Anesthesia awareness is not just a problem for the anesthesia department. That was a key message of JCAHO when it issued its recent Sentinel Event Alert on the issue. Preventing this terrible outcome requires the interaction of many players within the health care organization, and the risk manager can be pivotal in making sure the problem is addressed vigorously. The Joint Commission, along with the American Society of Anesthesiologists (ASA) and the American Association of Nurse Anesthetists (AANA), stresses that preventing anesthesia awareness, and dealing properly with patients do experience it, requires an organizationwide effort by top administrators.
That’s where the risk manager comes in. For starters, the Joint Commission urges you to develop and implement an anesthesia awareness policy that addresses these points:
- Education of clinical staff about anesthesia awareness and how to manage patients who have experienced awareness.
- Identification of patients at proportionately higher risk for an awareness experience, and discussion with such patients, before surgery, of the potential for anesthesia awareness.
- The effective application of available anesthesia monitoring techniques, including the timely maintenance of anesthesia equipment.
- Appropriate postoperative follow-up of all patients who have undergone general anesthesia, including children.
- The identification, management and, if appropriate, referral of patients who have experienced awareness.
For patients who have experienced anesthesia awareness, risk managers must assure access to necessary counseling or other support for patients who are experiencing post-traumatic stress syndrome or other mental distress.
Clinical advice available
Of course, much of the work in preventing anesthesia awareness will involve clinical decisions. The Joint Commission urges risk managers to refer anesthesia providers to their professional organizations for specific guidance, but the ASA and AANA offer these tips:
- Consider premedication with amnesic drugs, such as benzodiazepines or scopolamine, particularly when light anesthesia is anticipated.
- Administer more than a "sleep dose" of induction agents if they will be followed immediately by tracheal intubation.
- Avoid muscle paralysis unless absolutely necessary and, even then, avoid total paralysis by using only the amount clinically required.
- Conduct periodic maintenance of the anesthesia machine and its vaporizers, and meticulously check the machine and its ventilator before administering anesthesia.
- Anesthesia practitioners should be alert to patients on beta-blockers, calcium channel blockers, and other drugs that can mask physiologic responses to inadequate anesthesia.
Unfortunately, anesthesia awareness may occur despite your best efforts to prevent it. When it does, the Joint Commission expects health care providers to respond in a compassionate way. (In addition to just being good practice, taking the report seriously might help decrease the chance of being sued, since your response to complaints always has a major impact on the patient’s decision to seek a lawyer.) It offers these suggestions for responding to a patient who reports awareness:
- Interview the patient after the procedure, taking a detailed account of his or her experience and include it in the patient’s chart.
- Apologize to the patient if anesthesia awareness has occurred.
- Assure the patient of the credibility of his or her account and sympathize with the patient’s suffering.
- Explain what happened and the reasons, such as the necessity to administer light anesthesia in the presence of significant cardiovascular instability.
- Offer the patient psychological or psychiatric support, including referral of the patient to a psychiatrist or psychologist.
- Notify the patient’s surgeon, nurse and other key personnel about the incident and the subsequent interview with the patient.