A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com.
Comparisons between the airline industry and anesthesia care are common. One of the most commonly heard analogies is that the takeoff and landing of a jetliner are similar to induction and emergence during a general anesthetic. But there are other equally important analogies between the two professions. Today, payers, health care organizations and medical providers are focused more than ever on cutting costs. In this environment, it is helpful to look at other similarities between aviation and anesthesiology.
In the United States, both industries have exemplary safety records, but that was not always the case. In 1929, there were 51 fatal commercial airline accidents; today, that would equate to about 7,000 fatal accidents per year. The actual incidence of fatal accidents in commercial airlines today is about one in 1 million. Similarly, anesthesia-related mortality has declined from one death per 1,000 anesthesia procedures in the 1940s, to one in 10,000 in the 1970s, to one in 100,000 in the 21st century. In its 1999 report, To Err Is Human: Building a Safer Health System, the Institute of Medicine recognized anesthesiology as the only medical profession to reduce medical errors and increase patient safety.
In both aviation and anesthesiology, these increases in safety resulted from multiple factors, including improvements in:
- Technology
- Safety science: process standardization (i.e., Six Sigma methodology) and use of checklists that reduce the likelihood of human error
- Continuous Quality Improvement: systematic review of processes, implementation of changes and measurement of improvements
- Education and training
In this era of focused cost-cutting, some would argue that education and training are an unnecessary expense. In 2010, Michael O’Leary, the CEO of budget airline Ryanair, argued that many commercial flights need only one pilot. Asked what would happen if the lone pilot became ill and a co-pilot were not available, he responded that a flight attendant could be trained to land the plane if necessary. While many at the time disregarded O’Leary’s statement as a cheap publicity stunt, his argument should give us pause, whether we work in aviation or anesthesia.
Late last year, without advance notice, the Veteran Affairs Health System proposed a new nursing handbook. The proposed handbook would a) replace care currently provided in a team fashion with a requirement that all advanced practice registered nurses attain independent status, b) strip VA chiefs of anesthesiology from decision-making and shift control to the VA Washington, D.C. office and c) eliminate scope of practice as defined by state law. This decision was made without input from any VA chiefs of anesthesiology and without regard for the existing anesthesia service handbook.
As with the system employing a pilot and co-pilot in the cockpit, why would anyone disrupt the collaborative model for anesthesia care currently in place throughout the VA Health System? Why would the CEO of an airline disregard the contribution of pilot training to safety and argue that a flight attendant with abbreviated training could land a jet? Such an argument ignores the fact that piloting a jet — and administering anesthesia care — is not just a technical act. These skills require extensive education and training, the type that reduces risk and ensures safety. There is no definitive evidence that independent anesthesia care by nurse anesthetists is equivalent to that provided by the care team when a physician anesthesiologist is involved. In fact, independent studies show just the contrary.
Education and training do matter. Anesthesia care is not just a technical exercise.
There is one difference between these two situations. While consumers have the choice to fly or not fly in a plane with one pilot, veterans will not have a choice regarding their anesthesia care if the new VA nursing handbook is adopted.
James R. Mesrobian is an anesthesiologist.
