clinical privileges, and quality improvement and peer review.

The 1996 manual also contains ASA guidelines for department organization and standards and guidelines for patient care. Every anesthesia department chief should have a current copy close at hand as an essential reference.

The Manual for Anesthesia Department Organization and Management is available for $25 per copy, which includes postage and handling (Illinois residents add 7.75 percent sales tax). All publication orders must be prepaid and should be forwarded to the ASA Publications Department, 520 N. Northwest Highway, Park Ridge, IL 60068-2573.

'The Anesthesia Care Team' Statement Revised

The ASA Statement on the Anesthesia Care Team was printed incorrectly in the 1996 ASA Directory of Members. Two recommendations approved by the House of Delegates were inadvertently omitted. A corrected copy of the statement follows:

The Anesthesia Care Team

(Approved by House of Delegates on October 26, 1982, and last amended on October 25, 1995)

Anesthesiology is a recognized specialty of medicine. Anesthesia care personally performed or medically directed by an anesthesiologist, a physician who has completed an approved residency in anesthesiology, constitutes the practice of medicine. Certain aspects of anesthesia care may be delegated to other properly trained professionals. These professionals, medically directed by the anesthesiologist, comprise the Anesthesia Care Team.

Such delegation and direction should be specifically defined by the anesthesiologist director of the Anesthesia Care Team and approved by the hospital medical staff. Although selected functions of overall anesthesia care may be delegated to appropriate members of the Anesthesia Care Team, responsibility and direction of the Anesthesia Care Team rest with the anesthesiologist.

The Society believes that the involvement of an anesthesiologist in the care of every patient undergoing anesthesia is essential. This may be accomplished through personal provision of anesthesia care or by medical direction of the Anesthesia Care Team.

Members of the medically directed Anesthesia Care Team may include physicians and nonphysician personnel.

A. Those who assist in providing direct patient care during the perioperative period, for example:

ANESTHESIOLOGY RESIDENT -- a physician who is presently in an approved anesthesiology residency program.

NURSE ANESTHETIST -- a registered nurse who has satisfactorily completed an approved nurse anesthesia training program.

ANESTHESIOLOGIST'S ASSISTANT -- a graduate physician's assistant who has satisfactorily completed an approved anesthesiologist's assistant training program.

B. Others who have patient care functions during the perioperative period include:

POSTANESTHESIA NURSE -- a nurse who cares for patients recovering from anesthesia.

CRITICAL CARE NURSE -- a nurse who cares for patients in a special care area such as the intensive care unit.

RESPIRATORY THERAPIST -- an allied health professional who provides respiratory care to patients.

C. Support personnel whose efforts deal with technical expertise, supply and maintenance, for example:

Anesthesia technologists and technicians

Anesthesia aides

Blood gas technicians

Respiratory technicians

Monitoring technicians

In order to apply the Anesthesia Care Team concept in a manner consistent with the highest standards of patient care, the following essentials should be observed:

1. Medical Direction:
Anesthesia direction, management or instruction provided by an anesthesiologist whose responsibilities include:

a. Preanesthetic evaluation of the patient.

b. Prescription of the anesthesia plan.

c. Personal participation in the most demanding procedures in this plan, especially those of induction and emergence.

d. Following the course of anesthesia administration at frequent intervals.

e. Remaining physically available for the immediate diagnosis and treatment of emergencies.

f. Providing indicated postanesthesia care.

An anesthesiologist engaged in medical direction should not personally be administering another anesthetic and should use sound judgment in initiating other concurrent anesthetic and emergency procedures.

2. Delegation of any part of anesthesia care by an anesthesiologist to a member of the Anesthesia Care Team under the medical direction of the anesthesiologist should be fully disclosed.

3. Exploitation of patients, institutions, Anesthesia Care Team members, colleagues or payers is unethical.

ASA at a Glance

The following figures were compiled by ASA staff from available membership data as of April 30, 1996. Percentages reflect just less than 1 percent of unaccountable data due to individual member records with insufficient information.

The ASA Demographics Survey is mailed annually to members based on their month of birth or when a change in their practice occurs (change of address, change in membership status, etc.). The survey requests demographic information about the member's mode of practice, years in practice, age, gender, etc.

Figures: Age, Gender, Membership Status, Primary Modes of Practice

PRACTICE MANAGEMENT
The Minnesota Lawsuits: HCFA's Reimbursement Policy

Michael Scott, Director
Governmental and Legal Affairs

In the February 1994 ASA NEWSLETTER "Washington Report" column, I discussed an exchange of letters between the Health Care Financing Administration (HCFA) and ASA on the issue of the extent to which an anesthesiologist, while providing anesthesia care to a single patient in collaboration with a nurse anesthetist, was permitted to engage in activities unrelated to the case. In a letter to HCFA, ASA alluded to the fact that anesthesiologists engaged in medical direction of nurse anesthetists were expressly authorized by HCFA regulations to engage in other activities of short duration (e.g., pain block, epidural for labor) that are unrelated to the cases being medically directed.

HCFA responded to ASA's letter by advising that in single cases involving both an anesthesiologist and a nurse anesthetist, HCFA does not recognize the presence of the nurse anesthetist for reimbursement purposes (unless both providers are deemed medically necessary) and that the anesthesiologist is paid an unreduced fee as if he or she had performed the case alone. Under these circumstances, HCFA said, it is appropriate to require that the anesthesiologist be continuously involved in the case and not be performing duties unrelated to the case. This advice followed a 1993 HCFA directive to Medicare carriers on outside activities issued several months earlier, which also noted that the anesthesiologist "must be present in the operating suite while the certified registered nurse anesthetist [CRNA] is attending the case" (emphasis added).

Regular readers of this column are aware that two related lawsuits initiated by nurse anesthetists are currently pending in federal court in Minnesota. The first challenges the legality under the antitrust laws of termination of the CRNAs' employment by three hospitals about two years ago, alleging a conspiracy among the hospitals and anesthesiologists on staff in those hospitals to restrain the practice opportunities of the affected CRNAs. In an opinion last summer dissolving a "standstill" injunction imposed early on by the trial court, a federal court of appeals expressed skepticism as to the merits of the CRNAs' claims.

The second action, which rather clearly was brought to buttress the first, is in the nature of a "whistle blower" proceeding on behalf of the federal government, alleging Medicare fraud by many anesthesiologists, including those named in the antitrust case. It appears that a major focus of this action relates to reimbursement of anesthesiologists involved in "two provider" cases and to a claim that because anesthesiologists did not remain in the operating room with the nurse anesthetist for the duration of the procedure, they were engaged in Medicare fraud by accepting a full reimbursement for the case.

On March 25, 1996, in response to an inquiry from the CRNAs' counsel, the Director of HCFA's Division of Physician Services, Terry Kay, purported to explain development of HCFA's reimbursement policy in these cases. Of greatest importance in the Kay letter is his conclusion:

"HCFA does not now and never has permitted billing under the 'AA' [personally performed] modifier for medical direction of a single procedure. The 'AA' modifier is reserved for situations where the anesthesiologist is personally and continuously involved in the case, is present throughout the procedure and is not involved in providing any other anesthesia service."

It is important to note that if Mr. Kay was saying that the anesthesiologist must remain in the operating room throughout the procedure, that position has not previously been expressed in any HCFA document of which ASA is aware. HCFA's 1993 instructions to carriers, quoted above by Mr. Kay, make it clear that the anesthesiologist should remain in the "operating suite," but there is nothing in the instructions to suggest that the anesthesiologist must remain continuously in the operating room. The dictionary defines a suite as a series of connected rooms, used as a unit, which I think is how most people understand the term as used in connection with the ordinary complex of operating rooms found in most hospitals.

In a September 25, 1995, letter responding to an earlier inquiry from the CRNAs' counsel, Mr. Kay discussed the question of whether there are certain portions of the procedure requiring the anesthesiologist to be present in the operating room itself. He said: "[I]t is a reasonable interpretation of the payment regulations for us to expect that induction and emergence will be done in the operating room and the physician is present for both medically directed and personally performed cases."

This statement appears to add further confusion as to HCFA's interpretation of reimbursement rules. First, Mr. Kay referred to "a reasonable interpretation"; such language clearly implies there may be other reasonable interpretations. Second, he said the physician must be "present" for induction and emergence.

Assuming he was saying the physician must be present in the operating room for induction and emergence (which would seem to disregard the fact that a significant portion of emergence takes place outside the operating room), then the clear implication is that for other portions of the procedure, the physician need not be present in the operating room in personally performed cases as well as medically directed cases. I think most anesthesiologists would be shocked at the idea that it is appropriate to leave the patient at all (unless relieved) during the period from the beginning of induction to the end of emergence when the anesthesiologist is the sole anesthesia provider. Mr. Kay seems to be saying that it is all right to leave the room after induction and before emergence in all types of cases, but what I suspect he intended to say is that it is all right to do so only when another anesthesia provider remains in the room to monitor the patient's condition.

Mr. Kay's letter of March 25 said that it has always been HCFA's policy that the anesthesiologist in the "two provider" cases be personally and continuously involved and be present. If this is so, then obviously because of HCFA's 1993 directive, presence in the operating suite -- as distinct from the operating room -- satisfies HCFA's requirements for the "AA" modifier. If presence in the suite is not sufficient to meet HCFA's requirements as defined by Mr. Kay, then HCFA's position is a new one and is inconsistent with the advice given to carriers in 1993. If the terms of his earlier 1995 letter are to be accepted, the anesthesiologist in any event must be present in the operating room only during induction and emergence.

What is perhaps most important here is that we now have yet another interpretation from a representative of HCFA, expressed through the unusual route of letters to counsel in a pending lawsuit, concerning HCFA's requirements in these cases. Nevertheless, given Mr. Kay's position, this informal comment may give some insight as to future HCFA actions. Clearly, based on his most recent letter, an anesthesiologist will be safest if he or she remains in the operating room throughout the entire procedure and performs no anesthesia duties unrelated to the case. The anesthesiologist may also be safe as long as he or she is in the room for induction and emergence and is in the suite for the entire procedure, performing no other duties. If HCFA's more formal 1993 advice to carriers is to be believed, however, an anesthesiologist could also meet HCFA's requirement for the "AA" modifier and full reimbursement if he or she merely is present in the operating suite throughout and does not perform any anesthesia duties not related to the case.

Not surprisingly, Medicare carriers have taken a variety of positions on these issues, as is always the case when HCFA reimbursement policy is open to more than one reasonable interpretation. It is hard to conceive the circumstances under which a provider could be held to have acted improperly when he or she is following the carrier's advice. ASA members who practice in a manner that involves two anesthesia providers for a single patient will be well-advised to consult their own counsel and billing advisors as to the proper course of action in their area and confirm the advice received with the Medicare carrier for the locality.

There is also a "good news, bad news" aspect to this discussion. The good news is that this issue will presumably go away on January 1, 1998, when HCFA will begin to split the "personally performed" fee 50-50 between the anesthesiologist and nurse anesthetist. (HCFA has not yet made clear whether, when this happens, the anesthesiologist will enjoy the same flexibility to engage in other activities of short duration as now permitted in medical direction cases, but logic would seem to suggest that this would be so.) The bad news is that, of course, the anesthesiologist's fee will be cut in half for these cases -- a fact that will make no practical difference if the anesthesiologist employs the CRNA but will make a difference if the CRNA is self-employed or hospital-employed.

Copies of Mr. Kay's March 25 letter and the other documents referred to in this column can be obtained by contacting the ASA Washington Office at (202) 289-2222.

Michael Scott, Director
Governmental and Legal Affairs

RESIDENTS' REVIEW
Anesthesia Fellowships on the Rise -- New Wave or Dinosaur That Won't Die?

Zarina Memon, M.D.

Due to the current changing trends in the anesthesiology job market, many residents are opting to continue their training on a fellowship track and delay their job search. The focus of this article will be to present information on fellowship opportunities in anesthesiology critical care medicine and pain management.

Prior to completing their residency in a specialty program, residents should take time to decide whether training in a fellowship program would be a benefit to their career. Even if one chooses a fellowship and receives training in a subspecialty that is not recognized by the Accreditation Council for Graduate Medical Education, additional skills and knowledge in a specialized area of anesthesia can be acquired. This additional training may be helpful in obtaining a position in an anesthesia group practice or at an academic center.

Currently, there are a variety of anesthesia fellowships available, but only two -- critical care medicine and pain management -- are recognized by the American Board of Anesthesiology (ABA) with a certificate of special qualifications in those two subspecialties. Other fellowship programs (cardiothoracic, vascular, neurosurgical, obstetrics and pediatric anesthesia) are not recognized by the ABA but instead usually offer a certificate of completion as proof of training. Most fellowships require 12 months of training; however, some are longer. Regardless of the fellowship, most programs require satisfactory completion of anesthesiology residency training that meets the requirements of the ABA.

Critical care anesthesia is devoted to the acute and long-term care of critically ill patients with multiple organ derangements. There are other intensive care unit (ICU) training programs directed solely by surgical and medical teams, but the ABA does not recognize these for anesthesia accreditation. There are 40 anesthesiology critical care medicine programs offering approximately 107 positions throughout the United States (according to a 1995 survey of anesthesiology residency programs and children's hospitals).

A critical care medicine fellowship requires a minimum of 12 months of training after the completion of an anesthesiology residency, and the majority of the 12 months is spent in the medical treatment of critically ill patients in the ICU. The remaining months are structured to provide additional resources necessary to develop skills in teaching, administration and research. Exposure in the ICU should be broad and should include caring for both adult and pediatric patients.

Pain fellowships are currently popular and, thus, very competitive. There are several reasons for this. First, pain fellowship training positions around the country are limited in number. Second, it is one of the few areas in which new graduates are in demand because of their specialized training. There are currently 49 programs in the United States, most of which accept candidates only from their own residency programs. A number of these fellowship programs last for one year; however, some are two-year fellowships. There is a trend to increase pain fellowship training time from a 12-month period to a 24-month period in order to separate those who are truly interested in pain management from those who may be motivated only by future financial promises.

Good sources of information regarding anesthesiology fellowships include the Graduate Medical Education Directory, the ASA Executive Office and the Accreditation Council for Graduate Medical Education.

Zarina Memon, M.D., is a CA-2 anesthesiology resident at the University of Massachusetts Medical Center, Worcester, Massachusetts.

ASA NEWS
Nominations Sought for Media Award

Each year, the American Society of Anesthesiologists accepts entries for the ASA Media Award, an award given for an outstanding media presentation that effectively informs and educates the public about the practice of anesthesiology.

The Committee on Communications encourages members to submit or nominate local media presentations from broadcast (television or radio) and print (newspaper or magazine) media. The more interest that is generated for this award will result in a greater number of presentations on the subject of anesthesiology.

The winner receives a plaque and the opportunity to attend the presentation ceremony during the ASA Annual Meeting. The 1996 Media Award will be presented on Sunday, October 20, at the ASA Annual Meeting in New Orleans.

Deadline for the submission of entries is July 1 for media presentations released between July 1, 1995, and June 30, 1996. Any entries received after the deadline will be carried over to the next year.

Last year's Media Award recipient was CBS Health Correspondent Howard Torman, M.D., of CBS News in New York, New York. His program, "Patients' Fears About Anesthesia," which aired on "CBS This Morning" on December 19, 1994, discussed patient safety, preoperative evaluations and how patients can help to prepare themselves to be less fearful before surgery.

All entries should be sent to Margaret G. Pratila, M.D., Chair, Committee on Communications, American Society of Anesthesiologists, 520 N. Northwest Highway, Park Ridge, IL 60068-2573.

1995 PBLD Case Book Still Available

Published for the 1995 ASA Annual Meeting, this book presents the 87 cases of the Problem-Based Learning Discussions (PBLD) in their entirety in written format.

Although the optimal way to use a case study is in the format employed at the ASA Annual Meeting, these cases, their objectives, model outline discussions and references are of value to anesthesiologists for other educational purposes. Their uses include:

* oral case examination practice and review;

* case discussion sessions for education in community practice and academic settings; and

* individual postgraduate review.

The philosophy of this type of medical education is that the cases become the fulcrum for an active learning experience. The learner reads the case and then embarks upon an individual study program to identify and solve the problems posed in the case.

After these steps have been taken, the learner compares his/her efforts with the model discussion outline and references provided. Ideally, a group discussion with lively interaction is preferable to an individual study effort.

The cost of the book is $15, which includes postage and handling (Illinois residents add 7.75 percent sales tax). All orders must be prepaid. Contact the ASA Publications Department, 520 N. Northwest Highway, Park Ridge, IL 60068-2573.

Sedation and Analgesia Workshop Scheduled in Seattle

In one weekend, anesthesiologists can be updated on sedation and analgesia and anesthesia provided outside of the operating room as these issues relate to clinical practice and ASA. The ASA Workshop on Sedation and Analgesia and Anesthesia Outside the Operating Room will be held at the Sheraton Seattle Hotel and Towers in Seattle, Washington, on August 10-11, 1996.

The update includes practical concepts and applications as well as the relevant pharmacology and how to use it to your advantage or deal with it. As anesthesia services provided outside the operating room continue to grow in variety and location, the faculty will provide both logistic and medical strategies for dealing with this aspect of anesthesia practice and practice management.

Nikolaus Gravenstein, M.D., is the program chair. He will speak on "ASA Standards Outside the Operating Room." Other speakers and their topics are:

* Richard D. Carr, M.D., "Sedation/Analgesia Concepts and Applications" and "An Anesthesiology Sedation Service";

* Jeffrey B. Gross, M.D., "ASA Sedation/Analgesia Guidelines" and "Respiratory Effects of Sedatives and Analgesics";

* Vinod Malhotra, M.D., "Practical Considerations for Anesthesia Provided Outside the Operating Room I: Logistics and Economics" and "Practical Considerations for Anesthesia Provided Outside the Operating Room II: Specific Examples";

* John H. Pennant, M.D., "Laryngeal Mask Airway (LMA)" and "MRI"; and

* Mark F. Trankina, M.D., "Anesthesia for Electroconvulsive Therapy (ECT) and Radio Frequency Lesion (RFL)" and "Providing Anesthesia in the Cath Lab."

ASA is approved by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education programs for physicians.

ASA designates this continuing medical education program for 12 credit hours in category 1 of the Physician's Recognition Award of the American Medical Association.

Registration fees are $300 for active members, $125 for resident members and $650 for nonmembers. Registration is encouraged by July 8, 1996.

A block of rooms has been reserved at the Sheraton Seattle. A reservation form will be sent upon registration for the meeting. The form should be returned directly to the hotel by July 15, 1996.

ABA Announces...
ABA to Conduct Recertification Exam

The American Board of Anesthesiology (ABA) will administer its recertification examination during the two-week period of May 3-17, 1997.

The recertification program is voluntary for ABA diplomates whose certification is not time-limited. ABA diplomates may take the examination by computer at more than 40 test centers during the two-week period. The ABA will inform applicants of the test sites when the list is available

An application may be requested by writing to the Secretary, American Board of Anesthesiology, 4101 Lake Boone Trail, The Summitp;Suite 510, Raleigh, NC 27607-7506.

The deadline for receipt of completed recertification applications in the ABA Office is November 15, 1996.

Jack Moyers, M.D., 1921-1996

Jack Moyers, M.D., ASA past President (1978), died April 22, 1996, in Iowa City, Iowa. He was 74.

In addition to serving as ASA President, Dr. Moyers served as President-Elect (1977), First Vice-President (1976) and Vice-President for Scientific Affairs (1973-74). At the time of his death, he was President of the Anesthesia Foundation, a position he had held since 1988. He also was a longtime delegate from Iowa (1957-72) and served on numerous ASA committees, including the Committee on Representation to the American Medical Association (1979-94) and as ASA representative to the Council of Medical Specialty Societies (1981-86). He was chair of the organizing committee for the Ninth World Congress of Anaesthesiologists (1980-88).

He was a diplomate of the American Board of Anesthesiology and a member of the American Medical Association, Iowa State Medical Society, Johnson County (Iowa) Medical Society, International Anesthesia Research Society, Association of University Anesthesiologists, Society of Academic Anesthesiology Chairs, Anesthesia History Association and the Australian Society of Anaesthetists (honorary).

LETTERS TO THE EDITOR

Disclaimer

Misrepresented Comments Corrected

Editor's Note: The following letter was sent to ASA President Norig Ellison, M.D., in response to his "President's Page" in the March 1996 NEWSLETTER. It is being printed with the author's permission.

Dear Dr. Ellison:
Thank you for returning my call the other day and allowing me to expound on your editorial comments (ASA NEWSLETTER, March 1996).

Your first error was my job description! I have never worked for an HMO [health maintenance organization]. I currently work for a large and successful multispecialty group whose mission remains cost-effectiveness through quality. In fact, my primary job description includes patient and physician advocacy. While we contract with eight HMOs and helped form an HMO in 1981-82, there is no equity or agency relationship with any of them.

Second, while I did define HMOs as customers, HMOs are only one of many customers that managed care organizations must face. I did not state nor intimate that defining an HMO as a customer precludes quality or patient advocacy. HMOs are not much more than the leveraged and consolidated voices of the employers and their employees, the patients. I spent an inordinate amount of time in the talk and text reviewing this multiple stakeholder concept and its implications (M.G.M.A. and the Texas Tech University study). While business texts define the customer as the one who pays the bill, continuous quality improvement proponents expand that definition to include "the user of the output of one's process." Yes, only customers can define value (quality divided by cost), but physicians, patients, hospitals, governing bodies and other critical internal and external stakeholders must be included as customers. This schizophrenic environment with seemingly competitive priorities drives successful organizations toward continuous quality improvement efforts to resolve the value and managed care paradox (lowering costs and improving quality). While there are organizations whose sole focus is finance, I believe they are inherently unstable and cannot exist long-term in a capitalistic marketplace.

You falsely represented me by implying that I promote physician loyalty toward the HMO and not the patient, when you stated, "Does Dr. Levin's contention that HMOs are the customer not suggest at the very least that physician loyalties are divided, if not primarily owed to the HMO?" You then go on to link my comments to the disdainful HMO gag orders reported in the New England Journal of Medicine and The New York Times. I simply commented upon and attempted to demonstrate the HMO's command of the marketplace, demands for quality measures and ultimately, employer leverage due to the golden rule. Success in the marketplace mandates that anesthesiologists and all physicians provide for their customers.

One talking point from New Orleans must be reiterated: no customers consider us valuable enough to pay our billed charges. Since the patients, government and HMOs pay our bills, it should be clear by now that anesthesiologists have not yet created enough value to have their full fees paid. My conclusion was that the successful anesthesia group will have to provide both high quality of medical care and service to meet the customer's definition of value!

Finally, a retort to your underlying theme that capitation is inherently bad. Under fee-for-service medicine, there is no strategic or systemic alignment of both cost and quality. Who ever got directly paid by patients or the insurance company because of quality? Fee for service directly rewards for production, not productivity or efficiency.

This can only (theoretically) exist under capitation because the highest profit margin is created by having everyone perfectly healthy! "Doing things right the first time saves money" is what I stated, yet you once again misrepresented me when you implied that I advocate withholding services and not disclosing treatment options as an acceptable byproduct of managed care. I pointed out in my text and speech that there are different ways to implement utilization review, and I only supported quality, literature-based utilization review programs, not cost accounting utilization. You do yourself and the membership a disservice by referencing a thoracic surgery and anesthesia journal to support the popular media theme that managed care utilization decisions are nearly always made on the basis of cost. While it is true that if you "follow the money, you won't get lost," I challenge you to do your own unbiased research and find out how exciting and personally rewarding a well-run, quality-based utilization program can be. More often than not, that has been my experience throughout California. Patients are better served because we do not manage care as much as we try to manage risk. Perhaps it is a throwback to my days in the operating room, but utilization can also be the patient's last defense.

Please thank the ASA leadership for their willingness to hear my perspective. I was told to "tell it like it is" and I did. From the many comments at the meeting and telephone calls I've received since, I believe my message was accurately heard and understood by most. Taking the time to fully understand my summary comment, asking physicians to take the lead in quality improvement efforts (as you accurately accounted) should make it obvious that I am a patient, quality and physician advocate to the extreme. At New Orleans, I was just the messenger interpreting a Darwinian world of managed care economics, who was asked to help others sort out ethical and value-added business options for success.

Let me thank you once again for the opportunity to share my experiences and thoughts with the 500 anesthesiologists with whom I was honored to spend a morning.

Gary A. Levin, M.D.
Modesto, California

An Answer: Good 'Outcome' Sense

As an anesthesiologist who lectures to CRNAs [certified registered nurse anesthetists], among others, I feel obligated to respond to "A Question of Good Business Sense," the letter from David M. Green, M.D., in the March 1996 NEWSLETTER.

The main reason for teaching (lecturing) is to improve the anesthetic outcome for patients. As CRNAs will continue to administer anesthesia in the foreseeable future, it is in the patients' best interest that all practitioners be armed with the latest knowledge. I believe any other approach is shortsighted. Over the course of many years, I have found that CRNAs are an interested and interesting audience.

Finally, as a group, CRNAs make about half the money as anesthesiologists; decreasing the meeting expense, therefore, is not unreasonable. Both CRNAs and anesthesiologists need to work together to enhance patient care -- disseminating available information can only help.

F. Robert Weis, M.D.
Mobile, Alabama

Malignant Hyperthermia Support Acknowledged

I would like to take this opportunity to thank the members of the American Society of Anesthesiologists for the support given to the Malignant Hyperthermia Association of the United States. The recent grant of $15,000 toward a hotline coordinator will be instrumental in continuing our efforts to reduce the morbidity and mortality of malignant hyperthermia.

Once again, thank you for your support.

Richard A. Hillman, Executive Director
Malignant Hyperthermia Association of the United States
Sherburne, New York

The views and opinions expressed in the "Letters to the Editor" are those of the authors and do not necessarily reflect the views of ASA or the NEWSLETTER Editorial Board. The Editor has the authority to accept or reject any letter submitted for publication. Letters must be signed and are subject to editing and abridgment.

FAER REPORT
FAER Explains Program Descriptions and Deadlines

The Foundation for Anesthesia Education and Research (FAER) administers four programs that support young investigators at different stages early in their academic careers. In 1995, almost 400 application packets for these programs were sent on request to individuals, anesthesiology departments and institutional research offices.

Anesthesiology Research Fellowship

Awards are intended for residents in accredited anesthesiology programs who will spend one or two years engaged in full-time (>75 percent) anesthesia research under the sponsorship of an established investigator. Applicants propose a research plan that will provide significant training in research techniques and scientific methods and that can be accomplished in the planned time. Awards provide $30,000 per year for one or two years and are made to institutions on behalf of the specific individuals. Deadlines for application are July 31 and December 2, 1996.

Research Starter Grant

Awards are made to anesthesiologists holding a faculty appointment (associate, instructor, assistant professor) who are not yet ready to conduct independent research. Starter grants provide seed money to initiate projects that will advance the applicants' training and allow them to seek future additional support. Awards provide up to $25,000 for one year and are made to institutions on behalf of specific individuals. The sponsoring department or institution agrees to match the amount awarded. The department chair must guarantee that the applicant will be allowed 40-percent research time during the award period, and an experienced investigator must agree to advise the recipient. Deadline for application is July 31, 1996.

Anesthesiology Young Investigator Award

Awards are intended for anesthesiologists on the verge of becoming independent investigators. Although applicants must have an experienced investigator as an adviser, the project is planned and conducted primarily by the applicant. The work is intended to allow the applicant to become established as an independent investigator who will compete for other peer-reviewed funding. Applicants should be no more than five years out of their residency or fellowship and should hold a faculty appointment in an academic department of anesthesiology. Awards provide up to $35,000 per year for two years and are made to institutions on behalf of specific individuals. The department chair guarantees institutional or departmental matching funds and that the applicant will be allowed 60-percent research time during the award period. Deadline for application is December 2, 1996.

Educational Research Grant

Grants are intended to support research in anesthesia education, and proposals may include the design and evaluation of specific educational techniques and curricula, development of instruments for the prediction and evaluation of outcomes, or other original and creative investigations that have an impact on the quality of anesthesia education and care. Grants provide up to $15,000 per year and may be renewed contingent upon review of annual progress reports. Deadlines for application are July 31 and December 2, 1996.

The FAER grant application and review process closely resembles that of the National Institutes of Health. Grant applications are reviewed by the ASA Committee on Research for quality and relevance. Funding decisions are made by the FAER Board of Directors, based on the Committee on Research's ranking of proposals and funds available in the FAER budget. All applicants receive carefully prepared comments on their work, whether or not the projects are funded. It is hoped that this feedback will be helpful in allowing them to understand the processes involved in grant review. This rigorous review allows applicants to construct better packaging and more lucid presentations of their research proposals and strengthens their skills for future applications.

Applications are invited for projects involving basic research, clinical research and epidemiological research in anesthesiology. Questions about the appropriateness of a topic may be discussed with Alan D. Sessler, M.D., FAER Executive Director, at (507) 266-6866.

Application materials may be obtained by contacting Cynthia P. King, Assistant Director, FAER, Charlton Building, Mayo Clinic, 200 First St., S.W., Rochester, MN 55905; telephone: (507) 266-6866; e-mail: <king.cynthia@mayo.edu>.

Copyright (c)1996 American Society of Anesthesiologists. All rights reserved.

ASA NEWSLETTER

Contents

FEATURES: Examining the Scope of Professional Liability

ARTICLES

DEPARTMENTS

TO THE MEMBERSHIP Predictions?

PRESIDENT'S PAGE The 11th World Congress of Anaesthesiologists: 'The Olympics of Anesthesia,' A Challenge Is Issued

The World Federation

The Congress' Theme

The Challenge

The Next World Congress

WASHINGTON REPORT 'Insurance Portability' Bill Goes to Conference; Provisions Remain Controversial

President, Congress Agree on Spending for FY 1996

HCFA Issues Proposed Rule on Physician Work Values

HCFA Action on Teaching Instructions Due Soon

Professional Liability: What's Ahead?

What's Ahead?

References:

The Changing Pattern of Anesthesia-Related Adverse Events

Claims for Death, Brain Damage and Nerve Injury [Figure 1]

Claims for Respiratory System Damaging Events [Figure 2]

Claims Related to Respiratory, Cardiovascular and Equipment Damaging Events [Figure 3]

Claims Involving Inadequate Ventilation, Esophageal Intubation, Difficult Intubation [Figure 4]

Conclusion

Closed Malpractice Claims for Awareness During Anesthesia

Closed Claims Analysis

Awake Paralysis

Recall During General Anesthesia

Conclusion

References:

Anesthesia and Surgery: Not Always a One-Sided Affair

Legal Aspects

Interesting Accounts

Preventative Measures

Conclusion

References:

Central Line Complications From the ASA Closed Claims Project

References:

Pediatric Perioperative Cardiac Arrest Registry: An Update

References:

ASA Publishes 1996 Manual for Anesthesia Department Organization and Management

'The Anesthesia Care Team' Statement Revised

The Anesthesia Care Team

ASA at a Glance

PRACTICE MANAGEMENT The Minnesota Lawsuits: HCFA's Reimbursement Policy

RESIDENTS' REVIEW Anesthesia Fellowships on the Rise -- New Wave or Dinosaur That Won't Die?

ASA NEWS Nominations Sought for Media Award

1995 PBLD Case Book Still Available

Sedation and Analgesia Workshop Scheduled in Seattle

ABA Announces... ABA to Conduct Recertification Exam

Jack Moyers, M.D., 1921-1996

LETTERS TO THE EDITOR

Misrepresented Comments Corrected

An Answer: Good 'Outcome' Sense

Malignant Hyperthermia Support Acknowledged

FAER REPORT FAER Explains Program Descriptions and Deadlines

Anesthesiology Research Fellowship

Research Starter Grant

Anesthesiology Young Investigator Award

Educational Research Grant

TO THE MEMBERSHIP
Predictions?

PRESIDENT'S PAGE
The 11th World Congress of Anaesthesiologists:
'The Olympics of Anesthesia,' A Challenge Is Issued

WASHINGTON REPORT
'Insurance Portability' Bill Goes to Conference; Provisions Remain Controversial

Anesthesia and Surgery:
Not Always a One-Sided Affair

Pediatric Perioperative Cardiac
Arrest Registry: An Update

PRACTICE MANAGEMENT
The Minnesota Lawsuits: HCFA's Reimbursement Policy

RESIDENTS' REVIEW
Anesthesia Fellowships on the Rise -- New Wave or Dinosaur That Won't Die?

ASA NEWS
Nominations Sought for Media Award

ABA Announces...
ABA to Conduct Recertification Exam

FAER REPORT
FAER Explains Program Descriptions and Deadlines