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

  1. Type of healthcare facility:

Small Hospital/Health Centre District/Provincial Referral

  1. How many inpatient beds does your healthcare facility have?

<100 100-300 300-1000+

  1. How many operating rooms does your hospital have? -

How many are equipped for major surgery? -

How many are equipped for minor surgery? -

Personnel

  1. 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 -

  1. Do you believe there are enough anesthesia providers in your facility for the safe practice of anesthesia?

YES NO Sometimes

  1. 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

  1. 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 )

  1. Is there a process of certification and accreditation for the practice of anesthesia?

YES NO

  1. Do you believe you wereadequately trained to usethe available anesthesia equipment?

YES NO Sometimes

  1. 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

  1. Are patients evaluated by an anesthesia professional prior to administration of anesthesia with formulation of an appropriate anesthetic plan?

YES NO Sometimes

  1. Is an anesthesia professional immediately present with the patientthroughoutthe anesthetic?

YES NO Sometimes

  1. Do you utilize a checklist to confirmproperly functioning equipment is available before starting each anesthetic?

YES NO Sometimes

  1. Do you utilize the WHO Safe Surgery Checklist (locally modified if appropriate) for surgical procedures?

YES NO Sometimes

  1. Do you utilize a pre-anesthetic patient checklist prior to delivery of anesthesia?

YES NO Sometimes

  1. Are the details of each anesthetic documented in an anesthesia record?

YES NO Sometimes

  1. Is supplemental oxygen available to patients undergoing general anesthesia?

YES NO Sometimes

  1. Is pulse oximetry available for intraoperative anesthesia care?

YES NO Sometimes

  1. Is the airway and ventilation continuously monitored while providing anesthesia?

YES NO Sometimes

  1. Is adequacy of ventilation monitored with capnography?

YES NO Sometimes

  1. Is a “disconnect alarm” utilized during mechanical ventilation?

YES NO Sometimes

  1. Is circulation continuously monitored by palpation, auscultation, or display of the heart rate while providing anesthesia?

YES NO Sometimes

  1. Is arterial blood pressure measured at least every 5 minutes while providing anesthesia?

YES NO Sometimes

  1. Is there a means of measuring temperature at frequent intervals when indicated?

YES NO Sometimes

  1. Is depth of anesthesia regularly assessed by clinical observation or depth of anesthesia monitor?

YES NO Sometimes

  1. Are audible monitor signals and alarms activated at all times in the operating room?

YES NO Sometimes

  1. Is there the capability for continuous measurement of inspired/expired gas volumes in the operating room?

YES NO Sometimes

  1. Is there capability for measurement of inspired/expired volatile gas concentration in the operating room?

YES NO Sometimes

  1. Is your facility able to provide prolonged mechanical ventilation in the operating rooms or intensive care unit?

YES NO Sometimes

  1. Is post-anesthesia patient care transferred to appropriately trained personnel?

YES NO Sometimes

  1. Is a “handover protocol” followed for transfer of care from one anesthesia provider to another?

YES NO Sometimes

  1. Is there a designated area available for post- anesthesia care?

YES NO Sometimes

  1. Is pulse oximetry available for post-anesthesia care?

YES NO Sometimes

  1. 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