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Search and rescue: think globally and act locally.

January 2014 • Volume 118 • Number 1 Copyright © 2013 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000000018 The current issue of Anesthesia & Analgesia features a study from Odegard et al.1 describing changes in the incidence of cardiac arrest over time in the catheterization laboratories at the Children’s Hospital Boston. The study spans a 5-year period during which over 7000 catheterizations were performed, placing it among the busiest pediatric catheterization laboratories in the world. It compares 2 periods (2004–2005 vs 2006–2009) during which a substantial number of changes occurred: expanded facilities, increased patient volume, greater number of anesthesia staff, evolving intervention technologies,an enhanced system of communication and coordination among the various clinicians. The cardiac anesthesia service, which provides exclusive anesthesia coverage for catheterization, was engaged to provide sedation or anesthesia for a larger proportion of patients in the recent era (67% vs 51%) while sedation of the remaining patients was managed by a nurse at the direction of the catheterizing cardiologist. Two findings are particularly noteworthy. The overall incidence of cardiac arrest (0.96 per 100 catheterizations) is as high as the rate for cardiac surgery in the same institution (0.8 per 100 surgeries)2 and as much as 35-fold higher than the arrest rate for pediatric anesthetics in prior reports.3–6 Although the proportion attributed to sedation or anesthetic management during catheterization is lower compared with cardiac surgery (10% vs 27%),1,2 the incidence of anestheticrelated cardiac arrest during catheterization remains 4to 15-fold higher than cardiac arrest rates during pediatric anesthesia, depending on study populations and attribution definitions.3–6 This has become a high-risk area where training and practice standards have not kept pace. While credentialing bodies and training accreditation by the Accreditation Council for Graduate Medical Education focus exclusively on cardiopulmonary bypass procedures, Odegard et al.1 have demonstrated, at least by this metric, that interventional catheterization poses comparable risk. Although catheterization procedures do not typically result in dramatic blood loss or surgical tissue injury, these investigators describe profound hemodynamic effects caused by interventional catheters. In the hands of experienced cardiologists and cardiac anesthesiologists, anticipation, rapid recognition, and effective intervention lead to a rescue rate of 94%, although 26% required extracorporeal membrane oxygenation resuscitation. Many or perhaps most pediatric catheterization laboratories do not enjoy this level of anesthesia expertise. As the catheter technologies continue to evolve, one can expect these trends to accelerate and add growing numbers of patients deemed to be poor surgical candidates. Yet the question as to the optimal qualifications for those managing sedation (and resuscitation) during these high-risk procedures remains unanswered. Second, the incidence of cardiac arrests actually fell from 1.5 to 0.7 per 100 procedures in the more recent period. Many changes may have contributed to this improvement; new facility, more available cardiac anesthesia resources, higher proportion of cases managed by the cardiac anesthesia service, and new emphasis on communication and coordination between cardiologists and anesthesiologists. Other potential factors were not quantified: patient variables, case complexity, advancing technologies, and cardiologist experience. Thus, we will only be able to speculate on the cause(s) of this impressive improvement. Perhaps, given all the variables that are unique to each institution in such a dynamic area of clinical practice, expecting more precise conclusions is unrealistic. Nevertheless, this study establishes a benchmark that other institutions should strive to achieve or surpass. Given the myriad imponderables that may have an impact on outcomes in any institution, the most important message to take from this work is that rigorous, comprehensive, continuous outcome measurement coupled with regular multidisciplinary discussion of adverse events are the most powerful engines of local improvement. Each institution will have its own mix of patients, providers, and technologies. Rather than extrapolate an isolated component (e.g., cardiac anesthesiologists should provide all catheterization coverage), one needs to make those decisions on the basis of institutional outcome measures in the context of all the characteristics of a given environment. If one can match or surpass the remarkable results reported by Odegard et al.1, you are on the right track. While publication of studies such as this may help identify and frame the questions to ask, the solutions are much more likely to evolve locally. This study joins a growing number of reports in which comprehensive outcomes databases have shed light on areas of practice risk that ultimately guide improvement initiatives.7–10 They illustrate the importance of local information systems in improving outcomes. Developing the systems that enable us to search for these improvement opportunities and the Search and Rescue: Think Globally and Act Locally