SALG Scholarship

I was moved beyond words when I received the offer to become the inaugural SALG-BIDMC quality and safety fellow. The fellowship is the result of a unique collaboration between the Royal College of Anaesthetists and the Association of Anaesthetists through the Safe Anaesthesia Liaison Group (SALG) and the Beth Israel Deaconess Medical Centre (BIDMC) in Boston, Massachusetts. It is an opportunity that pairs part time clinical work within the department of anaesthesia at the BIDMC with a part time fully funded Master of Healthcare Quality and Safety (MHQS) at Harvard Medical School.

I was initially nervous at the idea of moving to a new city, to work in a new environment, without any support, but at the time of writing this article (about three months into the fellowship) I can honestly say that this has been one of the most amazing and eye-opening experiences of my career. Even more exhilarating is the prospect of what I can and hope to achieve throughout the remainder of my time in Boston. The resources, support and opportunities are endless.

The clinical portion of the fellowship requires that UK trained anaesthetists be at the level of ST5 or above and have successfully completed the FRCA as well as the USMLE Step 1, 2CK and 2CS examinations. You are expected to perform clinical duties at the level of a fellow in the USA, which means being able to manage most of the cases that take place at the BIDMC with consultant supervision available. The BIDMC, located in Boston’s Longwood Medical Area, is a teaching hospital affiliated to Harvard Medical School and is a level-1 trauma centre. Its neighbours include Boston Children’s Hospital, Brigham & Women’s Hospital, the Dana Farber Cancer Institute and, further down the road, Massachusetts General Hospital and Massachusetts Institute of Technology. The BIDMC is split between two buildings, which are just across the street from each other, and has 651 beds, 39 operating rooms, 12 procedural rooms, and is staffed by nearly 100 consultant anaesthetists, 96 anaesthetic trainees and 20 certified registered nurse anaesthetists. The department also supports numerous remote locations within the hospital, which can include up to 42 remote anaesthetic locations per day! They offer care in a variety of surgical specialties: cardiothoracic, transplant including liver, kidney and pancreas, complex head and neck, neurosurgery, hepatobiliary, plastics, bariatric, vascular, trauma and obstetrics, in addition to a comprehensive pain and regional service. While the clinical role appears to be predominantly service provision, it is all within daytime working hours, with the requirement for once monthly weekend shifts and no evenings. Given that I am still in training, the department ensures I am allocated to operating lists that I am interested in and that are appropriate for my training needs.

The non-clinical portion of the fellowship, the MHQS programme at Harvard, is fantastic! The course curriculum is delivered in the form of lectures and tutorials from global experts and key figures in the patient safety world, including the Institute of Healthcare Improvement and Ariadne Labs. There is a considerable amount of reading required, but it’s clear how the content of the course lays the groundwork for a deeper understanding of patient safety. My fellow colleagues are physicians from around the USA (Philadelphia, New York, Boston, Los Angeles) as well as from around the world (Israel, Saudi Arabia, Azerbaijan, China, Nigeria). The ultimate goal of the programme is to teach the core ingredients of quality and safety, the nuts and bolts, the history, the progress and the science. From a qualitative systems approach to improvement, to statistical process control, clinical informatics and so on, with the ultimate goal of applying this in an operational context at the BIDMC (a project described as a Capstone). Throughout the duration of the course, you are considered a Harvard student and have access to everything that Harvard University has to offer!

Absence of anaesthetic assistants

My journey began as I arrived into Boston on a Saturday, unpacked my things on a Sunday and promptly reported to work at the BIDMC on Monday, 1 July. I was nervous starting my first day in theatres, worried that perhaps my technical skills would not hold up. But I was delighted to discover several similarities; that propofol worked the same way in the USA as it does in the UK, that a difficult airway is managed with a similar level of anxiety, and that high-risk patients are appreciated as such based on the same assessment and examination! What was strikingly different, however, was the absence of anaesthetic assistants and induction rooms, the earlier start times, and the presence of dedicated anaesthetic Omnicells inside each theatre. An attending anesthesiologist (aka consultant anaesthetist) is allocated to your theatre, to offer help and supervision, but they are also likely to be responsible for supervising another theatre at the same time, or perhaps coordinating the entire theatre suite activities for that day. Patients are pre-assessed and consented in ‘holding areas’, which is also where nerve blocks and epidurals are sited pre- operatively. Some of the more subtle differences in practice are in the language, the preferred use of brand names for medication (e.g. Dilaudid, Versed, Zofran, Toradol), and the fact that dates are written as month/day/year.

In the hospital, the training schedule for junior colleagues is intense, they have fewer vacation days, but their logbooks get filled up quickly and the level of support is excellent. The anaesthetic department at the BIDMC has made huge strides in the way it promotes and values quality and safety. As part of a no- blame culture, they hold weekly Morbidity and Mortality meetings which are focused entirely on systems issues, transparency and lessons learned. They provide a peer support group in the event of a serious untoward incident, and they involve all trainees in a root cause analysis (RCA) exercise to help them gain quality assurance experience and tools. As the quality and safety fellow, I participate in several safety committee meetings, I mentor a group of residents in their RCA exercise and review all serious incidents.

Overall, the fellowship is designed in such a way as to complement the clinical and non-clinical work seamlessly. The two departments ‘speak to each other’ to help you manage your time and your rota. The current arrangement is broadly speaking two days a week in theatres, two days a week at Harvard and one day per week dedicated to protected research time. Yes, I am even involved in a research project using big data! At the end of my two years, I hope to stimulate change and incorporate safety incentives within BIDMC and develop collaborations between UK, USA and international safety scholars. After this fellowship, I aspire to be at the forefront of cultural change in healthcare quality and safety in anaesthesia, across the UK and globally.

Boston as a city is absolutely fantastic! The city is bustling with excitement, with excellent restaurants, museums, musical venues and places to explore. It has a rich history and culture, in particular in anaesthesia, and is the home of the Ether Dome! The Charles river divides Cambridge from Boston and is probably one of the most beautiful rivers to cycle along after a hard day’s work! Picture water that is peacefully calm, with the setting sun glistening over it, with the faint sound of rowing oars touching the water and a baby duck waddling along the path beside you. The classic Bostonian accent, which is just awesome in my opinion, can be heard at a Red Sox game. And since the BIDMC is the hospital of the Boston Red Sox, that means you can watch a game for a mere $5!

Suffice to say, my nerves have now settled.

Liana Zucco
SALG-BIDMC Safety Scholar
Beth Israel Deaconess Medical Centre & Harvard Medical School, Boston, USA