The introduction of TIVA training using the Fresenius TIVA system ™ in a District General Hospital

A Wong, P Gillen, A Kapila

Department of Anaesthetics, Royal Berkshire Hospital, Reading, RG1 5AN, UK.

Introduction: The Fresenius TIVA system ™ has been trialed in the DGH above which led to the acquisition of 14 base units for the provision of anaesthesia in February 2007. (A period of consultant training was undertaken prior to this with 10 consultant anaesthetists agreeing to provide mentoring for the post-fellowship anaesthetic registrar cohort.) This anaesthetic delivery system replaced the Graseby ™ TIVA anaesthetic pump. We report on the unique training program and the subsequent perceived efficacy of the new system.

Methods: The Fresenius TIVA system ™ has been developed using the ‘Marsh and Minto’ algorithms to provide data on estimated plasma and effect-site concentrations of Propofol and Remifentanil. The following parameters are required to be inputted:

1. Weight

2. Height

3. Age

4. Gender

This enables the derivation of time-to-wake up and other functions, which are continuously displayed on the base unit. It was agreed by the consultant body to limit the use of these systems to 2% Propofol and 50 mcg/ml Remifentanil to reduce system errors and improve clinical governance (CG). Due to the increased complexity of this delivery system it was felt that again due to CG issues, there ought to be a period of training for those clinicians who would use the system independently. The agreed training program involved a case series of at least ten cases, supervised by a training consultant with the  requirement to pass a written quiz designed by the  authors involving 19 system-specific questions. The learning outcomes were to produce a clinician capable of using the majority of features of the system in a safe manner.

Result:  

We describe the successful incorporation of this system into hospital clinical practice with the provision of approximately 1000 TIVA cases. In order to assess clinician response to this change individual opinion was canvassed. The majority of responses were positive. It is the authors’ intention to provide qualitative data to confirm these findings.

Discussion: There are a number of Clinical Governance issues surrounding the initial use of any new item of equipment or drug into clinical practice. It is incumbent of clinicians to ensure they have a safe working knowledge of any new device. The safe and efficacious use of TIVA has become a core competency in anaesthetic intermediate and higher training .¹ Literature search showed that it was a unique training package. In order to prove that learning has taken place, not only was there a written test at the end of the teaching session but also the trainee has to produce a list of supervised cases signed by one of the trainers. To complete integration, we plan to collect qualitative data by carrying out a survey amongst the trainers, consultants and trainees. We feel that this is a reasonable training model which we think can be efficacious in other institutions.

Acknowledgement: The authors acknowledge the assistance of Colin Maclean, Fresenius Representative.

References:

1. General Surgery/Gynaecology/Urology (+/- Transplantation). IN: The CCT in Anaesthesia III: Intermediate level. (ST years 3 and 4) Training and Assessment Manual. United Kingdom; 2007, 1^st Edition. pIII-A-29

2. The CCT in Anaesthesia IV: Higher and Advanced level. (ST years 5,6  and 7) Training and Assessment Manual. United Kingdom; 2007, 1^st Edition