Providing anesthesia in a surgery center is different from practicing in the hospital setting, due to a different patient mix, environment and average case acuity. Thomas Wherry, MD, principal for Total Anesthesia Solutions and consulting medical director for Health Inventures, discusses five essential skills for ASC anesthesia providers.
1. Experience with pediatrics. Dr. Wherry says if a surgery center is planning to perform surgery on pediatric patients, the contracted anesthesia group should include providers with pediatric anesthesia experience. This doesn't mean the anesthesiologist has to be fellowship-trained in pediatric anesthesiology — according to Dr. Wherry, fellowship training is more applicable for anesthesiologists assisting with complex in-patient cases.
He says anesthesiologists with pediatric experience are essential for cases that involve children because they understand the differences in dosage, airway management and medication needs between a child and an adult. "They're not just little adults," he says. "There is a physiologic difference and a medication requirement difference and a dosing difference. Airway management is probably the biggest one. You need to have that skill set, or it's not going to go well and the surgeons are not going to be happy."
He says when adding a new anesthesia provider or group, the ASC administrator should inquire as to how many pediatric cases the group has performed in the past. "You also might want to call other locations where they've practiced and make sure they are competent in dealing with pediatric patients," he says.
2. Knowledge of regional anesthesia and peripheral nerve blocks. Anesthesia providers who work in an orthopedic-driven surgery center should have a strong knowledge of how to perform peripheral nerve blocks, Dr. Wherry says. Peripheral nerve blocks are popular for orthopedic cases because they allow the provider to isolate a nerve in the arm or leg and anesthetize the area without putting the patient to sleep. "Peripheral nerve blocks take a higher skill level than other [regional anesthesia techniques] because you're really isolating a particular nerve, so you have to have knowledge of anatomy and be able to do that on patients of all shapes and sizes."
He says peripheral nerve blocks are also useful because the anesthesia provider can insert the block prior to surgery, give the patient a lighter general anesthetic and then wake them up more quickly after the procedure. The patient usually suffers less pain after surgery with a peripheral nerve block than with general anesthesia, he says. These techniques are especially useful as surgery centers treat more and more obese patients, who have a higher risk of complications under general anesthesia.
Dr. Wherry says the "ultimate" skill for a regional anesthesia provider is the ability to perform ultrasound-guided peripheral nerve blocks. "If I were going to open an orthopedic center, I would want providers that are very skilled at doing blocks and doing them efficiently," he says. If the provider is unskilled,, blocks may take up to 20-30 minutes to insert one, so a high skill level is necessary.
3. Strong airway management technique. As surgery centers increasingly treat more obese patients, Dr. Wherry says surgery center anesthesia groups must have significant expertise in airway management. He says the all providers should feel comfortable using a GlideScope or other fiber optic device — tools that every surgery center should provide.
He says airway management problems generally apply to obese patients, patients with obstructive sleep apnea and — in rarer cases — patients with anatomical abnormalities or congenital diseases. He says if your surgery center doesn't staff an anesthesiologist with airway management expertise, you may end up cancelling more cases or having bad outcomes.
4. Ability to manage patients with co-morbidities. The acuity of surgery center cases is only increasing, Dr. Wherry says. Twenty years ago, surgery centers were able to staff with providers who were at the end of their careers and had not undergone training in years. Nowadays, he says you need anesthesiologists and CRNAs who are comfortable dealing with patients with an American Society of Anesthesiologists Class 3 status, meaning the patient has severe systemic disease. Without an anesthesiologist or CRNA who is comfortable with these patients, you will end up sending cases to the hospital or transferring more cases than necessary.
He says anesthesia providers in an ASC setting should understand how to treat patients with multi-system diseases and co-morbid conditions such as diabetes and asthma. "It's a higher-skilled anesthesiologist or CRNA who is comfortable in the screening and management of these patients, as well as post-op management and making sure they go home to a safe environment," he says.
5. Cooperative attitude. Dr. Wherry says one of the most "underappreciated skills" of ASC anesthesia providers is the ability to cooperate with surgeons and other caregivers and act as a "perioperative physician" in the outpatient setting. He says anesthesiologists who are used to a hospital setting may not be accustomed to pitching in with surgery center initiatives and engaging in the whole running of the center.
"Especially if you're looking for a medical director, who is often an anesthesiologist, that person needs to be respected by the surgeons, work well with the nursing staff and be a good teacher and leader and mentor," he says. The anesthesiologist should want to work in a small, intimate environment and should care about seeing the patient though the pre-operative, operative and post-operative stages of care.
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1. Experience with pediatrics. Dr. Wherry says if a surgery center is planning to perform surgery on pediatric patients, the contracted anesthesia group should include providers with pediatric anesthesia experience. This doesn't mean the anesthesiologist has to be fellowship-trained in pediatric anesthesiology — according to Dr. Wherry, fellowship training is more applicable for anesthesiologists assisting with complex in-patient cases.
He says anesthesiologists with pediatric experience are essential for cases that involve children because they understand the differences in dosage, airway management and medication needs between a child and an adult. "They're not just little adults," he says. "There is a physiologic difference and a medication requirement difference and a dosing difference. Airway management is probably the biggest one. You need to have that skill set, or it's not going to go well and the surgeons are not going to be happy."
He says when adding a new anesthesia provider or group, the ASC administrator should inquire as to how many pediatric cases the group has performed in the past. "You also might want to call other locations where they've practiced and make sure they are competent in dealing with pediatric patients," he says.
2. Knowledge of regional anesthesia and peripheral nerve blocks. Anesthesia providers who work in an orthopedic-driven surgery center should have a strong knowledge of how to perform peripheral nerve blocks, Dr. Wherry says. Peripheral nerve blocks are popular for orthopedic cases because they allow the provider to isolate a nerve in the arm or leg and anesthetize the area without putting the patient to sleep. "Peripheral nerve blocks take a higher skill level than other [regional anesthesia techniques] because you're really isolating a particular nerve, so you have to have knowledge of anatomy and be able to do that on patients of all shapes and sizes."
He says peripheral nerve blocks are also useful because the anesthesia provider can insert the block prior to surgery, give the patient a lighter general anesthetic and then wake them up more quickly after the procedure. The patient usually suffers less pain after surgery with a peripheral nerve block than with general anesthesia, he says. These techniques are especially useful as surgery centers treat more and more obese patients, who have a higher risk of complications under general anesthesia.
Dr. Wherry says the "ultimate" skill for a regional anesthesia provider is the ability to perform ultrasound-guided peripheral nerve blocks. "If I were going to open an orthopedic center, I would want providers that are very skilled at doing blocks and doing them efficiently," he says. If the provider is unskilled,, blocks may take up to 20-30 minutes to insert one, so a high skill level is necessary.
3. Strong airway management technique. As surgery centers increasingly treat more obese patients, Dr. Wherry says surgery center anesthesia groups must have significant expertise in airway management. He says the all providers should feel comfortable using a GlideScope or other fiber optic device — tools that every surgery center should provide.
He says airway management problems generally apply to obese patients, patients with obstructive sleep apnea and — in rarer cases — patients with anatomical abnormalities or congenital diseases. He says if your surgery center doesn't staff an anesthesiologist with airway management expertise, you may end up cancelling more cases or having bad outcomes.
4. Ability to manage patients with co-morbidities. The acuity of surgery center cases is only increasing, Dr. Wherry says. Twenty years ago, surgery centers were able to staff with providers who were at the end of their careers and had not undergone training in years. Nowadays, he says you need anesthesiologists and CRNAs who are comfortable dealing with patients with an American Society of Anesthesiologists Class 3 status, meaning the patient has severe systemic disease. Without an anesthesiologist or CRNA who is comfortable with these patients, you will end up sending cases to the hospital or transferring more cases than necessary.
He says anesthesia providers in an ASC setting should understand how to treat patients with multi-system diseases and co-morbid conditions such as diabetes and asthma. "It's a higher-skilled anesthesiologist or CRNA who is comfortable in the screening and management of these patients, as well as post-op management and making sure they go home to a safe environment," he says.
5. Cooperative attitude. Dr. Wherry says one of the most "underappreciated skills" of ASC anesthesia providers is the ability to cooperate with surgeons and other caregivers and act as a "perioperative physician" in the outpatient setting. He says anesthesiologists who are used to a hospital setting may not be accustomed to pitching in with surgery center initiatives and engaging in the whole running of the center.
"Especially if you're looking for a medical director, who is often an anesthesiologist, that person needs to be respected by the surgeons, work well with the nursing staff and be a good teacher and leader and mentor," he says. The anesthesiologist should want to work in a small, intimate environment and should care about seeing the patient though the pre-operative, operative and post-operative stages of care.
Related Articles on Anesthesia:
Harvard Anesthesiologist Publishes Memoir on Advancements in Anesthesia Safety
PharMEDium Unveils OR Medication Verification System
Scientists Investigate the Boundaries of Consciousness