Trends in quality of anesthesia care associated with changing staffing patterns, productivity, and concurrency of case supervision in a teaching hospital

Background. The authors used continuous quality improvement (CQI) program d ata to investigate trends in quality of anesthesia care associated with cha nging staffing patterns in a university hospital. Methods: The monthly proportion of cases performed by solo attending anesth esiologists versus attending-resident teams or attending-certified register ed nurse anesthetist (CRNA) teams was used to measure staffing patterns. An esthesia team productivity was measured as mean monthly surgical anesthesia hours billed per attending anesthesiologist per clinical day, Supervisory ratios (concurrency) were measured as mean monthly number of cases supervis ed concurrently by attending anesthesiologists. Quality of anesthesia care was measured as monthly rates of critical incidents, patient injury, escala tion of care, operational inefficiencies, and human errors per 10,000 cases . Trends in quality at increasing productivity and concurrency levels from 1992 to 1997 were analyzed by the one-sided Jonckheere-Terpstra test. Results: Productivity was positively correlated with concurrency (r = 0.838 ; P < 0.001). Productivity levels ranged from 10 to 17 h per anesthesiologi st per clinical day. Concurrency ranged from 1.6 to 2.2 cases per attending anesthesiologist. At higher productivity and concurrency levels, solo anes thesiologists conducted a smaller percentage of cases, and the proportion o f cases with CRNA team members increased. The patient injury rate decreased with increased productivity levels (P = 0.002), whereas the criticalincide nt rate increased (P = 0.001). Changes in operational inefficiency, escalat ion of care, and human error rates were not statistically significant (P = 0.072, 0.345, 0.320, respectively). Conclusions: Most aspects of quality of anesthesia care were apparently not effected by changing anesthesia team composition or increased productivity and concurrency. Only team performance wits measured; the role of individu als (attending anesthesiologist, resident, or CRNA) in quality of care was not directly measured. Further research is needed to explain lower patient injury rates and increases in critical incident reporting at higher concurr ency and productivity levels.