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June 1997
Volume 61 |
Number 6
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Practice Options:
Office-Based Anesthesia: An Overview |
Thomas A. Joas, M.D.
In this and following issues, the ASA NEWSLETTER
will be publishing articles about some of the various practice
options available to anesthesiologists today -- inside the operating
room and in other venues.
It can reasonably be argued that Crawford W. Long, M.D., administered
the first office-based anesthetic (circa 1842). On the other hand,
it is well-documented that Ralph M. Waters, M.D., administered
many anesthetics for a variety of surgeons in an office-based
setting while he was in private practice in Sioux City, Iowa (circa
1930s).1
Until the late 1960s, the vast majority of publications referred
to anesthetic administration in hospital-based locations. Wallace
A. Reed, M.D., and John L. Ford, M.D., established a freestanding
ambulatory surgical center in Phoenix, Arizona, in 1969.2
In this setting, they proved that many so-called minor surgical
procedures could be done, not only successfully but also efficiently
and more economically than as an in-hospital patient.
With this information and with the changing social, governmental
and health industry awareness of health care expense, more and
more surgical procedures came to be done outside the hospital.
Published data3,4 corroborated
Drs. Reed and Ford's experience and expanded it to include a reduced
incidence of postoperative infections, more rapid healing and
greater patient satisfaction in recovery at home.
Many anesthesiologists who were aware of the impact of diagnosis-related
groups, or DRGs, on the provision of health care and reimbursement
sought alternate sites for their anesthetic practices. Earlier,
plastic surgeons, general surgeons and cosmetic dentists had been
operating in their own office-based surgical suites, administering
anesthesia themselves or employing nurse anesthetists. As medical
liability insurance premiums soared to crisis levels in the mid-1970s,
these surgeons began to seek a more skilled and knowledgeable
anesthetic provider who could provide additional medical expertise
to their practices and thus permit full concentration on the surgical
procedure at hand.
Community standards, which vary from state to state, evolved
to recognize that these surgical settings required, at the minimum,
an anesthetic care provider, with a majority of surgeons regarding
anesthesiologists as the provider of choice. Within this environment,
anesthesiologists were able to adapt to an independent practice,
deal with primarily healthy patients, become a member of the "team"
and enhance close personal/professional relationships with surgeons.
Within this type of practice, one must be available, affable,
affordable and capable. One must also be secure in personal capabilities
and limitations as the consultant in pulmonary and cardiovascular
physiology and pharmacology as well as the pharmacology of local
anesthetics and intravenous medications. More importantly, the
anesthesiologist is the only one capable of airway management.
In the author's practice, the facilities consist of two or three
operating rooms fully equipped with the standard monitoring devices
(EKG, NIBP, inspired oxygen analyzer, end-tidal CO2
monitor and pulse oximeter). An intravenous (I.V.) access line
is placed in all patients and, of course, all resuscitation equipment
such as defibrillators, respirators and advanced cardiac life
support recommended resuscitative therapeutic modalities are available.
While many procedures are performed using local anesthesia and
intravenous sedation, the capability exists for the use of inhalation
anesthesia (mask, laryngeal mask airway or endotracheal tube).
Roughly 60 percent of procedures are performed using a combination
of local anesthesia with intravenous sedation. This sedation may
be intermittent doses of narcotics, benzodiazepines, phenothiazine
derivatives, sedative/hypnotics or dissociative agents such as
ketamine. Some anesthesiologists prefer total intravenous anesthesia,
or TIVA. The comfort of both patient and surgeon is of significant
concern to the anesthesiologist in order to maintain good will
and continued case flow from the surgeon.
Patients are called preoperatively by the anesthesiologist at
some time preceding the day of surgery or the night before surgery.
Patients are called by both the anesthesiologist and the office
staff postoperatively. All operating rooms are equipped with the
standard monitoring devices; all facilities have recovery rooms
with the standard monitoring devices as well. Some facilities
have step-down capabilities with a major recovery area step-down
to a minor recovery area.
It should be noted that in California, legislation requires outpatient
facilities to have the above features and monitoring equipment.5
Broad guidelines were established through the use of accrediting
bodies in existence, i.e., Accreditation Association for Ambulatory
Health Care, Joint Commission on Accreditation of Healthcare Organizations
and American Association for Accreditation of Ambulatory Surgery
Facilities. The cost for most office-based facilities to modify
their existing structure was minimal as was the cost of accreditation
by one of the above agencies.
Because the legislation was sought by the Medical Board of California
with strong input from the plastic surgeons and because their
accreditation standards rely heavily on the type of anesthetic
used, there is strong language addressing anesthesia in this particular
legislation:
"No physician and surgeon shall perform procedures in
an outpatient setting using anesthesia, except local anesthesia
or peripheral nerve blocks, or both, complying with the community
standards of practice, in doses that, when administered, have
the probability of placing a patient at risk for loss of the patient's
life-preserving, protective reflexes. Outpatient settings where
anxiolytics and analgesics are administered are excluded when
administered in compliance with the community standard of practice,
in doses that do not have the probability of placing the patient
at risk for loss of life-preserving, protective reflexes."
Additionally, there are portions of the legislation that refer
to having similar medical/surgical privileges at a nearby acute
care hospital as well as written transfer agreements with that
hospital. The legislation further mandates establishment of peer
review committees, chart reviews and periodic committee meetings,
etc., which would closely parallel the organizational structure
of both ambulatory surgical facilities and acute care hospitals.
As a member of the "team," participation in the mandated
chart reviews, morbidity and mortality reviews, formulary reviews
as well as observing and upgrading Occupational Safety and Health
Administration-identified risks and regulations is expected.
Of course, all of the above requirements do not preclude the
unscrupulous practitioner from noncompliance. It is too soon to
tell how effective this legislation in California will be in shutting
down facilities for noncompliance; it has only been in effect
since July 1, 1996.
One of the more troublesome provisions of the legislation rests
with the interpretation by practitioners of the use of narcotics,
tranquilizers, etc., within their offices. This legislation is
not meant to restrict physicians from using any therapeutic
agents but to restrict their use based on the ability of patients
to maintain their protective reflexes.
Anesthesiologists considering this type of practice might necessarily
be concerned about remuneration. Customarily, cosmetic surgery
is paid on a "global fee" basis by cash, check or credit
card prior to the procedure. Few cosmetic procedures are covered
by third-party payers.
For those considering this type of practice, you should know
that office-based anesthesia practice has been one of the best
decisions this author has made. Since entering this type of practice
in 1984, there have been no night calls and no weekend call. Only
two cases have been done in the hospital, and these were done
by specific request. Your author has been able to pursue other
significant interests such as golf, bicycling and politics. The
net effect is that one can be more at peace with one's practice,
and patients and surgeons alike have been satisfied and complimentary.
References:
- Waters RM. The down-town anesthesia clinic.
Am J Surg. (Anesth Suppl) 1919; 33:71.
- Ford J, Reed W. The surgicenter: An innovation
in the delivery and cost of medical care. Ariz Med. 1969;
26:801.
- Davis JE, Detmer DE. The ambulatory surgical
unit. Ann Surg. 1972; 175:858.
- Williams JA. Outpatient operations. I. The surgeon's view.
Br Med J. 1969; 1:174-175.
- California Health and Safety Code, Section
1248 et seq. Chapter 1276, Stats. 1994.
Thomas A. Joas, M.D., is in the private
practice of anesthesiology in San Diego, California. He is Vice-President
of the Medical Board of California.
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