1. PURPOSE
To establish a structured Anesthesia & Procedural Sedation Quality Program that defines (1) what is measured (KPIs), (2) how performance is monitored (audits/registries), (3) how results are reported and reviewed, and (4) how improvement actions are planned, implemented, and sustained, including compliance monitoring for anesthesia/sedation documentation, PACU discharge processes, sedation adverse event reporting, and equipment safety checks.
2. SCOPE
This policy applies to anesthesia and sedation services delivered in:
- OR (Operating Rooms)
- PACU (Phase I and PACU-equivalent recovery areas)
- NORA (Non-Operating Room Anesthesia and anesthesia-supported procedural sedation locations)
It applies to all anesthesia professionals, privileged sedation providers, PACU staff, anesthesia technologists, quality/safety staff, data analysts, and departmental leadership.
5. PROCEDURES
5.1 L1 — Anesthesia & Sedation KPI Program (What You Measure; Reporting Cadence)
5.1.1 Governance Structure
- A. Establish an Anesthesia Quality & Safety Committee (or equivalent governance group) with defined terms of reference.
- B. Minimum membership: Head of Anesthesia (chair or delegate), PACU representative, sedation program lead, anesthesia technologist lead, quality/patient safety representative, and data/IT support.
- C. The committee approves KPI definitions, targets, reporting cadence, and action plans.
5.1.2 KPI Design Rules (Mandatory for Each KPI)
Each KPI must have:
- Name and rationale
- Numerator and denominator
- Inclusion/exclusion criteria
- Data source(s) (EHR/AIMS, PACU record, sedation record, incident reports, equipment check logs)
- Reporting cadence (monthly/quarterly)
- Target/threshold and trigger for escalation
- Assigned owner responsible for action when target not met
5.1.3 Minimum KPI Set (Department Standard Catalogue)
The department shall implement KPIs in the following domains (minimum list; add local priorities as needed):
- A) Safety Outcomes
- Perioperative cardiac arrest (OR/NORA/PACU)
- Numerator: number of arrests requiring CPR/defibrillation
- Denominator: total anesthesia cases + anesthesia-managed sedations
- Stratify by location (OR/NORA/PACU)
- Unplanned re-intubation / airway rescue in PACU
- Numerator: unplanned advanced airway placement or re-intubation in PACU
- Denominator: total PACU admissions
- Unplanned ICU transfer from PACU
- Numerator: unplanned ICU admission from PACU
- Denominator: total PACU admissions
- LAST events (regional anesthesia related)
- Numerator: suspected/confirmed LAST events requiring rescue actions/lipid
- Denominator: total regional blocks (single-shot + catheter)
- Sedation adverse events (moderate/deep)
- Numerator: events meeting registry definitions (see L4)
- Denominator: total moderate/deep sedations
- B) Process/Compliance (High-Value)
- Pre-anesthesia assessment completion rate
- ASA Physical Status documented
- Airway assessment documented
- Antibiotic prophylaxis time check documented in checklist flow (when applicable)
- Anesthesia machine daily check completion
- Difficult airway cart check completion
- MH cart / LAST kit check completion (where adopted)
- C) Recovery Quality (PACU)
- PACU discharge criteria documentation rate (including score use) (استطلاع)
- PACU exceptions documented when discharge criteria not fully met (استطلاع)
- PACU pain reassessment within defined time after intervention
- PONV rescue effectiveness (persistent vomiting rate)
- D) Efficiency / Flow (Balancing Measures)
- PACU length of stay outliers (e.g., > defined percentile)
- Case delays attributable to anesthesia readiness issues (equipment, missing consent, missing assessment)
5.1.4 Reporting Cadence and Review
- A. Monthly dashboard (core KPIs, trend lines, top 3 risks).
- B. Quarterly quality review (deep dive into outliers, event narratives, action plan progress).
- C. Immediate escalation to leadership for sentinel/high-severity events (e.g., death, severe neurologic injury, confirmed MH/LAST with arrest), with rapid review and action.
5.1.5 Escalation Triggers (Standard)
- A. KPI below target for 2 consecutive reporting cycles, or severe outlier in one month.
- B. Any event cluster (≥2 similar high-severity events in 30 days).
- C. Any equipment readiness failure associated with patient harm.
5.2 L2 — Record Completion Audit (Anesthesia Record + Sedation Record)
5.2.1 Audit Standard
Anesthesia documentation should be accurate and thorough across the phases of anesthesia-related care. (ASA)
Procedural sedation should have documented pre-assessment, monitoring, discharge instructions, and reporting of adverse events/close calls when appropriate. (publicshare.albertahealthservices.ca)
5.2.2 Audit Tool (Minimum Sections)
- A) Anesthesia Record Completion
Audit elements include (minimum):
- Patient identifiers and procedure
- Pre-anesthesia assessment present
- ASA class documented
- Airway assessment documented
- Consent documented
- Intra-anesthesia monitoring data recorded at appropriate intervals
- Medications documented (name/dose/route/time)
- Airway management documented (device/attempts/confirmation/complications)
- Fluids/blood products/EBL documented where relevant
- Adverse events documented and actions recorded
- OR→PACU handover documented (when applicable)
- B) Sedation Record Completion
Audit elements include (minimum):
- Pre-sedation assessment documented (Hx/PE, ASA class, airway screen, baseline vitals, NPO when applicable)
- Monitoring documented at required frequency (vitals + SpO₂; ECG/capnography when indicated by local rule)
- Sedation medications documented with time/dose/route
- Recovery observations documented
- Discharge criteria and discharge instructions documented (publicshare.albertahealthservices.ca)
- Adverse events/close calls documented and considered for reporting (publicshare.albertahealthservices.ca)
5.2.3 Sampling and Frequency
- A. Monthly random sample (minimum 20 cases or ≥2% of cases, whichever is larger), stratified by:
- OR vs NORA
- adults vs pediatrics (if applicable)
- anesthesia vs sedation
5.2.4 Scoring and Targets
- A. Use a checklist score: “complete / incomplete” per element.
- B. Define thresholds:
- Critical fields (patient ID, ASA, airway, key vitals, medications, airway management, discharge criteria) must be ≥95% compliance.
- Overall completion target: ≥90–95% depending on baseline performance.
5.2.5 Corrective Actions
- A. Feedback to individuals and unit leads within 14 days of audit.
- B. Template fixes (EHR mandatory fields) when systemic gaps are identified.
- C. Re-audit targeted elements within the next cycle.
5.3 L3 — PACU Discharge Compliance Audit (Score Use; Exceptions Documentation)
5.3.1 Audit Standard
All patients are continuously monitored during the recovery period/PACU and monitoring continues until the patient is stable and safely discharged meeting defined PACU discharge criteria. (استطلاع)
5.3.2 Audit Elements (Minimum)
- A. PACU admission documentation present (arrival vitals + airway/oxygen plan).
- B. Monitoring frequency documented according to PACU policy.
- C. Recovery score tool use documented (Aldrete/PAR or local tool) at required times.
- D. Discharge criteria documented (Phase I → ward/ICU/day surgery).
- E. Exceptions: If discharge occurred with exceptions, the rationale and authorization are documented, with mitigation and escalation plan. (استطلاع)
- F. Transfer handover documented (PACU → ward/ICU).
5.3.3 Sampling and Frequency
- A. Monthly sample of PACU discharges (e.g., 30 charts/month), stratified by:
- day surgery vs inpatient
- high-risk (OSA, elderly/frail, major surgery) vs routine
5.3.4 Reporting and Action
- A. Report compliance rate monthly with top 3 failure modes (e.g., missing score, missing exceptions documentation).
- B. Implement corrective actions: staff education, PACU documentation templates, discharge workflow redesign.
5.4 L4 — Sedation Adverse Event Registry (Program Registry + Reporting)
5.4.1 Registry Requirement
All adverse events and close calls occurring with patients receiving procedural sedation should be considered for reporting through the organizational safety reporting system. (publicshare.albertahealthservices.ca)
5.4.2 Registry Case Definitions (Minimum Dataset)
The registry shall capture events during sedation and recovery (until discharge criteria met), including at minimum:
- Apnea or assisted ventilation required
- Airway obstruction requiring airway maneuvers/adjuncts/CPAP
- Oxygen desaturation below defined threshold requiring intervention
- Hypotension requiring vasopressor or significant fluid bolus
- Bradycardia requiring atropine or escalation
- Aspiration or suspected aspiration
- Unplanned reversal agent use (naloxone/flumazenil)
- Unplanned escalation to anesthesia/rapid response/code
- Unplanned admission/ICU transfer related to sedation
- Medication error related to sedation (wrong drug/dose/route)
(If the facility uses a standardized sedation adverse event tool, it may be adopted to improve consistency; examples exist in published adverse sedation event reporting tools. (EMed))
5.4.3 Minimum Registry Fields
- Patient age group (adult/ped), ASA class
- Location (ED/endoscopy/IR/cath/CT/MRI/other)
- Intended sedation level (minimal/moderate/deep)
- Medications used (classes)
- Monitoring used (SpO₂, ECG, capnography)
- Event type, time, severity (no harm/harm), interventions performed
- Disposition (home/ward/ICU)
- Reporting status (incident report number)
5.4.4 Review and Feedback
- A. Monthly review of registry trends by Sedation Oversight (or anesthesia quality committee).
- B. Immediate review of severe events (intubation, cardiac arrest, aspiration with respiratory failure).
- C. Use registry findings to update privileging/training, monitoring requirements, and site readiness.
5.5 L5 — Equipment Check Compliance Audit
5.5.1 Equipment Checks Included (Minimum)
- A. Anesthesia machine daily check (documented).
- B. Difficult airway cart daily check and post-use restock.
- C. Crisis carts/kits where applicable (MH cart, LAST kit).
- D. Key monitoring equipment readiness checks in NORA sites (monitor availability, MRI-compatible monitoring readiness when applicable).
5.5.2 Audit Method
- A. Weekly spot checks in multiple areas (OR core + at least one NORA site + PACU).
- B. Verify:
- check log completed (date/time/signature)
- tamper seal intact where used
- critical items present and in date
- any defects escalated and resolved
5.5.3 Targets and Actions
- A. Target compliance ≥95% for required checks.
- B. Immediate corrective action for missing or expired emergency items (remove from service until corrected).
- C. Trend repeated failures as system issues (staffing, supply chain, checklist design).
5.6 L6 — Annual Risk Assessment and Improvement Plan
5.6.1 Annual Risk Assessment Inputs (Minimum)
- A. KPI trends (12 months)
- B. Audit results and repeat failure modes
- C. Sedation adverse event registry trends (publicshare.albertahealthservices.ca)
- D. Incident reports (clinical + medication + equipment)
- E. Complaints/compliments and patient experience signals
- F. Staffing/competency risks, service expansion (new NORA sites), equipment changes
5.6.2 Risk Assessment Method (Standard)
- A. Use a defined risk matrix (likelihood × impact).
- B. Identify “Top 10” anesthesia/sedation risks for the year (department risk register).
- C. Assign risk owners and define controls (policies, training, equipment, monitoring).
5.6.3 Annual Improvement Plan (Required Content)
- A. 3–6 priority improvement projects (e.g., PACU discharge documentation, sedation monitoring compliance, equipment check reliability).
- B. For each project: aim statement, baseline, target, interventions, timeline, and measurement plan (PDSA cycles).
- C. Education plan and communication plan.
- D. Sustainability plan (standard work + re-audit schedule).
5.6.4 Annual Report
- A. Produce an annual anesthesia quality report summarizing: KPI performance, audit results, adverse event trends, completed improvement projects, and next year priorities.
- B. Share summary with hospital quality governance.