Anesthesia complications can endanger patient safety, prolong case time and decrease patient satisfaction. While anesthesia has a history of high quality in surgery centers, Thomas Wherry, MD, founder of Total Anesthesia Solutions and medical director with Health Inventures, says ASCs should still be proactive in identifying high-risk patients and preventing potential issues. Here are six ways surgery center administrators can improve anesthesia safety.
1. Improve your pre-op screening process. The old truism, "an ounce of prevention is worth a pound of cure," applies to anesthesia in surgery centers, Dr. Wherry says. Most anesthesia complications can be predicted or pre-empted through a robust pre-operative screening process. He says surgery centers should work to improve that process by analyzing every complication to see if a screening could have predicted the issue.
"It's always worth it to go back and see what was missed and what you could have done differently," Dr. Wherry says. "Sometimes you can't predict when complications are going to happen, but it's worth going through." He says the ideal anesthesia staffing model will use the same anesthesiologist on a regular basis to help standardize pre-op screening requirements and define which patients need a pre-operative consult. Most patients at risk of complications will fall into one of several categories: obese patients, patients with obstructive sleep apnea, patients with history of cardiac issues, patients with history of airway issues and patients who have reacted badly to anesthesia in the past.
Because these issues are the major predictors of anesthesia complications, Dr. Wherry says a patient history can often be more telling than a blood test. He says surgery center leaders should meet quarterly with nurses to go over pre-op screening questions, recent complications and any changes that need to be made to catch at-risk patients in the future.
2. Come to a consensus on appropriate cases. While the American Society of Anesthesiologists has not published a recommendation on the appropriate weight or body mass index for surgery center patients, Dr. Wherry says each individual center should determine its case-by-case "cut off level" to reduce the risk of complications. He says the "cut off level" will depend on several factors. For example, some surgeries pose more risks than others; cataract surgeries or bunionectomies are less likely to see complications than tonsillectomies for patients with airway problems. A surgery center located next to a hospital may be more comfortable accepting higher-risk patients, knowing that patients can be transferred easily in case of complications. The presence of difficult airway equipment and stretchers appropriate for heavier patients may also contribute to the decision.
Appropriate patient weight is not an exact science, and the numbers will differ from center to center. "There's really no right number, but rather a range that people are comfortable with," Dr. Wherry says. "The very conservative side would be [a maximum BMI of] 35, with the high end up to 45-50." He says surgery centers should still endeavor to be welcoming to all patients. "You don't want to turn every case away, but you should have a good screening process and ask pointed questions," he says.
3. Encourage anesthesiologists to take enough time between cases. Most surgery centers emphasize reducing turnover times to improve efficiency and save money. However, Dr. Wherry says ASC administrators should encourage anesthesia providers to take as much time as they need to maintain high quality of care. Surgery centers that sacrifice quality and thoroughness in favor of saving money can increase the risk of complications, he says. Administrators should encourage anesthesia providers to arrive 30 minutes before the start of the case, and anesthesiologists should be given case details a day in advance to ensure adequate preparation.
Despite the desire to trim turnover times as much as possible, surgery center administrators should give anesthesia providers permission to take their time in the recovery room. "This is really huge when you have one provider and one OR, and there's no backup," he says. "The facility really needs to encourage providers to take their time. They should not let the pressure of room turnaround change their practice."
4. Install the right equipment. Appropriate, up-to-date equipment can help anesthesia providers handle complications when they arise. Surgery centers should involve anesthesiologists in purchase decisions to make sure they are comfortable with the selections. Dr. Wherry says surgery centers should be equipped with a maintained anesthesia machines, basic monitors and difficult airway equipment in case of unexpected issues. "In my experience, the most common anesthesia complications have been respiratory, and having the ability to manage a difficult airway if it's not predicted is essential," he says.
He says staff members should also be well-versed in using the anesthesia equipment. Surgery centers should hold regular in-services to prepare for different anesthesia complication scenarios and train staff to use equipment. Equipment should also be maintained and checked on a regular basis.
5. Establish DVT prophylaxis settings with medical advisory committee. Deep venous thrombosis and pulmonary embolism are serious surgical complications that can prove fatal if left untreated. While DVT and pulmonary embolism have historically been tied to inpatient surgeries, more and more surgery centers are establishing protocols on instituting DVT prophylaxis and educating patients on pulmonary embolism, Dr. Wherry says. He says surgery centers should establish a screening process to identify patients at higher risk for DVT or PE; warning signs include smoking, birth control use and morbid obesity. The center's medical advisory committee should also define protocols on when to apply sequential compression devices and when to use medication to minimize risk.
Delaying treatment for pulmonary embolism can significantly increase the risk of patient mortality, so surgery centers should develop ways to educate patients on the symptoms and appropriate response to PE. Discharge criteria should also include a check for PE symptoms, and providers can follow up with patients during the post-operative phone call.
6. Involve anesthesiologists in developing discharge criteria. Anesthesiologists and CRNAs should be involved in developing discharge criteria, Dr. Wherry says. As surgery centers perform larger, more complex cases, there should absolutely be a hand-off between the anesthesia provider and the discharge nurse, including a clear, concise report and discharge approval from the anesthesiologist. Surgery centers should develop a policy form that includes physiologic-based (rather than time-based) discharge criteria, allowing nurses to give move recovery time to patients who need it. The surgeon or anesthesiologist should also be able to request a longer recovery.
Surgery centers should also make sure their post-operative phone calls are effective, Dr. Wherry says. A phone call one day after surgery should be enough to pick up on anesthesia complications, based on the patient's answers to questions about pain, post-operative nausea and vomiting, sore throat and breathing or cardiac problems. Dr. Wherry says while most surgery centers ask the right questions, some fail to contact a high percentage of patients in the first place. "Facilities either don't do a good job of identifying the best phone number to call, or they make only one attempt, so the percentage of patients they reach is low," he says. "I've gone into facilities where they contact 30 percent of patients. That should really be over 90 percent."
Learn more about Total Anesthesia Solutions and Health Inventures.
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1. Improve your pre-op screening process. The old truism, "an ounce of prevention is worth a pound of cure," applies to anesthesia in surgery centers, Dr. Wherry says. Most anesthesia complications can be predicted or pre-empted through a robust pre-operative screening process. He says surgery centers should work to improve that process by analyzing every complication to see if a screening could have predicted the issue.
"It's always worth it to go back and see what was missed and what you could have done differently," Dr. Wherry says. "Sometimes you can't predict when complications are going to happen, but it's worth going through." He says the ideal anesthesia staffing model will use the same anesthesiologist on a regular basis to help standardize pre-op screening requirements and define which patients need a pre-operative consult. Most patients at risk of complications will fall into one of several categories: obese patients, patients with obstructive sleep apnea, patients with history of cardiac issues, patients with history of airway issues and patients who have reacted badly to anesthesia in the past.
Because these issues are the major predictors of anesthesia complications, Dr. Wherry says a patient history can often be more telling than a blood test. He says surgery center leaders should meet quarterly with nurses to go over pre-op screening questions, recent complications and any changes that need to be made to catch at-risk patients in the future.
2. Come to a consensus on appropriate cases. While the American Society of Anesthesiologists has not published a recommendation on the appropriate weight or body mass index for surgery center patients, Dr. Wherry says each individual center should determine its case-by-case "cut off level" to reduce the risk of complications. He says the "cut off level" will depend on several factors. For example, some surgeries pose more risks than others; cataract surgeries or bunionectomies are less likely to see complications than tonsillectomies for patients with airway problems. A surgery center located next to a hospital may be more comfortable accepting higher-risk patients, knowing that patients can be transferred easily in case of complications. The presence of difficult airway equipment and stretchers appropriate for heavier patients may also contribute to the decision.
Appropriate patient weight is not an exact science, and the numbers will differ from center to center. "There's really no right number, but rather a range that people are comfortable with," Dr. Wherry says. "The very conservative side would be [a maximum BMI of] 35, with the high end up to 45-50." He says surgery centers should still endeavor to be welcoming to all patients. "You don't want to turn every case away, but you should have a good screening process and ask pointed questions," he says.
3. Encourage anesthesiologists to take enough time between cases. Most surgery centers emphasize reducing turnover times to improve efficiency and save money. However, Dr. Wherry says ASC administrators should encourage anesthesia providers to take as much time as they need to maintain high quality of care. Surgery centers that sacrifice quality and thoroughness in favor of saving money can increase the risk of complications, he says. Administrators should encourage anesthesia providers to arrive 30 minutes before the start of the case, and anesthesiologists should be given case details a day in advance to ensure adequate preparation.
Despite the desire to trim turnover times as much as possible, surgery center administrators should give anesthesia providers permission to take their time in the recovery room. "This is really huge when you have one provider and one OR, and there's no backup," he says. "The facility really needs to encourage providers to take their time. They should not let the pressure of room turnaround change their practice."
4. Install the right equipment. Appropriate, up-to-date equipment can help anesthesia providers handle complications when they arise. Surgery centers should involve anesthesiologists in purchase decisions to make sure they are comfortable with the selections. Dr. Wherry says surgery centers should be equipped with a maintained anesthesia machines, basic monitors and difficult airway equipment in case of unexpected issues. "In my experience, the most common anesthesia complications have been respiratory, and having the ability to manage a difficult airway if it's not predicted is essential," he says.
He says staff members should also be well-versed in using the anesthesia equipment. Surgery centers should hold regular in-services to prepare for different anesthesia complication scenarios and train staff to use equipment. Equipment should also be maintained and checked on a regular basis.
5. Establish DVT prophylaxis settings with medical advisory committee. Deep venous thrombosis and pulmonary embolism are serious surgical complications that can prove fatal if left untreated. While DVT and pulmonary embolism have historically been tied to inpatient surgeries, more and more surgery centers are establishing protocols on instituting DVT prophylaxis and educating patients on pulmonary embolism, Dr. Wherry says. He says surgery centers should establish a screening process to identify patients at higher risk for DVT or PE; warning signs include smoking, birth control use and morbid obesity. The center's medical advisory committee should also define protocols on when to apply sequential compression devices and when to use medication to minimize risk.
Delaying treatment for pulmonary embolism can significantly increase the risk of patient mortality, so surgery centers should develop ways to educate patients on the symptoms and appropriate response to PE. Discharge criteria should also include a check for PE symptoms, and providers can follow up with patients during the post-operative phone call.
6. Involve anesthesiologists in developing discharge criteria. Anesthesiologists and CRNAs should be involved in developing discharge criteria, Dr. Wherry says. As surgery centers perform larger, more complex cases, there should absolutely be a hand-off between the anesthesia provider and the discharge nurse, including a clear, concise report and discharge approval from the anesthesiologist. Surgery centers should develop a policy form that includes physiologic-based (rather than time-based) discharge criteria, allowing nurses to give move recovery time to patients who need it. The surgeon or anesthesiologist should also be able to request a longer recovery.
Surgery centers should also make sure their post-operative phone calls are effective, Dr. Wherry says. A phone call one day after surgery should be enough to pick up on anesthesia complications, based on the patient's answers to questions about pain, post-operative nausea and vomiting, sore throat and breathing or cardiac problems. Dr. Wherry says while most surgery centers ask the right questions, some fail to contact a high percentage of patients in the first place. "Facilities either don't do a good job of identifying the best phone number to call, or they make only one attempt, so the percentage of patients they reach is low," he says. "I've gone into facilities where they contact 30 percent of patients. That should really be over 90 percent."
Learn more about Total Anesthesia Solutions and Health Inventures.
Related Articles on Anesthesia:
Study: Sniffing Position Optimal for Direct Laryngoscopy
Anesthesia Device Market to Reach $4B by 2017
Study: Preanesthetic Interview Can Improve Patient Satisfaction