Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Operating Theatre Protocols
9.11 His letter stated:
“There have been a few incidents lately regarding the induction of
anaesthesia on young children. In the interest of safety and harmony,
these issues need resolution. I request that the Anaesthetic Department
review the available medical evidence and determine the best practice
related to childhood anaesthesia. Further I would appreciate the
development of written protocols to outline the appropriate
techniques/agents to be used within Gisborne Hospital. As the next
Theatre Management Committee is scheduled for March, perhaps the
committee could review this material at that time.”
9.12 Comments made by the Head of the Department (Anaesthesia) to the
investigation team suggest that he was not consulted by the Group Manager
(Hospital) about the need to develop protocols. When asked whether Mr
Madden talked with him about the need for protocols he replied: “No. There
isn’t a set standard in existence. I told Dan Madden there were practice
variations about whether to put the IV first or induce with gas. Both are
totally in line.”
9.13 The minutes of the Theatre Management Committee meeting held on 22
March 2000 do not disclose any discussion of best practice related to
childhood anaesthesia or protocols on the subject. THL confirmed, however,
that the matter was discussed at that meeting but the discussion was not
recorded in the minutes. Dr Lucas said there was no established practice at
Gisborne as far as he was aware. He said he asked for a protocol to be
established but the issue was not resolved before he left.
Audit report
9.14 The Gow/Gordon audit report recommended:
“Practice guidelines/protocols should be developed after review of the
literature and discussed with all parties in a multi-disciplinary forum
prior to endorsement and implementation.
There needs to be consideration given to leadership development,
including time for training and for clinical resources to be supplied in
order to free up clinical leaders to both undertake this development and
to apply it in practice. Staff will also require dedicated time in order to
discuss the particular guidelines in a dedicated forum. This may well
require additional resources from purchasing authorities.”
Appropriate standards
9.15 My expert anaesthetist advised that the induction of anaesthesia in children is
different from that in adults. The emotional aspects of entering the operating
room and the associated actions leading to induction can be quite frightening
for paediatric patients and their families. Paediatric anaesthetists have the
responsibility of quickly gaining the confidence of parents and children.
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