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Standards in anaesthesia

Standards in anaesthesia. Iain Moppett. @ IainMoppett. Declarations. Deputy Director Health Services Research Centre National Emergency Laparotomy Audit Hip fracture Peer reviews National Hip Fracture Database Guidelines NICE Quality Standards Committee

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Standards in anaesthesia

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  1. Standards in anaesthesia Iain Moppett @IainMoppett

  2. Declarations Deputy Director Health Services Research Centre National Emergency Laparotomy Audit Hip fracture Peer reviews National Hip Fracture Database Guidelines NICE Quality Standards Committee AAGBI Guideline working groups: Fragility Fracture Network Safe Surgery Lead Nottingham University Hospitals Rainbow Trays

  3. Biased?

  4. Biased?

  5. Australian anaesthetists

  6. Australian anaesthetists

  7. Opinions These are my opinions – based on my interpretation of the evidence • You are welcome to disagree • I am almost certainly wrong

  8. Opinions Anaesthetic and perioperative care should be based on the needs of the patient, not the desires of the anaesthetist, surgeon or service set-up

  9. Standards are the bedrock of person-centred care

  10. Standards Don’t tell me what to do I’m a highly trained professional! Tell me what to do Standardisation would help my patients!

  11. Standards Guidelines and standards Clinical guidelines Endorsed guidelines Supported standards Joint statements Statements Professional documents

  12. Standards Guidelines and standards Clinical guidelines Endorsed guidelines Supported standards Joint statements Statements Professional documents

  13. Standards

  14. Standards

  15. Grand plan Why standards? Setting standards Problems

  16. Why standards? Reduce variation Driver for improvement Headspace Transparency of expectation Safety Quality of care Efficiency Equity

  17. Unwarranted clinical variation Five-fold difference across the UK Spinal decompression rates Length of acute hospital stay (UK) Moppett unpublished Atlas of Variation Australia 2017

  18. Unwarranted clinical variation ICU Bed Numbers ICU admissions per 100 admissions Wong et al BJA 2019 GIRFT-ICU

  19. Drivers for change? National Hip Fracture Database (E,W& NI) 2018

  20. Setting expectations

  21. STANDARD • Identical repetition • Compliance • Procedures • Deviation Hand washing & skin asepsis WHO Anaesthetic machine check Drug preparation? Standards of documentation

  22. Drug trays

  23. ROUTINE • Similar but not identical repetition • Selection • Clinical guidelines • Error Spinal vs general anaesthesia SGA vs TT Choice of operation Analgesia pathways

  24. NON-ROUTINE • Non-repetitive • Interpretation • Intuition • Failure The ‘difficult case’ Competing priorities Time / information pressure

  25. Minimal dose anaesthesia White et al. Anaesthesia 2016

  26. Most variation is due to the anaesthetist and the system not the patient

  27. Setting standards

  28. Setting standards Proper evidence

  29. Setting standards Proper evidence Dodgy evidence Theoretical evidence Opinion

  30. Setting standards Proper evidence Dodgy evidence Theoretical evidence Opinion That’s OK!

  31. Setting standards ‘Everything should be made as simple as possible, but no simpler’ Einstein, 1950ish

  32. Setting standards What if the standards are wrong?

  33. Setting standards What if they’re right? Fail fast

  34. Setting standards – the 80% guide Expect adherence 80% of the time >80% • Unthinking • Misleading data <80% • Wrong standards • Cultural problems

  35. I can’t tell my colleagues what to do?

  36. Which is more important? • Your colleagues’ professional pride? • Your patients’ quality of care?

  37. Nudge Consensus JDI and tell them afterwards

  38. Anaesthetists are trained to deal with uncertainty – writing standards can’t be that hard

  39. Problems Innovation The real world Boredom

  40. Innovation Refinement / evolution ✓ ︎ Revolution ?

  41. Work… Work-as-prescribed Work-as-imagined Work-as-disclosed Work-as-done Credit: Steve Shorrock. The Varieties of Human Work https://humanisticsystems.com/2016/12/05/the-varieties-of-human-work/

  42. Work… Work-as-imagined Work-as-prescribed Work-as-disclosed Work-as-done Credit: Steve Shorrock. The Varieties of Human Work https://humanisticsystems.com/2016/12/05/the-varieties-of-human-work/

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