ASA October 2003 Newsletter

Estimates tell us that up to 40 percent of procedures that some anesthesiology departments are requested to provide services for take place outside of the operating room, frequently in areas of the hospital that have never had anesthesiology department visits or services. These areas might include the cardiac catheterization/electrophysiologic mapping laboratories, infusion therapy suites, urology clinics (prostate biopsies, cystoscopies, etc.), radiation therapy suites, diagnostic and/or therapeutic radiology areas (i.e., interventional radiology, magnetic resonance imaging, diagnostic and therapeutic computed tomography scans), endoscopy suites, obstetrical units, bone marrow laboratories, emergency departments and many other places that patients are undergoing painful procedures and need and/or desire pain relief.

The lay press has emphasized the concept that no one should experience pain under any circumstances in the care of a physician, much less in a hospital setting. Additionally because pain has become the “fifth” vital sign, in many instances, those who have primary care of patients in the hospital, both inpatient and outpatient, have emphasized to their patients that pain relief is available to those who wish to have it. Thus there are many consultations to the anesthesiology department for pain relief in the form of total intravenous anesthesia, general anesthesia, etc., in locations that heretofore the department may have never been or had experience with the procedures in which they become involved.

The specialty itself has always been open to the relief of pain for those who need or desire it in appropriate circumstances. Yet this can cause scheduling and cost considerations as reimbursement for these services is often not considered a necessary expense; the growing numbers of patients needing or wanting sedation or general anesthesia for procedures must be included as part of the operating room schedule as a whole, or the director of the schedule will not be able to have the appropriate number of full-time equivalents available at the times needed. It is imperative that those departments needing anesthesia services of this type go through a central scheduling department such that personnel and ancillary care for the anesthesiology department are both available. [Not infrequently, these procedures take place in areas distant to the operating room, are ill-equipped at best and in general require two anesthesia personnel (anesthesia care team) to ensure that if disaster occurs, there is an extra pair of hands that can assist in a resuscitation, run for help, etc.]

Equally important, it is imperative that any patient undergoing “sedation,” etc., for a procedure go through the routine preoperative assessment clinic for evaluation. It is not unusual for the patient to have had minimal contact with a physician who has done little more than a short, directed history and examination and may completely miss major acute or chronic medical problems. You, as the examining anesthesiologist, may be the first physician that the patient has come in contact with who has reviewed a cardiac history, recent electrocardiograms, pulmonary and neurological status and has done a thorough examination of the basic, important studies and physical condition of the patient. These may or may not preclude the patient from undergoing the planned procedure safely. Sometimes you are the difference between whether or not that patient will make it through the procedure safely.

Many nonanesthesiologists are now requesting privileges (or worse yet, not even obtaining privileges) to do “sedations” in these “satellite” areas. Because of Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards that became effective January 1, 2001, guidelines in conjunction with the updated ASA Practice Guidelines for Sedation and Analgesia by Nonanesthesiologists, JCAHO has set forth multiple requirements. These requirements include presedation assessment, continuous physiologic monitoring, credentialing of individuals providing different levels of sedation, postsedation recovery and discharge, maintenance of institutionwide standards of care and quality assurance for all four levels of care. Practically speaking many institutions and hospitals have gradually required anesthesiology departments to set the institutionwide standards for all levels of sedation, initiate credentialing, etc. Be prepared. You and your department will ultimately become involved in some way in these matters as you set out to administer anesthesia in the “hinterlands.”

This issue of the ASA Newsletter will discuss these and other issues that we are now facing to a degree never experienced in the past. Reinforcement of what it truly means to be a consultant in anesthesiology is becoming increasingly important and meaningful. It is likely that this trend will continue without abatement.

Jesse A. Leak, M.D., is Clinical Professor, University of Texas Health Science Center at San Antonio, San Antonio, Texas.

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