March 2001
Volume 65 |
Number 3
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ADMINISTRATIVE UPDATE
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| Our
Patient Safety Record Is in Grave Danger |
Barry M. Glazer, M.D. ASA President-Elect
As your President-Elect, I will have to admit that this column
is difficult for me to write. As I compose these words, my thoughts
are overwhelmed by the Clinton Administration's decision, in its
final days, to publish the rule removing the Health Care Financing
Administration's (HCFA's) long-standing requirement that nurse
anesthetists be supervised by a physician.
At the inception of Medicare, this requirement was included in
the Conditions of Participation rules imposed by HCFA on hospitals
with which they must comply to be eligible for payments from the
Medicare system.
Removal of the federal requirement for physician supervision
will defer the decision to the states as well as to individual
hospitals. While nurse anesthetists must still comply with state
laws and hospital bylaws and rules, if this rule becomes effective,
there will no longer be a federal minimum standard for the delivery
of anesthesia care.
This change takes place in an environment, both within government
and within society, that permits lower levels of practitioners
to deliver progressively higher levels of care in every area of
medicine. A lack of understanding of the intricacies of medical
care allows society to be tolerant of what Representative David
Weldon, M.D., (R-FL) calls the dumbing down of medicine.
Mortality associated directly with anesthesia care has decreased
50-fold in the last half of the 20th century. While recognizing
this high level of safety, HCFA has chosen to ignore the reasons
for that safety record. Why is anesthesia care so safe today?
It is because of the contributions that anesthesiology as a medical
specialty has made to patient safety. Most people think first
of new monitoring devices and drugs as making anesthesia care
safer, and that is somewhat true. But the fact is, anesthesiologists
assured that those devices and drugs were suitable for clinical
care and were incorporated in daily practice. Anesthesiologists
set the standards of care that enabled those devices to become
used widely. Anesthesiologists did the research to determine what
the causes of anesthesia-related deaths were and developed the
practice parameters that teach how to avoid those deaths.
ASA formed a Committee on Patient Safety and Risk Management,
and our Committee on Professional Liability did the closed claims
study. Anesthesiologists produced patient safety videotapes. ASA
started the Anesthesia Patient Safety Foundation (APSF) almost
15 years before the American Medical Association started its National
Patient Safety Foundation, which was modeled after ours. The American
Association of Nurse Anesthetists, several months ago, withdrew
its contribution of $40,000 per year to APSF, while ASA continues
to contribute $400,000 yearly to that foundation, in addition
to our other activities in behalf of patient safety. And ASA contributes
more than $1 million per year to the Foundation for Anesthesia
Education and Research.
Long before newer monitors and drugs were introduced, the number
of anesthesiologists involved in patient care was increasing steadily,
and the number of deaths was decreasing even in the face of progressively
more complex surgeries on older and sicker patients. Anesthesiologists
have insisted on physician involvement in anesthesia care. In
the study that showed a death rate of one in 250,000 from anesthesia
—which HCFA uses to indicate how safe anesthesia care is today
every patient had an anesthesiologist involved in his or her care.
There are now strong scientific studies that demonstrate the
importance of an anesthesiologist being involved in the anesthetic
care of the patient and the contributions of the anesthesiologist
to safe care and good outcomes. But even in the absence of those
studies, at the inception of Medicare, common sense dictated that
in the critical care inherent to the administration of an anesthetic,
there must be a physician supervising such care to assure that
the medical problems of the patient are managed in the perioperative
period and that medical knowledge and sound medical judgment are
a required component of the patient's care.
Nurse anesthetists are certainly valuable in the delivery of
anesthesia care in a wide variety of settings, but none of those
settings exists without the presence of a physician, even when
no anesthesiologist is available. While the technical skills of
the nurse anesthetist deserve appropriate respect, every physician
knows that medicine is often unpredictable and that the administration
of an anesthetic may present a medical emergency at any time.
Federal regulations requiring the involvement of a physician in
anesthesia care are there to ensure the presence of the medical
expertise for addressing medical emergencies rapidly. Now those
regulations may not include that requirement even though medical
emergencies will continue to occur.
Be assured that ASA will continue to advocate for physician involvement
in the care of every patient receiving an anesthetic. Our efforts
at the federal level are not yet exhausted; the Bush administration
has delayed the effective date of this new rule from March 19
to May 18, and we are actively advocating for reversal of the
Clinton Administration's decision.
We also are aware that this activity may shift to the states.
Be assured that our commitment to this advocacy at the state level
will continue and increase. Patient safety is our primary concern,
and our ethical commitment to safe patient care will not allow
us to abandon this effort.
Please write to Secretary Tommy Thompson today, and ask your
family and friends to write as well: The Honorable Tommy Thompson,
Secretary, Department of Health and Human Services, 200 Independence
Ave., S.W., Washington, DC 20201; or e-mail at
hhsmail@os.dhhs.gov. For more information with a direct link
to Secretary Thompson, go to the revised Web site.
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