5 Current Challenges in Ambulatory Anesthesia

Here are five challenges affecting ambulatory anesthesia, and advice from a panel of experts for handling them effectively.

1. More complex procedures and patients

The procedures performed in ASCs are increasingly complex: Orthopedics and spine, for example, are specialties that present such procedures. But it’s not just the procedures that are getting more complex — it’s the patients as well.

“Patients undergoing surgery in ASCs have more comorbidities than they used to,” says David Shapiro, MD, CPHRM, LHRM, CHC, chair of the Ambulatory Surgery Foundation and chair-elect of the ASC Association. “For example, there’s more cardiac pathology for routine cataract procedures; patients are coming in with implantable cardiac devices. Anesthesia needs to really understand the ramifications of those kinds of factors.”

When even otherwise routine procedures, such as colonoscopies, are being performed on sicker patients, communication is crucial. Having the same providers in place day-to-day is also key, says Dr. Shapiro. These factors ensure the ASC maintains the utmost levels of safety and efficiency, because anesthesia can establish protocols for the day of treatment and their availability during the pre-op evaluation.

“That way, they can arrange for necessary pre-op intervention, test or clearance so the facility can know as much as possible about the patient’s underlying medical conditions and anticipate medical problems, including canceling the case in extreme situations,” says Dr. Shapiro. When the same anesthesia staff are involved in pre-op processes, ASCs can “avoid sameday cancellation, avoids disruption of the schedule, disposal of unused equipment that may have been prepped for a procedure — and prevents having to send the patient home, which is very upsetting after they’ve altered their lives around the procedure.”

Anesthesia should have the final say as to whether a case proceeds, he says, but cancellations should be rare if the aforementioned precautions are taken.

“Essentially, anesthesia should be in communication with nursing, surgeons and schedulers,” says Dr. Shapiro. “In facilities that work the best, anesthesia works closely with scheduling to address and prevent problems; if not, problems can begin with scheduling. For example, diabetics should be scheduled earlier in the day so that PO status is minimal and that insulin administration is disrupted as little as possible.

“In addition, the anesthesia team needs to be prepared and aware of the patient coming in, so it can have the requisite drugs and equipment on hand.”

2. Nerve blocks

Peripheral regional anesthesia is particularly well-suited to the ASC setting, as the technique leads to less post-op pain, fewer side effects of pain and anesthetic agents, and extended pain relief for patients.

“Nerve blocks are excellent adjuncts to anesthesia if, one, experienced practitioners are performing the procedure and, two, the patients are pre-educated by the surgeons and preoperative nurses with all consents signed and risks explained before the patients’ arrival at the ASC,” says Juan De La Riva, MD, anesthesiologist for the Fresno Dental Surgery Center in Fresno, Calif. “This will prevent prolonged turnover times and enhance patient satisfaction.”

Stanford Plavin, MD, an anesthesiologist, managing partner of Ambulatory Anesthesia of Atlanta and board member of Georgia Society of ASCs, has some practical tips for achieving nerve blocks’ benefit potential.

  • His practice has two ultrasound machines, purchased to “help us become more effective and efficient,” he says. “It’s just a matter of getting comfortable with ultrasounds on blocks. Now, we do all blocks in pre-op — not in a separate block room. It’s five to 10 minutes for most blocks, and we haven’t lost any time on cases.”
  • “We typically provide a post-op block sheet, with formal instructions about what to expect and understand when the block wears out,” says Dr. Plavin. Include, for example, a list of types of activity a patient will be restricted from post-op, and information on how long the affected area will be numb.

Use of the ultrasound is an “extra $80 or $90 in reimbursement for the physician,” says Dr. Plavin. (Be sure that your billing staff are up-to-date on how to code for this, if your facility — as opposed to the anesthesia provider or group — bills for anesthesia charges.) “More importantly, it improves quality of care. When you make that kind of commitment to a facility, it enhances the bond. And patients appreciate that you’re taking the time to perform the highest level of care.”

3. Post-op pain control

In-dwelling catheters for post-op analgesia are another tool that, with the right precautions, anesthesia can use to drive efficiency and patient satisfaction in your ASC.

“Indwelling catheters are like pain pumps, but are placed using ultrasound technology,” says Dr. Plavin. “They are in for a couple or three days to bathe the affected area in analgesia, which lets the facility perform more complex cases that would otherwise result in more post-op pain — posterior compartments, different joint procedures, bigger bone cases, complex shoulders, fractures — and that can bring higher reimbursement.”

Further, notes Dr. De La Riva, “The reimbursement, especially for indwelling catheters, is very good for both the facility and the provider.”

To ensure payment, Dr. Plavin’s group fully “documents the placement of the catheter, takes a digital image of the procedure, and backs it up on a hard drive, just to show if we get audited. We bill separately for the post-op analgesia, which cuts down on denials.”

For their parts, patients should be fully informed about expectations and be given instructions for removing the catheters.

“If they get confused, there should be several layers of availability of help,” says Dr. Plavin. “Patients really appreciate it, and it can drive business that you might otherwise think about doing in the hospital.”

4. Cost-containment

If anesthesia is truly committed to the success of your facility, it will do all it can to ensure business efficiencies.

“Anesthesia should critically look at the delivery of anesthesia to continually address the cost of anesthesia per case,” says Dr. Shapiro. “In some cases, nothing can be changed, because you need to maintain patient safety, but in other cases, you can find unnecessary or excessive use of disposables, or that a generic drug can be used.”

Dr. Plavin agrees, and offers that saving money doesn’t have to mean hardship for anesthesia providers.

“For example, if you switch to generic anti-emetics, not only are you spending $1.50 per dose compared with $15 or $20, but you can afford to offer it to more patients and cut down on post-op nausea, which leads to more efficiency overall,” he says.

Use of propofol for sedation is another strategy for saving money and enhancing patient care and efficiency.

“Using propofol improves efficiencies; if, instead of doing 13 or 14 cases by 5 p.m., you can do 18 cases by 3 p.m., that’s big money,” says Dr. Plavin. “In a GI center, at a $450 facility fee per procedure, you’re looking at millions in revenue annually. Not to mention the ability to schedule more efficiently — something that will increase surgeon satisfaction and patient satisfaction, because they don’t have to spend a month worrying before they are scheduled.”

A lot of these efforts begin in materials management, so anesthesia, not just surgeons, needs to be kept in the loop on purchasing, notes Dr. Shapiro. This also circles back to the concept of consistency among the anesthesia providers in the ASC setting.

“Surprises are bad in the ASC, and having anesthesia involved in many facets of the center can help eliminate those,” says Dr. Shapiro. “When anesthesia is involved in purchasing, it contributes to cost-containment efforts. When anesthesia is involved in scheduling and pre-op processes, you don’t end up cancelling a case on the operative day and wasting a pack or other supplies.”

5. Finding a focus

Regardless of the anesthesia staffing model your facility employs — part-owner, employee or contracted service — it’s important that the team that services your center be focused on and comfortable with ambulatory anesthesia in particular.

Anesthesia must “focus on the outpatient world; it’s a far better arrangement and less risky for the center than relying on a hospital-based anesthesia practice to service the ASC,” says Bob Prosek, CEO of Safe Sedation, based in Bethesda, Md. “The settings just work so differently.”

Dr. Shapiro agrees, pointing to the differences in getting a patient ready for surgery, OR turnover times, the patient’s post-op course, recovery time, the attention required by staff, and noting that the providers have to have a different mindset that accommodates all these factors while prioritizing safety as the prime objective.

“When I go into ASCs as a surveyor or consultant, if there is a problem with anesthesia, it’s usually that the providers aren’t attuned to the setting,” says Dr. Shapiro. “It’s not that they’re bad anesthesia providers, just that they’re not comfortable — which is why you need someone who specializes in ambulatory anesthesia. Your anesthesia providers can either make your facility work or cause it not to work.

“My other consideration is that the anesthesia team should really be the best advertisement for your facility there is: They help make it the place surgeons feel comfortable taking their patients, contribute to the time efficiencies that make it a place employees want to work, and ensure that everyone can feel good about the level of patient care,” says Dr. Shapiro. “The anesthesia team is integral to creating the ASC’s culture.”

Contact becker@beckersasc.com.

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