ANESTHETIC CAPACITY QUESTIONNAIRE
This questionnaire is based on the “International Standards for a Safe Practice of Anesthesia” most recently revised by the World Federation of Societies of Anaesthesiologists (WFSA) in 2010(Merry AF et al. Can J Anaesth 2010;57:1027). The purpose of this questionnaire is to determine the level of anesthetic capacity, and provide guidance for improving or maintaining standards for the safe practice of anesthesia.
First Name:
Last Name:
Email address:
Healthcare facility name:
Healthcare facility address:
Please provide additional comments at the end of this questionnaire
Facility Level
- Type of healthcare facility:
Small Hospital/Health Centre District/Provincial Referral
- How many inpatient beds does your healthcare facility have?
<100 100-300 300-1000+
- How many operating rooms does your hospital have? -
How many are equipped for major surgery? -
How many are equipped for minor surgery? -
Personnel
- How many of the following anesthesia providers are regularly available in your hospital?
Top of Form
Anesthesiologist (Doctor) -
Anesthesia resident (Doctor) -
Nurse anesthetist -
Anesthesia assistant -
Anesthesia officer -
- Do you believe there are enough anesthesia providers in your facility for the safe practice of anesthesia?
YES NO Sometimes
- If anesthesia is provided by non-medical personnel, are these providers appropriately certified/accredited and supervised by medically qualified specialist anesthesia professionals?
YES NO Sometimes
Organization/Training
- Is there an available anesthesia organization setting standards of practice, supervision of anesthesia training, and providing continuing education/professional development?
YES NO Sometimes
(If yes, then at what level? National Regional Local )
- Is there a process of certification and accreditation for the practice of anesthesia?
YES NO
- Do you believe you wereadequately trained to usethe available anesthesia equipment?
YES NO Sometimes
- Do you participate in the review of current anesthesia practice with regular confidential discussions of appropriate topics and cases with multidisciplinary professional colleagues?
YES NO Sometimes
Clinical Practice
- Are patients evaluated by an anesthesia professional prior to administration of anesthesia with formulation of an appropriate anesthetic plan?
YES NO Sometimes
- Is an anesthesia professional immediately present with the patientthroughoutthe anesthetic?
YES NO Sometimes
- Do you utilize a checklist to confirmproperly functioning equipment is available before starting each anesthetic?
YES NO Sometimes
- Do you utilize the WHO Safe Surgery Checklist (locally modified if appropriate) for surgical procedures?
YES NO Sometimes
- Do you utilize a pre-anesthetic patient checklist prior to delivery of anesthesia?
YES NO Sometimes
- Are the details of each anesthetic documented in an anesthesia record?
YES NO Sometimes
- Is supplemental oxygen available to patients undergoing general anesthesia?
YES NO Sometimes
- Is pulse oximetry available for intraoperative anesthesia care?
YES NO Sometimes
- Is the airway and ventilation continuously monitored while providing anesthesia?
YES NO Sometimes
- Is adequacy of ventilation monitored with capnography?
YES NO Sometimes
- Is a “disconnect alarm” utilized during mechanical ventilation?
YES NO Sometimes
- Is circulation continuously monitored by palpation, auscultation, or display of the heart rate while providing anesthesia?
YES NO Sometimes
- Is arterial blood pressure measured at least every 5 minutes while providing anesthesia?
YES NO Sometimes
- Is there a means of measuring temperature at frequent intervals when indicated?
YES NO Sometimes
- Is depth of anesthesia regularly assessed by clinical observation or depth of anesthesia monitor?
YES NO Sometimes
- Are audible monitor signals and alarms activated at all times in the operating room?
YES NO Sometimes
- Is there the capability for continuous measurement of inspired/expired gas volumes in the operating room?
YES NO Sometimes
- Is there capability for measurement of inspired/expired volatile gas concentration in the operating room?
YES NO Sometimes
- Is your facility able to provide prolonged mechanical ventilation in the operating rooms or intensive care unit?
YES NO Sometimes
- Is post-anesthesia patient care transferred to appropriately trained personnel?
YES NO Sometimes
- Is a “handover protocol” followed for transfer of care from one anesthesia provider to another?
YES NO Sometimes
- Is there a designated area available for post- anesthesia care?
YES NO Sometimes
- Is pulse oximetry available for post-anesthesia care?
YES NO Sometimes
- Are appropriate efforts maintained to prevent and treat post-operative pain?
YES NO Sometimes
Bottom of Form
Medications
Are the following medications regularly available? Write additional comments next to answer:
Ketamine injection (inj)YES NO Sometimes
Lidocaine 1% or 2% injYES NO Sometimes
Diazepam injYES NO Sometimes
Midazolam inj YES NO Sometimes
Meperidine (pethidine) inj YES NO Sometimes
Morphine injYES NO Sometimes
Epinephrine inj YES NO Sometimes
Atropine injYES NO Sometimes
Atracurium injYES NO Sometimes
Pyridostigmine injYES NO Sometimes
Inhaled anesthetic YES NO Sometimes
If yes, then please specify:
Nitrous Oxide
Isoflurane Sevoflurane Desflurane
Halothane Ether
______
Thiopental injYES NO Sometimes
Succinylcholine (Suxamethonium) injYES NO Sometimes
Pancuronium injYES NO Sometimes
Neostigmine injYES NO Sometimes
Lidocaine 5% intrathecalYES NO Sometimes
Bupivacaine 0.5% intrathecalYES NO Sometimes
Hydralazine injYES NO Sometimes
Furosemide injYES NO Sometimes
Dextrose 50% injYES NO Sometimes
Aminophylline injYES NO Sometimes
Ephedrine injYES NO Sometimes
Hydrocortisone injYES NO Sometimes
______
Propofol injYES NO Sometimes
Rocuronium injYES NO Sometimes
Vecuronium injYES NO Sometimes
Cisatracurium injYES NO Sometimes
Phenylephrine injYES NO Sometimes
Norepinephrine injYES NO Sometimes
Dopamine injYES NO Sometimes
Dobutamine injYES NO Sometimes
Milrinone injYES NO Sometimes
Amiodarone injYES NO Sometimes
Magnesium injYES NO Sometimes
Nitroglycerine injYES NO Sometimes
Calcium chloride injYES NO Sometimes
Potassium chloride injYES NO Sometimes
Equipment
Are the following equipment available and in functional condition? Write additional comments next to answer:
Adult/pediatric self-inflating breathing bags and masksYES NO Sometimes
Manual or electric suctionYES NO Sometimes
StethoscopeYES NO Sometimes
SphygmomanometerYES NO Sometimes
ThermometerYES NO Sometimes
Pulse oximeter (adult and pediatric probes)YES NO Sometimes
Oxygen concentrator or tank oxygen with tubingYES NO Sometimes
Laryngoscopes (Macintosh blades 1-4) and batteriesYES NO Sometimes
BougiesYES NO Sometimes
Examination glovesYES NO Sometimes
IV infusion/drug injection equipmentYES NO Sometimes
Suction catheters (16F)YES NO Sometimes
Endotracheal tubes (3-8.5mm)YES NO Sometimes
Oral airways (000-4)YES NO Sometimes
Nasal airwaysYES NO Sometimes
______
Complete anesthesia machine YES NO Sometimes
Pediatric anesthesia system YES NO Sometimes
VaporizersYES NO Sometimes
Bellows or bag to inflate lungsYES NO Sometimes
Face masks of various sizesYES NO Sometimes
Adult and pediatric resuscitator setsYES NO Sometimes
Oxygen supply failure alarm; oxygen analyzerYES NO Sometimes
Capnograph and sampling linesYES NO Sometimes
Defibrillator (one per operating room/ICU suite)YES NO Sometimes
Electrocardiograph monitorYES NO Sometimes
Electrocardiograph electrodesYES NO Sometimes
IV pressure infuser bagYES NO Sometimes
IV fluids (NS, LR, D5W) YES NO Sometimes
Magill forceps
Nasogastric tubes (10-16F)YES NO Sometimes
Spinal needles (22g, 25g)YES NO Sometimes
Peripheral nerve stimulatorYES NO Sometimes
Automatic non-invasive blood pressure monitorYES NO Sometimes
Sterile glovesYES NO Sometimes
Batteries size CYES NO Sometimes
______
Infusion pumps (2 per OR/ICU room)YES NO Sometimes
Electric warming blanketYES NO Sometimes
Electric overhead heaterYES NO Sometimes
Infant incubatorYES NO Sometimes
Laryngeal mask airways (sizes 2,3,4)YES NO Sometimes
Depth of anesthesia monitor (e.g. BIS) YES NO Sometimes
Ventilator circuitsYES NO Sometimes
Yankauer suckersYES NO Sometimes
Water trapsYES NO Sometimes
Comments (Please provide any additional comments or concerns below):
Developed by Adrian W Gelb & Pablo Guzman for WFSA