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September 1997
Volume 61 |
Number 9
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Practice Options:
Considerations in Setting Up an Office-Based Anesthesia Practice |
Rebecca S. Twersky, M.D., Chair
ASA Committee on Ambulatory Surgical Care
Marc E. Koch, M.D., Chair
SAMBA Ad Hoc Committee on Office-Based Anesthesia
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.
The growth of office-based surgery has provided an opportunity
for anesthesiologists to further expand their diverse role as
perioperative physicians. The office anesthesiologist must be
aware of other issues that heretofore have not been under the
purview of the hospital- or surgery center-based anesthesiologist.
It is incumbent upon our profession to provide the necessary education
and skills for anesthesiologists to function adeptly in this venue.
The underlying premise of this charge is the tenet that the office
be held to the same stringent standards expected of traditional
anesthetizing locations such as the hospital or ambulatory surgery
center (ASC). Unfortunately, this is not a uniform finding. In
fact, a recent survey of aesthetic surgeons found that 5 percent
of respondents did not monitor blood pressure, 7 percent neglected
to use pulse oximetry, and 11 percent did not continuously monitor
an electrocardiogram tracing.1
The office anesthesiologist's role as a patient advocate includes
both medical and nonmedical duties. These responsibilities may
include confirming that the surgeon has the appropriate credentials
to perform the surgery, helping to determine or assist with the
accreditation of the facility and equipping an office for surgery
or anesthesia. It will certainly include developing emergency
protocols, prescreening patients appropriately, supervising the
recovery of patients after anesthesia and gathering quality improvement
data. Also, it is important for the office anesthesiologist to
provide assurances to the surgeon that anesthesia services will
not leave them exposed to additional liability. Regrettably, not
all anesthesiologists' malpractice carriers provide coverage for
office-based practice.
The essentials for office anesthesiology closely parallel the
basic ASA standards for monitoring during anesthesia. The office
must have the ability to deliver positive pressure ventilation
with an ambu-bag or, if indicated, an anesthesia machine. It is
also imperative to assure that a safe and reliable source of oxygen
be available. A motor-driven suction device should always be present,
and along with monitoring equipment, the need for back-up power
should be considered.
Although a fiberoptic bronchoscope in every location would be
financially prohibitive, less costly emergency equipment such
as laryngeal mask airways, light wands and tracheotomy kits may
be valid inclusions. An office is usually devoid of technicians,
biomedical engineers or even colleagues to help in the event of
an equipment failure. Therefore, it is imperative that the anesthesiologist
be aware of the need for timely service checks and documentation
of prevention and maintenance programs according to manufacturer
specifications.
Inventory and supply concerns can easily be forgotten. Rather
than remember when your cart is missing a supply at a crucial
moment, a computerized system to track usage of medications and
supplies can alert you when an item needs to be re-stocked. It
is important to view your cart as a mobile intensive care unit
and have it replete with all of the standard, advanced cardiac
life support medication. If agents that can trigger malignant
hyperthermia are used, then the inclusion of dantrolene is mandatory.
There is at least one documented death in the office setting attributed
to its unavailability.2 When controlled substances
are stored in multiple sites, it is required that each location
have a unique Drug Enforcement Agency Certificate kept on site
and that special ordering forms (DEA Form 222) be completed correctly.
Developing alliances with companies that lease surgical and anesthesia
equipment will bolster an office's reliance on the anesthesiologist's
services and promote the value of the anesthesiologist as a perioperative
manager. The purview of the office anesthesiologist can extend
far beyond even these limits. For instance, having the knowledge
to advise surgeons on the various requirements necessary to obtain
accreditation and having the resources to answer questions about
certificates of need (both of which can lead to facility fee reimbursement)
further broaden the importance of a perioperative anesthesiologist-manager.
An affiliation with medical architects, construction companies,
health care accountants and attorneys may prove to be as valuable
to a surgeon as sound anesthesia skills.
Reimbursement trends in office anesthesiology are in a state
of flux. Studies need to be completed to demonstrate that shifting
particular procedures to less intensive settings leads to heightened
value. In the interim, it should not be surprising that some third-party
payers resist adding office-based anesthesiologists to their reimbursement
plans. Their concerns are partly attributable to issues surrounding
quality of care as well as the unsubstantiated proposition that
easier access to anesthesia services will translate into increased
utilization of surgical resources. Some insurance companies will
not credential office-based anesthesiologists unless they first
acquire hospital privileges, a definite problem for those practitioners
who have dedicated their entire practice to office-based services.
Notwithstanding, some companies are aware of the enhanced value
of office-based anesthesia and with documentation of quality care,
patient satisfaction, prudent utilization and reasonable efficiency,
it is likely that other third-party payers will follow.
Once the site visit is completed by the anesthesiologist, an
emergency medical services (EMS) verification should be documented;
that is, the responding EMS team must be located and their estimated
response time documented. It is also wise to review the local
EMS policy and protocols regarding responsibilities at a scene
when a physician is present. This will help avert misunderstanding
during critical periods. The local hospital emergency room (ER)
director also should be contacted and informed that anesthesia
services will be provided in the community. To best protect patients,
it is wise to offer an in-service to the local EMS and hospital
ER staff on common and serious anesthetic morbidity. This also
is an opportunity to promote public awareness of anesthesia services
and improve our visibility in the community.
As anesthesia and surgical services have evolved, so have the
selection of appropriate patients for the office setting. A preoperative
telephone call, completed by the anesthesiologist providing care,
will allow for sound judgment in selecting patients. As this practice
venue increases in popularity, more quality assurance data will
become available to guide in the selection of appropriate patients
for office-based procedures. ASA physical status remains a major
element in patient selection,3 but other factors are
less clear. Age limits and morbidity associated with specific
disease states such as asthma and morbid obesity need to be better
defined.
A review of closed claims involving anesthesia morbidity and
mortality in dental offices suggests that pre-existing conditions
such as obesity, cardiac disease, epilepsy and chronic obstructive
pulmonary disease should be taken very seriously, especially if
an anesthesiologist is not present.4 Advances in surgical
techniques as well as safer and shorter-acting medications may
broaden the patient population appropriate for office procedures,
as they have done for ambulatory surgery. In addition, as anesthesia
equipment and machines become better adapted to the office environment,
it is likely that even more patients will be able to undergo office-based
anesthesia.
Although our new role in the office setting has many implications,
the loss of control over our environment and practice style are
two drawbacks that have tempered growth of this practice opportunity.
Nonetheless, by expanding our medical and administrative knowledge
and skill, we can promote safety and patient satisfaction while
enhancing professionalism in our specialty and creating greater
reliance upon our services. It is incumbent upon us to provide
the educational framework to accomplish these goals and tirelessly
educate the public on the virtues of our involvement in perioperative
care.
Author's Note: This article was adapted in part from a
panel presentation on office-based anesthesia at the Society for
Ambulatory Anesthesia (SAMBA) 12th Annual Meeting on May 3, 1997.
References:
- Phero JC, Driscoll KM, MacDonnell WA. Appropriate selection
of anesthesia personnel for office dental anesthesia. Dent
Clin North Am. 1987; 31:21-35.
- American Society of Anesthesiologists, Closed Claims Project
Database Case 779, 1982.
- Courtiss EH, Kanter MA. The prevention and management of medical
problems during office surgery. Plast Reconstru Surg. 1990;
85:127-136.
- Jastak TJ, Peskin RM. Major morbidity or mortality from office
anesthesia procedures, a closed-claim analysis of 13 cases.
Anesth Prog. 1991; 38:39-44.
Rebecca S. Twersky, M.D., is Associate
Professor of Anesthesiology and Vice-Chair of Research at the
State University of New York Health Science Center at Brooklyn,
New York.
E-mail the author.
Marc E. Koch, M.D., is President and Chief
Executive Officer for Resource Anesthesiology Associates, P.C.,
Whitestone, New York.
E-mail the author.
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