October 1997
Volume 61 |
Number 10
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COMPONENT SOCIETY NEWS:
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| The Politics of
Patient Safety in New Jersey |
Ervin Moss, M.D., Executive Medical
Director
New Jersey State Society of Anesthesiologists
Interest in office-based anesthesia has exploded in the last
year as evidenced by articles published, lectures presented, the
inclusion of office-based anesthesia lectures in programs sponsored
by the Society for Ambulatory Anesthesia (SAMBA), a newly formed
office-based anesthesia organization and the sudden awareness
on the part of the anesthesia community that there is "life
beyond the hospital and surgicenter operating rooms."
Not only is there life, but the life is free of night call, weekend
call, trauma, emergencies and obstetrics; and, in addition, it
can be financially rewarding.
The vast potential for opportunity in office practice is documented
by the estimate that 25 percent of surgery will be performed in
offices by the year 2000. Office-based anesthesia was a topic
at the SAMBA Annual Meeting last May in Orlando, Florida, and
will be a topic at an ASA Annual Meeting refresher course lecture
in San Diego, California. A panel on this topic is scheduled to
be presented at the Postgraduate Assembly in New York in December
1997.
The New Jersey State Society of Anesthesiologists (NJSSA) has
long recognized the rediscovery of office-based anesthesia and
has actively attempted to prepare for it by encouraging regulations
that would extend the safety net created by the New Jersey 1989
Hospital and Surgicenter Regulations. We strongly disagree with
those who minimize the risks of office anesthesia. Since the first
death of a 16-year-old during an office abortion in New Jersey
in 1984, the NJSSA has warned the Board of Medical Examiners of
the dangers of anesthesia and surgery in unregulated, one-operating-room
offices. My article, published in the Anesthesia Patient Safety
Foundation Newsletter, Winter Issue 1997, detailed the attempts
of the NJSSA to prevent deaths and injuries to patients in offices.
The Board of Medical Examiners recently addressed this important
issue by publishing office-based surgery and anesthesia safety
rules through the state Department of Law and Public Safety. The
successful inclusion of surgeons into the New Jersey regulations
did not come easy. That battle was fought during the early years
of meetings with a multispecialty committee of the Board of Medical
Examiners. In order to move the process along, the NJSSA agreed
to work on a regulation that would only address anesthesia. The
"Politics of Patient Safety" at that point of time precluded
the inclusion of our surgical colleagues in the regulation. Eventually,
it became obvious that, unless surgical practice was addressed,
the regulation would be impotent. Office anesthesia cannot exist
without office surgery, and any attempt to regulate office practice
must include surgery.
The factions compromised to include the statement that surgeons
who intend to perform certain procedures in their office must
be credentialed to perform those same procedures in a hospital.
Further compromise was an alternate credentialing pathway in those
cases where the surgeon and the anesthesiologist practice in offices
alone and do not seek or desire privileges in hospitals. This
alternate pathway is now being developed by the New Jersey Board
of Medical Examiners.
It is important that office-based organizations view this as
a positive opportunity and expand their membership to include
surgeons. In turn, surgeons can contribute to patient safety by
addressing issues of credentialing, selection of appropriate procedure,
time limitations for office procedures and surgical protocols.
It is noteworthy that at the present time, without regulation,
anybody can do anything in an office! Some form of credentialing
is vital to protect the public from the dangers of anesthesia
and surgery in offices. The proposed regulation requires the surgeon
and the anesthesiologist to be credentialed in a licensed hospital,
but the regulation does not require the nurse anesthetist to be
credentialed, even though he or she may be the anesthesia provider
in an office in which conscious sedation is used.
Politics played a role in our search for support for office regulation
from the Medical Society of New Jersey (MSNJ). The MSNJ was placed
in a difficult position early in the process because its membership
was made up of specialty groups opposed to any office regulations.
Finally, at the June 4, 1997, public hearing, the MSNJ came forth
with a statement supporting the regulation.
Due to politics or possibly business interests, some malpractice
insurers of New Jersey physicians were initially not in support
of the regulations. More recently, one of the larger insurance
carriers, Princeton Insurance Companies of West Windsor, voiced
support for the proposed changes. However, it was the position
of another insurance provider, which was created and financed
by physicians in 1976, that it did not engage in practice guidelines.
How simple would it have been to charge a premium for office surgery
and anesthesia or deny coverage if certain criteria were not met?
Was this not the policy of Massachusetts insurers in the 1980s,
when financial reward was given to those who used oximetry and
end-tidal PCO2 monitors?
On May 19, 1997, the proposed "Surgical and Anesthesia Standards
in Physicians' Offices" were published in the New Jersey
Register. A public hearing was held on June 4. A written comment
period, usually lasting 30 days, was extended from May 19 to August
6, because of the volumes of comments, mostly negative.
At the hearing, David Mayer, M.D., representing the newly created
Society for Office-Based Anesthesia, presented his positive opinion.
Other support came from the Medical Society of New Jersey, the
New Jersey Department of Health, and the Society of Plastic Surgeons.
Letters of support were received from the ASA, SAMBA and from
the Medical Board of California.
Opposition was most intense from the New Jersey Association of
Nurse Anesthetists and the American Association of Nurse Anesthetists,
which sent three representatives, two of whom were attorneys,
to argue against the regulation. The proposed regulation requires
supervision of nurse anesthetists by an anesthesiologist when
general or regional anesthesia is performed in an office. This
requirement, in the opinion of the attorney general drafting the
regulation, was a logical extension of pre-existing requirements
for supervision of nurse anesthetists in licensed hospitals and
surgicenters.
Opposition was voiced by those engaged in office-based abortion
practices, and individual plastic surgeons protested the regulations
as a threat to their office practices. An editorial in The
Lawyer's Letter strongly criticized the regulation. An influential
state senator opposed the regulation as too costly, having been
advised by nurse anesthetists that the result would be the closing
of one-operating-room offices.
The regulation has been described as a "plot" by the
New Jersey Hospital Association to force work back to the hospitals
and as a method to put underutilized anesthesiologists back to
work in the hospitals. Despite deaths of children in MRI units,
there are some radiologists who opposed the regulations and still
claim monitors are not compatible with MRIs. The Radiological
Society of New Jersey did send a letter in support of the regulations
but requested 37 changes be made.
What will be the outcome is in question! The interest of the
NJSSA was to extend to offices the same components of the 1989
Hospital and Surgicenter Regulations. An anesthetic is an anesthetic
no matter where it is delivered, and the same attention to quality
care should be given no matter the location. It is unacceptable
to have a single death, no matter how rare, occur in an office
because of a diminution of the quality of the anesthesia provider,
the anesthesia equipment, the monitoring, the maintenance of equipment,
the nursing service or the qualifications and judgment of the
surgeon. Included in the proposed regulations is a reporting mechanism,
which would finally provide accurate data on in-office deaths
and morbidity.
This article but hints at the extent of the politics that have
swirled around an issue that should have met little opposition.
One would hope that the decade-long effort will bear fruit - saving
countless patients who otherwise would continue to be subjected
to substandard quality of care. If defeated, it will not be for
lack of trying.
The positive note is that the publicity surrounding the regulations
for so many years has alerted existing and planned office operating
room owners to the need for quality anesthesia and surgery in
an environment on par with licensed surgical centers. In addition,
patients (a.k.a., consumers) have been alerted by newspaper and
television reports, generated in some cases by the NJSSA, to the
dangers of unregulated office anesthesia and surgery.
Ervin Moss, M.D., is a practicing anesthesiologist
in central New Jersey.
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