| |
May 1999
Volume 63 |
Number 5
|
| |
|
| Role of the Anesthesiologist
in the Next Millennium: Perioperative Gatekeeper? |
Lee A. Fleisher,
M.D.
Most of the discussion of a perioperative physician, including
that in the current issue of the NEWSLETTER, has centered
around hospital-based services: managing the preoperative evaluation,
postoperative pain and postoperative intensive care unit. Given
that the majority of surgical procedures are performed on an ambulatory
basis, should our focus as a perioperative physician really remain
within the hospital or expand beyond the hospital setting? We
must not forget that a greater number of surgical procedures are
being performed on an outpatient basis, with an estimated 70 percent
of procedures expected to be performed outside of the hospital
setting by the year 2000. Anesthesiologists were the pioneers
in developing and diffusing outpatient surgery, much to the benefit
of our patients, and we should take lessons from the past with
regard to our role for the future. Simply, we should take the
lead in ensuring that patient safety is not compromised in our
quest to expand the number of procedures and medical risk acceptable
in patients who have surgery on an outpatient basis. We should
be the gatekeepers to the operating room and direct patients to
appropriate locations of care.
When outpatient surgery centers were initially developed, anesthesiologists
took an active and, some would argue, pre-eminent role in determining
who were appropriate candidates to have their procedures performed
in these locations.1 These pioneering
anesthesiologists ensured that appropriate standards of care and
quality assurance reviews were established. As the practice became
more widely accepted and diffused, these settings and standards
have varied greatly. For example, there are now multiple settings
in which outpatient surgery can be performed: hospital-based outpatient
settings, freestanding ambulatory facilities and now office-based
settings. There are also three different accreditation organizations,
the Joint Commission on Accreditation of Healthcare Organizations,
the Accreditation Association for Ambulatory Health Care and the
American Association for Accreditation of Ambulatory Surgical
Facilities, each of which has slightly different regulations,
yet they all strive to ensure safety standards.
Accreditation is not mandatory, however, and not all ambulatory
facilities are accredited. Many of these facilities are not prepared
to handle all types of emergencies. Office-based settings are
even less well-regulated, with accreditation being only a recent
phenomenon for a small number of groups. Therefore, we are increasingly
moving from the overregulated hospital environment to a less regulated
outpatient one. Additionally, there have been few studies that
document the safety of outpatient surgery. Specifically, there
has been no systematic determination of the number and outcome
of patients who are transferred to a hospital setting or are readmitted
shortly after discharge from outpatient surgery except from a
few academic centers connected with hospitals.2,3
As anesthesiologists, we are both qualified and well-equipped
to determine the potential resource needs, both intraoperatively
and for the immediate postoperative period, for procedures that
could be considered appropriate for an outpatient or office-based
setting, but which may not be appropriate for a particular individual.
Anesthesiologists have always believed that we are the only practitioners
who can "clear" a patient for an anesthetic. We should now expand
this role of the preoperative evaluation to be the gatekeeper
to the operating room and location of surgical care as one of
the critical variables. Such a role will not only lead to improved
visibility from the perspective of our patients, but could lead
to economic savings to the health care system by avoiding complications.
Of course, we need to continue our role as pioneers in providing
outpatient anesthesia for an expanding group of surgical procedures,
working in close concert with our surgical colleagues to push
the envelope in a safe and patient-oriented manner. However, if
the preoperative evaluation identifies a patient whose medical
history and planned surgical procedure place the patient at high
risk, then we should not abandon our core responsibility with
regard to patient safety for the surgical patient, and we must
be willing to encourage our surgical colleagues to perform the
procedure in a different venue even if this decreases our own
potential profits.
References:
- Wong HC. The evolution of freestanding
ambulatory surgical care. J Amb Care Manage. 1990; 13:11-20.
- Warner MA, Shields SE, Chute CG. Major
morbidity and mortality within 1 month of ambulatory surgery
and anesthesia. JAMA. 1993; 270:1437-1441.
- Twersky R, Fishman D, Homel P. What happens after discharge?
Return hospital visits after ambulatory surgery. Anesth Analg.
1997; 84:319-324.
Lee A. Fleisher, M.D., is Associate Professor
of Anesthesiology and Health Policy & Management, and Chief,
Division of Perioperative Health Services Research, Johns Hopkins
Medical Institutions, Baltimore, Maryland.
return to top
|