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Quality Improvement Scenario in Anesthesia
 
What follows are some messages posted recently to an anesthesia listserv that is limited to CRNAs. The first is from a student CRNA, the replies are from two very experienced CRNAs, followed by my own reply. I would be interested in your opinion of my response. Dan Simonson, CRNA Student: Yah to me this stuff is a no brainer however, it isn’t what I see happening in clinical at all. Over my career I’ve refused a lot of orders for various reasons, in the OR I just see capitulation but I will say it is mostly in 'grey' areas. As an example. We had this 58 y/o obese guy who has a large lower thoracic tumor 5 months ago or so. He was very very sick with lots of history etc. These tumors are notorious for bleeding and so we had 4 units in the fridge. As we are moving along I mention to the CRNA that its probable time to start giving a unit and be ahead instead of behind on a guy with significant CAD and 3 past MIs. He agrees but we have to "call the MDA" in order to do it. So we do. In comes the MDA who sees the pt is making urine, BP is 90/50 and HR is 110. Now, this guy came in with a BP of 89/55 and a HR of 105 initially. In my opinion that’s not normal for a guy who is obese, has HTN, has CAD and CABGs (need higher perfusion for those grafts). So I’m thinking we are already a little behind but at least we could get started now. Pt already had 2 liters of fluid in at this point and needed some phenylephrine to maintain BP. The MDA feels that on the pre op this was close to his normal, he is making urine and just to give him one unit and that’s all. We even had an ABG showing H&H of 9.2/29 (preop 9.9/31) which only means its trending down and likely much lower than it says). Now here is where it is grey. I don’t think that is appropriate tx but I'm the student. My CRNA however, doesn’t think its right either. When the MDA leaves I voice my concern (again) that we now have a cardiac pt who is tachycardic ( high O2 demand), hypotensive and with limited carrying capacity. Essentially, we are stress testing the guy on the table. He agrees but nothing changes. Needless to say I was right. The pts normal BP was 115/65 and HR 60's and the preOp was wrong. I found the info in the chart (which no one gets time to review but the MDA). By this time we had gone through 2 sticks of phenylephrine. and now are so behind we are running in phenylephrine, n/s and blood to keep his HR < 120 and BP ~ 80/50. Just ridiculous and could have easily been avoided. At one point I say to the MDA we need to switch to levophed or epinephrine and stop wasting time with a pure alpha (since arterial constriction doesn't matter so much when the vessels are empty. He does not like that idea and so we continue on a path which, I feel, was going to result in a code. About 20 minutes going like this another MDA, (who does all the hearts) wanders by. He sees the vitals and comes in freaking out. Let me give you and idea what he said without the colorful metaphors: WHY are you so far behind you don’t know what you are doing! WHY would you waste time with phenylephrine when the pt is empty? WHY would you only have started the blood/FFP/PLT this late? WHY WHY WHY WHY Hmm... where did I hear that before? Oh that’s right, I said it. However , in the interest of "cooperate to graduate", I kept my mouth shut. So essentially, the CRNA was blamed for everything, loudly I might add, in front of the surgical team. His response was "my hands were shackled what could I do?". Now you can imagine how this story was told later by the 2 MDAs. Lets just say that the CRNAs objections were never brought up but it was clearly all his fault. Now this is something I see happen on a daily bases, thought usually with much less critical things. How do you deal with these sorts of issues? Add to that a 20 yr CRNA at this facility was recently fired for (what I'm told) being too "difficult" and "not a team player". How do you deal with these sorts of things? An experienced CRNA replies: (Student), you were in a very difficult situation, and though you aren't culpable legally for the outcome as a student, pay attention to the fact that THE CRNA IS CULPABLE, DESPITE following the MDAs directions. Unfortunately, there is no shortage of ACT practices like you describe. As I have said before, repeatedly, the liability of a CRNA is NOT diminished by following bad MDA advice. And your CRNA "mentor" is a poor excuse for a CRNA. Oh yeah, I have heard all about "don't rock the boat", "I'll lose my job", "what else could I do?", etc. etc. Bullshit. PRIMUM NON NOCERE. You don't physically harm people, whose lives are entrusted to your care, to protect your paycheck. The fact of the matter is that as long as CRNAs continue TO ALLOW and to participate in crap like this, there WILL BE crap like this. "Easy for you to say", I'm sure many ACT CRNAs will say. Sure it's easy for me to say, because even when I locum in ACT practices, I don't forget that my duty of care is to MY PATIENT, NOT TO THE MDA. And just because the MDA is an idiot, doesn't mean that you should "go along to get along". In the scenario you describe, as a CRNA I have no problem just switching pressors ON MY OWN. THAT IS WHY I HAVE A LICENSE FROM THE STATE. And what happens if the MDA doesn't "like" it? You just point to the better vital signs. Oh, look. A miracle. The point is that it is morally reprehensible, as well as legally indefensible, to allow your patient to be damaged just to keep your fucking job, no matter what kind of crap excuse you dream up for yourself. And if you don't have the balls to force the issue, remember that it is easier to ask forgiveness than to get permission. As you can tell, this is a BIG issue for me, and I'll tell you why. I learned about this the hard way in my very first civilian job, in a major university-affiliated hospital. After a couple of months on the job, the chairman told me that I "used too many drugs". I needed to show him that I could do a "straight inhalation anesthetic". I was told to do that for an open cholecystectomy patient, ASA 3, known CAD with occasional angina relieved by NTG, COPD, smoker, HTN, etc.,etc. Since this was a teaching hospital, the gallbag took over three hours to do. Patient's VS all over the map as I used ONLY enflurane (which is not good for controlling HR, by the way). It was a nightmare. As we approached the end of the case, I called the chairman (who, of course, had never seen the patient or participated in any way in the anesthetic, beyond demanding that it be straight inhalation) to ask if I could give some morphine for the wakeup.! I was told, "NO, I TOLD you to do straight inhalation. If he needs morphine, he can have it in recovery." And you know what, I woke the patient up with no narcotic after a classical gallbag (eight inch subcostal incision), because I was "told to" by an MDA. I did this KNOWING IT WAS WRONG. Turns out the patient didn't need morphine in recovery because by the time we got there he was having a massive MI and going into cardiogenic shock. I had preopped the patient, met his wife (no other family, only each other). I told her I would take care of her husband. And this is what I did for them. And, no, I didn't stay at that hospital for long after this incident I post-oped the guy EVERY DAY for three weeks. He survived the MI to be discharged. That day, his wife hugged my neck and told me she was sure that her husband would have died if not for my "wonderful care". How do you think that made me feel? It's making me nauseated even now to recount this. I told the chairman that when the case came to M & M he could present it and he could explain why the patient had such a crap anesthetic, instead of my usual lots of narcotic, propranolol, adjuvant, "too many drug" anesthetic. Guess what. Case never made it to M & M. And I have NEVER knowingly harmed another patient because some MDA thought it was a good idea. And not just because it is unchristian and unprincipled and immoral--because it made me sick to my stomach to have that woman think I had saved her husband's life when I gave him the MI. Bottom line, though, is I DID IT, NOT THE MDA. And twenty five years later, I still have to think about that. So, we all make our choices and we all live with the consequences. But don't ever kid yourself into thinking that because you are "just following orders" that you are not just as guilty as the people who planned the concentration camps. YOU DID THE DEED. NOBODY ELSE. YOU ARE RESPONSIBLE. Lie to yourself if you want to, but it doesn't change the truth. I know that this is not going to be you in practice, (Student). But you will encounter just such self-delusional, self-serving justifications from a load of worthless CRNAs out there. And, if anyone on this forum recognizes yourself in the description, PLEASE DON'T BOTHER to offer an "explanation" for your craven behavior, because there is none. I also know that there are plenty of CRNAs out there who can't tell a good anesthetic from a bad one, since they can't pee without an MDA to let them, but that is another story. Either take care of the patient or find another line of work. Lou Dan Simonson’s Reply: I wouldn't let (a previous poster) get you too upset. All of these scenarios and questions are a matter of interpretation- and I think most of us enjoy the fact that you are willing to be candid as you are. I remember being a student, and I think you are doing exactly the right thing. Don't get tossed- we need you! What I would like to do, instead of pointing my wagging finger at everyone, is try to view your incident with an eye to the principles of quality improvement. It is unrealistic to think that anyone is going to remove all of the MDAs from hospitals and replace them with CRNAs. I try to think like a citizen - one who might one day have need of anesthesia care at your hospital. What would my expectation of your anesthesia providers be? That they are fighting like cats and dogs, that they hate each other, that they permit poor outcomes because of turf issues? I am certain that your hospital and all of its anesthesia providers do not see themselves in that light. And insofar as you are able to present these issues so that they are recognized as patient care quality issues, you will have a better chance at resolving them in favor of the patient. First of all, let's review with an impartial eye- "debriefing" is the term I like to use. In the scenario you described, you and the CRNA had diagnosed a problem and come up with a plan to resolve it. When you presented your plan to your supervising MDA, he did not agree and instead asked you to undertake a course of action that at best did not improve the situation and possibly made it worse. Another MDA came in later and yelled at you for not following the plan you recommended. If we are thinking quality improvement, the first thing we have to do is try to imagine that everyone involved in this scenario is competent and hard working - both the MDAs and the CRNAs (if that is not the case, then it is a personnel issue and not a quality issue). I can certainly imagine how this scenario could have happened even with competent, hard working MDAs and CRNAs. The errant MDA, if he is competent, obviously did not understand fully the predicament the patient was in. Why was that? Then there is the issue of the CRNA's (not the student- as you rightly point out, students are students) not being able to communicate his concerns effectively. Why did that happen? Is there a system in place such that if a CRNA disagrees with his supervising MDA, he can appeal? In Crew Resource Management (CRM- see my reference below), everyone, from the lowest person in the chain of command, has the right to call attention to a matter if they feel it is affecting the outcome. Why does the CRNA not have that right? And finally, why didn't the MDA who "rescued" the patient debrief the incident with you? If he felt strongly enough about the quality of the care that he had to yell at someone, why didn't he feel it was his duty to hang around after the case and discuss it? This incident, to me, is not about MDAs vs. CRNAs. It is about not having quality improvement methods in place to deal with poor outcomes, or having them in place and not using them. We need to stop accepting this type of outcome as a consequence of turf, and instead realize it is a failure of quality. As a potential patient, it is my view that both sides are culpable- the MDAs, of course, but also the CRNAs. The CRNAs at that hospital can use the huge emphasis on quality improvement put in place by Joint Commission to make these kinds of changes. That is what we should be discussing- not ragging on the MDAs, but instead focusing on the system of care that allows these kinds of incidents to happen and not to learn from them. I urge all of you to read the article I reference below. I am envious that the OR nurses can take credit for it- good for them! Student’s reply: Hey Dan :) Not upset at all just pointing out that the role of a student is often just to keep my mouth shut :) So far I have managed to "cooperate to graduate" (my 30 month motto) like a champ ! I’ll answer your questions as best I can: (note that the student quotes my post in italics then responds) If we are thinking quality improvement, the first thing we have to do is try to imagine that everyone involved in this scenario is competent and hard working - both the MDAs and the CRNAs (if that is not the case, then it is a personnel issue and not a quality issue). I can certainly imagine how this scenario could have happened even with competent, hard working MDAs and CRNAs. The errant MDA, if he is competent, obviously did not understand fully the predicament the patient was in. Why was that? Good question. I have no idea why it is after we explained everything that he did understand it. He was literally in the room every 15-20 minutes either because we called or he popped by. He certainly did not seem (and does not seem) like someone who was disinterested, just the opposite. Also, in general, I’d say he was a pretty bright guy. He just did not seem to understand the concepts. He kept saying that the pt was putting out good urine and the abg's looked ok. Of course those numbers are irrelevant in the big picture. A pt with CAD and post bypass, a smoker and obese should never have a BP and tachycardia as he did. It’s just not acceptable and highly dangerous. Also, someone mentioned beta blocker. I did that. No result. In fact I went with the most obvious one (esmolol) to control the HR and avoid lowering the BP anymore, it simply did not work. This further confirms that the pt was empty and crystalloid is NOT the answer with these patients (he got 5 liters total and urine was almost clear). The ABGs, from my perspective, were erroneous and the reason we were seeing tachycardia is straightforward, inadequate DO2 because of decreased CaO2. I just couldn’t convince the MDA of this for some reason. Then there is the issue of the CRNA's (not the student- as you rightly point out, students are students) not being able to communicate his concerns effectively. Why did that happen? Is there a system in place such that if a CRNA disagrees with his supervising MDA, he can appeal? In Crew Resource Management (CRM- see my reference below), everyone, from the lowest person in the chain of command, has the right to call attention to a matter if they feel it is affecting the outcome. Why does the CRNA not have that right? This is where the system breaks down. Now I see where you are going with this, I am a 'systems' guy as well. Often there is a systemic problem that leads to failures. In this case, that is certainly true but the system is one sided (it seems). I am also very pro CRM. We used it in air medical as a rule. However, for CRM to work there has to be 'investment' in the process at all levels. To some degree I wonder if that can happen when the "chief" is an MDA and there is clearly a "doctor club" in effect? The short answer is that there is no system for the CRNA to appeal anything and while I don’t think its true of every MDA, many clearly don’t believe you could add something to this sort of case. The only action a CRNA can take is to go to the Chief MDA after the fact. The impression I get (I may be wrong) is that little comes of that. You have to remember this is a place where CRNAs are not allowed to give paralytics when responding to a pager (which CRNAs carry) without getting an order from the MDA only. And finally, why didn't the MDA who "rescued" the patient debrief the incident with you? If he felt strongly enough about the quality of the care that he had to yell at someone, why didn't he feel it was his duty to hang around after the case and discuss it? Well, I actually approached him the next day. His response was polite but what he essentially said was that the patient was grossly mismanaged and it was because the "CRNA in there" didn't have a clue about how far behind he was. I just listened as he essentially said what we had been thinking. The other MDA was never mentioned. This incident, to me, is not about MDAs vs. CRNAs. It is about not having quality improvement methods in place to deal with poor outcomes, or having them in place and not using them. We need to stop accepting this type of outcome as a consequence of turf, and instead realize it is a failure of quality. As a potential patient, it is my view that both sides are culpable- the MDAs, of course, but also the CRNAs. The CRNAs at that hospital can use the huge emphasis on quality improvement put in place by Joint Commission to make these kinds of changes. That is what we should be discussing- not ragging on the MDAs, but instead focusing on the system of care that allows these kinds of incidents to happen and not to learn from them. I would agree there isn’t any quality improvement in place. Though I would suggest that some of the problems are stemming from CRNAs having the perception that they are powerless. The interaction between that CRNA and the 2 MDAs was no different than I have seen between an RN & an MD on a floor. It is clear who is in control. While I totally agree with your view I’m not sure how this could be implemented when the "buck" stops at the chief MDA? Another experienced CRNA replying: I agree. I think your MDA simply did not interpret the physiologic symptoms correctly. Why? Cannot say. I believe in his mind he was taking the appropriate action. An M&M on the subject wouldn't hurt... given by the student is equated with less finger pointing. I am also a proponent of CRM and studies show that potential mistakes are avoided and good ideas encouraged utilizing this philosophy/methodology. However, it requires "buy in" from all parties before implementation and modification of the hierarchical structure (ego pacification). Everyone/Anyone is supposed to be allowed to verbalize concerns without reproach. The last part in which the CRNA is "yelled at" should never have occurred .. and IF it was appropriate to call it to the CRNAs attention should have been done privately not in front of the student. Lots of learning. :O) Juan Quintana •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 1. Powell, S.M. and R.K. Hill, My copilot is a nurse--using crew resource management in the OR. AORN J, 2006. 83(1): p. 179-80, 183-90, 193-8 passim; quiz 203-6. Crew resource management (CRM) has been used for more than 20 years in the aviation industry to teach individual error countermeasures by developing nontechnical (i.e., cognitive, social) skills based on the observed traits of successful individuals and crews. The health care industry began to investigate aviation CRM after the Institute of Medicine's report, To Err is Human: Building a Safer Health System, recommended that medicine adopt aviation's approach to safety and error management. Initial results of implementing CRM in health care arenas have demonstrated reduced adverse outcomes, reduced errors, reduced length of stay, improved nurse retention, and changed attitudes and behaviors toward teamwork. http://www.ahrq.gov/clinic/ptsafety/chap44.htmhttp://astore.amazon.com/crnabiz-bookstore-20/detail/B000EBEFBU/104-7906288-8659967shapeimage_2_link_0shapeimage_2_link_1
January 7, 2008 9:33 AM
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Click to share your Comments Your Comments ? This incident, in my mind, relates to quality improvement in one major way. Quality improvement means that we learn from previous mistakes (our own and others). For the process to occur, the mistake must be recognized and responsibility must be taken. I could go on about how pathetic the response of the CRNA to both MDA's was, but that would be a lengthy topic. I am struck by the fact that the person who messed up (the MDA) was not confronted with his errors and the blame was instead shifted onto the CRNA and student. How is this doctor supposed to learn from his mistakes if he never has to own up to them? I do not understand how these two providers allowed this to happen. All they had to do was call the MDA into the room (in front of the surgeon and everyone else) to explain himself to the second (asshole) MDA. He was still present in the OR suite, right? I would say that four parties were wronged in this instance: the patient, the CRNA, the surgeon, and the MDA who messed up. David James Well, I agree the case was managed poorly why the MDA made the decisions he did I do not know, why the CRNA made the decisions he did I do know. The pressure to buck an attending is huge and in particular when your job is on the line. To avoid these problems I feel it is better to stand your ground on little things get the system used to saying yes to you, to take you seriously cause it is your ass on the line. If you cannot effect that change get the hell out of dodge. Stanley Kristiansen
For more about the legal ramifications of "Just following orders," see the Legal Briefs column from December 2004 on the AANA website: http://www.aana.com/lb1204.aspx Cathryn Hodsonhttp://www.aana.com/lb1204.aspxshapeimage_6_link_0
Dan Simonson replies: The point, to me, is that we have to create an environment where it is possible to admit mistakes. This takes the support of leadership. In team care settings, CRNAs are not often going to be the top leaders of departments, and the only way these changes are going to come about is with the express consent and involvement of the MD Chiefs of anesthesia. But that does not make the task impossible. I truly believe that there are many outstanding MD Chiefs of anesthesia departments- I have met and gotten to know several. The task for us is to create the resources for the CRNA leadership of those departments to use in approaching their MD counterpart and begin the dialogue. Creating a quality environment involves two overriding assumptions: 1. Everyone involved is competent and intelligent 2. Everyone is working as hard and as best they can. If we assume those two things and review these kinds of cases, it will give us insights that might actually improve what is going on. The Japanese started making better cars when they began assuming that their workers were skilled and that mistakes and poor quality were usually the result of poor systems, not poor workers. The first thing they did was to begin rewarding people for reporting errors rather than shaming or blaming them. So in this case, instead of wondering why the CRNA didn't act like they should have, let's accept that as the first problem! They didn't act like they should have because they didn't feel that acting as they should would have a better outcome than sitting on their hands. That is the issue here- not the blood loss or the phenylephrine dose. Given our assumptions above, why would a competent, intelligent CRNA who is working as hard and as best he can, act this way? Obviously, because he is not convinced that acting any other way will improve the outcome. Now assume this for the Anesthesiologist as well- and immediately you see the problem in its larger context.