| Time: | 12:50 h to 13:27 h |
| Venue: | Anaesthetic Room, OT, North Tower, SJMC |
| Present: | Dr. Charlie Chan Dr. Ngun Kok Wah Dr. Lilian Oh Datuk Dr. Radha Dr. Alan Wong |
| Absent: | Dr. Dalina Abdul Majid Dr. Robert Liew Dr. Ng Kwee Peng Dr. Mary Samuel Dr. Bachan Singh Dr. Tan Poh Hwa Dr. Anne Wong |
Matter Under Discussion
Letter of Complaint
Discussion
Background
Datuk Dr. Radha said that Dr. Mary, who was unable to attend the meeting because she was doing a list at the time, had informed him that she was, in fact, the anaesthetist involved in the incident. Although the time between the end of the first case and the start of the second case was indeed 1 h 25 min, to say that this was solely due to her attendance of the CCU case is a gross exaggeration.
The bulk of the time had, in truth, been spent in the recovery room on the resuscitation of the first patient whose BP had dropped post-operatively. Dr. Mary, being the only anaesthetist free at the time, had responded to the call for help from CCU and immediately after intubating the patient in CCU was able to return to the OT because Dr. Ngun Kok Wah had gone to relief her and take over management of the patient. On return to the recovery room, she spent some more time on resuscitation of the post-operative patient before starting the second case on the list. Dr. Mary maintains that she was away for about 20 min and definitely not more than 25 min in any case.
Maintain Current System
Dr. Charlie Chan was of the opinion that the current system had generally served us well and was probably the most workable system and should be maintained.
In consonance with the decision made by at the Ad Hoc Code Blue Team Review meeting held on 19th April 2004, in a code blue or other acute emergency, whether it be in the Emergency Room (ER) or other part of the hospital, the medical officer from ER will be the first respondent. He will be responsible to assess the situation and decide on the need to call any consultants.
Should an anaesthetist be needed, the anaesthetists who were covering emergencies, or failing them, any anaesthetists who were free, would attend code blues or any other acute emergencies.
As first respondents, the importance of proper training of the ER medical officers in Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), and intubation cannot be overemphasised.
Intensivist
Dr. Alan Wong, however, felt that a better solution would be to have an intensivist to manage all critical patients. It was essential that all patients in the critical wards, perhaps with the exception of cardiothoracic cases, be under their care to ensure that the intensivist has sufficient remuneration for his commitment to the hospital. The anaesthetists will also have to pass over management of patients, including postoperative patients, to the intensivists.
He said that many studies have shown that management of critically ill patients by intensivists have improved outcome and costing, and have even resulted in earlier discharge from critical wards.
However, to implement this, he suggested that there be two or three intensivists who would take turns to cover the critical wards. When not covering the critical care wards they would do OT work. This way, they could take turns to do the calls and even cover one another when anyone of them goes on leave. He also stressed that medical officers would also be needed to give 24 h coverage in shifts in the critical wards as it was not possible for the intensivists to be present in the hospital 24 h a day even when they were on call.
Emergency Physician
Datuk Dr. Radha said that it was very unlikely that we would be able to convince all the doctors (medical and surgical) to jointly manage all patients admitted to the critical wards together with the intensivist. He suggested that an emergency physician with either MRCP or FRCS as their basic specialisation would better serve the needs of the hospital. Such a physician could be made in charge of the Emergency Room and be responsible to attend all emergencies including code blues. However, he would only work during office hours and the anaesthetists would still cover emergencies after office hours. Such a system would not require any doctor to give up his patients in critical wards.
Dr. Ngun Kok Wah felt this was not a good system because the anaesthetists would be left to cover the unsociable hours while another doctor covered the less demanding hours.
Other Relevant Factors
Datuk Dr. Radha also pointed out that,
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Interruption of elective lists due to code blues or other similar events necessitating the services of an anaesthetist were rare and usually of less than 30 min duration.
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The main cause of delays in lists has consistently been surgical, whether it be due to surgeons coming late or taking longer than expected for the surgery.
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In the case of obstetricians, delays may also occur when they have to go up to labour ward to deliver patients in between cases. Should we then have an obstetrician on standby to handle such deliveries so as not to interrupt or delay the OT lists?
With regard to the training of the hospital medical officers, Datuk Dr. Radha expressed disappointment that in spite of repeated reminders, the hospital had failed to send the medical officers for training in Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), and training in intubation as mentioned above.
It was suggested that a "postal survey" be done among the anaesthetists to get feedback on their opinions on the various suggestions.
Timing of Cases As In the Hospital Records
Relevant times as revealed by Ms Tan.
| Start of second case | 16:42 h |
| End of first case | 15:16 h |
| Turn around time | 1 h 26 min |
Ms Tan also confirms that the major part of the turn around time in question was due to Dr. Mary resuscitating the first post-operative patient. The staff nurse recovering the patient also supports this view and further added that when Dr. Mary returned from the code blue, she again spent some more time with this patient.
Decision
A survey is to be carried out among the anaesthetists to get their views on,
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The system they would recommend to the hospital.
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Maintain present system, where the medical officer will be the first respondent to all code blues and acute emergencies and when needed, the most available anaesthetist be called in.
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Introduce intensivists who will manage all critical care patients, except cardiothoracic patients, alone or jointly with the primary physicians. Anaesthetists doing OT work will not be involved in the management of any critical care patients.
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Introduce emergency physicians who will be in charge of Emergency Room and who will respond to all code blues and other acute emergencies. Anaesthetists will still be responsible for the care of all critical care patients. The emergency physician will pass the cases back to the relevant anaesthetist (anaesthetist already looking after the patient or the anaesthetist covering emergencies at the time the emergency was called).
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If intensivists are to be introduced,
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Whether the anaesthetist will be interested in being one of the intensivists. This will entail a reduction in OT work.
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The number of intensivists they think will be optimum.
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Their willingness to give up
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Attendance of code blues and other acute emergencies.
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Management of patients admitted to the critical care units.
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Management of postoperative cases going to ICU/CCU.
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If emergency physicians are to be introduced, their willingness to cover code blues and other acute emergencies outside of office hours.
Posted:- 27 Oct 2004
Updated:- 07 Nov 2004