Understaffing in Anesthesiology Linked to Patient Deaths, ComplicationsJuly 20, 2022
Insufficient anesthesiologist staffing practices were linked with increased surgical patient morbidity and mortality, a retrospective, matched cohort study found.
In the study of over half a million patients, the risk-adjusted patient morbidity and mortality rate at 30 days was significantly higher when care teams had an anesthesiologist supervising three to four overlapping surgeries rather than one or two (5.75% vs 5.06%, respectively; adjusted OR 1.15, 95% CI 1.09-1.21, P<0.001), reported Sachin Kheterpal, MD, MBA, of the University of Michigan in Ann Arbor, and colleagues.
In addition, the morbidity and mortality rate was also higher in teams with an anesthesiologist covering two to three overlapping operations (5.25%) rather than just one or two (adjusted OR 1.04, 95% CI 1.01-1.08, P=0.02), the authors noted in JAMA Surgery.
“Cost reduction efforts often target high fixed-cost anesthesiology services, assuming that increased clinical responsibilities are noninferior to lower patient to anesthesiologist staffing ratios,” wrote Kheterpal and team. “Understanding the potential association with the quality of patient care is necessary to inform clinical care staffing decisions.”
In an accompanying commentary, Martin Almquist, MD, PhD, of Skåne University Hospital in Lund, Sweden, noted that “the complex procedure of anesthetizing a patient, temporarily removing consciousness and sensation, is often condescendingly referred to simply as turnover by surgeons.”
“However,” he continued, “just as surgeon competence, skill, volume, and experience are important for patient outcomes, data are accumulating showing that the number, skill, and experience of anesthesia staff are also of great importance for outcomes.”
The results of this study are in line with other studies showing the consequences of staffing shortages, the study authors said.
“Studies in the nursing field have shown that institutions with higher patient to nurse ratios have higher rates of overall patient death, death after complications (failure to rescue), and other adverse events,” wrote Kheterpal and co-authors. “Increased physician clinical workload has led to decreased quality of care and poor clinical outcomes, with specific examples found among internal medicine hospitalists and critical care intensivists.”
For this study, the team of researchers used data from the Multicenter Perioperative Outcomes Group electronic health record registry and included 578,815 adult patients (mean age 55.7, 55.1% women) who underwent a major noncardiac inpatient surgical procedure from January 2010 through October 2017 at 23 U.S. academic and private hospitals.
Patients were categorized as follows:
- Group 1: those that had an anesthesiologist covering one operation (48,555 patients)
- Group 1-2 (reference group): more than one to no more than two overlapping operations (247,057 patients)
- Group 2-3: more than two to no more than three overlapping operations (216,193 patients)
- Group 3-4: more than three to no more than four overlapping operations (67,010 patients)
Propensity score-matching was used to create balanced sample groups considering patient-, operative-, and hospital-level confounders.
The primary composite outcome was 30-day mortality and the occurrence of six major surgical morbidities: cardiac, respiratory, gastrointestinal, urinary, bleeding, and infectious complications.
Overall, morbidity and mortality occurred after 30,026 operations — 30-day mortality occurred after 2,607 operations, cardiac complications after 5,133, respiratory complications after 6,645, gastrointestinal complications after 6,694, urinary complications after 5,093, bleeding complications after 4,457, and infectious complications after 4,963 operations.
Kheterpal and colleagues also found a higher risk of patient morbidity and mortality when they compared surgeries where an anesthesiologist was covering only one operation to those where they were overseeing one to two (5.48% vs 5.06%, respectively; adjusted OR 1.09, 95% CI 1.02-1.16, P=0.01).
“If 1:1 staffing occurred only with higher-acuity operations, substantial variation from the reference group (group 1-2) might be expected; however, the rationale for staffing 1:1 could include both high-risk patients (requiring more attention) and low facility caseloads (i.e., idle clinicians). These findings may not be relevant to typical anesthesia practice,” they wrote.
The authors also noted that the cohort of hospitals observed may not be representative of all clinical environments, which was a study limitation. Furthermore, they acknowledged the possibility of unmeasured confounders, such as intraoperative patient acuity, proximity of operating rooms, and surgeon stress levels.
Kheterpal reported receiving grants from the NIH, Blue Cross Blue Shield of Michigan, Merck, Apple, and Becton Dickinson outside the submitted work. One co-author reported serving as a paid consultant for TRYP Therapeutics outside the submitted work.