On Sunday, June 5th 2022, during Euroanaesthesia 2022 in Milan, the Patient Safety and Quality Committee (PSQC) of the European Society of Anaesthesiology and Intensive Care (ESAIC) held the Patient Safety Experts Meeting, inviting participants from ESAIC, other international societies and industry partners. The Patient Safety Experts Meeting is a unique opportunity for experts worldwide to openly discuss the most current issues in patient safety in perioperative care. It is a regular event at Euroanaesthesia.
Dr Daniel Arnal (Madrid, Spain), Chair of the PSQC, guided the meeting by first asking the participants:
What are the most crucial current patient safety matters in perioperative care?
Right from the start, several delegates named physician well-being a central topic of patient safety during EA22, including burnout in doctors and nurses, staff mental health, and fatigue management. This theme was also a hot topic during the International Forum on Perioperative Safety and Quality (IQS), a meeting organised on behalf of ESAIC and the American Society of Anaesthesiologists (ASA) on June 4th, the day preceding EA22, chaired by Dr Benedikt Preckel (Amsterdam, The Netherlands), the incoming chair of the PSQC.
The main reasons for the loss of well-being and compromised mental health in staff were discussed. These included staff shortage and its consequences, work overload, long working hours (especially during nightshifts) and pushing to meet unrealistic targets. These, in turn, can lead to fatigue and, eventually, burnout.
We know that technical skills are compromised by fatigue, but we must also be more aware of how non-technical skills suffer. Fatigue is proving lethal to physicians as well as patients. It was reported during the congress that physicians died from falling asleep at the wheel when travelling home after a night shift. A few delegates mentioned that we should focus more on well-being, how to be joyful in our work and find fulfilment through a healthy work-life balance.
Several delegates suggested we develop a toolbox of skills that could be used in the clinical environment to empower staff to prevent the stages preceding burnout. Smart rostering, changing schedules, flexible working patterns, and avoiding losing the influence and power of anaesthesiologists at the frontline (caused by too much interference by healthcare management) were named solutions.
Professional stress was also named the leading cause of compromised mental health, and it was recognised that we need better tools to objectively measure professional pressure. There is a need for large multicentre trials focusing on this topic and education to help residents become aware of the risks and develop potential coping strategies. In addition, a long-time view of professional quality-of-life, including optimised curricula and career planning, should be offered to trainees, who should be involved in all current and future safety programmes.
Another topic brought forward was Patient Empowerment: we need to consider patients more as partners in achieving a better outcome, e.g., through pre-habilitation and shared decision-making programmes.
Participants commented on the need to improve communication with patients. Discussions should be had about what care is appropriate, giving all the necessary information, including whether it is better not to have surgery and exploring other treatment options. Physicians should know better what goals patients have and what they are expecting from us and the healthcare system. We should be more often looking at quality indicators of our work, thereby forgetting that the patient is at the centre of care.
Human factors training, including communication training, coordination of the whole team and between different professions and good use of checklists (which probably also need to be reviewed and revised) were named as possible interventions.
Another big topic discussed during the expert meeting was the interaction between humans and technology, also called automation. Much money is invested in technology, but man-machine interfaces need to be considered a risk factor for safety issues, e.g., alarm fatigue and distraction. Data management can take physicians away from the patient and using different IT systems may also cause human factors issues. We have many devices that generate big data but still need to learn how to adequately use the available IT solutions so that the data supports physicians effectively. It was discussed how the industry could better support patient safety with answers from the data that is being collected. Transitions that involve information, including handovers (especially medical prescriptions and other medication safety issues), were described as central issues to be covered in the future.
Medication safety and how we can reduce preventable harm from medication errors – the topic of the World Patient Safety Day on September 17th – was discussed, as well as the role of patient blood management.
Other topics raised were the definition and implementation of minimum standards in ICU and perioperative anaesthesiology, climate change and sustainability, lessons learned from the COVID pandemic and improving the image of anaesthesiology with the public.
In a second discussion round, Dr Arnal asked the delegates:
What are the best strategies that we could recommend to address these topics?
Many delegates came up with suggestions for improving staff well-being and preventing burnout and fatigue. First, it´s about money and hiring sufficient staff to do all scheduled tasks. But it’s not just about the staff shortage but also how we serve our team and, increasingly, how we source new staff.
We must collect all solutions and available strategies supported by the industry to find ways to implement respective solutions in our hospitals. We also need support to achieve these goals; help from the government/organisation, the surgeons, our anaesthesia teams, and patient organisations, as well as directly from patients and their relatives.
At an organisational level, we need to decrease workflow (increased workflow increases the risk of errors) and offer solutions to maintain staff well-being, e.g., education for staff on how to improve sleep hygiene at hospitals (allowing power naps and short periods of rest) and offering rest facilities that are private and quiet. Adequate salaries for physicians are requested in some countries, as some physicians work in two or more jobs due to low wages. The government and hospital administrators could facilitate support by implementing independent National Investigation Bodies and Patient Safety Officers surveying national and local policies.
On a team level, we need to be more aware of our colleagues, whether they are tired or need food/drink during a short pause. The connection between decision fatigue and performance is well documented. Decisions become compromised on long or night shifts, and we do what is easiest, which is only sometimes best for our patients. This data is already available and can support raising this fatigue issue and promote change.
We need to learn how to speak up if we have concerns regarding our well-being or that of our team members. This also places responsibility in the hands of each team member: everybody should be mindful of developing symptoms of fatigue and burnout. Within a team, on a peer-to-peer level, we can support each other.
We also need to cooperate with our surgeons, who face increased workflow pressure. For instance, during the nightshifts, it would be wise to choose what needs to be prioritised. Scheduling the most challenging cases at the beginning of the night shift would help prevent errors.
The Choose Wisely Campaign also seeks to limit unnecessary operations and better select which procedures are performed, thus combatting overtreatment. Decisions on whether to perform a function or not require a well-informed patient (and relatives) and make patient-centred communication necessary. Doctors often need more time to speak to patients, and patients are not always honest about their goals and needs. Therefore, patient organisations and relatives should cover the last aspect to develop a more apparent shared decision for each patient.
Getting more information on a patient’s home situation (using adequately developed checklists) and post-discharge reports from patients on their experience in the hospital are helpful tools that could easily be implemented in our institutions.
Dr Arnal specifically asked the industry partners (who were participating for the first time in the Expert Meeting) how the industry could support medical staff and hospitals in achieving these improvements. They mentioned that technology should help physicians, not make processes more complex. They agreed they have to evaluate how we can better use the vast amount of data generated every single moment and the big data collected over the years.
It is essential to investigate how this data can better predict and evaluate where things go well and where they can be improved to reduce the workload and pressure of decision-making.
Can we use this data to identify which patient may need more specific attention and where to place attention when care providers are fatigued? How should technology present our data without causing overwhelm and alarm fatigue? But there was also a request from physicians to the industry: please refrain from giving your products calculating that staff can be reduced. We all know that further reduction in staff will increase errors and mistakes and worsen patient outcomes.
We look forward to discussing with experts in Patient Safety and Quality next year in Glasgow. It will be interesting to see whether we have progressed in some of the topics mentioned above and which new issues arose in the months after the beautiful congress in Milan.Read the Newsletter