4 Considerations for Anesthesia Provision in an Orthopedic ASC
Surgery centers are accepting complex orthopedic cases with greater frequency, putting pressure on anesthesia providers to master regional techniques and shorten recovery room times. Here T.K. Miller, MD, an orthopedic surgeon with Carilion Clinic Orthopedics and medical director at Roanoke (Va.) Ambulatory Surgery Center, discusses four considerations for anesthesia provision in an orthopedic-driven ASC.
1. Regional anesthesia makes it easier to move orthopedic procedures to ASCs. Developments in regional anesthesia are creating opportunities for orthopedic-driven surgery centers, Dr. Miller says. In the last several years, his surgery center has started transitioning ACLs, rotator cuffs and fracture management from the hospital into the outpatient setting.
He says the expansion of regional blocks and pre-emptive analgesia was critical to the change. "We found that once we started performing proactive pain management rather than responsive pain management — moving to blocks and scheduled analgesia — if patients are comfortable and there's no safety issue, it's pretty hard to justify doing them in the hospital setting," he says.
He says to make the shift, a surgery center absolutely must have anesthesiologists who are comfortable performing blocks. "If the anesthesiologists are good with blocks, the patients don't have to go as deep anesthesia-wise," he says. "You have less post-operative nausea and less delay in the recovery room. Blocks and multi-modal pain care have allowed us to pick procedures based on perioperative safety, not post-operative management."
2. Anesthesia for complex orthopedic cases may require investment in an ultrasound. Dr. Miller says the introduction of regional blocks to his surgery center required an investment in an ultrasound unit, which can be a significant expense for an ASC.
He says the investment may not be necessary if the ASC is staffed by older anesthesiologists who can perform regional management without an ultrasound. "We've got older anesthesiologists who are very good at regional management without using an ultrasound," he says. "There are also several anesthesia programs across the country where they really emphasize regional anesthesia and pain control."
3. Longer recovery room times may be necessary for complex orthopedic patients. Dr. Miller says his surgery center schedules more complex orthopedic patients earlier in the day, anticipating longer recovery room times. He says the surgery center has a two-hour limit on any case performed in the facility, which helps the schedule by automatically screening patients whose co-morbidities would prevent them from recovering quickly enough.
He says that the more your anesthesia providers perform regional blocks, the shorter your recovery room times should be. "It's been an evolutionary process for us," he says. "Once your anesthesia providers are good with their blocks — and ours are — we rarely have cases longer than two hours."
4. Recovery room times should be benchmarked to improve anesthesia provision. Dr. Miller recommends benchmarking recovery room times to keep track of which providers are moving patients out of the surgery center more quickly. He says it's not about "picking on any one person," but rather dissecting the reasons for a longer recovery room time.
He says the trends could be based on patient population, medication or provider ability — it's simply good to know the cause. "We've found things that help our providers from a purely educational standpoint and make a difference in perioperative medicine," he says. "We've found that with a block on board, we don't need to give as much sedation to patients when they come into the OR."
Related Articles on Anesthesia:
ASA Opposes Recently Released $1.1B Federal Cuts to Medicare
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Study: Ultrasounds Help Properly Diagnose Critical Care Patients
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