Anesthesia & Analgesia:
Book, Multimedia, and Meeting Reviews: Book Review
Anesthesiology Clinics is published every 4 months by Elsevier. The March 2011 issue is on “Quality of Anesthesia Care,” including the need for innovative payment and delivery mechanisms. As health care demands grow in the face of limited resources, anesthetic practices will evolve through managerial techniques, technical solutions, and innovative applications. “Quality of Anesthesia Care” helps to define and set an important framework for managing today's clinical practice.
The book structure consists of 12 chapters, by a total of 35 established and up-and-coming authors, over 167 pages, not including the preface or the index. Chapters are succinct yet informative with appropriate figures and diagrams. Each chapter touches on a unique facet of anesthesia quality, including how teamwork and communication affects outcomes, how simulation is being used to improve patient care, when the promise of information technology will become reality, the need to specifically address complications in elderly surgical patients, the importance of multidisciplinary education to promote collaboration among all providers caring for a patient, the key role of end-of-life care, pain as an important metric of any quality program, the nature of medication errors in the surgery suite, efforts to make the operating room more green, and the crucial role of engaging house staff from the ground up in improving patient safety at teaching hospitals.
“Quality of Anesthesia Care” helps define a framework for a modern, efficient, “quality conscious” daily clinical anesthesia care. Keeping within the constructs put forth by the Institute of Medicine (IOM), a useful working definition of quality is determined by 6 attributes: safety, effectiveness, patient centeredness, timeliness, efficiency, and equity. In contrast is Donabedian's framework for measuring quality with 3 dimensions: structure, process, and outcome. How the 2 paradigms overlap can help us become smart about evaluating the quality of our own practices. For example, safety (IOM) is an outcome (according to Donabedian), but is effectiveness (IOM) considered structure or process by Donabedian or is it both structure and process? The IOM framework focuses on process because patient centeredness, timeliness, efficiency, and equity look to be more process measures than outcome measures.
The chapter on outcomes research using clinical databases reminds us of their inherent limitations. For example, sicker patients having larger surgeries will have higher risk for adverse events after the surgery. However, such database study results do not necessarily help guide clinicians with specific patient management decisions (to give more or less fluids, for example). In addition, these registries struggle to evolve as the clinical questions and state of knowledge advance. The legal and ethical challenges with regard to confidentiality and regulatory requirements are also neatly summarized.
Other valuable insights exist throughout; for example, the chapter on using information technology to improve quality in the operating room highlights the practical integration, automated process monitoring, and decision support available currently. The need for ease of access for important information is highlighted, and examples of real-world systems are shown, which integrate multiple patient monitors, live video, and scheduling data, all within a single user interface. The nice chapter on using real-time clinical decision support shows the untapped potential for skillful use of the Anesthesia Information Management System. This highlights the importance of the Anesthesia Information Management System–based reporting of events and the real-time user application of data. As a result, physicians can develop this technology to monitor/improve clinical results, increase nonmonetary benefits for patients, and align treatment goals directly with the patient's needs.
The authors of a separate chapter on effective communication and multidisciplinary education deftly accentuate the importance of skillful communication. The concern is that human error as a result of miscommunication remains a cause of morbidity and mortality. For example, training of residents together as teams can show each member the important nuances of the other disciplines.
Another chapter makes the point that patient satisfaction is not only related to customer service but is also linked directly to amelioration of pain. Improvement of institutional accountability for the treatment of pain is something we are seeing in all our hospitals.
This issue of Anesthesiology Clinics on “Quality of Anesthesia Care” does an outstanding job describing how the interdisciplinary management of technology, outcomes research, and real-time clinical management can open doors for improved patient well-being. This text helps define an accepted model for quality care via timely medical practices.