|Year : 2016 | Volume
| Issue : 1 | Page : 13-16
Adverse events survey in the postanesthetic care unit in a teaching hospital
Mohamed Sayed Hajnour1, Patrick S K Tan2, Abdelazeem Eldawlatly1, Tariq A Alzahrani1, Abdulaziz E Ahmed1, Rashid Saeed Khokhar1
1 Department of Anesthesia, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
2 Department of Anesthesia, University Malaya Medical Centre, Kuala Lumpur, Malaysia
|Date of Web Publication||25-Oct-2016|
Mohamed Sayed Hajnour
Department of Anesthesia, King Khalid University Hospital, King Saud University, P. O. Box 7805, Riyadh 11472
Source of Support: None, Conflict of Interest: None
Background and Objectives: This is a survey study of adverse events in the postanesthesia care unit (PACU) at the University Malaya Medical Center (UMMC).
Patients and Methods: After obtaining the hospital ethics committee approval, 2704 patients who were operated and admitted to the PACU at UMMC were included in the survey. The survey period was from July 1, to September 30, 2005. The modified Aldrete score was used in the PACU. If it was <9 on a 10-point scale that was defined as a patient complication. A patient diagnosed with a complication was immediately notified by the recovery nurse to the attended anesthesiologist who managed the case, and a survey report was completed.
Results: Nearly 9.7% reported incidents of adverse events included two accidents of cardiac arrests. The majority of which were due to hypothermia and cardiovascular instability. Most incidents were in American Association of Anesthetists 3 and 4 category. General surgery was associated with the highest incidents. Most of the incidents resulted in prolonged PACU stay.
Conclusions: This study provides auditing information on adverse incidence in the PACU with issues of care delivery; besides, it highlights a roadmap for quality improvement for a better patient care.
Keywords: Anesthesia; postanesthesia care unit; survey on adverse events
|How to cite this article:|
Hajnour MS, Tan PS, Eldawlatly A, Alzahrani TA, Ahmed AE, Khokhar RS. Adverse events survey in the postanesthetic care unit in a teaching hospital. Saudi J Laparosc 2016;1:13-6
|How to cite this URL:|
Hajnour MS, Tan PS, Eldawlatly A, Alzahrani TA, Ahmed AE, Khokhar RS. Adverse events survey in the postanesthetic care unit in a teaching hospital. Saudi J Laparosc [serial online] 2016 [cited 2019 May 21];1:13-6. Available from: http://www.saudijl.org/text.asp?2016/1/1/13/193040
| Introduction|| |
The role of the postanesthesia care unit (PACU) has evolved from passive observation to an important determinant of speed of recovery and discharge of patients. It is, therefore, important to identify the types of problems encountered in this area and their mode of presentation and areas for improvement. The incidents in the PACU may be attributed to different reporting techniques, patient populations, or both.  In a prospective study on the complications in the PACU in a teaching hospital, a figure of 23.7% was reported.  So far, there are few data on PACU incidents from developing countries such as those in South-East Asia. Previous studies have identified the overall incidents of adverse events occurring in the PACU as 5%-30%.  In a study of 37,079 patients in the PACU, minor complications were reported in 22.1% and major complications in 0.2%.  Both the Closed Claims Study in the United States and the Australian Incident Monitoring Study (AIMS) have highlighted the importance of PACU and the potential for serious adverse events that may occur there. The factors associated with postoperative complications are site and nature of surgical operation, duration of anesthesia, American Association of Anesthetists (ASA) physical status of the patient, anesthetic technique, and whether the procedure is elective or emergency.  This is a survey study of adverse events in the PACU at the University Malaya Medical Center (UMMC).
| Patients and Methods|| |
The survey on adverse events was conducted at the PACU and included all patients who underwent surgical procedures under anesthesia at UMMC. Two thousand seven hundred and four patients were included in the survey. Exclusion criteria included all day case patients and pediatrics (age <18 years). Reporting was a voluntary of actual or potential incidents. Features of the reporting form were a combination of tick boxes that related to patients' demographic data, contributing and alleviating factors, suggested corrective strategies, and outcomes of the adverse event. At the end of a patient's stay in the PACU, the nurse scored the modified Aldrete score before discharging the patient to the ward. If it was <9 on a 10-point scale that was defined as a patient complication.  Any complication was immediately notified to the anesthesiologist in charge of the patient, then he completed the self-reporting survey form. Completed data forms were collected daily from the postcall anesthetists and from the nurse documentation.
PASCA is a specialized surgical Intensive Care Unit (SICU) bed slot within the PACU area to be utilized as a crash or temporal resolution when advanced care needed and no SICU bed available. Information about elective or emergency patient admissions to (PASCA)/SICU, taken from the OR documents.
All data were entered into an Excel spreadsheet (Microsoft Corporation, Seattle, WA, USA) and analyzed with respect to the following fields: Nature of surgery, surgical category, ASA status, outcome, presenting problem, contributing factors, and suggested corrective strategies. In case of presenting problem category overlaps, the presenting problem that appeared to be the most important in the development of the adverse event was designated as the main problem.
| Results|| |
Different types of adverse events were reported in 267 patients represented 9.7%. The most common adverse events were cardiovascular complications (56%) followed by hypothermia (54%) [Table 1]. We noted almost 81.2% of the adverse events occurred among patients in ASA groups 3 and 4 [Figure 1]. Adverse events were mainly associated with general surgery (35%), orthopedic surgery (18%), and gynecological surgery (15%) [Figure 2]. Forty percent of patients who had an adverse event ended with a prolonged stay in the PACU with 34% of them admitted to the PASCA/SICU [Figure 3]. Patient factors were perceived by the recovery doctor to have accounted for 45% of adverse events [Figure 4].
|Figure 1: Distribution of American Association of Anesthetists Groups 1-4 among adverse events. Blue: American Association of Anesthetists 3, green: American Association of Anesthetists 2, red: American Association of Anesthetists 1, pink: American Association of Anesthetists 4|
Click here to view
|Figure 2: Incident of adverse event and type of surgery. ENT: Ear, Nose, and Throat surgeries, GS: General surgery, Gyne: Gynecological procedures, OBS: Obstetrics procedures, ORTHO: Orthopedics procedures|
Click here to view
|Figure 4: Recovery doctor's perception of principal contributing factors to adverse events. INADEQUATE BLOOD CRO: Inadequate blood crossmatch, INADEQUATE COMMUNICA: Inadequate communications|
Click here to view
| Discussion|| |
In the present survey, the incidence of adverse events was 9.7% which was similar to previous studies. , It is also important to note that complications occurred predominately in general surgical and orthopedics procedures. Anecdotal experience from the institution suggests that patients recovering from major orthopedic surgeries have undergone long and complex surgery and utilize nursing and recovery area resources to a higher degree than other groups. Often, these patients are not fulfilling ICU admition criteria, but also not stable enough to be returned immediately to the general wards. Similar findings have been noted in the AIMS, with the majority of incidents occurred in PACU following general/orthopedic surgery. 
Although 85% of survey population was young, the adverse events were 6.8% only; but in older age group, adverse events accounted for 29%. Moreover, ASA 3 and 4 category patients were associated with 81.1% of the incidents. It is well known that advanced age is associated with comorbidities such as hypertension, diabetes mellitus, and ischemic heart disease. This may be the reason why our findings vary from those of Hines et al. prospective survey of over 38,000 patients, in which most of the adverse events occurred in patients who were of ASA status 1-2.  In our survey, 56% of adverse events were cardiovascular due to hypotension and/or tachycardia. These could be attributed to many factors such as hypovolemia and/or hypothermia.
Respiratory incidents account for a significant proportion (24%) of adverse events. This compares with a range of 9%-55% in international data. , Hypoventilation accounts for the majority of the respiratory incidents due to inadequate reversal of nondepolarizing muscle relaxants. The recommendation for objective assessment of all patients who have received neuromuscular blockade is strongly supported not only for the prevention of inadequate ventilation but also for the prevention of awareness.  Many minor PACU adverse events have an important impact on resource utilization. In the survey, almost 40% of adverse events required prolonged stay in PACU. Bothner et al. reported an incidence of 6% of adverse events which prolonged recovery stay in 26%. 
Cardiac arrest occurred in two patients (0.7%) with similar causes due to uncontrolled bleeding. Poor communication among health-care givers and between health-care givers and patients is important contributing factor to incidents. This factor was also deemed to be significant in a similar study, reflecting inadequate patient preoperative preparation. , Improvement in written, verbal, and electronic transmission of information needs to be addressed as a matter of urgency. In the study, 45% of the principal contributing factors were due to patient factors because most of the patients had poorly optimized comorbid diseases. In addition, the data showed a significant relationship between duration of surgery and shivering, postoperative pain severity, and delayed recovery.
There are limitations to our survey, that it did not cover day case procedures and pediatrics, they are of special consideration and needed a different approach in PACU, also whole year duration auditing surveys reduce the bias and get better results, but it was practically difficult.
| Conclusions|| |
Survey studies provide a wealth of clinical information from possible corrective strategies and conclusions can be suggested. Three recommendations can be made. First, the PACU is an extremely important facility that requires considerable institutional support. Second, adequate staff number and competencies are required for this facility. Nursing staff should be skilled in airway management, cardiovascular manipulation, drug delivery, and other organ support. Third, adequate measures to prevent intraoperative hypothermia must be practiced because the latter has major effects on metabolism, which endangers patient safety. The treatment of hypothermia consumes a large amount of limited and expensive resources. To reduce the incidence of PACU adverse events and stay, such problems should be identified and treated as soon as possible.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hines R, Barash PG, Watrous G, O'Connor T. Complications occurring in the postanesthesia care unit: A survey. Anesth Analg 1992;74:503-9.
Bennett-Guerrero E, Welsby I, Dunn TJ, Young LR, Wahl TA, Diers TL, et al.
The use of a postoperative morbidity survey to evaluate patients with prolonged hospitalization after routine, moderate-risk, elective surgery. Anesth Analg 1999;89:514-9.
Bothner U, Georgieff M, Schwilk B. The impact of minor perioperative anesthesia-related incidents, events, and complications on postanesthesia care unit utilization. Anesth Analg 1999;89:506-13.
Zeitlin GL. Recovery room mishaps in the ASA Closed Claims study. ASA Newsl 1989;53:28-30.
Van der Walt JH, Webb RK, Osborne GA, Morgan C, Mackay P. The Australian incident monitoring study. Recovery room incidents in the first 2000 incident reports. Anaesth Intensive Care 1993;21:650-2.
Kluger MT, Bullock MF. Recovery room incidents: A review of 419 reports from the anaesthetic incident monitoring study (AIMS). Anaesthesia 2002;57:1060-6.
Rose DK, Byrick RJ, Cohen MM, Caskennette GM. Planned and unplanned postoperative admissions to critical care for mechanical ventilation. Can J Anaesth 1996;43:333-40.
Moller JT, Wittrup M. Hypoxia in the post anesthesia care unit. Anesthesiology 1990;75:890-5.
Bergman IJ, Kluger MT, Short TG. Awareness during general anaesthesia: A review of 81 cases from the anaesthetic incident monitoring study. Anaesthesia 2002;57:549-56.
Tennant I, Augier R, Crawford-Sykes A, Ferron-Boothe D, Meeks-Aitken N, Jones K, et al.
Minor postoperative complications related to anesthesia in elective gynecological and orthopedic surgical patients at a teaching hospital in Kingston, Jamaica. Rev Bras Anestesiol 2012;62:188-98.
Poorsheykhian M, Emami Sigaroodi A, Kazamnejad E, Raoof M. Incidence of post general anesthesia complications in recovery room. J Guilan Univ Med Sci 2012;21:8-14.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]