Performing High Acuity Cases in ASCs: The Anesthesiologist's Role

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Operation 2Higher acuity cases such as joint replacement and spinal fusions have moved into the ambulatory surgery center setting over the past few years as minimally invasive techniques allow surgeons to perform traditionally inpatient procedures in an outpatient setting.

The anesthesiologist plays a crucial role in making these cases successful. If patients have a great experience, appropriate pain expectations and continue to make progress after they return home, they're likely to recommend the center to others and revisit the next time they need a procedure.

"When a patient says they didn't have a good experience and felt sick, we just can't cut that person loose. We have to check up on them and I think ASCs do a great job of looking at the patient surveys and following up," says Charles Tullius, MD, an anesthesiologist in Savannah, Ga. "If the patient has one knee done at the center, they'll return when they need the next knee done if the surgery and postoperative recovery went well."

Catherine Schmidt, MD, an anesthesiologist with Northern Wyoming Surgical Center in Cody, and Dr. Tullius discuss some of the biggest challenges with high acuity cases in ASCs and their role in making sure these cases are successful at the center.

Challenges
More complex orthopedic and spine procedures are now moving into the outpatient setting, which has economic and clinical value for the patients. However, not all patients are safe for surgery in the ASC and the anesthesiologist may be the last person in line to recognize a potential issue before moving forward with the case.

"Anesthesiologists must be especially vigilant at ASCs with the higher acuity cases," says Dr. Schmidt. "We strive to maintain hemodynamic stability during and after these cases. One challenge we specifically have is that we are not allowed to administer blood products at the ASC."

As a result, patients who are at high risk of complications are often taken to the hospital setting. Issues such as obesity and sleep apnea present huge challenges to anesthesiologists as well. Obese patients process anesthesia differently, which could lead to complications. However, obese patients also make up a significant percentage of patients who will need the orthopedic procedures that are moving into ASCs today.

"If the patient's medical problems aren't in control and they receive a large dose of anesthesia, sending them home right away may be unsafe," says Dr. Tullius. "They may look fine while they are at the center, but they mobilize their medicine after they go home and if they don't have the proper supervision, there could be unsafe consequences."

The second big issue Dr. Tullius often sees among patients is undiagnosed sleep apnea. Delivering anesthesia to someone with sleep apnea could have disastrous results, but many patients claim they don't have the time to undergo a sleeping study to confirm the diagnosis. Nurses can ask questions about symptoms of sleep apnea, but without the tests it's difficult to pinpoint.

Controlling patient pain
The advent of regional anesthesia allows anesthesiologists to control the patient's pain for outpatient procedures and feel comfortable sending them home within hours of surgery. Dr. Schmidt has a team of surgical nurses assist her with peripheral nerve block procedures and airway management to ensure everything goes smoothly.

The anesthesiologist must feel comfortable administering regional anesthesia blocks; otherwise they rely on narcotics to control postoperative pain.

"The patients' pain control depends on the skill and speed of the surgeon and the ability of the anesthesiologist to mitigate pain," says Dr. Tullius. "A big shoulder operation is painful and if the anesthesiologist does a pain block that lasts 12 to 14 hours, the pain is mitigated. But if they don't and the patient is given narcotics, that could make them sleepy and they are sent home with the narcotics in their system."

Patients at Northern Wyoming Surgical Center are able to stay up to 23 hours which gives the medical team extra time to ensure patients have recovered enough to return home. She uses peripheral nerve blocks to minimize postoperative pain and educates the patient about using continuous nerve blocks after discharge.

"For high acuity orthopedic cases we do at our ASC, the current trend includes performing effective peripheral nerve blocks to minimize the pain postoperatively. Often this means sending patients home with continuous nerve blocks that can keep a shoulder, hip or knee numb for two to three days after a shoulder, hip or knee replacement," says Dr. Schmidt. "Since these patients can only spend one night at an ASC, our goal is to ensure excellent postoperative pain management so patients don't end up in the ER the next day."

Practicing efficiency
Surgery center physicians and administrators want to remain efficient and fill their schedules with the appropriate patients.

"Much of the responsibility of ensuring that high acuity cases run smoothly and have good outcomes at ASCs is the purview of the anesthesiologist," says Dr. Schmidt. "We take care of the patient's medical illnesses as well as surgical-specific issues while the patients are at the ASC. We function much as the internal medicine physician or pediatrician would in the hospitals and as anesthesiologists; this is the definition of perioperative physician."

Communication between the surgeon, surgery center and anesthesiologist is very important to prepare for each patient. This will prevent cancellations, or worse — transfers — from the center. Dr. Schmidt outlines the process at her center to identify issues and promote efficiency:

Nurses make a preoperative phone call to obtain a patient history three to four days before surgery.
Go through "Anesthesia Alerts" with the patients to identify issues ahead of time.
Obtains cardiac testing results, sleep study results, lab work and x-ray results beforehand.
The nurse informs the anesthesiologist of any pertinent medical or surgical issues to manage them before the day of surgery.

"The best quality of care for every patient is due to great teamwork," says Dr. Schmidt. "Our ASC team, from administrator to housecleaner, works together to ensure efficiency."

When anesthesiologists identify preoperative issue on the day of surgery, the case must be cancelled. Canceling cases throws a wrench in the ASC's well-oiled machine and comes at a financial loss. However, anesthesiologists must speak up if they identify a patient they aren't comfortable proceeding with at the center.

"You can fix a lot of that problem by making preop phone calls far enough in advance so there aren't any surprises on the day of surgery," says Dr. Tullius. "Find out a week in advance that the patient is having chest pain when they walk up steps so in the intervening time you can get them to a cardiologist for stress tests and make sure they are okay before undergoing the surgery. If you find that out on the day of surgery, the case has to be cancelled."

Future potential
As procedures and anesthesiology evolve, there is a potential that more cases will move from the inpatient hospital setting to the outpatient surgery center. Economically, surgery centers are less expensive than hospitals and will continue to be a good option for appropriate cases.

"I am hopeful that in the future we will continue this trend and it will allow us to perform other high acuity cases in the ASC setting," says Dr. Schmidt. This may be the case as surgeons currently performing outpatient procedures in the hospital setting transition those cases to the ASC.

However, Dr. Tullius sees surgery for the sickest patients remaining in the hospital. "I really think the trend will be that hospitals will take the sickest cases and the ASCs will go back to performing the high volume cases," he says.

This article also appears here in the Winter 2014 Edition of Communique by Anesthesia Business Consultants.

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