What is "Respondeat Superior"?
The employer or another supervisor is responsible for the actions of a CRNA....if a CRNA is employed by a hospital and is directed by an anesthesiologist, the hospital and the anesthesiologist are liable (respondeat superior) as well as the CRNA.
What is the difference between assault and battery??
ASSAULT: unlawful threat of actions by a person intended to inflict, by force, corporal injury.
BATTERY: Unlawful constraint or physical violence inflicted on a person without his consent....ex: administration of an anesthetic to an unwilling patient. If during a general anesthetic for a case you realize there was no anesthesia consent obtained, then you can be charged with battery.
What is "Borrowed Servant"??
Employee comes under the direction and supervision of a 3rd person who can direct the activities of the employee, not the employer. The Borrowed Servant rule pertains to situations in which an employer loans an employee to another employer.
EX: If the anesthesiologist is the independent and the CRNA is a hospital employee, then an anesthesiologist who supervises a CRNA is liable for the CRNA's negligence, even if the CRNA is an employee of the hospital.
What is the difference between 'libel' and 'slander'??
LIBEL: defamation of another person by written means. Ex: If the anesthesiologist writes on the chart that the patient with HIV has AIDS.
SLANDER: defamation of another person by verbal means. Ex: After the case, the anesthesiologist tells the patient's family that the surgeon was negligent.
The Statute of Limitations places a time constraint on the plaintiff to fil action....it is variable from state to state, varies by nature of the case and by the circumstances of the case.
What are 2 exceptions to the Statute of Limitations for filing a lawsuit claiming negligence??
1. The plaintiff is under a disability which keeps the plaintiff from bringing the suit (e.g. children, persons under legal guardianship).
2. The plaintiff may not have been able to discover that there was an injury caused by negligence before the Statute of Limitations expired.
[NOTE: The DISCOVERY RULE states that the action originates once the plaintiff discovers, or should have discovered, he/she has been injured.]
NEGLIGENCE: The failure to use reasonable care, which is that level of care recognized as acceptable and appropriate given the circumstances.
Ex: The patient with spina bifida has a known allergy to latex, and the anesthetist does nothing to prevent contact of the patient with latex.
What is the most common cause of malpractice claims against anesthesiologists??
What peri-operative incident does the most frequent lawsuit involve??
The most common lawsuit incident is inadequate ventilation/inadequate oxygenation.
What are the top 3 anesthesia-related injuries that lead to malpractice (negligence) claims, other than damage to teeth or dentures??
Death (22% of claims)
Nerve Damage (22% of claims)
Brain Damage (8% of claims)
What is "Common Law"??
Common Law is a system of law based on the principles of legal precedent rather than on legislative enactments in case resolution.
What is 'Statutory Law'??
Statutory Law is enacted by state legislature....these laws have most impact on nursing. It defines nursing, who may practice, scope of practice, requirements for registration and revocation of licensure.
Under which class of laws does the CRNA practice??
Professional responsibility of the CRNA is usually under Common Law and Civil Law.
Which amendment of the US Constitution gives the states the right to enact laws to protect the health and safety of their citizens??
The 10th Amendment of the US Constitution states: "The powers not delegated to the US by the Constitution, nor prohibited by it to the States, are reserved to the states, respectively, or to the people." The 10th Amendment is the source of the states "police power" or right to regulate the public, health, welfare and safety.
The purpose of Informed Consent is that the patient has the right to reasonbly informed participation in decisions involving his/her health care....every adult of sound mind has a right to determine what shall be done with his/her own body.
What are the 6 elements of Informed Consent?
The patients diagnosis
The general nature/purpose of the anticipated procedure
The risks/consequences involved
The prospects of success
The prognosis if the procedure is not performed
The alternative methods of treatment available, if any.
The patient is informed of the contemplated procedure, including its reasonably anticipated risks & complications, its possible benefits, and the therapeutic alternatives. If more than one type of anesthetic is contemplated, then explain both, including risks.
[NOTE: Informed consent does NOT necessarily involve a description of the treatment or management of complications]
What principle mitigates the information provided to obtain patient consent??
The duty to disclose is measured by the amount of knowledge the patient needs.
Its the duty of the CRNA to obtain informed consent prior to the procedure. Consent may be written, verbal or implied, although written consent may be most useful. Consent must be 'informed' to ensure that the patient/guardian has sufficient information about the procedures and their risks to make a reasonable and prudent decision whether to consent.
In what circumstances my Informed Consent be implied??
"Implied" consent may be present in circumstances in which the patient is unconscious or unable, for any reason, to give his/her consent, but where it is presumed that any reasonable and prudent patient would give consent if able.
EX: a child requires emergency surgery and the parents are not present for consent.
During the pre-op review you notice "do not resuscitate" orders in the patient's chart....what must be done during the pre-op visit??
During the pre-op evaluation, the patient's DNR status MUST BE CLARIFIED with the patient and the patient's family, and the DNR order must be consistent with the hospital's policies and state and federal law.
Package inserts (drug labels) ARE required by law to contain dosing statements for children...but is often done in the form of a disclaimer, b/c "the contents of the package insert must by law be based in adequate, well-controlled studies involving children".
A drug label for Marcaine states: "until further experience is gained in children younger than 12 years, administration of Sensorcaine (bupivacaine HCl) injection is not recommended". If, in the best interest of the patient, you use Marcaine in a 10 year old, have you violated any medical or legal rights??
NO...you are within your medical and legal rights to use this drug in the 10 year old patient. "Unapproved use does NOT imply an improper use and certainly does not imply illegal use".
What is an emancipated minor??
What qualifications may enable a minor to receive the status of emancipated minor?
A minor (<18 years old) who has been given the global right to make their own health-care decisions.
Patients <17 years old may be awarded the status of emancipated minor if they are...
Minors who are a parent
In the military
What does the "Mature minor doctrine" state??
The Mature Minor Doctrine applies to a minor who has decision-making capacity and is legally and ethically capable of giving informed consent in specific situations as determined by the court.
TORT: a civil wrong (a civil wrong-doing) by which a person has violated his duty to another as stated in a general law and for which the courts grant compensation via legal process.
EX: If the consent form is not signed, and anesthetics are administered, this is referred to as an "Intentional Tort".
EX: The CRNA discusses the patient in the next case in the crowded staff elevator...a civil wrong-doing, and in this case, the malpractice issue is a breach of confidentiality.
What is the Nurse Practice Act??
The Nurse Practice Act codifies (sets forth in legal terms) the duties and practices of advanced practice nursing in 'state' statutes. In each state (the guidelines vary state to state), it provides a legal framework for public protection of patients receiving nurse anesthesia services and protects against charges of "practicing medicine".
What is "Res Ipsa Loquitur"??
"The Thing Speaks For Itself"....this is a doctrine in law meaning that a person is presumed to be negligent if the object that caused an injury was entirely under the control of that person and the incident is one which ordinarily does not happen in the absence of negligence.
EX: if a patient awakes with a peripheral nerve injury in a body region unrelated to surgery, the res ipsa loquitur doctrine applies....b/c anesthesia renders patients insensible to their surroundings and unable to protect themselves from injury, this doctrine may be invoked in anesthesia malpractice cases.
If a nurse is convicted of drug possession, the state board of nursing (BON) is the controlling agency that would revoke the license to practice.
What is the incidence of substance abuse among CRNAs??
What 2 drugs account for >70% of substance abuse by anesthesia providers?
The incidence of anesthesia drug misuse among the CRNA population was nearly 10% in a 1999 survey.
The potent opioids, Fentanyl and Sufentanil, are the drugs most frequently abused by anesthesia providers.
Opioid withdrawal is characterized by 3 or more of 11 s/sx...what are these 11 s/sx of opiate withdrawal??
3. Muscle aches
4. Lacrimation or rhinorrhea
5. Pupillary dilation
6. piloerection (goose bumps)
NOTE: These s/sx often present as a bad case of the "flu".
Which legislature act requires the employer to provide reasonable accommodation for the chemically dependent CRNA??
The American with Disabilities Act (ADA) passed in 1990
What are 9 specific considerations for an actively recovering CRNA to re-enter practice following treatment for chemical dependency??
1. The elapsed time
2. Legal constraints
5. Clinical and cognitive skills
6. Emotional readiness
7. Job availability
Who is responsible for a CRNA's personal negligence??
Increasingly, the CRNA is responsible for his/her own negligence, but depending upon the CRNA's working relationship, the surgeon, anesthesiologist, dentist or hospital could also be named in any case of negligence.
What are 4 elements that must be proved when applying the doctrine of Res Ipsa Loquitur??
In order for this doctrine to apply, the following must be proved...
1. The injury is of a kind that typically would not occur in the absence of negligence
2. The injury must be caused by something under the exclusive control of the anesthesia provider
3. The injury must not be attributable to any contribution on the part of the patient
4. The evidence for the explanation of events must be more accessible to the anesthesia provider than to the patient.
NOTE: If a defendant's attorney for a CRNA being accused of negligence believes the plaintiff has not provided sufficient testimony about any of these key elements, the attorney may ask the judge for "Summary Judgement" or "Directed Verdict"...if this motion is granted by the judge, then the case is removed from the jury.
An anesthesia provider has been served with a complaint and a summons requiring an answer to the complaint.
What has formally happened??....and what is the FIRST action to take upon receiving a summons??
When the patient-plaintiff's attorney files a complaint and demand for a jury trial with the court and the anesthesia provider has been served with a complaint and summons requiring an answer to the complaint, a Lawsuit has been filed.
Once notified of the lawsuit, the anesthesia provider must 'first notify his/her insurance carrier', whose job it is to provide compentent legal counsel....but this should be done ASAP b/c a time limit is placed on the complaint.
What are 4 elements comprising the "Anatomy of Medical Negligence Action"??
In a medical negligence action, the plaintiff must prove to the court the following 4 elements....
1. DUTY: reasonable care, as defined by the Standard of Care, is expected.
2. BREACH OF DUTY: failure to meet the Standard of Care
3. DAMAGE: the plaintiff must have suffered some injury, either physical or emotional
4. CAUSE: the damage the plaintiff received was caused by the defendant that deviated from the Standard of Care. There must be a direct or actual cause between the practioner's actions and the damage the plaintiff received. THe plaintiff must also prove proximate cause.
When filing a suit, a plaintiff must prove duty, breach of duty, damage and cause...which also includes proximate cause.
What is 'proximate cause'??
A "proximate cause" is a cause that was foreseeable before the event took place. An alternate definition is that which when viewed in retrospect is not thought of as extraordinary.
What are 2 common tests used to establish causation??
1. The first is the 'but for' test....if the injury would not have occurred 'but for' the action of the defendant...
2. The second is the 'substantial factor' test....if the act of the defendant was a 'substantial factor' in the injury despite other causes, then proximate cause is established.
In non-criminal tort cases, what is the name for the party who alleges having been harmed, and the party who is accused of causing harm??
The Plaintiff alleges having been harmed.
The Defendant is accused of causing the harm to the plaintiff
List and describe the 3 types of damages a patient may be entitled to if the CRNA has been found neglient??
1. GENERAL Damages: those such as pain & suffering that directly result from the injury
2. SPECIAL Damages: those actual damages that are a consequence of the injury, such as medical expenses, lost income, and funeral expenses
3. PUNITIVE Damages: those that are intended to punish the physician/CRNA for negligence that was reckless, wanton, fraudulent, or willful.
What are depositions??
Depositions are Q&A sessions during which the lawyers for both sides question witnesses as part of a lawsuit.
Compare/Contrast an 'expert' witness with a 'factual' witness.
Ideally, according to ASA guidelines, there should be no difference in the testimony of an expert or factual witness....however, legally and realistically, an 'expert' witness may give opinions, whereas a 'factual' witness may not
What is 'Amicus Curiae'??
Amicus curiae literally is "Friend of the court"....during the appeals process, an appellate court permits persons who are not parties to the case to provide relevant information to the appellate court on the law to be applied....the procedure used to provide this relevant information is a brief Amicus Curiae....a brief filed as a 'friend of the court'.
The patient falls off of the OR table...which doctrine or law applies???
Res ipsa loquitur 'the thing speaks for itself'
In the PACU, a patient states he had intra-op recall...what do you do??
If recall occurs, an honest explanation of the incident should be given...a referral for follow-up with a mental health professional may be necessary.
What is the most common reason for law suits related to OB??
There are 2 types of policies written by professional liability companies....Occurrence and Claims Made. What are the differences in these policies??
"Occurrence Policies": the preferrable type, cover the insured for ALL ACTS WITHIN THE POLICY PERIOD, regardless of when the lawsuit is filed.....this feature makes the policy attractive for the CRNA...however, this type of policy makes long-range risk and liability planning difficult for the company that provided coverage.
"Claims-Made Policy": a much less favorable policy for the CRNA...under this policy, the insured must have coverage with the same company AT THE SAME TIME OF THE INCIDENT & CONTINUOUSLY THROUGH THE DATE THE CLAIM IS MADE OR LAWSUIT IS FILED....this type of policy encourages the CRNA to remain with one company over a long period of time and stabilizes the market, from the insurance company's point of view.
Professional liability coverage limits have 2 monetary component limits, indicated with a slash between 2 numbers....for example, $1,000,000/ $3,000,000.
What do these 2 limits represent??
The limits of professional liability comprise 2 components:
1. The number preceding the slash is the 'maximum liability coverage available for ANY ONE EVENT IN A POLICY YEAR....so in the example, the $1,000,000 would be the maximum liability coverage for any one event in a policy year.
2. The number following the slash is the COVERAGE AVAILABLE FOR ANY NUMBER OF EVENTS IN THE POLICY YEAR....of note, these limits concern the payment of verdicts and settlements only and are not depleted by expenses incurred in litigation, such as attorney's fees, charges, and so on.
What is "Tail Coverage"??
Tail Coverage is liability insurance protection for claims filed AFTER the insured is no longer covered by the insurance policy. It is necesary coverage b/c a majority of malpractice suits are filed 1-3 years after the event in question.
What is "Umbrella Coverage"??
Umbrella Coverage is a type of insurance that is activated at the time of the need to pay a claim that EXCEEDS THE LIMIT of the coverage on the standard malpractice liability insurance policy.
Some characteristics of research include....
1. Validity (both internal & external validity)
2. Reliability (the extent to which data collection, analysis & interpretation are consistent & to which the research can be replicated)
What are the 8 stages of the research process??
1. Identification of the problem
2. Review of relevant literature & knowledge
3. Formulation of the hypothesis or research question
4. Development of an approach for testing the hypothesis
5. Execution of the research plan
6. Analysis and interpretation of the data
7. Dissemination of the findings to interested colleagues
8. Evaluation of the research report
In its most elemental form, a "Hypothesis" is either a proposition of the solution to a problem or a stated relationship among variables....that establishes & defines the independent & dependent variable.
What are the 3 forms a hypothesis may take???
A hypothesis may be....
1. DIRECTIONAL Hypothesis (will include the words 'less' or 'more')
2. NON-DIRECTIONAL Hypothesis (states there 'is a difference' without specifying the direction of the difference)
3. NULL Hypothesis (states there 'is no difference' in the relationship or proposed solutions to the problem)
[NOTE: INDEPENDENT Variable....the variable to be manipulated or is presumed to influence the outcome. DEPENDENT Variable....the outcome variable that is dependent upon the independent variable.]
There are many ways to classify research methods...one of the most popular categorizations is to separate the methods into 'observational' and 'experimental' (interventional) studies.
"Observational" studies are those in which data is gathered without performing & specific interventions affecting the assignment of groups or effects on group members.
What are "experimental" (interventional) studies???
In an Experimental study, subjects are assigned to groups (RANDOMIZATION), an INTERVENTION(s) is performed, and attempts to eliminate (CONTROL) bias & confounding variables "before" the data are collected.
[NOTE: Recall the elements of an experimental study include "R-I-C"...Randomization, Intervention, & Control]
"Observational" studies may be classified as Case-series, Case-control, Cross-sectional, or Cohort studies.
In a simple Case-series, the author describes some interesting or intriguing observations that occurred for a small number of patients. There are no control subjects, thus the case-study does not have the nature of "proving" something, but often leads to a hypothesis and subsequent investigation.
How do Case-Control and Cohort Studies (other classes of observational studies) differ???
Cohort and Case Studies are called "Longitudinal" studies b/c they involve an extended period of time defined by point when the study begins and the point when it ends. In a cohort study, the researchers select a group of people who "have something in common" (e.g. a risk factor), & then monitor the "cohort" forward in time. A cohort study asks, "What will happen?" and thus is a "Prospective" study.
A Case-Control study begins "at the end" with the presence or absence of an outcome and then looks backward in time to try to detect possible causes or risk factors that may explain the outcome......therefore, a case-control study is a "Retrospective" study that asks, "What happened?".
What is "BIAS" in a research method??
Bias is a "Systematic Effect" in the study that produces an error on our interpretation of the results.
There are several types of bias, to include...Selection bias, Confounding bias, & Measurement bias.
[NOTE: Selection Bias....occurs when 2 groups are compared with respect to some variable without acknowledging or realizing that the groups are different in other important ways.
Confounding Bias....occurs when multiple variables are intertwined so that although we may assume the variable under study is important, the truth is that the confound variable may be more important.
Measurement Bias....occurs if the methods used for making measurements when comparing different groups have different scales or sensitvities.....this bias may be avoided in a "blinded study".]
What does the term "Blinding" refer to?? What may be avoided by doing a blinded study???
The term BLINDING (or masking) refers to the process of controlling for obvious and occult biases arising from the subjects' or researchers' reaction to what is taking place.
In a Blinded study (masked study), measurement bias may be avoided if the person performing the measurements does not know which group is being measured....this is called a "Single-blind" study.
In a "Double-Blind" study, neither the researcher nor the subject is aware which treatment or manipulation the subject is receiving.
In either blinded study, measurement bias is avoided.
What type of research design method is the 'gold standard' and why??? What are the disadvantages to this 'gold standard' design method???
The idealized 'gold standard' research design in medical research is the RANDOMIZED CLINICAL TRIAL (RCT).....this is ideal because....
1. The subjects are Randomly assigned to the research groups, minimizing selection bias
2. The study is prospective (looking forward in time)
3. The dependent variable is measured
4. It provides the greatest justification for concluding Causality
5. It is subject to the least number of biases.
The greatest obstacles to RCTs are the great expense, efforts needed, and duration of the study. To minimize and overcome these disadvantages, RCTs are often carried out as multi-center trials.
As with research study design methods, there are many ways to categorize types of data & measurements.
What are 4 categories of measurement/data types???
4 levels or degrees of measurement or data types are...
Nominal & Ordinal data are often called "Qualitative" observations.
Interval & Ratio data are often called "Quantitative" observations....these 2 types of data are 'continuous' in nature.
What are characteristics of the NOMINAL measurments/data???
NOMINAL Scales are used for the simplest types of data that fit into "Categories"
Nominal data simply "Identify" the data....if there are only 2 categories of data (ex: male & female), the observations are "Binary or Dichotomous".
EX: Blood Typing (A, B, AB, O) or Eye Color
What are characteristics of the ORDINAL measurements/ data??
ORDINAL Scale measurements are still classified by categories (like nominal) but some measurements may have more, or are greater than other observations, and thus are "ordered or ranked"
EX: Order of race finish (1st, 2nd, 3rd, etc), pain scores, the ASA Classification scheme.
What are the characteristics of the INTERVAL measurements/data??
INTERVAL data measure the "Quantity" of something for which the differences between the numbers have meaning on a numerical scale built upon equally spaced intervals.....technically, interval data DOES NOT HAVE AN "ABSOLUTE ZERO" point on the scale.
EX: Temperature (F or C) scales, calendar years, or the IQ scale.....the distance (or interval) between adjacent measurements is meaningful and "quantifiable", not simply "more" or "less".
What are the characteristics of the RATIO measurements/data??
RATIO data/measurements are Quantitative, numerical observations that can be ordered and equally spaced, but which are based upon a numerical scale that HAS AN ABSOLUTE ZERO point on the scale.
EX: Temperature (on Kelvin scale..."absolute temperature"), blood pressure, distance and height or weight.
What is Operationalization???
Operationalization is the process of making the characteristics inherent in a given variable, condition or process 'clear and familiar to others'
For example, if a study examined critically ill patients it would be essential to operationalize the term "critically ill patients" in order to clearly delineate the term so that the research might be replicated without change.
What are 3 different classes of statistical techniques used to analyze and interpret research data??
Once the observations have been collected, they are often categorized and described by "descriptive statistical techniques".
If a relationship between data has been hypothesized, "correlational statistical techniques" may be used to describe the extent to which two (or more) variables are related to each other or for quantifying the degree of that relationship.
"Inferential statistical techniques" provide a set of procedures that allow the researcher to 'infer' that the events observed in the sample will also occur in the larger unobserved population from which the sample was obtained.
What are the Population and the Sample in statistical terms???
POPULATION refers to any target group of things (animate or inanimate) in which there is interest.....it is the "entire collection of observations" or subjects that have something in common and to which conclusions are inferred.
SAMPLE is the "subset of the target population"....they are taken b/c of the impossibility of observing the entire population....it is generally not affordable, convenient or practical to examine more than a relatively small fraction of the population.
What is a "Distribution"???....what is "Normal Distribution"??
The group or set of all the observations of a variable along with the frequency of their occurrence and placement of the values is called the "Distribution" of the variable.
A distribution may be based upon empirical observations or may be a 'theoretical probability distribution' that is defined by an algebraic equation.
The most important distribution is the "Normal" distribution....also called the "Gaussian or Bell-Curve" distribution.
[NOTE: Normal Distribution (Bell-curve) is important b/c it has been empirically noted that when a biologic variable is sampled repeatedly, the pattern of the numbers plotted as a histogram resembles the normal curve....thus, most biologic data are said to follow or to obey a normal distribution.
Equally important, a mathematical theorem ('the central line theorem') allows the use of the "assumption" of Normality for certain purposes, even if the population is not normally distributed.]
What are the 3 descriptive statistics that specify the central tendency, or middle, of numerical data??
The MEDIAN is the center or middle data point if the data can be ordered (ranked) from smallest to largest....it is the point at which half the observations are smaller, half are larger.
The MODE is the most frequently occurring value in a data set.
The MEAN is the arithmetic "average" of the numerical observations in a sample.
What 2 measures of a data sample describe the "spread" or "variability" of the data??? (hint: variability = deviation)
The "Spread" (or dispersion) or "Variability" of data is described by the "Range" and the "Variance & Standard Deviation".
The RANGE is simply the difference between the largest and smallest observation.
The STANDARD DEVIATION is a measure of spread of the data about their mean.....it measures the "average" spread of the observations/data about the mean.
The VARIANCE is the square of the standard deviation.
"Inferential" Statistical techniques are either "Parametric" or "Non-Parametric"....what do these terms mean???
When data follow a 'normal distribution', the methods of PARAMETRIC Statistics can be used.....Parametric refers the ability to describe the distribution with a specific set of values, or parameters.....for the normal distribution, only 2 parameters are required to define and describe the distribution....the 'mean' and the 'standard deviation'.
If it is not possible to describe the data with a set of parameters, then NON-PARAMETRICAL methods are required.
What are 3 questions to ask when choosing an appropriate statistical test??
1. Do the statistical methods assume a normal distribution???...thus parametric methods are appropriate, or whether non-parametric methods are needed (data is not normally distributed).
2. How many groups are being compared???.....there may be 1, 2 or multiple groups to characterize.
3. Are the data in the groups paired or unpaired???......"Were the 'same individuals' studied "before" and "after" some intervention or condition?".....if yes, (the same individuals were studied before and after an intervention), then these are "paired" data groups and not independent groups.
Which statistical test compares the difference between the means of Normally distributed interval or ratio data from 2 independent groups??
The "Unpaired" (2-sample) STUDENT's T-TEST is used to compare the difference between the means of 2 independent groups, provided the observations are normally distributed interval measurements.
However, when there is normally distributed interval or ratio data, the PAIRED T-TEST (a.k.a. T-Test...comparing dependent samples) evaluates the difference between "Dependent", paired samples (ex: pre-treatment and post-treatment) outcomes.
Given non-parametric nominal data from 2 or more independent groups (samples), which statistical test evaluates the difference between 'observed' and 'expected' frequencies??
The "CHI-SQUARED" analysis of contingency tables evaluates the difference between "observed" and "expected" frequencies from nominal or ordinal data that are not necessarily Normally distributed.
Which non-parametric test is the equivalent of the Un-paired T-Test for non-parametric ordinal data???
The MANN-WHITNEY RANK SUM TEST tells whether medians between 2 independent non-parametric groups of ordinal data are different.
After individual observations are 'ranked', the ranks are analyzed just as though they were the original data.....the various incarnations of the general rank sum test are often used by researchers in the health field for non-parametric data.
Which parametric test evaluates the difference "among" the means of interval or ratio data from more than 2 independent groups, or more than 1 independent variable???
An ANALYSIS OF VARIANCE (ANOVA) Tests the difference among the means of more than 2 independent groups or more than 1 independent variable given Normally distributed interval or ratio data.
What is the appropriate statistical test to determine whether a variable 'x' (the independent variable) predicts the outcome of another variable 'y' (the dependent variable)???
"SIMPLE LINEAR REGRESSION" evaluates the association between 2 parametric, numeric variables.....linear regression produces an equation in the form of [y = mx + b] that allows 'predication' of the outcome variable 'y' (the dependent variable) given the 'predictor' variable 'x' (the independent variable).
Quality Assurance is a system or program that provides an organized procedure for the evaluation of the level of care provided (quality care assessment) and the establishment of mechanisms for improvement......a QA program examines adverse outcomes and evaluates the roles of practioners in the adverse events. Basically, QA documents problems and assigns blame, but doesn't correct or remedy the problems in a systematic fashion.
Whose responsibility is QA??....and What is the goal of traditional QA programs??
Each hospital dept. or service is responsible for monitoring quality in their particular area, as required by The Joint Commission (a.k.a. JCAHO).
The goal of traditional QA programs is identifying deviations from the norm ("outliers or bad apples")....QA programs...
1. Define the norm (standard of care)
2. Determine whether adverse events were caused by deviations from the norm
3. Prevent occurrence of adverse events
[NOTE: The first step in a QA program is to define the norm or set the standards; QA has been superseded by Quality Improvement (QI). The major pitfall of a QA program is "inconsistent reporting of data"....to avoid this, a succinct/standardized check-off form should be used].
What are 2 barriers to anesthesia information systems??
1. Lack of standards
2. Lack of interfaces
What the 4 requirements of the Joint Commission for a hospital's QI or QA program??
The Joint Commission requirements for QA (or QI) activities require the hospital to...
1. Design a process or function
2. Measure performance
3. Assess performance (by statistical analysis or comparison with other data sources)
4. Improve process/performance or function
What is Continuous Quality Improvement (QI)???
Continuous QI is basically the practice of continually evaluating anesthesia practice to identify systematic problems and implementing strategies to prevent their occurrence, thereby improving patient outcomes.
Unlike QA, which focuses on the anesthesia provider, QI focuses on the process used to deliver care.
An effective QI program sets goals and objectives, selects indicators, identifies causes for the problems, implements corrective action, and monitors the effect of those actions on the quality of care....The GOAL IS TO IMPROVE THE QUALITY OF CARE!
An "indicator" is a tool used to measure, over time, the performance of functions, processes, and outcomes of an organization.
What are 3 examples of indicators??
Indicators are events (good or bad) that are looked for during the review of clinical care.....indicators are events that are events that the anesthesia dept. wishes to 'monitor' to make sure that there are no problems.
1. "Esophageal intubation"
2. Intra-op Recall
3. "Wet Tap" or PDPH
In the QI process, indicators are used to measure the performance of functions, processes and outcomes of an anesthesia dept over time.
Do incident reports provide indicators of the QI process???....Are lawsuits used as indicators of the QI process??
Incident reports may help provide indicators of the QI process, but law suits are not indicators.
[NOTE: "Criteria" are statements that specify acceptable incidence of an event (good or bad) occurring....Criteria generally include the word "should", implying that this is something that the dept should strive to achieve.... examples include....
1. "No more than 4% of same-day surgery patients should require admission to the hospital for anesthesia-related causes"
2. "There should be fewer than 2% wet taps during attempts at epidural catheter placement"
Quality Improvement (QI) measuring over time performance function and outcomes is what??.... an indicator, a goal, a criteria, a standard, or an occurrence???
Measuring Over Time Performance Function & Outcomes is an INDICATOR....an indicator is a tool used to measure (over time) the performance of functions, processes, and outcomes of an organization.
[NOTE: Anesthetic Outcome is measured over time]
"Outcome" is that which comes out of, or results from, something else....the issue, the result, the consequence....an example would be reduced incidence of wrong site surgery by using a site verification signature sheet and performing 'time-outs'.
"Process" is a particular method of doing something, generally involving a number of steps or operations....an example would be doing anesthesia (pre-op visit, ordering labs or ECG, etc.) and then conducting the anesthetic plan (induction, drugs, maintenance, etc).
What is "audit" and give an example???
"Audit" is an examination of an account by proper officers or persons appointed for that purpose, who compare the charges with the vouchers, examine witnesses, and report the result. ....an example would be an on-going QI audit of anesthetic incidences to be studied for trends in the department.
What is "Standard of Care"??
The "STANDARD OF CARE" is the conduct and skill of a prudent practitioner that can be expected by a reasonable patient.....reasonable care by a professional.....it is a very important medicolegal concept b/c a bad medical result d/t failure to meet the standard of care is malpractice.
What is the highest form of evaluative criteria for CRNA clinical practice, as set forth by the AANA???
PRACTICE STANDARDS are the highest mandate for clinical behavior.
How do Practice Standards differ from Practice Guidelines & Position Statements???
POSITION STATEMENTS....are the least forceful criteria & usually represent emerging trends, address economically driven practice modalities, or discuss procedural policies.
PRACTICE GUIDELINES....are the next highest form of evaluative criteria and are guides to provider behavior and critical decision making that are commonly accepted within the anesthesia profession.
PRACTICE STANDARDS....are the highest form of evaluative criteria....a standard represents behaviors that must be exercised by the prudent CRNA in similar circumstances.
What is a "Sentinel Event"???
SENTINEL EVENT is an 'unexpected occurrence' or variation involving serious physical or psychological injury, or risk thereof.
[Sentinel means....sends an alarm or that requires immediate attention].
What is a "Critical Incident"??
CRITICAL INCIDENT is an event that causes or has the potential to cause injury if not noticed and corrected in a timely manner.
EX: A ventilator disconnect
Of the below examples....match the example to the correct definition (Criteria, Standard or Indicator).....
1. "During all anesthetics, the patient's oxygenation, ventilation, circulation, and temperature shall be continually evaluated"
2. "Patients experiencing an ocular injury during procedures involving anesthesia care"
3. "Fewer than 0.2% of general anesthesia patients should require emergency re-intubation in the PACU".
2. INDICATOR (these usually involve the word "should")
Whose responsibility is risk management???....and what are 3 goals of risk management???
Risk Management is the responsibility of risk managers employed by the health care organizations.
1. Prevent injury
2. Prevent litigation
3. Prevent financial loss
What procedures do you perform when during a case a piece of equipment fails, resulting in either a patient morbidity or mortality??
First, if a piece of equipment fails, it must be removed from service and a replacement substituted.
A piece of equipment involved or suspected in an anesthesia accident must be immediately sequestered and not touched by anybody, particularly service personnel.
If a severe accident occurred, the equipment may need to be inspected by qualified representatives of the manufacturer, service personnel, plaintiff and defense attorneys, and the insurance companies involved.
If the failure is a pattern of failures, the device must be reported to the FDA's Medical Device Reporting Hotline (1800-638-6725).
Conscious sedation monitoring guidelines apply to what anesthesia care settings: academic centers, tertiary care centers, rural community hospitals, and/or urban community hospitals??
The ASA Standards for Basic Anesthetic Monitoring, including Monitored Anesthesia Care (MAC), apply to ALL Anesthesia Care Settings.
Identical Standards of Care (SOC) apply to MAC and Regional or General Anesthsia.
What is the single greatest danger associated with Monitored Anesthesia Care (MAC)???
LACK of VIGILANCE b/c so-called minor surgical procedures are often being performed.
Which monitors are required during MAC of the pediatric patient???
During MAC, the SAME MONITORS are required as are during GETA (GA)....
1. Precordial or Esophageal stethoscope
4. Pulse Ox
What organization published in 1979 a document that was a landmark for the advancement of machine technology and patient safety b/c it provided guidelines to manufacturers regarding minimum performance, design characteristics, and safety requirements for anesthesia machines??....what is this standard called???
The standard, published by the American National Standards Institute (ANSI) was the "Z79.8-1979" Machine Standard. This standard was later superseded by the American Society for Testing and Materials (ASTM) "F1161-88" Standard in 1988.
The ANSI is responsible for marking "I.T. Z79" on ETTs....which indicates that the ETT material has been determined to be free of any tissue irritant or toxic properties.
What are the 9 parameters that the anesthesia machine must monitor in order to comply with the ASTM "F1850-00" standard???
To comply with the ASTM "F1850-00" (2000), newly manufactured anesthesia machines must have monitors that display the following parameters....
1. Continuous breathing system pressure
2. Exhaled Tidal Volume
3. Ventilatory CO2 concentration
4. Anesthetic vapor concentration
6. Arterial O2 concentration
7. O2 supply pressure
8. Arterial BP
9. Continuous ECG
What is the responsibility of the National Institute for Occupational Safety and Health (NIOSH)???....and how are the responsibilities carried out???
The NIOSH is a federal agency responsible for assuring that workers have a safe and healthy working environment.....this agency was to meet these goals through the conduct and funding of research, through education of employers and employees about occupational illness, and through establishing occupational health standards.
What are the 3 responsibilities of the Occupational Safety and Health Administration (OSHA)???
OSHA is responsible for enacting job health standards....investigating work sites to detect violation of standards, and enforcing the standard by citing violators.
In 1990, the Food & Drug Administration (FDA) instituted the Safe Medical Device Act....what does this act require???
The FDA Safe Medical Device Act (1990) requires hospitals to "report instances in which medical devices cause or contribute to death, serious illness, or serious injury"....and that any medical personnel who become aware of the problem to remove the equipment from patient contact and to report the problem to their supervisor(s).
The incident report must be made by the hospital Risk Manager to the FDA within 10 days of the incident.
The National Practioner Data Bank (NPDB) requires input (information) from what 5 sources???
1. Medical malpractice payments
2. License actions by medical boards
3. Professional review or clinical privilege actions taken by hospitals and other health care entities (including professional societies)
4. Actions taken by the Drug Enforcement Agency (DEA)
5. Medicare/ Medicaid exclusions
How is the standard of care established???....and what 2 sources are typically consulted to establish the Standard of Care (SOC)???
Ultimately, the SOC is what a jury says it is...(Barash).
There are 2 main sources of information as to exactly what is the expected SOC.
1. Traditionally, the beliefs offered by expert witnesses in medical liability lawsuits regarding what is actually being done in real life ("de facto SOC") were the main input juries had in deciding what was reasonable to expect from the defendant.
2. The second, much more objective, source for defining certain component parts of the SOC is the published SOC, guidelines, practice parameters, and protocols now becoming more common. These serve as hard evidence of what can be reasonably expected of practitioners and can make it easier for a jury evaluating whether a malpractice defendant failred to meet the applicable SOC.
What agency sets and enforces quality standards for ambulatory surgical facilities???
Quality Standards are set and enforced either by government regulation, through a licensing process, or by accreditation by private organizations such as the Accreditation Association for Ambulatory Health Care (AAAHC)....which is an independent accreditation organization whose principle activities are to develop standards, conduct surveys, and confer accreditation on ambulatory health care providers.
In the US and Canada, "hospital-based" ambulatory surgcial facilities receive accreditation through The Joint Commission.
How is Macroshock, or electrocution, prevented in the OR???
Macroshock, or electrocution, is prevented by isolating the OR power supply from ground, via an isolation transformer which is not grounded, and provides 2 live ungrounded voltage lines for OR equpiment.
What are the first 2 actions to take in an airway fire??....what are the next actions???
The first action to take in an airway fire is to 'simultaneously'....
1. Stop Ventilation and Remove the ETT
2. Turning Off/ Disconnecting the Oxygen
The sequence of subsequent actions varies (order differs slightly in different texts) but includes....
3. Pour saline into the airway
4. Remove burning materials
5. Mask ventilation and Re-intubation
6. Diagnose the injury (bronchoscopy or laryngoscopy)
7. Administer short-term steroids
8. Monitor for at least 24 hours
9. Administer antibiotics
10. Provide ventilatory support
What 4 actions can be taken for the patient who will undergo laser surgery???
1. Eyes are taped and covered with moist gauze
2. 25-30% FiO2 administered with Nitrogen (air) or Helium
3. Fire resistant ETT is used
4. ETT cuff filled with NS (& methylene) as precaution against inadvertant hit by the laser.
What are 5 perceived barriers to patient safety in regard to patient outcomes???
1. The culture of blame in the health care system....an individual is targeted for blame
2. Poorly designed report systems
3. The prime focus on error reporting is not seen as a way to prevent sentinel events, rather people fear job loss, litigation, and negative publicity
4. Lack of hierarchial teamwork
5. The healthcare system expects perfection from all individuals at all times.