There are two periods of time during which an anesthesiologist may request to have a case at an ASC cancelled — during the pre-op screening process and on the day of the procedure, according to Thomas Wherry, MD, principal of Total Anesthesia Solutions and medical director of Health Inventures.
Dr. Wherry describes five common reasons during these two periods when anesthesiologists may cancel a case.
Pre-op screening cancellations
Cancellations that occur during the pre-op screening process are usually the result of either the anesthesiologists and/or the ASC not communicating well with the surgeon's office about the type of patients that should not be treated at the surgery center, Dr. Wherry says. Here are three patient qualities that could force the anesthesiologist towards cancellation:
1. High BMI. A high patient weight may exceed an anesthesiologist's comfort level. "That often depends on the type of surgery," says Dr. Wherry. "If you're getting into airway surgery or a surgery that is going to require a patient in an unusual position, such as spine, often the anesthesiologist won't feel comfortable. An anesthesiologist might feel comfortable doing a carpal tunnel on one patient but not comfortable doing a tonsillectomy on the same patient."
Cancellations because of high BMI are very common during the screening process, he says, but they should not be occurring on the day of surgery. ASCs should have a BMI limit established, with any patients exceeding the limit going to the hospital. If patients are close to the limit, an ASC will want to consider allowing the anesthesiologist to screen them in advance.
2. Obstructive sleep apnea. Cancellations for patients with obstructive sleep apnea may occur if the sleep apnea is moderate or severe, and, like BMI, the type of surgery is also a consideration. "If it's airway surgery, for example, we're going to be more likely not to do the case in an ASC setting," says Dr. Wherry.
3. Respiratory problems. A lingering respiratory problem that has not resolved may also make an anesthesiologist uncomfortable. "This might be somebody who has recent case of pneumonia or acute asthma attack that hasn't completely resolved," Dr. Wherry says.
Identifying these three possible hindrances to patient treatment boils down to developing a good pre-op system where all of the anesthesiologists and CRNAs are on the same page about what is and is not a good candidate for a freestanding ASC, he says. "That will vary based on providers, their comfort level, proximity to a hospital and the experience of the anesthesia provider in working in that environment."
An ASC does not want to miss these warning signs, because doing so could result in…
Same-day cancellations
"Most people think same-day cancellations, [for an ASC] with a good pre-op system, excellent communication with the anesthesia group and the anesthesia group having consistent guidelines amongst the anesthesiology providers, should be close to zero," Dr. Wherry says. "When I go out and survey centers, the same-day cancellation rate directly correlates to the quality of the pre-op system and how well they are triaging the patients prior to the day of surgery." Cancellations should be relatively rare, likely between .01 to .05 percent of all cases, he says. Dr. Wherry says that same-day cancellations should never occur for reasons that could have been detected earlier.
Here are the fourth and fifth reasons Dr. Wherry says are the typical causes for anesthesia cancellations.
4. NPO violation. This goes back to your pre-op system — what the patient was told and how clear the instructions were on when to stop eating or drinking. "No matter how good you do or how clear your instructions are, you still get patients that misinterpret them," Dr. Wherry says. "You still get the occasional patient that eats an apple on the way to the ASC and one should not proceed for elective surgery on a patient with a full stomach."
Some ASCs will allow afternoon patients to have a light meal. This can present complications if, on the day of surgery, the physician asks to move the surgery up to the late morning. "Now you've let the patient have a light meal at 7:00 or 8:00 and you lose that flexibility to move the patient up," Dr Wherry says.
More and more ASCs are going back to instructing the patient to eat or drink nothing after midnight, even for patients with a surgery in the afternoon. "If a patient makes a big deal out of this, then [the ASC can] go to the anesthesiologist to see about customizing the guideline for the patient," he says.
5. Missed acute illness. There is the occasional instance when an onset of an illness was not identified during a phone call to the patient. "The common most reasons for this are acute or severe respiratory infection — an acute onset of asthma or some new cardiac condition," Dr. Wherry says. "For places that do a lot of cataracts, it's not uncommon for a patient to come in with new-onset atrial fibrillation. It wouldn't be prudent to proceed in that scenario."
Learn more about Total Anesthesia Solutions.
Learn more about Health Inventures.
Read more practical guidance about anesthesia:
- 4 Ways to Improve the Provision of Anesthesia
- Critical Guidance for Complying With Anesthesia Infection Control Rules