Anesthesia awareness alert is call to action

Patients must be identified, counseled, referred

If an obviously upset patient told a nurse that he thought he remembered his surgery taking place, would appropriate steps be taken, or would the patient’s complaint be dismissed or ignored?

Your organization needs effective strategies to prevent and manage anesthesia awareness, according to a new Sentinel Event Alert from the Joint Commission on Accreditation of Healthcare Organizations.

The alert gives recommendations for this underrecognized and undertreated condition, which affects an estimated 20,000 to 40,000 patients annually.

As a quality manager, you must help nurse anesthetists and anesthesiologists determine their roles in complying with the recommendations, notes Jeffery Beutler, CRNA, MS, executive director of the Park Ridge, IL-based American Association of Nurse Anesthetists.

"You need to lay out the process of how to prepare the patients for surgery ahead of time, so they know the risks associated with anesthesia, including awareness, what are people going to do during the procedure to prevent that from happening, and what to do postoperatively to identify any incidents of awareness," he says.

It is up to individual hospitals to determine how they will incorporate the sentinel event recommendations into existing procedures, but you should draw upon the expertise of anesthesiologists, recommends Eugene P. Sinclair, MD, president of the American Society of Anesthesiologists, also based in Park Ridge.

"Because there is wide variation in how awareness is defined, efforts that are adopted may be difficult to measure with any consistency," he adds.

Here are recommendations for management of anesthesia awareness from the Sentinel Event Alert:

Educate clinical staff on anesthesia awareness.

"From a quality perspective, anyone providing anesthesia should have clear guidelines on what they should be doing to prevent awareness under anesthesia," says Beutler.

You need to ensure that the individual doing preoperative counseling is explaining to patients the difference between a general, regional anesthetic, and local anesthetic with sedation; and as part of the informed consent, they need to be told there is a possibility they will have recall, Beutler says.

"Fortunately, it’s very rare; and most of the time when it does happen, it’s things that are normal, such as when waking up at the end of a case and somebody is doing an extubation," he adds. "But if you don’t explain that to the patient, they don’t know it’s normal."

Ensure appropriate postoperative follow-up of all patients who have undergone general anesthesia, including children.

"You need to be sure whoever is doing the post-anesthetic assessment of the patient is asking the right questions in the right way," Beutler says. "In the past, a lot of people have ignored this issue because they were afraid of planting an idea in a patient’s head."

Beutler recommends standardizing the questions for this assessment, and asking patients: "What is the last thing you remember before you went to sleep?" "What was the first thing you remembered when you woke up?" and "Do you remember anything in between?"

"By asking these questions, you are able to elicit any immediate recall they might have," he says.

Identify patients who have experienced awareness.

In addition to postoperative assessment, your organization should do a sample assessment after discharge, Beutler recommends.

"If a patient does have recall, they may not remember it right away. It may not show up for several months," he explains.

Therefore, a sample of patients should be surveyed three or six months after surgery on at least an annual basis to determine if any have had recall that they did not have previously, Beutler says.

"You don’t have to do that with every patient, but this sample would at least give you a sense of whether you have a problem at your organization," he adds.

Provide necessary counseling for patients who are experiencing post-traumatic stress syndrome or other mental distress.

Any patient who reports an episode of anesthesia awareness should be treated with respect and compassion, Sinclair emphasizes.

"Patients who have stress or anxiety over recalling parts of their surgery can often be substantially relieved by discussing their experience with their anesthesiologist and other health care professionals," he adds.

"For those patients who need more help, we recommend that counseling be offered," Sinclair notes.

Post-op follow-up is important

In addition to anesthesia providers, you should work with other providers who will be seeing the patients postoperatively, including the post-anesthesia care staff, surgeon’s offices, and diagnostic physicians and their office staff, so when patients return for postoperative visits, signs and symptoms of an awareness event can be identified, Beutler says.

"The problem is: Many times, we are not finding out about this until the patient is several weeks or months out of the hospital," he adds.

"Their memory starts coming back about what happened; but by this time, they are out of the system. They are probably not under the care of the surgeon anymore, and they may not even know where to get the help that they need," he explains.

Give providers specific directions for how to get help for these patients, and how to prevent and treat the ensuing post-traumatic syndrome that sometimes is associated with awareness, Beutler advises.

"That is a major focus for the Joint Commis-sion," he points out.

"Certainly, prevention is important to them, but if it does occur, does the organization have the right people and processes in place to get appropriate help for the individual? That is equally important," Beutler adds.

[For more information on anesthesia awareness, contact:

Jeffery Beutler, CRNA, MS, Executive Director, American Association of Nurse Anesthetists, 222 S. Prospect Ave., Park Ridge, IL 60068-4001. Phone: (847) 655-1100. Fax: (847) 692-6968. E-mail:

Eugene P. Sinclair, MD, President, American Society of Anesthesiologists, 520 N. Northwest Highway, Park Ridge, IL 60068-2573. Phone: (847) 825-5586. Fax: (847) 825-1692. E-mail:]