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  In this article
Abstract
Introduction
Methods
Results
Discussion
Conclusion
Appendix
References
Article Figures
Article Tables

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  Table of Contents 
ORIGINAL ARTICLE
Year : 2019  |  Volume : 20  |  Issue : 1  |  Page : 1-8
 

Survey of work practices among anesthesiologists in India


1 Department of Neuroanesthesia and Critical Care, Medanta - The Medicity, Gurugram, Haryana, India
2 Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
3 Department of Anesthesia, Aster Aadhar Hospital, Kohlapur, Maharashtra, India
4 Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India

Date of Submission29-Jan-2019
Date of Acceptance01-Mar-2019
Date of Web Publication6-May-2019

Correspondence Address:
Dr. Ashish Bindra
Room No. 710, Neurosciences Centre, All India Institute of Medical Sciences and Associated Jai Prakash Nrain Apex Trauma Centre, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_9_19

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  Abstract 


Context: Improvement in perioperative care can reduce anesthesia-related morbidity. Noncompliance to protocols and poor working practices can compromise patient safety.
Aims: The objective was to survey the working practices of anesthesiologists in India and find out the most commonly overlooked aspects in perioperative period.
Setting and Design: Prospective cross-sectional survey involving practicing anesthesiologists in India, conducted over a period of 2 months.
Methods: An online questionnaire, including questions pertaining to pre-, intra- and post-operative phases during conduct of anesthesia was mailed to anesthesiologists (members of the Indian Society of Anesthesiologists) over a period of 2 months through the online survey builder SurveyMonkey. The questionnaire was delivered to 13,700 anesthesiologists, of which 2055 responded. Results are expressed as numbers or percentages.
Results: Checklist compliance, equipment check, and perioperative record-keeping are the most commonly overlooked aspects by anesthesiologists in perioperative period. The survey also highlights the shortage of postanesthesia care units across the country.
Conclusions: Checklist compliance, equipment check, and record-keeping are potential areas for improvement. Professional societies should promote better practices, monitoring standards and should also formulate minimum standards for different setups where anesthesia can be delivered safely.


Keywords: Anesthesia, practice, safety, survey


How to cite this article:
Bindu B, Bindra A, Kumar S, Kulkarni S, Rath GP, Prabhakar H, Vishnubhatla S. Survey of work practices among anesthesiologists in India. Indian Anaesth Forum 2019;20:1-8

How to cite this URL:
Bindu B, Bindra A, Kumar S, Kulkarni S, Rath GP, Prabhakar H, Vishnubhatla S. Survey of work practices among anesthesiologists in India. Indian Anaesth Forum [serial online] 2019 [cited 2019 Oct 17];20:1-8. Available from: http://www.theiaforum.org/text.asp?2019/20/1/1/257691





  Introduction Top


Operating rooms (OR) are considered as high-risk areas for medical errors (ME), and mishaps here can hamper patient safety. Two-thirds of adverse events that cause patient deaths reportedly occur in surgical clinics or OR.[1] Commonly reported ME in the OR include wrong surgical site, medication errors, equipment failure, and errors related to poor information flow.[2] Anesthesiology is a high risk and medico-legal vulnerable speciality. Besides clinical complications, common errors in anesthesia occur due to misjudgment, failure to check equipment, faulty technique, inattention, haste, inexperience, communication failure, inadequate pre-operative assessment, and preparation.[3] Experience of practitioner, level of fatigue, and type of setup and infrastructure also contribute to it.

Aiming to reduce anesthesia -morbidity and mortality, several practice guidelines, and checklists have been introduced.[4],[5] There are data available regarding compliance to these safety checklists from the Western world.[6] However, there are a little data available from developing countries like India. We, planned a cross-sectional survey aiming to explore working practices among anesthesiologists and adherence to checklists across India, and find out the most commonly overlooked aspects by anesthesiologists in perioperative period.


  Methods Top


We conducted a questionnaire-based survey. First, the print version was distributed to 20 anesthesiologists at investigators' institute. Shortcomings in the questionnaire were noted and necessary changes incorporated. Then, as a pilot study to test the feasibility of the questionnaire, the modified questionnaire was distributed to 100 anesthesiologists at a local conference, of whom 60 responded. Some minor changes were incorporated into the questionnaire. The final questionnaire was sent to 14,252 anesthesiologists in India. Based on this, the requisite number of respondents was 2055, for a confidence level of 95% and 2% margin of error.

After ethical clearance from investigators' institute, electronic version of the final questionnaire was E-mailed via the online survey builder SurveyMonkey over a period of 2 months (December 2016–February 2017). The questionnaire was E-mailed to 14,252 anesthesiologists whose contact details were obtained from the Indian Society of Anesthesiologists (ISA). The questionnaire included 39 carefully selected, simple, straight-forward, logically sequenced questions based on demographics and practices in pre-, intra- and post-operative phases [Appendix 1]. As a strategy to increase response rate, reminders were sent at regular intervals. The survey was closed at the end of 2 months (once the requisite number of responses was achieved). After completion of the survey, data were downloaded and entered into Microsoft Excel sheet. Respondent replies to some questions were missing, and were not included in analysis. Of total 78,122 replies to all questions, 2019 replies were discarded due to incomplete response. Data wer analyzed using (StataCorp. 2015. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP). Results are expressed as numbers or percentages.

Those answers in the questionnaire [Appendix 1] that represent practices that can hamper patient safety were considered as “undesirable practices.” These “undesirable practices” were divided into practice-related, equipment-related, checklist-related, drug-related and record keeping-related categories [Table 1].
Table 1: Response received: “Undesirable Practices” and their overall incidence

Click here to view



  Results Top


The questionnaire was E-mailed to 14,252 anesthesiologists, and was delivered to 13,700 anesthesiologists. 2055 anesthesiologists responded (response rate of 15%). Forty-eight respondents were Indian anesthesiologists working outside India, whose responses were excluded from the analysis. Responses of 2007 anesthesiologists were analyzed.

The distribution of setup of our respondents is shown in [Figure 1]a. Forty-nine percentage (989/2007) of respondents had >10 years' experience (including training period), with almost equal distribution of those with <5 years' (26%; 530/2007) and 5–10 years' experience (24%; 488/2007). Thirty-six percentage respondents were working in teaching hospitals and 64% in nonteaching hospitals. Only 15% of respondents practised specific specialties of anesthesia (i.e., cardiac-, neuro-, onco-, obstetric and gynecological-, pediatric-anesthesia) exclusively, whereas 32% (645/2007) catered to general cases alone (i.e., general surgical, urological, gastrosurgical, and orthopedic surgery cases) [Figure 1]b. Majority of our respondents (82%) were assisted by OR assistants (ORA). Ninety-four percentage (787/838) of those working in private setups had ORAs compared to 79% (484/611) in government setups. More than 90% of those practising cardiac-, neuro- or onco-anesthesia had ORAs.
Figure 1: (a) Distribution of respondents based on set up. (b) Distribution of respondents based on specialty

Click here to view


The result of response received is shown in [Table 1].

Checklist compliance and equipment check were found to be the most commonly overlooked stages preoperatively. About 44% of respondents do not use the World Health Organization (WHO) safe surgery checklist. Overall, 46% did not practise the American Society of Anesthesiologists (ASA) preanesthesia checkout recommendations. Neither the WHO checklist nor ASA checkout recommendations were followed by 26% of respondents. Overall, 13% of anesthesiologists were found to perform preanaesthesia checkup (PAC) directly on the day of surgery. Sixty-four percentage did not confirm the availability of a working defibrillator, whereas 42% did not check sodalime prior to beginning of anesthesia.

Intraoperatively, record-keeping was most commonly overlooked aspect. A significant percentage (17%) maintained no/minimal anaesthesia records. While 77% maintained manual records of anesthesia, only 6% had electronic record keeping services.

Appropriate monitoring of patients while shifting was the most commonly overlooked aspect postoperatively. Eight-seven percentage respondents reported inadequate monitoring of patient vitals while shifting.

While shifting to OR for emergency surgeries, patients were accompanied only by technical staff/patients' relatives at 12% of respondents' work places. Eighty-three percent of anesthesiologists (100%, 98%, and 100% of cardiac, neuro- and onco-anesthesiologists, respectively) used closed circuits, whereas the rest still use open circuits (40% of freelancers, 20% of those working in government setups). We observed that 21% of respondents (36% of obstetric/gynecological anesthesiologists; 28% of those in government setups) shift patients directly to ward after surgery; only 58% shift to postanesthesia care units, whereas 20% (96% of cardiac anesthesiologists; 58% of neuro-anesthesiologists) shift patients to intensive care unit postoperatively.


  Discussion Top


Working practices among anesthesiologists in India are variable and depend on type of the setup available and personal choice of anesthethesiologist conducting anesthesia. The present survey is an attempt to generate data regarding practices being followed by anesthesiologists in different parts and set-ups of India.

A recent survey by the World Federation of Societies of Anesthesiologists (WFSA) in 2015–2016 regarding global anesthesia workforce reported the total number of anesthesiologists in India to be 16,500.[7] The strength of our survey is that it was sent to all members of the ISA which is the largest official body of anesthesiologists in India. The sample contacted was very large (86.4%; 14252/16500) and well representative of the actual population. The response rate obtained was 15%.

A high percentage of our respondents did not carry out adequate machine check and important equipment check before the initiation of anesthesia care [Table 1]. The same may be due to presence of alternate person like ORA checking the equipment or due to a team consisting of fellow anesthetists, trainee anesthetists collectively taking care of the patient. International recommendations for monitoring and equipment-check are in place,[5],[8] but, adherence to them remains an issue. Proper preuse equipment check has been shown to avoid critical incidents in anesthesia.[9] Interestingly, more practitioners having ORAs did not check oxygen cylinder, soda lime, and drug expiry, when compared to those without ORAs. Our findings favor the availability of ORAs in reducing “undesirable practices,” though we feel that anesthesiologists must still reconfirm equipment check. Earlier authors have made similar observations and concluded that trained assistants reduce errors in anesthesia.[10] While designating duties to ORA one should always remember that doctor is responsible for the paramedical staff working under him. This is vicarious liability. A doctor when consulted by a patient owes him certain duties, namely a duty of care in deciding whether to undertake the case, a duty of care in deciding what treatment to give and a duty of care in the administration of that treatment. A breach of any of those duties gives a right of action for negligence to the patient.[11] Thus, in the case of anesthesia, if the anesthetist administers an expired medicine to the patient, is liable for negligence even if s/he had delegated the work to the ORAs. The doctor is held liable for medical negligence if he fails to exercise the minimum standard that a medical professional should possess by the virtue of the profession. The test is the standard of the ordinary skilled man exercising and professing to have that special skill. In the case of a medical man, negligence means a failure to act in accordance with the standards of reasonably competent medical men at the time.[12] An anesthetist is supposed to have the requisite skills and knowledge needed for the purpose and s/he has a duty to exercise reasonable degree of care in the conduct of his duties. A surgeon or an anesthetist will be judged by the standard of an average practitioner of class to which he belongs or holds out to belong.[13] The patient is a “consumer” and the medical assistance a “service”[14] and thus the aggrieved by any deficiency in the treatment from both private clinics and Government hospitals, are entitled to seek damages under the Consumer Protection Act.[15] Hence, it is advised that anesthesiologist must prepare and administer the drugs himself and should not rely on others. Properly following the operation theater check list is mandatory. Similarly not checking the anesthesia machine or anesthesia equipment before giving anesthesia is also considered as carelessness in eyes of law.

The percentage of anesthesiologists maintaining electronic data is very low in India and the practice of record-keeping here is entirely individual dependent. According to the Indian law, case for medical negligence can be filed within 3 years of the incident. With increasing time gap and the presence of different care providers at the time of hearing, it is difficult to recall each minor detail of the procedure which occurred in OR. Moreover, court does not rely much on memory as evidence. There are no means to know what happened within the four walls of procedure room. Medical records kept by the anesthesiologist is the only document through which legal, medical as well as research can be evaluated at a later date. An accurate, complete, and neat record should be maintained keeping in mind all the medico-legal aspects.[16] According to our survey, anesthesia records need to be maintained more meticulously as the number of lawsuits involving medical negligence is on the rise everywhere and proper records provide important evidence in favor of practitioners.[17] Most developed countries have very strong documentation practices.[18] Electronic anesthesia records improve documentation in anesthesia.[19]

Communication is another lacuna. Thirty-three percentage of our respondents did not discuss intraoperative adverse events with the surgeon. Our results are similar to those of Lingard et al. who reported communication failure in 30% of team exchanges.[20] One-third of these communication failures reportedly jeopardized patient safety. Teamwork and effective sharing of information allows proper understanding of facts and decision-making, thereby preventing errors. Communication of side effects to the patient is equally important. In the court of law, it is considered as act of omission. Medication check and teamwork have been promoted as patient safety practices.[21]

Our findings emphasize the need to establish postanesthesia care units in India. Immediate post-operative period is a high-risk period for anesthetic complications and demands strict patient vigilance.[22] Critical incidents, most commonly respiratory and cardiovascular problems,[23] occur during the first post-operative hour. To meticulously monitor patients during this phase, it is essential to monitor them in the recovery room or post anesthesia care unit after surgery.

With anesthesiology being a high-risk specialty, “undesirable practices” can pose problems to patient safety, directly, or indirectly.[24] Europe (in the Helsinki Declaration)[25] and WFSA[26] have made several recommendations to improve patient safety in anesthesiology. This survey tried to study some of these recommendations like availability of all necessary equipment before initiation of anesthesia care, availability of defibrillator, post-operative monitoring, etc in the Indian context.

To the best of our knowledge, there is no similar reporting of fine details of anesthesia practice. Most of the reported surveys have dealt with a particular type of anesthesia (regional/general) delivered and associated issues. Surveys regarding various perioperative checklists show that the compliance rates are not too high. The WHO safe surgery checklist has been an important addition to perioperative care. Its implementation has been associated with a reduction in death and complication rates[27] and lower communication failures. Its implementation and compliance have been studied in several countries. The absence of team members in up to 40% of cases have been reported.[6] A compliance rate of 54% was reported by Rydenfält et al.[28] Use of the WHO checklist was analyzed in India at a single university hospital for pediatric surgeries, over a period of 2 years. Authors found that there was a tendency to nonadherence to the checklist by junior trainees in emergency cases and in the absence of senior colleagues. The WHO checklist was incompletely filled in 2.5% of cases.[29] Our results highlight the fact that checklist-compliance and equipment-check are the most commonly overlooked aspects of preoperatively. Lack of strict protocols, scant Indian guidelines and a wide variety of setups ranging from corporate hospitals to government medical colleges and small nursing homes are major hindrances. Altering OR personnels' conceptions of “risk” and “patient safety” have been suggested as ways of improving compliance to the WHO checklist.[27] Reported reasons for poor compliance to checklists include the lack of motivation, training,[30] awareness, time and complicated formats, and need to be looked into.[31] We suggest that involving ORA, but under personal supervision whenever available, to complete checklists might achieve better compliance and results. Motivation, awareness, protocols to guide individualistic practices, incident reporting, regular audits and incentives to best performers might help achieve better compliance.

Most of the existing checklists have limited anesthesia-related components.[4] Based on our results, the inclusion of aspects such as equipment check, drugs safety, and record keeping in perioperative checklists can help improve practice. However, aspects such as the site of surgery, consent, and airway difficulty covered by the WHO checklist must not be overlooked.

There was a low response rate to our survey despite frequent reminders; our results need to be interpreted accordingly. Many other important aspects of anesthesia care like consent for anesthesia, the practice of explaining alternative anesthetic options, motivation and fatigue levels among anesthesiologists, etc., were not covered in this survey. To some extent, practices like preoperative PAC clinic, electronic record keeping services, etc., are determined by hospital policy and do not reflect anesthesiologists' practice alone. Our objective was to gather data regarding current anesthesiology practises in India as it is scarcely documented.


  Conclusion Top


This survey was a step toward identifying lacunae in services provided by anesthesiologists in the perioperative period. There is disparity among anesthesia services provided due to varying protocols and setups. The specific areas need to be addressed: checklist compliance, equipment check, record keeping, and postanesthesia care units. Professional societies should promote better practices, monitoring standards and should also formulate minimum standards for different setups where anesthesia can be delivered safely.

Acknowledgment

The authors would like to thank Sanyam Aggarwal, Student, Faculty of Law, University of Delhi.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  Appendix Top


Appendix 1: Questionnaire used for the survey

Work practices among anaesthesiologists in India – Questionnaire Survey

  • Your city of practice:
  • How many years of experience do you have in anaesthesia (including PG period)?


  • <5 years 5–10 years >10 years

  • What kind of setup do you work in (Can pick >1 options)?


  • Govt. Corporate Free lancer Medical College (Govt/Pvt)

  • What is your present post?


  • Resident Junior Consultant Senior consultant

  • What time do you reach your operation theatre at the beginning of your duty?


  • 15 min prior 30 min prior Just in time

  • How long do you take to prepare the operation theatre in the morning (after initial preparation by technician) before induction?


  • No time 5 minutes 10 minutes

  • Do you have anaesthesia technicians in your hospital?


  • Yes No

  • Which subspeciality of anaesthesia do you practice (Can pick >1 options)?


  • General Cardiac Neuro Pediatrics Gynaecology Oncoanaesthesia

  • What kind of PAC services do you have (Can pick >1 options)?


  • Before admission Prior evening Day of surgery

  • How do you maintain your own anaesthesia records?


  • Electronic Manual No/minimal record keeping with you

  • Do you have a standard anaesthesia proforma for attaching in patients file?


  • Yes No

  • In emergency cases, who accompanies the patient from em.ward/ICU to OT (Can pick >1 options)?


  • Nursing staff Technical staff Anaesthesia personnel Surgeon Patient's relative

  • Who checks the anaesthesia machine?


  • Anaesthesia technician Anaesthesia specialist Both

  • If the anaesthesia machine check is routinely done by technician, do you confirm it with him before starting case?


  • Yes No Sometimes Not applicable

  • How often do you confirm availability of an Oxygen cylinder in the operation theatre before inducing patient?


  • Always Never Sometimes

  • How often do you ensure a working defibrillator in the operation theatre before inducing patient?


  • Always Never Sometimes

  • How often do you confirm fasting status of the patient before inducing anaesthesia?


  • Always Never Sometimes

  • How often do you check patients' consent before surgery?


  • Always Never Sometimes

  • Do you recheck patient identity and site of operation before surgery?


  • Yes No Sometimes

  • How often do you tell the anaesthesia technician or concerned staff to arrange for special equipment required (ultrasound, fibreoptic bronchoscope, equipment for positioning) after shifting the patient inside operation theatre (rather than before shifting)?


  • Never Sometimes Always

  • How often do you check expiry date of drugs before loading them?


  • Always Sometimes Never

  • What kind of breathing circuit do you use?


  • Open Closed

  • If closed, how often do you ensure change of sodalime in the morning before inducing first patient?


  • Always Never Sometimes'

  • How often do you confirm whether the patient has received/not received morning dose of medications (like antihypertensives, insulin, thyroid drugs)?


  • Always Sometimes Never

  • Do you use WHO safe surgery/any other check list?


  • Yes No

  • If yes, when do you usually fill the WHO safe surgery checklist?


  • Before induction After induction Both

  • How many parts does the WHO safe surgery checklist have?


  • 1 2 3 Don't know

  • Is the safe surgery checklist read out verbally in the presence of surgeon, anaesthesiologist, patient and scrub nurse?


  • Yes No Sometimes

  • Do you follow ASA preanaesthesia recommendations for conduct of anaesthesia?


  • Yes No

  • Who checks the result of antibiotic sensitivity test done preoperatively (Can pick >1 options)?


  • Anaesthesiologist Surgeon Nurse Test not done

  • Do you document patients' preoperative neurological status/deficits in intraoperative anaesthesia notes?


  • Yes No Sometimes

  • Do you forget to complete (or supervise completion of) anaesthesia notes in patient file and OT records before shifting patient out of operation theatre?


  • Yes No Sometimes

  • Do you put proper postoperative advice in patients' record before shifting patient out of OT?


  • Yes No Sometimes

  • How often do you discuss intraoperative adverse events and complications with surgeon?


  • Always Sometimes Never

  • Do you recheck blood and blood products immediately before transfusion?


  • Yes No Sometimes

  • Which of these monitors do you apply while shifting patient from operation theatre to ICU/PACU (Can pick >1 options)?


  • ECG NIBP SpO2 Invasive None All

  • After shifting patient to ICU/PACU, do you always check ventilator settings of patient?


  • Yes No Sometimes

  • Where do you shift patient after surgery?


  • ICU PACU Ward

  • Do you check vitals of patient after shifting to ICU bed?


  • Yes No Sometimes




 
  References Top

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World Alliance for Patient Safety. WHO Surgical Safety Checklist and Implementation Manual. Available from: http://www.who.int/patientsafety/safesurgery/ss_checklist/en/. [Last accessed on 2017 Jun 03].  Back to cited text no. 4
    
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[PUBMED]  [Full text]  
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