|Year : 2020 | Volume
| Issue : 2 | Page : 96-99
Safe anaesthesia practices in a budding institute: How far have we reached?
Ajay Kumar1, Bhavna Gupta1, Anish Gupta2, Vijay Adabala1, Sagarika Panda1, Ravi Kant3
1 Department of Anesthesiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of CTVS, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
3 Director, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
|Date of Submission||08-May-2020|
|Date of Decision||09-Jun-2020|
|Date of Acceptance||09-Sep-2020|
|Date of Web Publication||15-Dec-2020|
Dr. Bhavna Gupta
Department of Anesthesiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
Source of Support: None, Conflict of Interest: None
Anaesthesia is a medical speciality that is pertinent to safety of patients who are undergoing surgical procedures. The type of anaesthesia, critical care and pain services is considered as a benchmark of quality of care provided in any tertiary care institute. This is prerequisite in order to provide quality of care based on sound organisation, good clinical practice and adequate communication with other healthcare workers involved. Several important efforts have been undertaken especially in an integrated manner in developing countries, where anaesthesia services are often provided by unqualified personnel at remote places. The principal reasons in the resource poor areas are critical shortage of trained anaesthesia providers. The patient safety plan must provide a systematic, coordinated and continuous approach to the reduction of medical errors. This includes quality of care, development of guidelines, clinical audits, education and training. In addition, importance of other tools like critical incident reporting, use of simulation for training of residents and staffs and use of checklists are also growing. This article highlights the development of department of anaesthesia in a remote location of India and it focuses on the important elements of safe anaesthesia practice, use of advanced model of teaching by the faculty members and how the anaesthesiologist being expert in critical care and airway management have provided par excellence services in the current challenging times of COVID-19 pandemic crisis situation.
Keywords: Anaesthesia, critical incident, quality, safety
|How to cite this article:|
Kumar A, Gupta B, Gupta A, Adabala V, Panda S, Kant R. Safe anaesthesia practices in a budding institute: How far have we reached?. J Med Evid 2020;1:96-9
|How to cite this URL:|
Kumar A, Gupta B, Gupta A, Adabala V, Panda S, Kant R. Safe anaesthesia practices in a budding institute: How far have we reached?. J Med Evid [serial online] 2020 [cited 2021 Jan 27];1:96-9. Available from: http://www.journaljme.org/text.asp?2020/1/2/96/303550
| Introduction|| |
Perioperative mortality and morbidity depends not only on the type of surgery and skills of surgeon but also on the quality of anaesthesia services provided in any institute. Anaesthesia advancements are particularly susceptible to the level of development. In a developing country like India, anaesthesia is often provided by unqualified personnel at remote places, which overall affects the patient outcome. In this article, we would like to focus on the development of department of anaesthesia in a remote location of India. It provides a general preview of historical past, advancements till date and futuristic vision of the department.
| Foundation|| |
Pradhan Mantri Swasthya Suraksha Yojna was launched by the Government of India under the Ministry of Health and Family Welfare with the main objective of correcting regional imbalance in the availability and affordability of tertiary care healthcare services and also to augment quality medical education, creating a critical mass of medical doctors, and conduct research in countries relevant to the area. All India Institute of Medical Sciences (AIIMS), Rishikesh, came into existence as an institute of national importance through an act of parliament.
| Chronicle|| |
The historical date of providing anaesthesia service at the institute for the first time is remembered as 3rd June 2014. The department started with a single operation room (OR) in that year. Despite the limitations of initial set-up, human resource and equipment, the department has progressed to a steady pace to its present strength and achievements. Initially, patients came mostly from the hilly areas of Garhwal and Uttar Pradesh; at present, we receive patients from all over Uttarakhand and the adjoining states.
Keeping pace with the development of medical sciences, anaesthesia services are being provided for a wide variety of surgical cases. These include general surgery, obstetrics and gynaecology including labour analgesia, ophthalmology, paediatric surgery, otorhinolaryngology, orthopaedics, oral and? maxillo-facial surgery, burns and trauma specialty. The anaesthesia department over the years has grown exponentially not just in the number of operation theatres, but also in the overall expansion of the department. In the current scenario, the department is providing services to fifty operation rooms (ORs), including 21 functional modular ORs consisting of cardio-thoracic vascular, robotic, gastro-intestinal, oncosurgery, paediatric, neurosurgery, emergency, trauma and minor surgeries. The modular ORs were initiated in a phasic manner, and there was an exponential rise in number of all the surgeries since the inception of institute [Figure 1]. A 15-bedded intensive care unit (ICU) was also established in May 2019. Anaesthesia is also provided at outreach centres. The department follows an integrated approach and standard protocols for patient care, education and research.
|Figure 1: Exponential rise of cases over the years. Green bar reflects the number of minor cases and yellow bar reflects the number of major cases|
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| Departmental Services|| |
Acute pain service serves to manage perioperative pain. It is an organised speciality where interventional pain management procedures are also performed to cure chronic pain. Services provided are at par with other established institutes such as C-arm guided nerve blocks. The dedicated team reviews regularly and ensures that patients are receiving adequate pain relief and are satisfied.
Cardiac anaesthesia, a super-speciality of anaesthesia, is devoted to the perioperative care of patients undergoing cardiac surgery and related invasive procedures. Advanced services such as providing care of patients of fontan surgery and enodvascular procedure in cath lab. Day-to-day work of trainees is supervised and rotational posting is ensured in various areas including ORs, ICU, intensive coronary care unit, catheterisation laboratory, echocardiography room and cardiothoracic surgery department.
In view of the ever-expanding demand and need of the hour, our neuro-anaesthesia team provides services to the neurosurgery patients round the clock. It provides advanced services such as awake craniotomy, intracranial Doppler, navigation guided tumor resection and intraoperative neuro-monitoring for providing a better outcome for patients in the post-operative period.
Intensive care unit
A dedicated team of qualified intensivists and critical care fellows provide speciality care to the medical and surgical patients admitted in Intensive Care unit. Creation of COVID ICUs exclusively for the patients of affected with Covid-19 have been done in a record time. Negative pressure Covid care areas with high exchange rate of circulating air have kept the infection of health care workers to bare minimum. Advanced care such as percutaneous tracheostomy, haemodialysis and hyperbaric oxygen therapy, plasmapheresis and advanced haemodynamic monitoring are available.
Established in 2019, it provides anaesthesia and pain and critical care services to the department of onco-surgery, head and neck, breast and endocrine surgery and surgical gastroenterology.
Facilities and equipment
All modular ORs have standard air turn over, humidity and temperature control with electronic monitors. These are also equipped with radiation exposure prevention, fire hazard prevention, anaesthesia gas scavenging system, colour coded waste management for safety of healthcare workers as well as patients. State of the art hyperbaric chamber is available to provide treatment to patients of fire hazard. All the operation theatre complexes are equipped with standard-of-care monitors and equipments which include anaesthesia workstation, multi-para monitors, respiratory gas monitor, cardiac output, peripheral nerve stimulator, nerve locator, portable ultrasound and difficult airway carts. The anaesthesia workstations have microprocessor enabling low-flow as well as minimal-flow anaesthesia for adults, paediatrics and infants. It is both electronically controlled and ventilator driven with dual-flow sensing technology. We have also developed a Google Sheet in which all the residents enter their data regarding peri-operative management of patients operated in all ORs in real time [Figure 2]. Perioperative anaesthesia record sheets and logbooks are maintained by the residents of the department and are scrutinised on a regular basis by the faculty in-charge. A box plot diagram reflecting the operation theatre in hours is reflected in figure
|Figure 2: Data of cases done in operation theatres, as plotted on online Google Sheet, accessed by residents and the faculty of department|
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| Critical Incident Reporting and Quality Indicators|| |
All the quality indicators of the operation theatre are gathered on a monthly basis, and there is a critical analysis of anonymously reported incidents in the ORs. The critical incidents are within normal limits, as reflected in [Table 1]. For the purpose of quality improvement, we maintain records of utilisation rate (hours) of ORs [Figure 3], percentage of unplanned ventilation following anaesthesia, percentage of adverse anaesthesia events, mortality rate and re-intubation rate. The institute has applied for NABH accreditation for quality and safety of care provided to patients.
|Figure 3: Box plot diagram reflecting the range of operation theatre hours for various surgical specialities. OT: Operation theatre|
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| Educational Facilities|| |
The central library of the institute has more than 450 books on anaesthesiology and periodicals, available 24 × 7, and also provides remote access to the faculty members. Database journals include Clinical Key, Clinical Learning, Ovid Database, New England Journal of Medicine, JAMA and Evidence-Based Biomedical Literature database, which are up to date and provide evidence-based clinical information for medical specialities and clinical topics for reference.
| Academic Programme|| |
The academic programme for the Doctorate of Medicine (DM) residents is ever evolving and one of the finest in the country. The institute is pioneer in vignette-based multiple-choice question assessment for theory and objective structural clinical examination. Multiple-choice questions consist of a stem of clinical vignette/case, with a lead-in (question) and response options (four distractors and one preferred response), and the answer provided by the student is then assessed. Evidence suggests that didactic lectures have a retention of only 5%. The institute has incorporated Bloom taxonomy model of teaching in all classrooms. This enhances student's participation in learning and creating interactive environment and to gain analytical thinking. The Bloom's taxonomy model is incorporated in all anaesthesia classroom teaching sessions. It incorporates three domains of learning objectives – cognitive, affective and sensory or psychomotor. This is developed to promote higher forms of learning in students in the form of analysing, evaluating, imparting conceptual knowledge and processing, rather than simply memorising factual information. The cognitive model serves to include knowledge, comprehension, application, analysis, synthesis and evaluation. It has promoted higher form of learning, critical analysis, psycho-motor skills by practicing the procedures in simulation settings rather than simply memorizing factual information. There is emphasis on emotional intelligence to improve doctor–patient interaction and fulfilment of expectations of patient. Right from the beginning, department of Anaesthesiology has achieved many awards at state and national levels. Our residents have presented their papers in various conferences at state, national and international levels. Many of them have achieved first places in paper presentations and quiz competitions. Our faculties are invited as guest faculties at various national and international conferences as well.
| Departmental Training And Research Activities|| |
Department has fixed guidelines for anaesthetic procedures to be undertaken and curriculum planning for junior residents. Teaching activities take place regularly in the department, 4-5 days a week, which includes seminars, journal clubs, case discussion, tutorials etc. This is in addition to daily teaching activity based on cases conducted in ORs & Intensive Care Unit. Department of Anaesthesia and Intensive Care of Hospital encourages study and research activities and is committed to provide comprehensive, dynamic and continuous training and education to our residents (basic and advanced airway, hemodynamic monitoring, ultrasound in ICU etc) .
Anaesthesiologists have not only participated in critical care of COVID-19 patients, but have also worked as front line physicians in emergency, out patient and ORs. Various faculties of department have initiated courses specific to COVID 19 management, including ventilator and airway management in COVID 19 patients.
| Postlude|| |
The institute is in continuous progress in leadership of current Director of the Institute. His vast experience in India and abroad has helped in chalking out ten year, 50 years and 100 years plan for the Institute in reaching newer heights and in expanding, by leaps and bounds. None of these successes would be possible without the support of our dedicated, talented faculty members and the outstanding administrative and technical support provided by our central office and all the affiliated departments.
| Dedicated Speciality|| |
Our vision is providing the highest standard of safe anaesthesia, analgesia, related services and perioperative management to our patients in the ORs, post-anaesthesia care unit and ICU and to successfully integrate with all other clinical disciplines in a holistic and patient-centred approach.
Our mission is delivery of our anaesthesia and critical care services in all departments requiring anaesthesia care through perseverance, constant motivation, sincerity, affordability, innovation and vigilance.
Values and principles
We follow our vision and mission as virtues integrated in each member of the department which includes – punctuality, commitment, team spirit, professional development, promotion of clinical research and teaching and educational activities.
You can never cross the ocean until you have the courage to lose sight of the shore
We would like to acknowledge: Dr Sanjay Agarwal, Prof and Head of department, Anesthesiology. Dr YS Payal, Dr Debendra Kumar Tripathy, Dr Ankit Aggarwal, Dr Ajit Kumar, Dr Gaurav Jain, Dr Praveen Talawar, Dr Deepak Singla, Dr Priyanka Gupta, Dr Asutosh Kaushal and Dr Mridul Dhar.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tao KM, Sokha S, Yuan HB. The challenge of safe anaesthesia in developing countries: Defining the problems in a medical center in Cambodia. BMC Health Serv Res 2020;20:1-10.
Wolff M, Wagner MJ, Poznanski S, Schiller J, Santen S. Not another boring lecture: Engaging learners with active learning techniques. J Emerg Med 2015;48:85-93.
Yang M, Dong H, Lu Z. Role of anaesthesiologists during the COVID-19 outbreak in China. Br J Anaesth 2020;124:666-9.
[Figure 1], [Figure 2], [Figure 3]