Year : 2020 | Volume
| Issue : 1 | Page : 28-32
Variability in risk tolerance and adherence to guidelines in “go or no-go” decisions among anesthetists in Saudi Arabia
Sara M Alkassimi1, Razan A Habib1, Abeer A Arab2, Abdulaziz M Boker3
1 Department of Anesthesia and Critical Care, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
2 Consultant of Anesthesiology, Department of Anesthesia and Critical Care, King Abdulaziz University, Jeddah, Saudi Arabia
3 Consultant of Anesthesiology, Department of Anesthesia and Critical Care; General Supervisor, Clinical Skills and Simulation Center, King Abdulaziz University, Jeddah, Saudi Arabia
Dr. Abdulaziz M Boker
Department of Anaesthesiology and Critical Care, General Supervisor of Clinical Skills and Simulation Center, King Abdulaziz University Hospital, P. O. Box: 80215, Jeddah
Source of Support: None, Conflict of Interest: None
|Date of Submission||21-Apr-2019|
|Date of Acceptance||28-May-2019|
|Date of Web Publication||6-Jan-2020|
Background: Anesthetists deal with many situations where they decide whether proceeding with anesthesia is safe or not. These are termed “go or no-go” decisions. Although guidelines have been developed to ensure safe anesthesia, many factors affect anesthetists' decision in practice. Therefore, we aimed to assess the variability in risk tolerance when making “go or no-go” decisions among anesthetists in Saudi Arabia.
Materials and Method: A questionnaire-based study that included anesthetists practicing in Saudi Arabia from 1--14th October 2017 was conducted. The questionnaire presented 11 clinical scenarios that involved deviation from guidelines, followed by four questions where the participants were asked to decide whether they would proceed with administering anesthesia, write a comment explaining their decision, to predict whether a colleague would make the same decision, and if they had a previous similar experience.
Results: A total of 124 anesthetists responded, of which 56.5% were consultants. There was no absolute consensus over the decision to proceed in any scenario. Most of the respondents who would proceed (67.35%) expected a colleague to make the same decision. Anesthetists who encountered a previous similar experience were more likely to proceed (P = 0.000). There was no significant difference among the respondents' decisions according to years of experience (P = 0.121). Analysis of the comments showed that procedure urgency and presence of alternatives to deficient resources were the most frequent factors that dictated anesthetists' decision.
Conclusion: There is a wide variation in risk tolerance among anesthetists. Further simulation-based studies are needed to identify and address factors that affect anesthetists' decisions.
Keywords: Anesthesia; clinical decision-making; patient safety
|How to cite this article:|
Alkassimi SM, Habib RA, Arab AA, Boker AM. Variability in risk tolerance and adherence to guidelines in “go or no-go” decisions among anesthetists in Saudi Arabia. Saudi J Anaesth 2020;14:28-32
|How to cite this URL:|
Alkassimi SM, Habib RA, Arab AA, Boker AM. Variability in risk tolerance and adherence to guidelines in “go or no-go” decisions among anesthetists in Saudi Arabia. Saudi J Anaesth [serial online] 2020 [cited 2020 Nov 23];14:28-32. Available from: https://www.saudija.org/text.asp?2020/14/1/28/275097
| Introduction|| |
In the field of health care, anesthesiology is acknowledged as the leading specialty invested in patient safety. Many solutions to safety issues have been developed, including incorporating technologies (i.e., in patient monitoring) and identifying solutions for human and system factors that contribute to unsafe practices. Anesthesia and aviation are often compared with each other regarding the improvements in safety. In aviation, the pilot decides whether the aircraft can operate safely or not based on preflight checks. This decision is termed “go or no-go” decision. There are strict “go or no-go” safety standards applied to aid the pilot in making that decision.
Similarly, anesthetists deal with a wide spectrum of situations where they decide if it is safe or not to proceed with anesthesia. International standards and national guidelines have been developed to assist the anesthetist in making those decisions and minimize critical incidents., However, these guidelines were not strictly and uniformly followed as reported by Greiget al., who found considerable variability in risk tolerance among anesthetists. Safe administration of anesthesia should be a priority to physicians and can be accomplished by strict application of evidence-based guidelines.,,
We hypothesize that there is significant inconsistency in risk tolerance and adherence to guidelines among anesthetists in decision making. Therefore, the aim of our study was to assess the level of variability in risk tolerance when making “go or no-go” decision among anesthetists in Saudi Arabia and identify factors that affect the anesthetist when making those decisions.
| Materials and Method|| |
This is a cross-sectional questionnaire-based study that was approved by the Ethical committee of our institution; (Ref. No. 511--17). The study included anesthetists practicing in Saudi Arabia during the study period, whom are estimated to be 800 physicians. The required sample size calculated with 95% confidence interval was 260. Data were collected via a self-administered electronic questionnaire that was distributed online for 2 weeks (October 1--14th, 2017).
The questionnaire used in our study was originally developed by Greiget al. The corresponding author was contacted and the original questionnaire used in their research was obtained with the author's consent to use it in our research. It consisted of 11 scenarios which were constructed after reviewing critical incident data related to anesthesiology [Table 1]. Each scenario presented a clinical situation implicating that guidelines were not fulfilled, followed by four questions where the participants were asked to decide whether they would proceed with the case and rate their answer to this question using a four-point Likert scale, write a comment explaining their decision, whether they had a previous similar experience to the presented case, and to predict whether a colleague with similar experience would make the same decision. The second part of the questionnaire covered demographic data and details about anesthesia training of the participants.
The original questionnaire was reviewed by the authors prior to distribution to determine its relevance and applicability based on current guidelines and standards of anesthesia practice followed in Saudi Arabia. Minor modifications were made in order to use familiar terminology. English language was used in constructing and responding to the questionnaire. A pilot study was conducted on a small group and no difficulties were encountered.
Continuous variables were presented as mean and standard deviation (SD). Categorical variables were presented as frequencies and percentages. Participants' comments were analyzed using thematic analysis. The association between the decisions to proceed with the procedure (definitely would not, probably would not, probably would, definitely would) and level of practice, total number of years of practice, main place of training, and encountering a previous similar situation were examined by χ2 test. The analysis was performed in 95% confidence interval. P value of <0.05 was considered significant. The analysis was performed using Statistical Package for Social Science (SPSS), version 20 (IBM, Armonk, NY, USA).
| Results|| |
A total of 124 anesthetists practicing in Saudi Arabia answered the questionnaire with a response rate of 15.5% [Table 2]. The mean age of all respondents was 42.95 (8.7) years, with 108 (87.1%) male and 16 (12.9%) females. As per level of practice, 70 (56.5%) were consultants, 20 (16.1%) were senior specialist\senior registrar, 26 (21.0%) were specialists, and eight (6.5%) were residents. Most of the respondents had their main training in anesthesia outside Saudi Arabia (90\123, 73.2%), but all of the respondents were currently practicing in Saudi Arabia.
The anesthetists' responses regarding the decision to proceed or not in each case scenario varied widely [Supplementary Table] [Additional file 1]. There was no absolute consensus over the decision to proceed in any scenario. However, a majority of decision was observed in multiple scenarios. In scenarios one, 10, and 11, the majority decision was (not to proceed with the case) chosen by 91.1%, 72.6%, and 80.7% of respondents in each scenario, respectively. In contrast, 70.97% and 83.9% chose to proceed with the case in scenarios three and eight, respectively.
Most anesthetists predicted that colleagues would agree with their decision. Of those who chose “to proceed” in suboptimal conditions, 67.4% expected that a colleague with similar experience would make the same decision. On the other hand, 46.98% of those who chose “not to proceed” expected a colleague with similar training to cancel as well.
Anesthetists with different levels of practice (e.g., consultant, senior specialist, specialist, and resident) gave statistically similar answers regarding the decision to proceed or not (P value 0.18). Variability in decision making was also statistically nonsignificant across the different categories of number of years of practicing anesthesia (P value 0.1). However, when scenarios were analyzed individually, anesthetists with 10 or more years of experience were more likely to cancel the procedure in scenario 11 compared with anesthetists with less years of practice (1--9 years) (P value 0.02). Respondents who encountered a previous similar situation to the scenarios presented were more likely to proceed with the procedures (P value 0.000). There was no statistically significant difference in the decision to proceed when the respondents were compared by the place where they have received the anesthesia training (Saudi Arabia versus other countries) (P value 0.13) [Table 3].
Thematic analysis of the comments showed that procedure urgency, the perceived consequences of the decision especially if the consequences were expected to be harmful to the patient, and the presence of alternatives to deficient resources were the most frequent factors that dictated anesthetists' decisions. Many respondents would proceed in the presence of alternatives, especially when the procedure is an emergency. Others mentioned they would cancel until optimal conditions are achieved. Additional factors mentioned in the comments include the presence or lack of resources, adherence to standards, and guidelines and presence of a hospital policy.
| Discussion|| |
The study found a wide variation in decision making among anesthetists in Saudi Arabia, which is consistent with previous reports. Even in scenarios where guidelines were clearly not met and a complete “no-go” decision was expected, there were still opposing decisions. For example, in scenario one, there was a majority agreement to cancel the procedure justified by many of the respondents that it would be unsafe to proceed with a nonfunctioning gas analyzer as it carries a risk of awareness and transmitting dangerously high levels of the anesthetic agent to the patient. However, there were still few respondents who chose to proceed, explaining that total intravenous anesthesia could be used safely. On the other hand, a majority decision to proceed was observed in scenarios three and eight. In the eighth scenario, which described that ultrasound was not available for venous catheter insertion, most anesthetists have decided to proceed, particularly those who encountered a previous similar situation. This decision was supported by many participants due to the urgency of the procedure mentioned in the case (abscess drainage) and their experience in central venous catheter (CVC) insertion without ultrasound guidance by relying on anatomical landmarks. Although the evidence supports the use of ultrasound to guide CVC insertion in adult patients as it has been found to reduce the number of complications and increase the safety and quality of CVC placement, most respondents were confident with the blind technique.,
The practice of quality anesthesia care requires anesthesiologists to maintain their physical and mental health. This principle was violated in scenario eleven, which asked whether anesthetists would proceed with the list if they had a 3-day history of flu-like symptoms and pyrexia. Respondents with 10 or more years of experience were more willing to cancel the list, explaining that it will affect the anesthetist's concentration and efficiency, and there is a risk of transmitting the infection to the patients.
Senior anesthetists were found to proceed in suboptimal conditions more than trainees as reported by Greiget al. In contrast, our study found similar decisions among anesthetists across different levels of practice, years of practice, and places of receiving anesthesia training (Saudi Arabia versus other countries). Encountering a previous similar experience was the only strong influencer on decision making in our study. Respondents who encountered a previous similar situation were more likely to proceed than those who did not.
In scenario 10, regarding working with fatigue and few hours of sleep, many mentioned that according to their hospital policy, a day off is given after on-calls and thus ensuring that this scenario is prevented. Similarly, many factors are encountered by anesthetists which may affect their decision including resource availability, external pressure, and procedure urgency. Stating a hospital policy to ensure optimal conditions before commencing with anesthesia is one of the solutions to avoid deviation from guidelines and adopt a safe work environment.
Although the anesthetists' decisions varied widely in all scenarios, most of them expected a high level of agreement with their decision from their peers. Unexpectedly, respondents who chose to proceed “go decision” expected that a colleague with similar experience would make the same decision (67.4%) more than those who chose to cancel the procedures “no-go decision” (46.98%). The expectation that peers would agree with the anesthetists' decision describes that the action of deviating from guidelines is perceived as acceptable or that the environment, resources, and necessity to maintain productivity dictates their decision. Regardless, when deviation from guidelines is believed to be acceptable and tolerated just to maintain productivity, errors occur which jeopardize the patient safety.
We are knowledgeable of some unavoidable limitations in our study. First, this research was conducted using a questionnaire that presented scenarios with critical incidents. This method of data collection provides less information on the actual behavior of the respondents in these situations. Observing the anesthetists in real-life critical incident or simulation-based studies would be more accurate and informative. However, details that were given in the free text response for each decision have confirmed the credibility of the responses and results.
| Conclusion|| |
Anesthetists are frequently compelled to work in conditions that are not ideal due to many individual and organizational factors. Hence, strict application of guidelines and standards of practice would decrease the variability in decision making regardless of the factors confronted by anesthetists and ensure safe administration of anesthesia.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gaba DM. Anaesthesiology as a model for patient safety in health care. BMJ 2000;320:785-8.
Kaissi A. “Learning” from other industries: Lessons and challenges for health care organizations. Health Care Manag 2012;31:65-74.
Checketts MR, Alladi R, Ferguson K, Gemmell L, Handy JM, Klein AA, et al
. Recommendations for standards of monitoring during anaesthesia and recovery 2015: Association of anaesthetists of Great Britain and Ireland. Anaesthesia 2016;71:85-93.
Hartle A, Anderson E, Bythell V, Gemmell L, Jones H, McIvor D, et al
. Checking anaesthetic equipment 2012: Association of anaesthetists of Great Britain and Ireland. Anaesthesia 2012;67:660-8.
Greig PR, Higham HE, Darbyshire JL, Vincent C. Go/no-go decision in anaesthesia: Wide variation in risk tolerance amongst anaesthetists. Br J Anaesth 2017;118:740-6.
Halkes MJ, Snow D. Re-use of equipment between patients receiving total intravenous anaesthesia: A postal survey of current practice. Anaesthesia 2003;58:582-7.
He C, Vieira R, Marin JR. Utility of ultrasound guidance for central venous access in children. Pediatr Emerg Care 2017;33:359-62.
Saugel B, Scheeren TWL, Teboul JL. Ultrasound-guided central venous catheter placement: A structured review and recommendations for clinical practice. Crit Care 2017;21:225.
Sinha A, Singh A, Tewari A. The fatigued anesthesiologist: A threat to patient safety? J Anaesthesiol Clin Pharmacol 2013;29:151-9.
] [Full text]
Beatty PC, Beatty SF. Anaesthetists' intentions to violate safety guidelines. Anaesthesia 2004;59:528-40.
[Table 1], [Table 2], [Table 3]