"The best surgical outcomes, highest profits and greatest patient satisfaction are found at well-managed ASCs that have an awareness of how areas such as anesthesia affect ASCs’ general operations,” says Susan Kizirian, RN, MBA, the chief operating officer at Ambulatory Surgery Centers of America.
To help ASCs stay current, several experts provide information on recent anesthesia-related clinical and business developments.
Clinical developments
Experts report three recent clinical developments in ASC anesthesia:
• Lipid rescue in the ASC. Recent case studies show that intravascular infusion of a lipid emulsion, or lipid rescue, can treat severe drug toxicity caused by anesthesia. It works by quickly drawing the local anesthesia out from the cellular level. With anesthesia there is always the risk, albeit small, that the treatment may have a toxic or poisonous effect on a patient.
“While the toxicity risk is miniscule and, in fact, I have never seen it, it does occur, and an ASC should take proactive measures to counteract any potentially fatal reaction,” says Drew Lieberman, MD, an anesthesiologist and the medical director at Outpatient Surgical Services in Plantation, Fla. “For its rapid effect and life-saving quality, it would be wise for ASCs to stock a lipid rescue right alongside their other standard resuscitative drugs.”
• More lenient liquid rules. ASCs are slowly beginning to follow the American Society of Anesthesiologists liquid NPO guidelines for general anesthesia, which state that ambulatory children and adults (those without conditions associated with increased risk for pulmonary aspiration) may drink liquids up to two hours before surgery.
“Even though the ASA NPO guidelines make clear that longer liquid fasts have no added benefit in most patients, ASCs have been slow to universally change from the more traditional standard of not permitting liquids for six hours or more before surgery,” says
Ms. Kizirian.
However, as more ASCs recognize the clinical value of the more lenient standards, there is a shift in the industry to adopt the ASA NPO guidelines, says Ms. Kizirian. For example, patients are likely to be better hydrated when presenting for surgery.
“As adequate hydration is a key factor in a good surgical outcome, any practice that allows for an optimum intake of clear liquids is beneficial,” explains Ms. Kizirian. In addition, patients will not have to present for surgeries first thing in the morning and can instead accommodate their own schedules. “By eliminating the six-hour-or-longer liquid fast, patients can more easily schedule afternoon appointments, which can alleviate a lot of their stress; this also directly correlates with better outcomes,” adds Ms. Kizirian.
In addition to these clinical benefits, the more lenient guidelines can also result in other patient benefits. For example, patient satisfaction can be increased because patients will be able to have a glass of water, black coffee or juice, and brush their teeth in the morning; they will also have more options for scheduling appointments, which in turn provides the ASC with more flexibility in scheduling surgeries, says Ms. Kizirian.
• Increased use of consciousness monitors. Technology that measures depth of consciousness, or the effects of anesthesia on a patient’s level of consciousness, is increasingly being used in the ambulatory setting. The Bispectral Index Monitor first emerged on the market about eight years ago but, until
recently, consciousness monitoring has not been
widely utilized in the ambulatory setting.
While neither the ASA nor the American Association of Nurse Anesthetists explicitly endorses the use of consciousness monitoring, both organizations do raise the point that it should at least be considered in their position statements on preventing intraoperative awareness.
“Brain function monitoring … should be considered, particularly in situations where the risk of intraoperative awareness is increased,” says the AANA’s “Unintended Awareness Under General Anesthesia” position statement.
The ASA’s practice advisory, “Practice Advisory for Intraoperative Awareness and Brain Function Monitoring,” lists the many options in consciousness monitors now available, all but one of which track spontaneous electrical activity:
• Bispectral Index,
• Danmeter Cerebral State Monitor/Cerebral State,
• Entropy,
• Narcotrend,
• Patient state analyzer,
• SNAP index, and
• AEP Monitor/2 (which tracks evoked electrical
activity).
As the first to enter the market, the Bispectral Index, or BIS, is generally the most widely used.
“As more and more ASCs recognize their enormous clinical benefits, they are incorporating them into their anesthesia practice,” says anesthesiologist Jeff Bergman, MD, staff anesthesiologist at ENH in Evanston, Ill. “ASCs want to give their patients as little anesthesia medication as possible so that they can wake rapidly, alertly and experience few, if any, side effects. By
monitoring the patient’s brain activity and affect of anesthesia on the patient, the BIS monitor along with the usual standard monitors helps the anesthesiologist determine the minimum dose necessary while still providing an adequate level of anesthesia for the patient.”
By gauging the amount of anesthesia medication
necessary for each patient, an ASC is using only medication dosage required and thereby saves money, adds Dr. Bergman.
Reimbursement and other business developments Experts report three recent reimbursement and business developments in ASC anesthesia:
• Aetna delayed monitored anesthesia colonoscopy policy. Aetna announced in December that, effective April 1, it would stop reimbursing for monitored anesthesia care for colonoscopies which would, therefore, effectively eliminate the use of propofol during those procedures. Claiming that the short-acting intravenous anesthetic agent, used for the induction of general anesthesia, is “medically unnecessary,” the policy did contain exceptions for riskier patients such as those older than 65, pregnant women, and patients with illnesses where other medications would be risky. Aetna would have become the third large payor, joining Wellpoint and Humana, to refuse this reimbursement. After outcry from GI societies and practitioners, the insurer announced it would delay implementation of the policy indefinitely.
“This was a policy shift that could have had serious consequences for anesthesiologists. And while Aetna called off the policy for now, unfortunately, I do not think we have seen the last of these attempts by Aetna and other insurers,” says Dr. Lieberman. “But for now we can breathe a sigh of relief.”
Aetna’s press release in fact states its plans to enact the policy: “[O]nce these new [sedation] options are available in the marketplace, we will move forward with our policy.”
“Clearly this would have severely affected the business of anesthesiologists who provide some or all of their services in the gastroenterology field,” says Dr. Lieberman. “Also, it would particularly hurt ASCs, who generally provide services to healthier patients.”
Older patients, or patients with a co-existing disease, such as heart disease or lung disease — in other words, those for whom payors are more likely to deem propofol “medically necessary” — are generally served in a hospital. But ASCs want to be able to offer what they view as the most patient-friendly sedation option even to patients considered healthy. In other words, such a policy would interfere with physician-patient decision-making regarding appropriate sedation practices for colonoscopy.
“This type of policy squashes the good faith judgment of doctors and casts doubts on their ability to make the best medical choices for their patients,” says Dr. Lieberman. “It may also discourage patients from having this potentially life saving screenings.”
Further, the reimbursement problem could have been tricky as, when providing a patient with a colonoscopy, it is not always apparent at the onset what, if any, anesthetic medication must be used.
“During the course of the procedure it may become necessary for an anesthesiologist to provide
propofol — services under this type of policy that would not be reimbursed,” Dr. Lieberman explains.
• Medicare adds ESWL to ASC list. In January, Medicare added extracorporeal shock wave lithotripsy to the list of ASC-approved procedures with a national average payment of $1,719.
“This is great news for ASCs as this is both a profitable and necessary service,” says Dr. Lieberman. “ASCs can perform this procedure, and the accompanying anesthesia, safely, conveniently and less expensively than in an inpatient facility. Medicare now joins most other private payors who are already reimbursing for the service.”
• Staffing shortage is resolving. The lengthy anesthesiologist shortage has softened in many regions of the nation.
“The shortage is resolving itself in many areas primarily as a factor of supply and demand,” explains Dr. Bergman. “Because of the demand, medical schools and teaching hospitals in the past number of years have expanded their anesthesia residency programs and thereby expanded the pool of qualified anesthesiologists.”
In addition, ASCs are often a more attractive alternative than a hospital to many anesthesiologists.
“We have not found it difficult to recruit anesthesiologists to our ASC due to the hospitable work environment we can offer, including shorter hours and no weekend work, and because of our quality reputation in the community,” says Dr. Lieberman.
And today’s anesthesiologists may be better equipped to provide services in an ASC. Ms. Kizirian has discovered anesthesia groups and organizations cropping up across the nation specifically trained to provide services within an ambulatory surgery center setting.
“It is incredibly advantageous to find a pool of trained anesthesiologists who understand the tenets vital to an ASC such as preoperative assessment, intraoperative and PACU anesthesia care protocols that facilitate patient comfort and outcome while creating efficiency in the provision of care,” she explains.
While working with a large anesthesiology group can offer many benefits such as good coverage and reliability, it may not always be advantageous.
“Most anesthesiologists come from a hospital background and, therefore, it can take time to train one for your ASC environment,” says Ms. Kizirian. “With a large group there is no assurance that the anesthesiologist sent in for service is one that the ASC has trained to understand ambulatory surgery-specific anesthesia.”
Ms. Kulvin is a freelance writer.