The anesthesia team of the future

Karsten Bartels, Atilio Barbeito and G. Burkhard Mackensen

Department of Anesthesiology, Duke University
Medical Center, Durham, North Carolina, USA
Correspondence to G. Burkhard Mackensen, MD, PhD,
FASE, Associate Professor of Anesthesiology, Box
3094 Anesthesiology, Duke University Medical Center,
Durham, NC 27710, USA
Tel: +1 919 684 6025; fax: +1 919 681 8993;
e-mail: b.mackensen@duke.edu
Current Opinion in Anesthesiology 2011,
24:687692

Purpose of review
This review is aimed at highlighting the recent developments and opportunities that are
likely to impact the anesthesia team of the future.
Recent findings
The anesthesia team of the future aims to provide well tolerated, efficient, and costeffective perioperative care. Certified and subspecialty trained anesthesiologists lead
a diverse team of care providers in increasingly dissimilar environments. The spread
of electronic health record systems has been the basis for the development of
clinical decision support applications that promise to integrate quality control,
enhanced efficiency, research opportunities, and improved patient care in the
perioperative period. Perioperative epidemiology is a likely area of growth within the field
of anesthesiology ultimately enabling the anesthesia team to translate precise real-time
information into improved outcome.
Summary
The anesthesia team of the future will require the anesthesiologist to provide expertise
across the entire domain of perioperative medicine. Meaningful decision support
systems rely on accurate data analysis and incorporation of current clinical guidelines
and recommendations.
Keywords
anesthesia team, perioperative epidemiology, perioperative medicine
Curr Opin Anesthesiol 24:687692
2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
0952-7907

Introduction
Changing clinical demands, technological advances, and
the extension of anesthetic care across the entire perioperative continuum are redefining the current practice
of anesthesia. Developments such as large-scale patient
safety initiatives, availability of credentialed subspecialty
training programs, increasing utilization of electronic
health records (EHRs), the implementation of outcomesbased evidence into clinical practice, as well as the establishment of value-based purchasing in healthcare will
continue to affect how we provide care for our patients.
Meeting the challenge of improving cost-effective perioperative clinical care, engaging in high-quality research,
and advancing educational opportunities for our trainees
necessitates a broad vision for the anesthesia team of
the future. This review considers the current and future
clinical practice patterns of the perioperative anesthesia
team, discusses the impact of technology on how this team
operates and utilizes information, and describes to what
extent these developments can be translated into novel
concepts that include epidemiologic considerations.

perioperative care. These aims are a reflection of a passionate commitment to the care of surgical or critically ill
patients as well as those in acute or chronic pain, and our
commitment to continually improve the anesthetic care
we provide. The anesthesia care team is directed by
an anesthesiologist and consists of physicians, including
anesthesiologists, fellows, and resident physicians in training as well as nonphysicians such as anesthesia assistants,
physician assistants, and specialized registered nurses,
including advanced practice registered nurse practitioners
(ARNPs), certified registered nurse anesthetists (CRNAs),
and pain management specialist registered nurses [1]. All
these care providers take on unique tasks in the preoperative clinic, inside the operating room, the postoperative
care unit (PACU), the ICU, or the pain clinic. Increasingly,
they also find themselves performing cases in nontraditional anesthetizing locations such as gastroenterology
suites, the electrophysiology laboratory, or the hybrid
operating room. In addition, some countries, such as
Denmark, France, Germany, Israel, and Norway, have a
long tradition of having physicians, often anesthesiologists
with additional training in emergency medicine, deliver
prehospital emergency care [2,3].

Clinical practice

The overarching goals of the anesthesia team are to

provide high-quality, cost-effective, and well tolerated
0952-7907 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anesthesiologists have chosen to enhance their skills to

provide the best perioperative care possible. This has led
DOI:10.1097/ACO.0b013e32834c15b6

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688 Technology, education, training, and information systems

to formalized didactic curricula and certification of special

competence in anesthesia subspecialties other than pain
medicine and critical care: The Scandinavian Society of
Anesthesiology and Intensive Care Medicine recognizes
or is implementing advanced educational programs
in pediatric anesthesia, obstetric anesthesia, and critical
emergency medicine [4]. In the USA, the Accreditation
Council for Graduate Medical Education (ACGME)
currently certifies fellowship programs in critical care
medicine, pain medicine, adult cardiothoracic anesthesiology and pediatric anesthesiology and soon obstetric
anesthesiology. Further subspecialty training is available
but not limited to regional anesthesia, neuroanesthesia,
perioperative echocardiography, and hyperbaric medicine.
The practice of perioperative medicine has evolved over
time and is expected to present new challenges and
opportunities. Standardization of medical practice aims
to reduce healthcare cost while improving outcomes.
Such standardization in perioperative medicine may be
accomplished by introducing clinical pathways that
encompass the entire perioperative period from the
preoperative evaluation to the postdischarge disposition.
Despite published evidence that these clinical pathways
improve outcome [5,6], they are widely underutilized in
perioperative medicine. This is where customized initiatives towards procedure-specific, location-specific (inside
the operating room and outside the operating room settings), and patient-specific care permit the amalgamation
of clinical pathway approaches with individualized perioperative care. Individualized care starts with a thorough
preoperative evaluation of the patients current medical
status, which is important to establish a clinical risk
profile for the planned procedure. Credentialed providers
in the preoperative clinic not only recognize relevant risk
factors (e.g., coronary artery disease as a risk factor for
a perioperative myocardial infarction), but also complete
any essential diagnostic steps such as echocardiographic
evaluations, interrogation of pacemakers and automatic
implantable cardioverter defibrillators, or pulmonary
function tests. In concert, these activities lead to treatment decisions that permit preoperative optimization
and may influence short-term and long-term outcomes.
Individualization continues throughout the entire procedural aspects of care and may reach well into the
postdischarge period, such as in ambulatory surgery
patients who benefit from postoperative pain services.
The development of clinical pathways in perioperative
medicine will only succeed in tight collaboration with
all specialties involved, but their implementation will
critically depend on the leadership of the anesthesia team
of the future.
Despite the growing perception that modern anesthesia
care is sufficiently well tolerated, many would agree that
perioperative care is ultimately not as safe or reliable as

Key points
 Incorporating evidence-based medicine algorithms
into all aspects of perioperative medicine will define
the anesthesia team of the future.
 Perioperative epidemiology poses an opportunity
for improved patient care, research, and education.
 The anesthesia team of the future employs simulation-based training and quality assurance systems.
 The anesthesia team of the future needs to lead the
implementation of clinical pathways in perioperative medicine in tight collaboration with all
specialties involved.
it could be. In addition, long-term effects of both surgery
and anesthesia require innovative research efforts to
develop effective strategies that secure long-term benefits.
Although the profound proinflammatory response to
surgery may be important for wound healing, it also has
potential negative implications for the development
of postoperative pain and other surgical outcomes.
By utilizing perioperative immunomodulation to blunt
the cytokine response to surgical incision, Hu et al. have
recently demonstrated how novel translational approaches may be employed to affect surgical morbidity,
namely postoperative pain [7,8]. Examples of this nature
remind us to investigate interventions designed to
prevent long-term adverse effects from undergoing a
procedure in addition to improving immediate patient
safety. Programs such as the Flawless Operative Cardiovascular Unified Systems (FOCUS) initiative by the
Society of Cardiovascular Anesthesiologists aim at utilizing principles of human systems engineering, which
have been successfully applied by the aviation industry,
to advance perioperative patient safety [9]. The Anesthesia Patient Safety Foundation (APSF) launched in
1985 has a significantly longer history as an independent
nonprofit corporation with the vision that no patient shall
be harmed by anesthesia. Recent initiatives of the APSF
include improved medication safety, audible physiologic
alarms, standardization of Anesthesia Information
Management Systems (AIMSs), and the consideration
of long-term outcomes. As we strive to further improve
care, the anesthesia team of the future will also have to
rely on the development of standards for simulation [10].
Key industries such as aviation, nuclear power, and
the military have long recognized the advantages of
simulation for training, assessment of competence, and
research and development. On the basis of the belief
that simulation may offer similar benefits to healthcare,
several countries have called for simulation to become
a compulsory part of training. In Australia and New
Zealand, The Australian and New Zealand College
of Anesthetists (ANZCA) established the Effective
Management of Anesthetic Crises (EMAC) course in
2002 [11], which is now a training requirement and widely

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The anesthesia team of the future Bartels et al. 689

used in continuous professional development. Training

of future generations of anesthesia providers and continuing medical education (CME) in anesthesiology
and critical care management will increasingly rely on
simulation-based education and training. Ultimately,
simulation-based assessment of anesthesia providers
and the anesthesia team offers an objective and reliable
method to guarantee continued improvement of the
quality of care for patients.
Technology

The anesthesia team of the future will likely draw

substantial amounts of patient data from automated data
collection systems. More recently, the addition of realtime data analysis has spurred applications for clinical
decision support systems. Integrating automated data
collection with analysis and decision support has been
a concept applied throughout the realm of anesthetic
practice: AIMSs continue to replace traditional paper
charts and are becoming a de facto standard of care
for anesthesia services provided preoperatively in the
operating room, the PACU, ICU, and at remote locations
[12,13]. In addition to providing a more accurate and
complete reflection of the patients perioperative physiologic parameters, AIMS-generated data have been
utilized to improve anesthetic care at various levels: using
real-time reminders, optimal compliance with quality
initiatives and benchmarks, such as timely administration
of prophylactic administration of antibiotics [14], as well
as review and documentation of allergies into the anesthetic record [15], have been achieved. The concept of
integrating data collection of clinical parameters, automated data analysis, and real-time decision support has
also been successfully applied outside of the operating
room. For example, continuous collection and automated
assessment of patient characteristics and ventilator
settings in the ICU have been used to provide immediate
alerts to the patients care providers and thereby
decreased the incidence of potentially injurious mechanical ventilation settings [16]. The portability of
electronic resources is ever increasing, and its impact
on perioperative and emergency care will continue to
expand. Utilizing a smart phone application that provided
up-to-date resuscitation algorithms in a study of a simulated medical emergency, physicians performed at a
significantly higher level than their peers who had to
rely solely on their memory [17]. Mobile devices are also
likely to transform how we provide postoperative care:
cell phone photographs of surgical wounds taken by
patients at home following ambulatory surgery have been
used to assess wound complications and to determine the
need for in-person evaluation by the treating physicians
[18]. Patients who were discharged on postoperative
day 1 following carotid endarterectomy were successfully
managed utilizing universal mobile telecommunications
system (UMTS) video cell phone technology [19].

An ambitious but desirable goal would be to continuously

collect patient parameters throughout their hospital
stay and to provide ongoing analysis and meaningful
decision support for the caring providers. The role of
the anesthesia team is obvious: having been at the helm
of AIMS and its applications for clinical decision support
provides a unique opportunity to apply this knowledge
to improve care hospital-wide and possibly even at home.
Every anesthesiologist is familiar with false and irrelevant
alarms. Who better than an anesthesiologist could design
smart environments that learn from the patient and case
first, and then adjust accordingly? To carry this concept
outside of the operating room and ICU and to integrate
data collection and analysis systems to provide decision
support throughout all stages of a hospitalization should
be a domain of the anesthesia team of the future.
To support these efforts, professional societies such as
the American Society of Anesthesiologists (ASA) are
communicating with governmental bodies such as the
Centers for Medicare and Medicaid Services (CMS) to
ensure incentives for anesthesia providers that make
meaningful use of EHR.
Randomized controlled trials have demonstrated
improved outcomes when protocols are implemented
into decision-making in many different areas [6,20].
Local clinical data collected by automated systems will
need to be analyzed using established guidelines and
peer-reviewed literature in order to generate local guidelines and protocols of care where applicable. However,
the volume and diversity of data that need to be assessed
are such that this cannot be accomplished by single
institutions but rather will require entrepreneurial
initiatives to accomplish. Efforts such as the Multicenter
Perioperative Outcomes Group (MPOG) lead the way to
promote multi-institutional collaboration on outcomes
research that ultimately aims to advance knowledge
and improve patient care in perioperative medicine.
It will not be sufficient to only initiate such a system;
its quality and impact will in large parts be determined by
its maintenance. A semi-automated system that is continuously updated to provide evidence-based care is an
ultimate goal of outcomes-based medicine. To spearhead
these developments throughout perioperative medicine
is a key task for future anesthesiologists.
Perioperative epidemiology

We cant act on what we dont know; we wont know

until we search; we wont search for what we dont
question; we dont question what we dont measure
Mikel Harry (Six Sigma authority)
The technological advances described above have
transformed the way we practice medicine, just as they
are changing the way we do everything else. One of the

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690 Technology, education, training, and information systems

results of this transformation is the vast amount of data

that are created by new technologies in the process of
delivering care. EHRs, AIMS, bar code readers, digitized
X-rays, and the like are filling our servers at a pace faster
than we can keep up with. The information technology
community calls this phenomenon Big Data and some
have referred to the current era as the industrial revolution of data [21,22]. A small current example for the need
to provide clinical outcome data is the Medicare Hospital
Inpatient Value-Based Purchasing Program [23]. Hospitals will be rewarded based on reported actual quality
performance measures. Bonus payments may reach up to
2% of the entire Medicare reimbursement for a hospital
and are based on clinical process of care measures such
as the administration of prophylactic antibiotics within
1 h prior to surgical incision.

The role of the anesthesia team is evolving to accompany

this technological transformation. The modern anesthesia team is one that is becoming progressively more
involved with the perioperative care of patients; one that
is deeply interested in the surgical population as a whole
and in optimizing the way care is delivered around
a surgical procedure. Epidemiology may be defined as
the study of the distribution and determinants of disease
frequency in human populations and the application
of this study to control health problems [24]. Here,
we introduce the term perioperative epidemiology to
describe the activity of studying surgical populations with
the purpose of improving the way we deliver care around
the time of surgery.

What will the system look like?

Key in this evolution is the field of data management and
analytics, a discipline that is also growing rapidly. Experts
in this field are finding new ways to extract information
from large datasets and transform it into knowledge that
can be used. Comparative effectiveness research is one
such approach that includes mining of large-scale datasets
to test if newer procedures or treatments compare favorably to established ones. Industry has been successful in
many cases, but healthcare, and especially perioperative
care, has not seen transformational results yet.

We propose an iterative process where patient variables

and data from the process of care, together with structure
measures, are collected and transferred in real-time to
a central database (Fig. 1). The database will combine
information from the hospitals EHR, AIMS, ICU, and
PACU systems, laboratory, radiology, and others. The
data will be filtered and controlled for quality and then
displayed in real-time through interactive interfaces
using visual analytics principles. Visual analytics is the
science of analytical reasoning facilitated by interactive

Figure 1 The proposed model depicts the flow of data throughout the perioperative period

Perioperative care

Other clinical
databases

Structure
Peer
reviewed
literature

Logistics

Process
National
Guidelines
Local
protocols &
guidelines

Patient

Data
analysis

Research

Finances
New
hypotheses

Data
display

Qualty filters

Patient variables will be collected together with structure and process measures and then transferred in real time to a central database that will combine
information from other clinical databases. The data will be filtered and quality-controlled and then displayed in real time through interactive visual
interfaces. The information generated through this system, plus new information emerging from local research, national/international guidelines, and a
local review of the latest peer-reviewed literature will all be combined to generate local guidelines and protocols and/or assist clinical decision-making.
The local data displayed in real time will also generate new hypotheses for research. Lastly, the central data repository could be interconnected with
financial and logistics systems.

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The anesthesia team of the future Bartels et al. 691

interfaces. It focuses on the analysis of overwhelming

amounts of disparate, conflicting, and dynamic information
and attempts to facilitate the interaction between humans
and information.
Ideally, the information will be available to anyone at any
time and in any place and will be searchable and allow for
seamless manipulation. This real-time feedback loop not
only will provide up-to-date information that is reflective
of local practices and can inform clinical decision-making,
but will also be hypothesis generating. An intriguing
example of such immediate analysis is using Google
search queries related to influenza-like illness: the level
of influenza activity was predicted 12 weeks earlier than
with traditional methods from the Centers for Disease
Control and Prevention [25].
The collection of data to develop guidelines will be
essential for the development of patient-specific work
plans. Research is integral to this process and represents a
great opportunity for our specialty to engage in clinical
studies that reach beyond the traditional four pillars of
our anesthetic domain (anesthesia, critical care medicine,
pain medicine, and critical emergency medicine).
It requires the ability to analyze complex data, which
we do not yet teach all our trainees. Training anesthesiologists as translational investigators by including
research as one of the ACGME core competencies as
suggested by Reves [26] would not only prepare future
anesthesiologists to lead the quest for improving clinical
care based on individual patient data analysis, but also
provide them with the skills to enhance the quality and
quantity of anesthesia research.
We are fortunate to practice at a time when medicine will
change more rapidly and fundamentally than ever before.
Recent developments in regards to the Omics sciences
genomics, proteomics, and metabolomics will likely
impact perioperative care and our approach to basic questions. These include, but are not limited, to the quest for
biological reasons examining why similar patients can have
significantly different clinical outcomes after surgery, how
to better tailor perioperative drug therapy, or how to
improve prospective risk assessment by incorporating
genomic profiling. Ultimately, these developments may
have implications ranging from individualized additional
preoperative testing and optimization, to perioperative
decision-making, options of monitoring approaches, and
critical care resource utilization.
Lastly, the central data repository could be interconnected with financial and logistics systems to monitor
and manage elements such as operating room and bed
availability, restocking of supplies, and operating room
utilization and cost. Development of efficient staffing
processes has already been described on the basis of

institution-specific models derived from AIMS-generated data [27].

In summary, technology is rapidly changing the way we
deliver care around the time of surgery. We anticipate the
anesthesia team of the future to continue to broaden
its scope and to lead a multidisciplinary group that will
include health IT, data management and analytics, visual
analytics, and other experts with the goal of enhancing the
care of the surgical population in the years to come.
We introduce the term perioperative epidemiology to
describe such activity.

Conclusion
Predicting the anesthesia team of the future beyond
the outlined content of this review is challenging.
Major unknowns such as the financial consequences of
healthcare reform and overall healthcare cost, dramatic
trends towards minimal-invasive procedures, as well as
other emerging technologies will likely have a significant
impact. Therefore, the anesthesia team of the future
needs to adapt to the demands of surgical innovation,
assume new supervisory and management roles, and
move swiftly into new opportunities, thus contributing
to the optimization of care and outcomes across the entire
perioperative continuum. This requires not only CME
and simulation-based quality assurance but also specialized training in finance, law, healthcare administration,
public health, and ultimately, research. Managing,
utilizing, and analyzing increasing amounts of clinical
data to enhance perioperative care will continue as an
additional growth area of our specialty. What remains
certain is that the perioperative anesthesia team of the
future is a quintessential component to the success of
any hospital or operating suite as it provides reliable, well
tolerated, modern, and cost-effective care.

Acknowledgements
The authors would like to thank Dr Debra A. Schwinn for her efforts in
reviewing this manuscript and providing valuable feedback. The authors
would like to thank Cheryl J. Stetson for assistance in manuscript
preparation.

Conflicts of interest
The authors have no conflict of interest and were supported by departmental funds of the Department of Anesthesiology, Duke University
Medical Center.

References and recommended reading

Papers of particular interest, published within the annual period of review, have
been highlighted as:

of special interest
 of outstanding interest
Additional references related to this topic can also be found in the Current
World Literature section in this issue (pp. 711712).
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