Secondary Logo

Journal Logo

Availability of Anesthesia Equipment in Chinese Hospitals

Is the Safety of Anesthesia Patient Care Assured?

Juan, Xie, PhD*; Xinqiao, Fu, PhD; Shanglong, Yao, MD; Yuguang, Huang, MD§; Buwei, Yu, MD; Shiying, Yuan, MD; Pengqian, Fang, PhD*; Hanqing, Zeng, MD

doi: 10.1213/ANE.0b013e31825018cf
Patient Safety: Case Report
Free
SDC

Availability of physiologic monitoring equipment to ensure the safe administration of anesthesia is an expected standard in many parts of the world. Many hospitals in China may not have an adequate quantity and variety of anesthesia delivery and patient monitoring equipment to assure safe administration of anesthesia patient care. We present some typical cases of hospitals of different sizes and located in regions with different economic levels; our data demonstrate that there is a lack of available anesthesia administration and patient monitoring equipment in small hospitals and hospitals in economically underdeveloped regions.

Published ahead of print March 30, 2012

From the *College of Medicine and Health Management, Huazhong University of Science & Technology, Wuhan City; Outpatient Office, and Departments of Anesthesiology and Urology, Union Hospital affiliated to Tongji Hospital, Huazhong University of Science & Technology, Wuhan City; §Department of Anesthesiology, Beijing Union Hospital, Beijing City; and Department of Anesthesiology, Shanghai Ruijin Hospital, Shanghai City, China.

Supported by the Chinese Society of Anesthesiology, program from Education Ministry (the research on Management and Surveillance of Chinese State Hospital, Code 10JZD0027).

The authors declare no conflicts of interest.

Drs. Xie Juan and Fu Xinqiao are co–first authors.

Reprints will not be available from the authors.

Address correspondence to Fang Pengqian, PhD, College of Medicine and Health Management, Huazhong University of Science & Technology, Hankong Rd. 13#, Hankou, Wuhan City, Hubei Province, China, 430030. Address e-mail to pfang@mails.tjmu.edu.cn.

Accepted February 3, 2012

Published ahead of print March 30, 2012

Although human factors are of major importance in assuring anesthesia safety, adequate anesthesia administration and monitoring equipment allocation is a necessary condition in anesthesia patient care13 (Table 1, Ref. a). Minimum requirements for equipment to administer anesthesia safely and monitor patient physiology are increasingly being defined by standards and guidelines in many nations across the world36 (Table 1, Refs. b–e). The development of these monitoring standards received a major stimulus from work published by Eichhorn et al. in the mid to late 1980s.7,8

Table 1

Table 1

The American Society of Anesthesiologists (ASA) Standards for Basic Anesthetic Monitoring specifically states,

“During all anesthetics, the patient's oxygenation, ventilation, circulation and temperature shall be continually evaluated.” (Table 1, Ref. b)

The ASA Standards recommend assessing patient physiology using monitors for inspired oxygen, pulse oximetry, end-tidal carbon dioxide (ETCO2), breathing circuit low pressure/disconnection, electrocardiogram (ECG), arterial blood pressure (noninvasive or invasive as appropriate), and body temperature (BT). These requirements are similar to those in other parts of the world; examples include and are not limited to Europe,3 India (Table 1, Ref. c), Great Britain,4 South Africa (Table 1, Ref. d), Australia and New Zealand (Table 1, Ref. e), Singapore (Table 1, Ref. f), Mexico (Table 1, Ref. g), and Japan (Table 1, Ref. h).

Anesthesiology is a relatively young medical specialty in China. It was not until 1989 that the Chinese Ministry of Public Health recognized anesthesiology departments as important clinical entities within hospitals.9 Significant modernization of anesthesiology as a recognized patient care medical specialty in China has blossomed in only the past 2 decades. Before this recent history, anesthesiology departments in China had been ignored by hospital administrators, resulting in sparse resource deployment in many health care facilities; the quantity and quality of equipment to administer anesthesia and monitor patients was insufficient in a variety of hospital settings.10,11 In addition, there is resource inequality in different regions of China. The shortage of equipment to safely administer anesthesia care is potentially hazardous to patients requiring anesthesia. This survey presents information about some typical hospitals, representative of the various (a) total bed census, and (b) economic regions across the country, to gain a broader and current appreciation of the magnitude of the deficiencies in anesthesia administration and patient monitoring equipment in China.

Back to Top | Article Outline

Case Descriptions

The information of surveyed hospitals is presented in Table 2. The hospitals were grouped according to their available bed census: super-scale hospitals ≥1000 beds, large-scale hospitals of 500 to 999 beds, medium-scale hospitals with 100 to 499 beds, and small-scale hospitals <100 beds.

Table 2

Table 2

Back to Top | Article Outline

Case 1

Hospital A, a super-scale hospital with 1800 beds, is located in a more economically developed province with a gross domestic product (GDP) per capita in 2009 of $5900 (the overall GDP per capita of China in 2009 was $3263). The medical quality control center of this province was founded in 2003. This hospital has 32 operating rooms (ORs). Anesthesia delivery and monitoring equipment in this hospital consists of 34 anesthesia machines, 47 ECG monitors, 47 peripheral oxygen saturation (SpO2) monitors, 47 noninvasive blood pressure (NIBP) monitors, 18 BT monitor probes, 35 ETCO2 monitors, and 4 anesthetic gas monitors. In addition, the anesthesiology department is equipped with 5 defibrillators, 4 fiberoptic bronchoscopes, 7 target-controlled infusion pumps, 1 peripheral nerve stimulator, and each of the 32 ORs is capable of invasive hemodynamic monitoring.

The average daily number of anesthetics is 12 central neuraxial (subarachnoid anesthesia, epidural anesthesia, or combined subarachnoid-epidural anesthesia) and 25 general anesthetics.

Back to Top | Article Outline

Case 2

Hospital B, a medium-scale hospital with 310 beds, is located in a rural region of the same province as hospital A. This hospital has 8 ORs. Anesthesia delivery and monitoring equipment in this hospital consists of 8 anesthesia machines, 7 ECG monitors, 8 NIBP monitors, 7 BT monitor probes, and 1 ETCO2 monitor. There are no anesthetic gas monitors, SpO2 monitors, defibrillators, target-controlled infusion pumps, fiberoptic bronchoscopes, or peripheral nerve stimulators. One of the ORs is capable of invasive hemodynamic monitoring.

The average daily number of anesthetics is 8 central neuraxial and 5 general. All anesthetized patients are cared for without SpO2 monitoring.

Back to Top | Article Outline

Case 3

Hospital C, a large-scale hospital with 683 beds, is located in a province of Central China, with a GDP per capita in 2009 of $3200. This hospital has 16 ORs. Anesthesia delivery and monitoring equipment in this hospital consists of 10 anesthesia machines, 16 ECG monitors, 16 NIBP monitors, 16 SpO2 monitors, 8 BT monitor probes, 8 ETCO2 monitors, 1 defibrillator, 1 fiberoptic bronchoscope, and 1 peripheral nerve stimulator. There are no anesthetic gas monitors or target-controlled infusion pumps; half of the ORs are capable of invasive hemodynamic monitoring.

The average daily number of anesthetics is 9 central neuraxial and 8 general.

Back to Top | Article Outline

Case 4

Hospital D, a small-scale hospital with 60 beds, is located in the urban region of the same province as hospital C. This hospital has 2 ORs. Anesthesia delivery and monitoring equipment in this hospital consists of 2 anesthesia machines, 2 ECG monitors, and 2 NIBP monitors. There are no SpO2, BT, anesthetic gas, or ETCO2 monitors; there are no defibrillators, fiberoptic bronchoscopes, target-controlled infusion pumps, or peripheral nerve stimulators. None of these ORs is capable of providing invasive hemodynamic monitoring.

The average weekly number of anesthetics is 4 central neuraxial and 1 to 2 general.

Back to Top | Article Outline

Case 5

Hospital E, a super-scale hospital with 1300 beds, is located in Western China in an economically underdeveloped province with a GDP per capita in 2009 of $2000. This hospital has 38 ORs. Anesthesia delivery and monitoring equipment in this hospital consists of 17 anesthesia machines, 17 ECG monitors, 17 NIBP monitors, 13 SpO2 monitors, 2 BT monitors, 10 ETCO2 monitors, 2 defibrillators, and 3 target-controlled infusion pumps. There are no anesthetic gas monitors, fiberoptic bronchoscopes, or peripheral nerve stimulators. Two of the 38 ORs are capable of invasive hemodynamic monitoring.

The average daily number of anesthetics is 14 central neuraxial and 6 general.

Back to Top | Article Outline

Case 6

Hospital F, a medium-scale hospital with 335 beds, is located in the same province of Western China as hospital E. This hospital has 5 ORs. Anesthesia delivery and monitoring equipment in this hospital consists of 3 anesthesia machines, 3 ECG monitors, and 3 NIBP monitors. There are no SpO2, BT, anesthetic gas, or ETCO2 monitors. There are no defibrillators, fiberoptic bronchoscopes, target-controlled infusion pumps, or peripheral nerve stimulators. This hospital cannot provide invasive hemodynamic monitoring.

The average daily number of anesthetics is 4 central neuraxial and 1 general. All anesthetized patients are cared for without SpO2 monitoring.

Back to Top | Article Outline

DISCUSSION

The anesthesiology community worldwide has subscribed to the concept that there are fundamental standards for monitoring of patients undergoing anesthesia care. The World Federation of Societies of Anaesthesiologists (WFSA) has summarized this perspective in its 2008 International Standards for a Safe Practice of Anaesthesia (Table 1, Ref. i).

“These standards are recommended for anesthesia professionals throughout the world. They incorporate and elaborate upon the core components of the Safe Anaesthesia part of the 2008 World Health Organization's World Alliance for Patient Safety “Safe Surgery Saves Lives” global initiative. These WFSA standards are intended to provide guidance and assistance to anesthesia professionals, their professional societies, hospital and facility administrators, and governments for improving and maintaining the quality and safety of anesthesia care.” (Table 1, Ref. i)

The WFSA, recognizing that there are geographic settings where the defined standards have not been met, recommends that,

“… provision of anesthesia under such circumstances should be restricted to procedures which are absolutely essential for the urgent or emergency saving of life or limb, and every effort should be made by those responsible for the provision of healthcare in these areas and settings to ensure that the standards are met. Provision of anesthesia care at standards lower than those outlined as mandatory for anesthesia for elective surgical procedures simply cannot be construed as safe acceptable practice.” (Table 1, Ref. i)

The WFSA 2008 International Standards for a Safe Practice of Anaesthesia (Table 1, Ref. i) outline, as do example standards cited from individual countries (Table 1, Refs. b–h),46 the essential oxygenation, ventilation, circulation, and BT monitoring necessary for safe anesthesia patient care.

Morbidity increases when standard monitoring recommendations are not used during anesthesia patient care. As an example, an analysis of 1097 anesthesia-related accidents revealed that 31.5% of these adverse events could have been prevented if more extensive patient physiologic monitoring, especially SpO2 and ETCO2 monitors, had been used.12

Oxygen monitoring is not available for anesthesia patient care in many hospitals in China. The various case examples in this survey demonstrate that pulse oximetry and ETCO2 monitoring are not always available for anesthesia patient care in medium- and small-scale hospitals in China. ETCO2 monitoring assures adequate ventilation and confirms proper placement of an endotracheal tube.13 Bradycardia is characteristically present in 90% of cardiopulmonary arrests.14 Without continuous monitoring of ECG, this danger sign is difficult to detect and treat. ECG is the only monitor consistently available in most anesthesia patient care settings in China, as documented by this survey.

A compelling aspect of this survey is the recognition that anesthesia patient care in a variety of locations in China is deficient, lacking basic monitoring of a patient's oxygenation. A global health improvement and patient safety initiative of the World Health Organization and WFSA is currently addressing this patient safety concern. The Lifebox project is designed to make pulse oximetry available wherever patients are receiving anesthesia. The statement of purpose of Lifebox is:

  • “1. To preserve and protect the health of patients worldwide by providing and assisting in the provision of equipment and support services in low resource and lower-middle income countries at no or reduced cost.
  • 2. To advance the education in healthcare of the general public and especially those in the medical or similar professions by the provision of education and training worldwide.” (Table 1, Ref. j)

China is a more economically advantaged country than the “third-world”(developing) countries that are the usual targets for assistance from Lifebox, which is all the more reason why correction of any deficiency in oxygen monitoring that exists in this country is ripe for resolution.

In recent years, China has witnessed improvement in anesthesia technology in large- and medium-size hospitals resulting in an increase in the frequency with which general anesthesia is selected for patient care. A similar trend in smaller hospitals in China has not resulted in a comparable increase in the frequency with which general anesthesia is selected for patient care. This study documents that in China, hospitals with ≥500 beds, especially when providing general anesthesia, can usually provide basic oxygenation, NIBP, and ECG monitoring recommended in the WFSA 2008 International Standards for a Safe Practice of Anaesthesia, but cannot assure comparably acceptable ETCO2 and BT monitoring; many hospitals with ≤499 beds cannot meet either of these recommendations. Of note is the paucity of SpO2 and ETCO2 monitoring capability in the surveyed hospitals with ≤499 beds.

Anesthesia equipment surveyed in this study is of significantly higher quality at hospitals in more economically developed regions of China than in economically underdeveloped regions. Detailed equipment inventory records revealed that the anesthesia delivery and physiologic monitoring equipment in hospitals from the Western region (economically underdeveloped) was mainly manufactured in China, with a large proportion of it having been in service for >10 years. In contrast, the hospitals in the economically developed Eastern regions of China have a patient care equipment advantage, having been able to import a large quantity of more modern equipment from overseas. The equipment performance, user-friendliness, reliability, and safety are likely enhanced with this more modern equipment.

The proportion of hospitals in China with >500 beds (large-scale hospitals) is >90% and they constitute nearly 40% of hospitals in underdeveloped regions (Table 1, Ref. k). Deficiencies in anesthesia delivery and patient monitoring equipment in these hospitals present a great challenge to the provision of safe anesthesia patient care in China. Unfortunately, this is coupled with a fledgling Chinese system of anesthesia quality control. This survey of 12 hospitals in 6 provinces in China documented that although an Anesthesia Quality Control Centre (AQCC) in Zhejiang Province has existed for nearly 20 years, the AQCC of Henan Province is only 5 years old and in the other 4 provinces, 2 have established an AQCC for no more than 3 months whereas 2 provinces have no AQCC.

Limitations of this survey include the selection process of the surveyed hospitals, which was not random and only represented 18% of the provinces and an extremely small proportion of the >320,000 hospitals and clinics15 within China. The fact that any hospital delivering anesthesia patient care for elective nonemergency surgery in China was identified by this survey as substandard with respect to WFSA 2008 International Standards for a Safe Practice of Anaesthesia is a major concern for the welfare of citizens in China. At the current time, China does not subscribe to 1 national guideline for monitoring of patients during anesthesia care. The Chinese Society of Anesthesiology has not established monitoring guidelines in similar fashion to other countries, and has not adopted the WFSA 2008 International Standards for a Safe Practice of Anaesthesia. Adopting national standards and developing anesthesia quality control processes in anesthesia departments throughout China are highly desirable goals.

A second critique of this survey is that hospitals may not have a full set of anesthesia delivery and monitoring equipment available for every OR because not all ORs are used all of the time; thus, the available equipment might actually be sufficient for the number of rooms in which patients are being provided anesthesia. In other words, the equipment that does exist can be moved from one OR to another, depending on patient needs, because not all available ORs within a hospital are used simultaneously. Although it may be true that the anesthesia delivery and monitoring equipment resources available are matched only to the number of ORs in which anesthesia patient care is taking place, there may be situations when emergency surgery mandates that anesthesia care be provided and this may occur in hospitals with limited resources, i.e., less than a 1 to 1 match between the anesthesia delivery and monitoring equipment and the number of ORs in which anesthesia care is provided.

A third critique of this survey could conclude that because there are no data in China that accurately calculate anesthesia-related accidents, it is impossible to analyze the relationship between the anesthesia equipment allocation and anesthesia quality. Although there are no specific anesthesia quality data in this survey, the anesthesiology literature is replete with data that clearly establish the relationship between patient safety and the monitoring standards recommended by the World Health Organization, WFSA, ASA, and individual countries.

A final critique of this survey is that the financial support provided by companies that manufacture anesthesia administration and monitoring equipment represented a conflict of interest with the potential for financial gain for the companies as a result of potential future equipment purchases. We acknowledge this concern yet believe that collecting the data and documenting the deficiencies of anesthesia safety equipment were so compelling for the public benefit in China that accepting the resource support from the manufacturers to accomplish the survey was acceptable. The need to secure more anesthesia administration and patient safety monitoring equipment is documented. The fact that manufacturers that provided funding for the survey may benefit financially is true and is equally true for other manufacturers that produce the same devices and did not fund this survey. The operative principle of this survey is focused on what is best for patients, not how companies may benefit financially.

It is obvious from the cases described in this survey that there is a gap between anesthesia equipment allocation in Chinese hospitals and accepted standards for safety, especially for smaller hospitals in the economically underdeveloped regions of the country. The information revealed by this survey supports the recommendations that monitoring standards be established in China, anesthetizing locations be equipped to meet these standards, and a more formal and organized anesthesia quality control system be developed throughout the entire country to assure anesthesia safety for all patients in China.

Back to Top | Article Outline

DISCLOSURES

Name: Xie Juan, PhD.

Contribution: This author helped write the manuscript.

Attestation: Xie Juan has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

Name: Fu Xinqiao, PhD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Fu Xinqiao has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

Name: Yao Shanglong, MD.

Contribution: This author helped design the study and conduct the study.

Attestation: Yao Shanglong has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

Name: Huang Yuguang, MD.

Contribution: This author helped design the study and conduct the study.

Attestation: Huang Yuguang has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

Name: Yu Buwei, MD.

Contribution: This author helped design the study and conduct the study.

Attestation: Yu Puwei has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

Name: Yuan Shiying, MD.

Contribution: This author helped design the study and conduct the study.

Attestation: Yuan Shiying has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

Name: Fang Pengqian, PhD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Fang Pengqian has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

Name: Zeng Hanqing, MD.

Contribution: This author helped write the manuscript.

Attestation: Zeng Hanqing has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

This manuscript was handled by: Sorin J. Brull, MD, FCARCSI (Hon).

Back to Top | Article Outline

ACKNOWLEDGMENTS

The authors thank Professor Alan Jay Schwartz for his generous editorial help and the contribution he made in improving the anesthetic safety of China. We are grateful to Professor Sorin Brull for his help in the submission. We owe a debt of gratitude to the hospital directors and staff for their support during the data collection. And finally, we thank Abbot Trading (Shanghai) Co., Beijing Fresenius Kabi Pharmaceutical Co., and AstraZeneca (Wuxi) Trading Co., Ltd. for their assistance during the survey process.

Back to Top | Article Outline

REFERENCES

1. Committee on Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Safer Health System. Kohn L, Corrigan J, Donaldson M eds. Washington, DC: National Academy Press, 1999: 241
2. Tao X. The field analysis report about the anaesthesia security problem. Forum Anesth Monit 2008;15:399–404
3. Gaba DM. Anesthesiology as a model for safety in health care. BMJ 2000;320:785–8
4. Editorial Board of the Journal of Anesthesia. International standards for a safe practice of anesthesia: a step toward total quality assurance of anesthesia practice. J Anesth 1994;8:510–3
5. Kotur PF. Monitoring and the anaesthesiologist. Indian J Anaesth 2002;46:244–5
6. Buhre W, Rossaint R. Perioperative management and monitoring in anaesthesia. Lancet 2003;362:1839–46
7. Eichhorn JH, Cooper JB, Cullen DJ, Maier WR, Philip JH, Seeman RG. Standards for patient monitoring during anesthesia at Harvard Medical School. JAMA 1986;256:1017–20
8. Eichhorn JH. Prevention of intraoperative anesthesia accidents and related severe injury through safety monitoring. Anesthesiology 1989;70:572–7
9. Shuren LI. Development and expectation of anesthesiology in China. J Capital University Med Sci 2006;27:563–4
10. Tang XF, Chen GL, Deng XM. An investigation into the present situation of military anesthesia. Hosp Admin J China PLA 1999;6:355–6
11. Chen KZ, Fang C, Zhang J. The Anesthesiology State and Development of Anhui Province. Forum Anesth Monit 2006;13:292–5
12. Tinker JH, Dull DL, Caplan RA, Ward RJ, Cheney FW. Role of monitoring devices in prevention of anesthetic mishaps: a closed claims analysis. Anesthesiology 1989;71:541–6
13. Donald MJ, Paterson B. End tidal carbon dioxide monitoring in prehospital and retrieval medicine: a review. Emerg Med J 2006;23:728–30
14. Wright DG, Bali IM. Anaesthetic monitoring: clinical practice in anaesthetic rooms and theatres. Ulster Med J 1993;62:32–6
15. Chinese Ministry of Public Health. Chinese Health Statistics 2009. 1st ed. Beijing: Peking Union Medical College Press, 2009
© 2012 International Anesthesia Research Society