Anesthesiology in the ASC Traveling the Road Less Traveled

By Marc Koch, M. D., M.B.A.

A report in the Canadian Journal of Anesthesia states that the “optimal anesthetic technique in the ambulatory setting would provide for excellent operating conditions, a rapid recovery, no postoperative side effects, and a high degree of patient satisfaction.”¹ Although this quote should be taken in the clinical sense, let’s examining the term “operating conditions” through an administrative crucible illustrates some of the challenges facing many surgery centers.

Excellent operating conditions. It’s a tall order that presents quite a challenge for Ambulatory Surgery Center (ASC) and office-based operatory administrators. Following a well worn path, however, might not be the right road to take. To hit this goal, administrators need to take the road a little less traveled—and challenge themselves to do things a little differently.

Here are just some of the assumptions that need to be questioned:

Anesthesiology has to be provided from a local group. While hospitals typically use local medical groups to provide anesthesiology services, providing anesthesiology in the outpatient setting, in many cases, requires a whole different orientation.That is, while anesthesiologists who are accustomed to practicing in the hospital might be great clinicians, the clinical, operational and administrative tasks in the outpatient setting are not the same. Success in the hospital does not necessarily translate into triumph in the outpatient setting, and vice versa.

For example, outpatient anesthesiology providers may need to take into account non-clinical matters more often than their in-patient counterparts. For instance, a nervous 20-something breast augmentation patient might not want to hear the complete laundry list of potential adverse anesthesia outcomes. As a result, the anesthesiologist needs to read the patient’s body language and determine how far the conversation should go. If the anesthesiologist goes too far, the patient might cancel the procedure which, at its extreme, harms the surgeon’s practice and leaves the anesthesiologist or CRNA’s job security in the balance.

Similarly, the expedience of performing a pre-operative evaluation can sometimes be important. Although not cutting corners is obvious, probing a patient on their zeal to quit smoking or explaining the downside of a third helping of veal parmesan to a morbidly obese patient needs to weighed against the surgeon and facility’s need to complete the day’s cases on time. All of that being said, some centers pride themselves on the warm and fuzzy ambience and actually welcome a deeper level of personal engagement, assuming that the facility and surgeon’s scheduling of cases permits such interaction. The anesthesiologist needs to be flexible enough to adapt a style that supports the overall culture and goals of the center regardless if it an office-based facility performing surgery one day a month or a 6-room surgery center performing 50 cases a day.

Do local anesthesia providers coming from the hospital have the right orientation to do so? Some do and some don’t.Do larger national practices or anesthesia management companies have that it takes? Again, some do and some don’t. In general, national providers, especially those that have broad and deep expertise in outpatient surgeries, may be tuned into just the right frequency and consider the venue-specific nuances part of the ambulatory challenge.

Anesthesia is an individual sport—if I find good clinicians I will be all set. Anesthesia is actually a team-sport. In the hospital, dedicated anesthesia technicians ensure that the par levels of routine and seldom used medications and supplies are maintained. A variety of anesthesia specialty carts—such as pediatrics, malignant hyperthermia-- pepper the hallways. The development of inventory sheets and maintenance of the right levels of equipment, supplies and medications in all anesthetizing locations does not happen by accident. In addition, the preventative maintenance on equipment occurs, often with nobody even noticing. In the outpatient setting, these tasks are often taken for granted, sometimes leaving the facility and its owners open to liability—not to mention the potential harm to unsuspecting patients. Some of the larger national anesthesia providers and management companies have the horsepower and skill to pick up some of these duties or at least guide facilities in the right direction.

In the hospital, finding out patients’ insurance information may be a few clicks away or, at worst, a walk to medical records. In either case, getting the information is as routine and unemotional as grabbing a cup of coffee. In some ASC and office-based facilities, however, this is not always the case. In fact, some facilities might resent “outsiders” rummaging through their charts, using their copier, or probing patients on their insurance. As a result, accomplishing the goal of getting information, while not being intrusive, is one part art and two parts science. Similarly, gaining electronic access has the potential to be an elixir to operational friction but many facilities simply are unwilling or unable to do so. Again, a national anesthesia company may have seen and worked with a broad repertoire of operational presentations and may be more apt to face the needs of any center with confidence and assuredness.

Although some hospital-based anesthesia groups gain help or support from the hospital’s contracting department, in the ambulatory environment this support is non-existent, not offered or ineffective. This may change given the growing need for ASCs to subsidize anesthesia departments. In either case, it is job number one for the anesthesia group to be highly adroit at contracting since effective contracting can improve their professional compensation, limit ASC subsidization or both.

Less complicated surgeries require less skilled anesthesia providers—so ASCs can cut costs by relying on less expensive clinicians. Sure enough, many outpatient surgeries can be less complicated than inpatient procedures. But some can be more difficult. Try putting to sleep a patient who is wider than they are tall for gastric banding, or a brittle and frail patient for a shoulder surgery. Costs saving discussions are seldom complete without someone asking about an RN, physicians’ assistant or the operating surgeon delivering anesthesia themselves. The adage that you pay for what you get holds true in the anesthesia world too.

Even though outpatient surgeries can be less complicated and less traumatic than inpatient procedures, anesthesiologists need to work without a back-up team in the outpatient setting. In some ambulatory facilities, there are no other anesthesiologists down the hall, nor is there a team of emergency medicine specialists ready to attend to any code blue situations. And, while emergencies might be rare, not having a well-trained and skilled anesthesiologist or CRNA at the helm when one pops up could turn a low risk surgery into a life-threatening situation.

Consider the following incident that was reported on in an Institute for Safe Medication Practices Medical Safety Alert:

“A physician, who was performing a surgical procedure and administering anesthesia at the same time, thought he could safely administer Propofol while performing a breast augmentation. Unfortunately, the patient died of hypoxic encephalopathy because the doctor failed to notice the patient’s rapidly declining respiratory status, as had his surgical assistant, who was not qualified to monitor patients under deep sedation or anesthesia.”

In addition to providing enhanced patient safety, qualified anesthesiologists and CRNAs can provide operational, bottom-line benefits to the facility. An experienced anesthesiologist or CRNA, who truly understands the ins and outs of outpatient surgery, can use anesthetic techniques that improve recovery times and reduce post-operative side effects. How does this impact the bottom line? Imagine this, a dyed-in-the-wool hospital anesthesiologist administering high-dose narcotic techniques to shoulder surgery patients can be like throwing sand in your center’s engine. Patients with refractory pain or vomiting in the recovery room clog throughput and this has a domino effect with mounting room delays, slow turnover and expensive overtime accruals for the nurses and administrative staff that must stay late to finish the schedule.

Compare this to an anesthesiologist who uses a regional anesthesia technique and whose patients arrive in the PACU lucid, pain-free, without nausea. Turnover and throughput are unencumbered while operating room efficiency and patient satisfaction are enhanced.

A good anesthesiologist can work with any equipment and supplies. Sure enough, an anesthesiologist might be able to make due with any equipment when push comes to shove and they are confronted with an emergency. Not having the right depth and breadth of logistical support, however, makes problems more likely, and their rapid detection and treatment less likely. Having access to the right equipment could be the difference between life and death in some situations. For example, in one situation, when a 49-year old female went into respiratory arrest after anesthesiology was administered for a simple laser resurfacing procedure around her eyes and mouth, she died because there was no emergency equipment on the premises.

Some National anesthesiology providers have dedicated logistics departments. They can work with facilities to help them develop inventory sheets, establish and maintain par levels of equipment, medications and supplies as well as assist with equipment preventative maintenance. Facilities can concentrate more fully on delivering the best surgical care.

In the final analysis, many facility administrators are busy; maintaining the status quo is comfortable and seemingly permits greater mindshare to be applied to the core surgical issues facing centers. For others the known shortcomings of the incumbent anesthesia group outweigh the unknown risks of change. Could the road to success require taking a different approach? For some, perhaps trying a national anesthesia company—especially one that recruits local anesthesiologists to augment existing personnel—may be able to offer a “best of breed” approach and lend value in countless ways. These groups provide management oversight and an additional layer of accountability and responsibility. Beyond putting together or rounding out an anesthesia department, a national anesthesia company can help address anesthesia logistics, quality management, contract with payers and ensure that collections are optimized They can also manage human resources issues as well such as emergency coverage, benefits coordination and conflict resolution. Can this make or break a facility? Sometimes. Can anesthesia management companies improve facility operations by offering an amalgam of local clinicians and robust administrative ability? It depends. Anesthesia management companies are not all cut from the same cloth and certain ones can help more than others and picking the wrong one can worsen an already bad situation.

By taking a more comprehensive and in-depth approach to anesthesia many centers can improve patient outcomes, safety, operational efficiency and bottom-line results.

References

   1. (Paul F White, PhD, MD, Update on ambulatory anesthesia. Canadian Journal of Anesthesia, 52: R 10 (2005).

Marc Koch, M.D., M.B.A., is president and CEO of Somnia Inc., New Rochelle, NY. For more information, go to www.somniainc.com    

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