Cases & Commentaries

Waiting Too Long

Commentary By Mark A. Rosen, MD

The Case

A 31-year-old gravida 1, para 1 woman presented
at 40 weeks in the early stages of labor having received limited
prenatal care at an outside clinic. Physical exam performed by the
obstetrics resident was suggestive of placenta previa and an
anesthesiologist was called to prepare for a cesarean section
(C-section). The anesthesiologists were short-staffed and also
covering the operating rooms on a different floor, but felt they
could be available if needed emergently. Shortly afterward, fetal
heart rate monitoring suggested fetal distress and the patient was
transferred to the operating room for emergent C-section. The
anesthesiologists were called again but were unavailable due to
another operative emergency. After significant delay, the patient
was ultimately anesthetized and underwent C-section. Unfortunately,
the baby was delivered with profound neurologic abnormalities,
including quadriplegia and cortical blindness.

The Commentary

What went wrong? While lack of an available
anesthesiologist to provide urgently needed anesthetic seems the
obvious conclusion, there are other factors that, had they been
considered, could have helped avoid the catastrophic outcome.

When allocating health care resources, it is
important to balance the goal of providing safe, efficient,
effective, and timely care with available funding. This simple
principle also applies to medical personnel staffing. A rational
protocol for staffing is required to allocate medical personnel for
delivery of optimal routine and emergency medical care.
Mathematical modeling, such as analysis of Poisson distributions of
events, has proved helpful in defining optimal manpower needs. For
example, these techniques have been employed to assess neurosurgeon
and orthopedic surgeon staffing needs for trauma centers.(1,2)
Similar methods have been used to determine optimal number of beds
and occupancy to minimize staffing costs in an obstetrical unit
(3), as
well as the minimum number of operating room nurses that should be
on call for urgent procedures. After inputting manpower
availability and risk tolerance, these models enumerate all
possible shift combinations and identify those with the lowest cost
that ensure the pre-specified level of service.

Although one might strive to ensure availability
of adequate personnel in all circumstances, this level of
preparedness would involve unreasonable costs in part by leading to
substantial overstaffing during times of average census.
Mathematical analyses cannot make the crucial decision about what
level of risk should be tolerated. Is it acceptable to make
manpower decisions that might lead to understaffing during two
simultaneous emergencies once in 5 years? How about once in 10
years? Who establishes this level of accepted risk: physicians,
insurance companies, legislators, or the courts? There are no easy
answers. As in this case, however, it is inevitable that at times
volume will exceed capacity and caregivers must be prepared.

The Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) requires staffing assessment using
specific indicators such as patient complexity based on clinical
service and human resource outcomes. For example, JCAHO requires
that emergency departments have sufficient numbers of qualified
staff to care for patients, including direct and indirect
caregivers, and nurses must have the required skills to care for
patients to whom they are assigned. If data such as the frequency
of medication errors, incidence of wound infections, or patient
satisfaction surveys reveal inadequate staffing, appropriate action
must be undertaken for correction. Outcomes research is beginning
to address these critical questions, and it is driving policy
decisions. For example, a recent study demonstrated higher
mortality rates with lower nurse-to-patient ratios (4), a finding that has led California to mandate certain
minimum ratios.

In trying to ensure the availability of qualified
staff at all times, larger hospitals (or hospital units, such as
obstetrics) have an advantage over smaller ones. For a given risk,
larger units have the ability to staff more efficiently
(particularly if workers on other units are "cross trained" to
cover a variety of tasks when needs arise); whereas, smaller units
in remote settings are at increased risk of not being able to
respond to large upticks in volume or simultaneous emergencies.

In the present case, we don’t know whether
staffing analyses were ever considered, nor whether this facility
commonly experienced simultaneous emergencies. Certainly, if the
events presented in this case were not a rare exception, more
anesthesia provider personnel should have been available.

Issues of anesthesiologist availability are
complicated by a current and projected shortfall of
anesthesiologists.(5-8)
During the second half of the 1990s, the number of residents
graduating from anesthesiology training programs decreased
substantially, resulting in a workforce that has grown little in
recent years. Despite an upturn in graduating anesthesia residents,
there remains a projected shortfall. The supply of certified
registered nurse anesthetists has also decreased slightly and is
likely to decrease further.

For many hospitals, anesthesiologists are not
available to staff labor and delivery separate from those available
to staff the operating rooms.(9)
This has been problematic in the US, as well as other
countries.(10,11)
In a comprehensive survey of hospitals in the State of Ohio, a
complete surgical team was immediately available in 100% of Level
III hospitals (in which a separate anesthesiologist is mandatory),
but only 35% of Level I hospitals had an anesthesiologist
immediately available.(12)
This has obvious implications for the provision of a safe
environment to manage potential obstetric emergencies, such as
women who wish to labor after previous C-section, with the
associated increased risk of uterine rupture. In fact, the American
College of Obstetrics and Gynecology (ACOG) and JCAHO now mandate
"immediate availability" of an anesthesiologist (and obstetrician)
at hospitals where women labor after previous cesarean section.
Although "immediate availability" was left undefined as to a
specific amount of time or the physician’s exact whereabouts,
it is generally understood to imply the anesthesiologist must be in
the hospital. In smaller hospitals, changes in hospital staffing or
referral patterns will be necessary to accommodate these
requirements.

Preparation for emergency care involves more than
establishing the optimal number of providers. It requires training,
organization, and adept communication among health care workers.
The use of high-fidelity patient simulators for training health
care professionals has increased in recent years. Simulators have
been widely adapted for use in anesthesia crisis resource
management, and these methods are rapidly spreading to other
medical disciplines.(13)
For example, teaching modules for crisis management recently have
been established for radiologists. Participants manage clinical
scenarios on lifelike computer-controlled manikins within realistic
clinical environments. A large component of simulator-based
training is experiential and involves learning how to communicate
clearly and directly, with the goals of improving situational
management and team effectiveness skills. This sort of
multidisciplinary team training may not prevent understaffing at a
moment of crisis, but can give providers a set of tools to make
their responses more rational, productive, and ultimately
safer.

In this case, what was told to the
anesthesiologist by the obstetrician? Was the situation
communicated as unstable, urgent, or a problem that 'might' happen?
Did the anesthesiologist convey how likely or not someone could be
available emergently? Were contingency plans considered? The
anesthesiologist conceivably could have called in another
anesthesiologist given the pending potential to be acutely
understaffed. In the setting of no serious vaginal bleeding and the
absence of a worrisome ("non-reassuring") fetal heart rate tracing,
the obstetrician could have temporized by tocolytic administration
and volume replacement, pending availability of an
anesthesiologist.

Extraordinary circumstances often require
uncommon responses, including employment of skills and knowledge
rarely used. Given the situation of 'fetal distress'
(non-reassuring fetal heart rate pattern) suggestive of developing
fetal asphyxia, proceeding with emergent cesarean section using
local, infiltration anesthesia by the obstetrician was indicated.
Regretfully, local anesthesia techniques for cesarean section are
rarely taught to obstetrical residents; in fact, most obstetricians
have never seen one performed. This seems most unfortunate in a
world where an anesthesia provider cannot always be immediately
available for all obstetric emergencies.

Take-Home Points

  • Mathematical modeling can
    facilitate careful planning for medical staffing requirements,
    which should include defined and rational protocols for primary and
    back-up responders, particularly for emergency care. Optimal care
    must be balanced with the reality of limited resources.
  • Preparation for emergency care requires training,
    organization, and proficient communication. Expert and professional
    interpersonal and communication skills are essential for the
    effective exchange of information required to provide optimum
    patient care and for the most advantageous collaboration among
    health care workers. Simulators and teamwork training can
    facilitate such learning.
  • Extraordinary
    circumstances often require skills and knowledge rarely used.
    However, they must be learned and may benefit from being rehearsed
    (much like annual CPR training) for those rare times when they may
    become essential.

Mark A. Rosen,
MD
Professor and Vice Chairman of Anesthesia
Professor of Obstetrics, Gynecology, and Reproductive Sciences
Director of Obstetrical Anesthesia
Director of the Anesthesia Residency Training Program
University of California, San Francisco

References

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