Rajeev Subramanyam

An abstract is unavailable. This article is available as a PDF only.

Patient safety is the most important aspect of anesthetic care. For both healthcare professionals and patients, the ideal would be no significant morbidity or mortality under anesthesia. Lessons from harm during healthcare can be shared to reduce harm and to increase safety. Many nations and individual institutions have developed robust safety systems to improve the quality and safety of patient care. Large registries that collect rare events, analyze them, and share findings have been developed. The approach, the funding, the included population, support from institutions and government and the methods of each vary. Wake Up Safe (WUS) is a patient safety organization accredited by Agency for Healthcare Research and Quality. Wake Up Safe was established in the United States in 2008 by the Society for Pediatric Anesthesia. The initiative aims to gather data on adverse events, analyze these incidents to gain insights, and apply this knowledge to ultimately reduce their occurrence. The purpose of this review is to describe the patient safety approaches in the USA. Through a national patient safety database WUS. Similar approaches either through WUS international or independent safety approaches have been described in Australia-New Zealand, India, and Singapore. We examine the patient safety processes across the four countries, evaluating their incident review process and the distribution of acquired knowledge. Our focus is on assessing the potential benefits of a WUS collaboration, identifying existing barriers, and determining how such a collaboration would integrate with current incident review databases or systems.

Background: Unintended postoperative hypothermia in infants is associated with increased mortality and morbidity. We noted consistent hypothermia postoperatively in more than 60% of our neonatal intensive care (NICU) babies. Therefore, we set out to determine whether a targeted quality improvement (QI) project could decrease postoperative hypothermia rates in infants.Objectives: Our SMART aim was to reduce postoperative hypothermia (37.5°C). Data collected was analyzed using control charts. The factors associated with a reduction in hypothermia were explored using regression analysis.Results: There were 295 infants in the project. The percentage of postoperative hypothermia decreased from 60% to 37% over 26 weeks, a special cause variation below the mean on the statistical process control chart. Reduction in hypothermia was associated with an odds of 0.17 (95% CI: 0.06–0.46; p <.001) for compliance with the transport incubator and 0.24 (95% CI: 0.1–0.58; p =.002) for prewarming the OR ambient temperature to 26°C. Two infants had hyperthermia.Conclusions: Our QI project reduced postoperative hypothermia without incurring hyperthermia through multidisciplinary team collaboration with the guidance of QI experts from the USA.

Background In the last 30 years, significant advances have been made in pediatric medical care globally. However, there is a persistent urban-rural gap which is more pronounced in low middle-income countries than high-income countries, similar urban-rural gap exists in India. While on one hand, health care is on par or better than healthier nations thriving international medical tourism industry, some rural parts have reduced access to high-quality care. Aim With this background, we aim to provide an overview of the present and future of healthcare in India. Methodology With the cumulative health experience of the authors or more than 100 years, we have provided our experience and expertise about healthcare in India in this narrative educational review. This is supplemented by the government plans and non government plans as appropriate. References are used to justify as applicable. Results With the high percentage of pediatric population like other low to middle-income countries, India faces challenges in pediatric surgery and anesthesia due to limited resources and paucity of specialized training, especially in rural areas. Data on the access and quality of care is scarce, and the vast rural population and uneven resource distribution add to the challenges along with the shortage of pediatric surgeons in these areas of specialized care . Addressing these challenges requires a multi faceted strategy that targets both immediate and long-term healthcare needs, focusing on improving the facilities and training healthcare professionals. Solutions could include compulsory rural service, district residency programs, increasing postgraduate or residency positions, and safety courses offered by national and international organizations like Safer Anesthesia from Education Pediatrics, Vital Anesthesia Simulation Training, and World Federation of Society of Anesthesiologists pediatric fellowships. Conclusion India has achieved great strides in perioperative health care and safety. It has become the major international medical industry due to high-quality care, access and costs. Crucially, India needs to establish local hubs for pediatric perioperative care training to enhance healthcare delivery for children.

Background: Propofol‐based total intravenous anesthesia is gaining popularity in pediatric anesthesia. Electroencephalogram can be used to guide propofol dosing to the individual patient to mitigate against overdosing and adverse events. However, electroencephalogram interpretation and propofol pharmacokinetics are not sufficiently taught in training programs to confidently deploy electroencephalogram‐guided total intravenous anesthesia.Aims: We conducted a quality improvement project with the smart aim of increasing the percentage of electroencephalogram‐guided total intravenous anesthesia cases in our main operating room from 0% to 80% over 18 months. Balancing measures were number of total intravenous anesthesia cases, emergence times, and perioperative emergency activations.Methods: The project key drivers were education, equipment, and electronic health record modifications. Plan‐Do‐Study‐Act cycles included: (1) providing journal articles, didactic lectures, intraoperative training, and teaching documents; (2) scheduling electroencephalogram‐guided total intravenous anesthesia teachers to train faculty, staff, and fellows for specific cases and to assess case‐based knowledge; (3) adding age‐based propofol dosing tables and electroencephalogram parameters to the electronic health record (EPIC co, Verona, WI); (4) procuring electroencephalogram monitors (Sedline, Masimo Inc). Electroencephalogram‐guided total intravenous anesthesia cases and balancing measures were identified from the electronic health record. The smart aim was evaluated by statistical process control chart.Results: After the four Plan‐Do‐Study‐Act cycles, electroencephalogram‐guided total intravenous anesthesia increased from 5% to 75% and was sustained at 72% 9 months after project completion. Total intravenous anesthesia cases/mo and number of perioperative emergency activations did not change significantly from start to end of the project, while emergence time for electroencephalogram‐guided total intravenous anesthesia was greater statistically but not clinically (total intravenous anesthesia without electroencephalogram [16 ± 10 min], total intravenous anesthesia with electroencephalogram [18 ± 9 min], sevoflurane [17 ± 9 min] p < .001).Conclusion: Quality improvement methods may be deployed to adopt electroencephalogram‐guided total intravenous anesthesia in a large academic pediatric anesthesia practice. Keys to success include education, in operating room case training, scheduling teachers with learners, electronic health record modifications, and electroencephalogram devices and supplies.

Background: Inhalational anesthetic agents are potent greenhouse gases with global warming potential that far exceed that of carbon dioxide. Traditionally, pediatric inhalation inductions are achieved with a volatile anesthetic delivered to the patient in oxygen and nitrous oxide at high fresh gas flows. While contemporary volatile anesthetics and anesthesia machines allow for a more environmentally conscious induction, practice has not changed. We aimed to reduce the environmental impact of our inhalation inductions by decreasing the use of nitrous oxide and fresh gas flows.Methods: Through a series of four plan‐do‐study‐act cycles, the improvement team used content experts to demonstrate the environmental impact of the current inductions and to provide practical ways to reduce this, by focusing on nitrous oxide use and fresh gas flows, with visual reminders introduced at point of delivery. The primary measures were the percentage of inhalation inductions that used nitrous oxide and the maximum fresh gas flows/kg during the induction period. Statistical process control charts were used to measure improvement over time.Results: 33 285 inhalation inductions were included over a 20‐month period. nitrous oxide use decreased from 80% to <20% and maximum fresh gas flows/kg decreased from a rate of 0.53 L/min/kg to 0.38 L/min/kg, an overall reduction of 28%. Reduction in fresh gas flows was greatest in the lightest weight groups. Induction times and behaviors remained unchanged over the duration of this project.Conclusions: Our quality improvement group decreased the environmental impact of inhalation inductions and created cultural change within our department to sustain change and foster the pursuit of future environmental efforts.

Background: Propofol total intravenous anesthesia (TIVA) is increasingly popular in pediatric anesthesia, but education on its use is variable and over‐dosage adverse events are not uncommon. Recent work suggests that electroencephalogram (EEG) parameters can guide propofol dosing in the pediatric population. This education quality improvement project aimed to implement a standardized EEG TIVA training program over 12 months in a large pediatric anesthesia division.Methods: The division consisted of 63 faculty, 11 clinical fellows, 32 residents, and 28 nurse anesthetists at the Children's Hospital of Philadelphia. The program was assessed for effectiveness (a significant improvement in EEG knowledge scores), scalability (training 50% of fellows and staff), and sustainability (recurring EEG lectures for 80% of rotating residents and 100% of new fellows and staff). The key drivers included educational content development (lectures, articles, and hand‐outs), training a cohort of EEG TIVA trainers, intraoperative teaching (teaching points and dosing tables), decision support tools (algorithms and anesthesia electronic record pop‐ups), and knowledge tests (written exam and verbal quiz during cases).Results: Over 12 months, 78.5% of the division (62/79) completed EEG training and test scores improved (mean score 38% before training vs 59% after training, p < .001). Didactic lectures were given to 100% of the fellows, 100% (11/11) of new staff, and 80% (4/5 blocks) of rotating residents.Conclusion: This quality improvement education project successfully trained pediatric anesthesia faculty, staff, residents, and fellows in EEG‐guided TIVA. The training program was effective, scalable, and sustainable over time for newly hired faculty staff and rotating fellows and residents.

Wake Up Safe is a patient safety organization consisting of 40 institutions with a mission to improve the processes of care and outcomes for newborns, infants, and children having anesthesia for surgery and medical procedures. It was recognized that the level of quality improvement (QI), knowledge, and experience varied greatly between member institutions. In Fiscal Year 2015, the group's leadership created a subcommittee on QI and education in efforts to provide member institutions with the skills and resources to use QI methodology to improve care at their own institution. This subcommittee developed a program to improve members' knowledge in safety analytics and QI science and to help members implement change in their own institutions. This review describes the development and implementation of this initiative. As a result of this initiative, significant progress was made improving the QI capability of the collaborative over a two‐year period. This educational and support program included workshops, an online discussion forum, site visits, and project presentations.