Meena Desai, MD, managing partner of Nova Anesthesia Professionals, discusses 10 important things every ambulatory surgery center leader should know about anesthesia provision in an ASC.
1. Robust triage process is essential. Patient selection is extremely important in an ASC because not all patients are appropriate for outpatient surgery. ASCs should work to identify patients that will not require a transfer to the hospital, which generally means patients with an ASA score of 1 or 2. Dr. Desai says that while most ASCs can identify patients with an ASA score of 4, many surgery centers run into trouble when identifying 3s — those patients with severe systemic disease that could cause surgical complications.
"A lot of ASCs do not do triage well," she says. "The rising rate of obesity causes issues with airway difficulties and obstructive sleep apnea, so we've also got to appreciate changes that affect the triage process." She says that triage should ideally be performed as soon as the patient is scheduled, and the anesthesia provider should be heavily involved. ASC administrators and anesthesiologists should discuss the regulations in their state to determine which patients can be treated at the surgery center. In some states, only patients with an ASA score of 1 or 2 can be treated, while other states allow patients with a score of 3.
Dr. Desai recommends giving nurses algorithms to determine whether patients are appropriate for ASC surgery. "Because [triage] is a non-reimbursable activity, our practice has trained nurses to do it," she says. "The nurses follow certain algorithms that you've designed for them, and then they check in with the physician."
2. Anesthesiologists and surgeons must communicate about clinical decisions. Dr. Desai says hostility between anesthesiologists and surgeons most commonly arises when the two parties fail to communicate about a clinical decision. "For instance, when you tell a surgeon to cancel a patient, they need to know exactly why you want to cancel," she says. "They're usually thinking, 'It's more convenient for me, and you're making it less convenient, and you're also taking revenue from me to somewhere else.'" The anesthesiologist should explain to the surgeon why the patient is not appropriate for outpatient surgery.
Anesthesiologists should also be careful about the way they respond to surgeon questions, Dr. Desai says. "We're often defensive," she says. "They ask a question, and instead of interpreting it as a question, we defend our position." She says if the surgeon asks why the patient needs an EKG, the anesthesiologist should calmly explain why the EKG is necessary. She says this is most easily accomplished if the center's anesthesia providers are included on ASC committees. That way, anesthesiologists will be present for discussions about patient selection, and surgeons will respect anesthesia providers for taking the time to contribute to the discussions.
3. ASC leaders should talk to anesthesiologists about drug shortages. Drug shortages are affecting surgery centers and hospitals across the country, and ASC administrators must discuss the issue with anesthesiologists to make sure center processes are adjusted accordingly, Dr. Desai says. "When we had a propofol shortage, it was important to work with anesthesiologists closely and discuss the [alternative drugs] they would be using," she says. "Anesthesia not only has to use those drugs, but figure out the different mixtures and then inservice the recovery room because patients come out looking different." In a hospital, there may be more facility-wide discussion of drug shortages; in an ASC, the administrator must take responsibility for engaging anesthesiologists on the subject.
4. Standing protocols can speed up patient discharge without anesthesiologist supervision. The two anesthesia-related issues that generally prevent timely patient discharge are nausea and vomiting, Dr. Desai says. "The ASC should get an anesthesiologist to train staff on standing protocols that help the recovery nurse act faster and more efficiently," she says. She says the ASC should apply risk stratification for nausea and vomiting to every patient during the initial phone call. Once the ASC has recorded the patient's risk of nausea and vomiting, the staff can proceed with surgery knowing what to expect. "That makes our nausea and vomiting rate very low and increases patient satisfaction hugely," she says.
She says the ASC should also implement policies around pain, such as a pain scale or a pain score. The physician and anesthesiologist should discuss how the ASC will react if the patient is experiencing pain. For example, the patient might receive oral medication first for mild pain.
5. Every new anesthesiologist should undergo a thorough orientation. When new providers join the group or start working at the ASC, Dr. Desai says they should go through a robust orientation process. "Policies at the ASC often aren't made clear to the anesthesia personnel, "she says. "I think you need to have somebody from the anesthesia group who will look over those policies and make sure everybody in the anesthesia group knows them." When new anesthesia providers join the ASC, she says they should be oriented to the facility one-on-one rather than just thrown into the mix.
6. Anesthesia groups should be expected to staff providers consistently. Dr. Desai says problems arise when ASC anesthesia groups interchange providers constantly, forcing surgeons and staff to get used to a new provider on a regular basis. "Most providers that come in are hospitalists, and they don't know the ASC," she says. "As a surgeon, you're hesitant as soon as you realize that the anesthesiologist is not familiar with ASCs." She says anesthesia groups should be expected to staff several providers on a consistent basis, and the ASC should ask the group not to introduce a provider without several years of anesthesia experience.
7. Anesthesiologists can give input on CO2 monitoring changes. As of July 1, the American Society of Anesthesiologists recommends that anesthesiologists use end tidal CO2 monitoring for moderate sedation as well as deep sedation, a change from past regulations that only recommended monitoring for deep sedation. "You should involve your anesthesiologist in discussing what you need," she says.
8. ASC leaders should talk to anesthesiologists about standardizing supplies. Just like ASC surgeons, anesthesiologists have preferences when it comes to equipment and drugs, Dr. Desai says. Unfortunately, surgery centers don't have the same capital as hospitals and may struggle to provide several different brands of the same drug.
Make sure anesthesiologists are aware of the center's financial situation and the positive effect of standardization. "If you have five anesthesiologists, you should talk to them about the one or two muscle relaxants that you need," she says. "You don't need five different ones, and if they have those discussions with each other, it's a much easier process."
9. ASC anesthesiologists are tailor-made for leadership roles. Anesthesiologists, who spend time at the center on a regular basis and work with every ASC surgeon, are a perfect fit for leadership roles. Dr. Desai says some administrators might assume anesthesiologists are not interested in playing a part in ASC operational decisions, especially if they aren't investors.
On the contrary, she says, many anesthesia providers want to feel more involved with their centers and will put in the time to serve on committees or take medical directorship positions. "While surgeons come in and out and only see things piecemeal, anesthesiologists see everyone's role and every interaction," she says.
10. Remove the obstacles to providing care, and anesthesia providers will be satisfied. Anesthesiologists practice at surgery centers because they enjoy the increased efficiency and decreased bureaucracy, Dr. Desai says. Make sure that you remove all obstacles to providing great care. "Eliminate things that cause mental problems or difficulties ahead of time, like triaging of patients, making sure a case is accurately scheduled and ensuring the anesthesiologists have everything they need," she says. "All those things can contribute to mental distress and frustration."
Learn more about Nova Anesthesia Professionals.
Related Articles on Anesthesia:
Anesthesia Quality Institute Launches Anesthesia Incident Reporting System
Trinity Mother Frances Health System Names Dr. Gifford Eckhout Chief of Anesthesia
University of Iowa Hospitals Settles $300k Lawsuit Over Anesthesiologist Negligence
1. Robust triage process is essential. Patient selection is extremely important in an ASC because not all patients are appropriate for outpatient surgery. ASCs should work to identify patients that will not require a transfer to the hospital, which generally means patients with an ASA score of 1 or 2. Dr. Desai says that while most ASCs can identify patients with an ASA score of 4, many surgery centers run into trouble when identifying 3s — those patients with severe systemic disease that could cause surgical complications.
"A lot of ASCs do not do triage well," she says. "The rising rate of obesity causes issues with airway difficulties and obstructive sleep apnea, so we've also got to appreciate changes that affect the triage process." She says that triage should ideally be performed as soon as the patient is scheduled, and the anesthesia provider should be heavily involved. ASC administrators and anesthesiologists should discuss the regulations in their state to determine which patients can be treated at the surgery center. In some states, only patients with an ASA score of 1 or 2 can be treated, while other states allow patients with a score of 3.
Dr. Desai recommends giving nurses algorithms to determine whether patients are appropriate for ASC surgery. "Because [triage] is a non-reimbursable activity, our practice has trained nurses to do it," she says. "The nurses follow certain algorithms that you've designed for them, and then they check in with the physician."
2. Anesthesiologists and surgeons must communicate about clinical decisions. Dr. Desai says hostility between anesthesiologists and surgeons most commonly arises when the two parties fail to communicate about a clinical decision. "For instance, when you tell a surgeon to cancel a patient, they need to know exactly why you want to cancel," she says. "They're usually thinking, 'It's more convenient for me, and you're making it less convenient, and you're also taking revenue from me to somewhere else.'" The anesthesiologist should explain to the surgeon why the patient is not appropriate for outpatient surgery.
Anesthesiologists should also be careful about the way they respond to surgeon questions, Dr. Desai says. "We're often defensive," she says. "They ask a question, and instead of interpreting it as a question, we defend our position." She says if the surgeon asks why the patient needs an EKG, the anesthesiologist should calmly explain why the EKG is necessary. She says this is most easily accomplished if the center's anesthesia providers are included on ASC committees. That way, anesthesiologists will be present for discussions about patient selection, and surgeons will respect anesthesia providers for taking the time to contribute to the discussions.
3. ASC leaders should talk to anesthesiologists about drug shortages. Drug shortages are affecting surgery centers and hospitals across the country, and ASC administrators must discuss the issue with anesthesiologists to make sure center processes are adjusted accordingly, Dr. Desai says. "When we had a propofol shortage, it was important to work with anesthesiologists closely and discuss the [alternative drugs] they would be using," she says. "Anesthesia not only has to use those drugs, but figure out the different mixtures and then inservice the recovery room because patients come out looking different." In a hospital, there may be more facility-wide discussion of drug shortages; in an ASC, the administrator must take responsibility for engaging anesthesiologists on the subject.
4. Standing protocols can speed up patient discharge without anesthesiologist supervision. The two anesthesia-related issues that generally prevent timely patient discharge are nausea and vomiting, Dr. Desai says. "The ASC should get an anesthesiologist to train staff on standing protocols that help the recovery nurse act faster and more efficiently," she says. She says the ASC should apply risk stratification for nausea and vomiting to every patient during the initial phone call. Once the ASC has recorded the patient's risk of nausea and vomiting, the staff can proceed with surgery knowing what to expect. "That makes our nausea and vomiting rate very low and increases patient satisfaction hugely," she says.
She says the ASC should also implement policies around pain, such as a pain scale or a pain score. The physician and anesthesiologist should discuss how the ASC will react if the patient is experiencing pain. For example, the patient might receive oral medication first for mild pain.
5. Every new anesthesiologist should undergo a thorough orientation. When new providers join the group or start working at the ASC, Dr. Desai says they should go through a robust orientation process. "Policies at the ASC often aren't made clear to the anesthesia personnel, "she says. "I think you need to have somebody from the anesthesia group who will look over those policies and make sure everybody in the anesthesia group knows them." When new anesthesia providers join the ASC, she says they should be oriented to the facility one-on-one rather than just thrown into the mix.
6. Anesthesia groups should be expected to staff providers consistently. Dr. Desai says problems arise when ASC anesthesia groups interchange providers constantly, forcing surgeons and staff to get used to a new provider on a regular basis. "Most providers that come in are hospitalists, and they don't know the ASC," she says. "As a surgeon, you're hesitant as soon as you realize that the anesthesiologist is not familiar with ASCs." She says anesthesia groups should be expected to staff several providers on a consistent basis, and the ASC should ask the group not to introduce a provider without several years of anesthesia experience.
7. Anesthesiologists can give input on CO2 monitoring changes. As of July 1, the American Society of Anesthesiologists recommends that anesthesiologists use end tidal CO2 monitoring for moderate sedation as well as deep sedation, a change from past regulations that only recommended monitoring for deep sedation. "You should involve your anesthesiologist in discussing what you need," she says.
8. ASC leaders should talk to anesthesiologists about standardizing supplies. Just like ASC surgeons, anesthesiologists have preferences when it comes to equipment and drugs, Dr. Desai says. Unfortunately, surgery centers don't have the same capital as hospitals and may struggle to provide several different brands of the same drug.
Make sure anesthesiologists are aware of the center's financial situation and the positive effect of standardization. "If you have five anesthesiologists, you should talk to them about the one or two muscle relaxants that you need," she says. "You don't need five different ones, and if they have those discussions with each other, it's a much easier process."
9. ASC anesthesiologists are tailor-made for leadership roles. Anesthesiologists, who spend time at the center on a regular basis and work with every ASC surgeon, are a perfect fit for leadership roles. Dr. Desai says some administrators might assume anesthesiologists are not interested in playing a part in ASC operational decisions, especially if they aren't investors.
On the contrary, she says, many anesthesia providers want to feel more involved with their centers and will put in the time to serve on committees or take medical directorship positions. "While surgeons come in and out and only see things piecemeal, anesthesiologists see everyone's role and every interaction," she says.
10. Remove the obstacles to providing care, and anesthesia providers will be satisfied. Anesthesiologists practice at surgery centers because they enjoy the increased efficiency and decreased bureaucracy, Dr. Desai says. Make sure that you remove all obstacles to providing great care. "Eliminate things that cause mental problems or difficulties ahead of time, like triaging of patients, making sure a case is accurately scheduled and ensuring the anesthesiologists have everything they need," she says. "All those things can contribute to mental distress and frustration."
Learn more about Nova Anesthesia Professionals.
Related Articles on Anesthesia:
Anesthesia Quality Institute Launches Anesthesia Incident Reporting System
Trinity Mother Frances Health System Names Dr. Gifford Eckhout Chief of Anesthesia
University of Iowa Hospitals Settles $300k Lawsuit Over Anesthesiologist Negligence