Seeking to reduce the incidence of critical events in high-risk patients, the NAPA Anesthesia Patient Safety Institute (NAPSI)—NAPA’s certified Patient Safety Organization (PSO)—conducted a systemwide review of NAPA’s adverse events data. NAPA maintains one of the nation’s largest anesthesia clinical outcomes databases, comprising data from more than 2 million patients each year served by NAPA’s nearly 5,000 clinicians. As one of roughly 100 PSOs federally certified by the Agency for Healthcare Research and Quality, NAPSI is approved to use clinical outcomes data for analysis and performance improvement activities.
This research identified five high-risk clinical scenarios that contributed to significant adverse events at healthcare institutions nationwide. Combining data with clinical expertise, NAPSI developed the Anesthesia Risk Alerts (ARA) program in 2019. This patient safety intervention was implemented at all NAPA clinical sites across 22 states.
As a novel approach to mitigating operating room (OR) risk, the ARA program was honored for national level innovation in patient safety and quality with a 2022 Eisenberg Patient Safety and Quality Award by The Joint Commission and the National Quality Forum.
Situation
Barriers to collaboration have been identified across various industries. In the OR, patient safety may be compromised by a lack of trust or respect, misaligned goals, knowledge deficits, or poor communication skills.
After examining adverse-event analytics, NAPSI developed a strategy to improve OR safety for high-risk patients. For complex patients, this included a standardized protocol incorporating risk assessment, clinical collaboration, and a defined decision-making process that optimizes analytical thinking and produces better clinical outcomes. This data-driven research and professional best practices led to the ARA program, an innovative, patient-first, QI initiative that is reducing the incidence of serious adverse clinical events across NAPA’s partner facilities.
Solution
The ARA program encourages that prior to undergoing an anesthetic, every patient is assessed by the anesthesia clinician for five high-risk clinical scenarios. If one or more is present, the anesthesia clinician performs a specific mitigation strategy defined for each ARA, as follows:
- Known/suspected difficult airway: Second practitioner present to assist for induction and emergence for all general endotracheal anesthetics
- High BMI (> 45): Second practitioner present to assist for induction and emergence for all general anesthesia cases
- Pulmonary hypertension: Consultation about the case with a second clinician
- Risk category ASA status 4 or 5: Consultation about the case with a second clinician
- OR fire risk: Follow fire mitigation protocols as prescribed by the local institution
ARA compliance is digitally tracked on every anesthetic case across NAPA partner sites to ensure that all patients are getting assessed for these high-risk scenarios, and that the recommended risk mitigation strategy is being applied. NAPA’s local leadership (Anesthesia site chiefs or Quality site leaders) receive regular feedback on these metrics to discuss outcomes with their providers on an ongoing basis, and all NAPA clinicians receive monthly feedback about their individual performance via data on their compliance with the ARA program. Additionally, NAPA’s dedicated, regional Quality nurses provide continual feedback on the program to providers at the local level.
These risk assessments and mitigation strategies have resulted in more than 95% compliance across our clinical teams and resulted in a decrease in related critical adverse events, notably in the patient population of high BMI and ASA > 4 patients.
Transforming Culture
NAPA’s ARA program is innovative in how it routinely collects data about adverse events and applies this information into actionable mitigation strategies. ARA also utilizes novel approaches to patient safety adopted from other fields, including medical decision-making, cognitive errors, dual process model of reasoning, and blue team/red team challenge methodology.
Uniquely, each ARA mitigation strategy requires collaboration with other healthcare providers. As needed, difficult airway assistance can be rendered by the circulating nurse, endoscopy nurse, surgical technician, labor and delivery nurse, or even the surgeon. The only requirement is that the second clinician must be knowledgeable and skilled enough to actually assist with the airway management, and that they be fully available at the time of induction and emergence to assist if needed. Prevention of OR fires requires collaboration among all members of the OR team.
Because this program is intrinsically collaborative, it has fostered a culture of collaboration in which clinicians, regardless of skill level, have begun to discuss cases with colleagues or ask for assistance, even in cases that are not identified as “high risk” under the ARA program.