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Anesthesia Risk Alerts: A Novel Approach to Mitigating Risk in the OR


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By Leo Penzi, MD, Chief Medical Officer; Julie Marhalik-Helms, BSN, RN, Vice President, Quality Improvement; and Brent Lee, MD, MPH, FASA, Director, Clinical Excellence and Performance Improvement, North American Partners in Anesthesia (NAPA)


North American Partners in Anesthesia (NAPA) was recently honored with the 2022 John M. Eisenberg Patient Safety and Quality Awards National Level Innovation for its Anesthesia Risk Alerts (ARA) program. This effective protocol, implemented under NAPA’s Patient Safety Organization (PSO), provides anesthesia clinicians with novel mitigation strategies to better manage five high-risk clinical scenarios in the perioperative setting, including:

  1. known/suspected difficult airway
  2. patients with a body mass index (BMI) greater than or equal to 45
  3. American Society of Anesthesiologists (ASA) status 4 or 5
  4. pulmonary hypertension
  5. populations of patients at risk for operating room (OR) fire

We identified these five scenarios during quality improvement analysis of clinical outcomes data collected from approximately 6 million patients over a two-year period. NAPA’s 6,000 anesthesia clinicians report adverse event data on every patient cared for at the nearly 500 hospitals, ambulatory surgery centers, and offices we serve. In examining this data, we noticed that a number of adverse events were attributable to these particular high-risk clinical scenarios. Once we recognized the connection, we sought a way to reduce patient harm in these five targeted areas.

The ARA program acknowledges that variation in the clinical process of anesthetizing patients for surgery is normal and to be expected. By anticipating unexpected events, clinicians are positioned to monitor for those variations which might result in adverse events and take appropriate mitigation actions.

A Proactive Safety Approach

This “proactive safety” approach, classically described as “Safety II,” has historically been applied in other industries such as aviation, military, cybersecurity, and nuclear energy. In adapting this approach for the OR, we looked to these same industries for innovative techniques and practical solutions that foster an intentionally analytical and more collaborative model for clinical thought processing. These include dual process decision-making, cognitive debiasing, and red team/blue team methodology. Such strategies complement the intuitive thinking that clinicians are trained to enact. ARA methodology also incorporates published practice guidelines from national medical societies. The resulting ARA program recommends the following risk mitigation strategies for the five identified scenarios:

  1. Known or suspected difficult airway: second practitioner present to assist for induction and emergence for all general anesthetics
  2. BMI greater than or equal to 45: second practitioner present to assist for induction and emergence for all general anesthesia cases
  3. Pulmonary hypertension: consultation about the case with a second clinician
  4. American Society of Anesthesiologists (ASA) status 4 or 5: consultation about the case with a second clinician
  5. OR fire risk: follow fire mitigation protocols as prescribed by the local institution

Program Results

Within two years of implementing the ARA program in April 2019 across NAPA’s partner healthcare facilities nationwide, we achieved over 95% compliance with screening all patients for the five high-risk scenarios and performing the secondary risk mitigation strategy if warranted. During the same period our metrics indicated a significant decrease in the incidence of adverse events.

A welcome benefit of the ARA program is that by encouraging clinicians to work together in performing the mitigation strategies, ARA is promoting a perioperative safety culture and collaboration in and beyond the OR. Since implementing ARA, a NAPA anesthesiologist says, “One achievement for all the anesthesia clinicians at our site is that with this program our communication skills have greatly improved in discussing difficult cases and risk stratification with surgeons, administration, and other subspecialties like cardiology and pulmonology. We have also learned to better communicate with patients about the risks involved. It is worth noting that we have observed a significant change in culture during surgical time outs, where the circulating nurse is now more specifically speaking about fire risk. In addition, the preoperative team seems to be much more aware of ASA 4, pulmonary hypertension, low heart ejection fraction (EF), and difficult airways. They now take the time to alert us if and when they are privy to information before we are.”

NAPA is grateful to The Joint Commission and National Quality Forum for honoring the ARA program with the Eisenberg Award, and thereby sharing it with clinicians nationwide. This recognition acknowledges NAPA’s mission to be a catalyst of positive change. We are proud that our investments in quality are making meaningful contributions to improving patient safety for all.


Leo J. Penzi, MD, serves as Executive Vice President and Chief Medical Officer for NAPA. Dr. Penzi has spent the majority of his career as a clinical anesthesiologist. Since joining NAPA in 1991, he has served in many leadership roles, including as Executive Vice Chairman at one of NAPA’s quaternary care hospitals. He has also served on numerous hospital and health system leadership committees and has extensive experience in operating room operational efficiency, quality improvement, and patient safety. Dr. Penzi is a diplomate of the American Board of Anesthesiologists. He received his medical degree from New York University and completed his anesthesia residency training at NewYork-Presbyterian/Columbia University Irving Medical Center. Contact: .

Julie Marhalik-Helms, RN, BSN, is Vice President of Quality Improvement for NAPA. She has been recognized multiple times by Becker’s Hospital Review as one of “50 Experts Leading the Field of Patient Safety.” Ms. Marhalik-Helms is also the Vice President of The Anesthesia Business Group (ABG), which was co-founded by NAPA in 2003, and has served as Vice-Chair of the Anesthesia Business Group (ABG) Qualified Clinical Data Registry (QCDR) since 2015. From 2014 through 2018 she was also a member of the Practice Quality Improvement Council, a quality committee of the Anesthesia Quality Institute (AQI). Her broad patient safety agenda includes oversight of NAPA’s PSO, the NAPA Anesthesia Patient Safety Institute (NAPSI), and reporting to the Centers for Medicare and Medicaid Services (CMS) Merit-based Incentive Payment Systems (MIPS) program, among other quality initiatives. Prior to joining NAPA, Ms. Marhalik-Helms held various roles in the Bon Secours Health System and owned a consulting company providing compliance and accreditation support, including creation and implementation of quality, risk management, and infection control programs. She received her nursing degree from Old Dominion University. Contact: .

Brent Lee, MD, MPH, FASA, is an anesthesiologist and the Director of Clinical Excellence and Performance Improvement at NAPA. Dr. Lee received a Master of Public Health degree from the Harvard School of Public Health in Boston, MA, and previously served in the U.S. Public Health Service as an Epidemic Intelligence Service Officer at the Centers for Disease Control and Prevention (CDC). He received his medical degree from Brown University School of Medicine, completed his anesthesia residency at Georgetown University Hospital, and completed a fellowship in trauma anesthesia at the University of Maryland/Shock Trauma Center. Dr. Lee is a Fellow of the ASA. Contact: .