Anesthesia Induced Sleepless Nights

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Anesthesia Induced Sleepless Nights
Anesthesia Coverage Keys to Success

• Thomas Wherry, M.D.
• Anesthesiologist, Surgery Center of Maryland
• Consulting Medical Director, Health Inventures
• May 15, 2008

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To give an anesthetic is one thing. To practice
the Art of Anesthesia is another. The proper
administration is more than a mechanical process
it entails bringing to bear on the case in hand
all our present knowledge of the science,
combined with the personality of the anesthetist,
who should, for the time being, live the rhythm
of the anesthetic ..
Science and Art of Anesthesia by Colonel William
Webster, CanadaThe C.V. Mosby Company, 1924.
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Real Scenarios

• New 3 OR joint venture ASC in one hospital town
  group spread too thin, cannot cover all
  rooms.but demands high end equipment.
• ASC wants to add 3rd room..other 2 rooms at 50 -
  group wants subsidy.
• Surgeons bring their own anesthesia provider -
  ASC has over 80 anesthesia providers on staff
  creating daily chaos.
• Hospital base group randomly rotates staff to ASC
  poor patient outcomes.
• Anesthesia providers place tight restrictions on
  what type of patients can be safely done in ASC
  high cancellation rate and ASC losing cases to
  hospital.
• ALL MD group covers ASC, one MD for each room
  controversy/discussion on how to handle PACU
  problems if MDs in OR
• ASC desires coverage until the last patient goes
  home anesthesia refuses
• Moderate Sedation Endoscopy/Locals in afternoon
  anesthesia leaves when their cases done..

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The Challenges

• What should an ASC expect?
• What does an Anesthesia Group want?
• Anesthesiologists, CRNAs AAs
• Coverage choices
• Solution to real scenarios

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What should an ASC expect from anesthesia?

• Character/Culture
• Clinical Input on Key Processes
• Competency
• Consistency
• Compliance
• No Crap

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Your anesthesia providers must adopt the ASC
Culture

• The Culture does make a difference
• Desirable place for patients to receive care, and
  for surgeons and employees to work
• Focus on customer service
• High level of clinical quality
• Make decisions that can affect change quickly
• Emphasis on efficiency and profitability
• Teamwork valued

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Clinical Input The Key Processes of an ASC
Medical Staff Relations Leadership
Process Improvement
Registration and Admitting
Surgical Process
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Examples of Clinical Input

• Monitor schedule
• Provide basic guidelines
• Oversee policies and processes
• Provide in-servicing
• Intervene when necessary (in all phases)
• Be available
• Review charts for the next day
• Give feedback

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Clinical Input Pre-Operative Preparation

• Complete Pre-Op Early
• Fix scheduling errors
• Prepare for special needs of patient or surgeon
• Investigate and remedy medical issues
• Educate patient and alleviate fears
• Available for clinical questions
• Review charts prior to day of surgery

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Clinical Input What Should Anesthesia Leadership
Address w/ Medical Staff?

• What Type of Procedures Can Be Done Safely in
  an ASC?
• What type of patient can safely be done in ASC?
• Ultimate Determinants
• Community standard
• Surgeon, nursing patient comfort level
• Anesthesia availability, interest quality
• Medical Executive Committee approval oversight

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Clinical Input American Society of
Anesthesiologists (ASA)
Practice Advisory For Preanesthesia Evaluation
Asahq.org
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Clinical Input Preoperative Tests

• Routine ( tests intended to discover a disease
  in an asymptomatic patient) do not make an
  important contribution to the process of
  perioperative assessment
• Selective ( tests ordered after consideration of
  specific information..) may assist the
  anesthesiologist in making decisions

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Clinical Input a sample matrix for minimally
invasive surgery
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Clinical Input The Surgical Process

• The Well-Oiled Machine
• anesthesia ready to go
• Quick Induction Patient Prep - Everyone pitches
  in
• Rapid turn around time (less than 10 minutes as
  everyone pitches in)
• OR flow closely monitored by the OR charge nurse
  anesthesiologist vigilance

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Clinical Input The Recovery Process
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Competency/Consistency The Anesthesia Team

• Strong Leadership
• Small core of providers (minimize rotations)
• Providers with the right skill set
  personality
• Cohesive group one voice
• Anesthetic pathways

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Competency/Consistency
.any one surgeons individual presence is
intermittent. The anesthesia care team is led by
an ambulatory anesthesiologist as medical
director of the facility, the anesthesiologist
works with the administrative and surgical
teams. . Anesthesia care providers who are
scheduled at the ASC on a regular basis
understand the philosophy and pace of the ASC and
are able to provide efficient quality care.
Ambulatory Anesthesia Surgery by Paul F White,
U.S.WB Saunders Company Limited, 1997.
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The process of the screening process is a crucial
first step that allows for the provision of safe,
effective, and efficient medical careThe
development of preoperative evaluation systems in
response to outpatient and same day admission
surgery provides the challenge of organizing
services into formal systems with guidelines
formulated on the basis of mutual agreement and
established clinical practiceit is imperative
that the anesthesia staff reach a consensus on
significant preoperative evaluation issues and
adhere to them in dealing with patients and
surgeons and associated organizations.
Conspicuous or consistent deviation from these
practices will only serve to undermine the
confidence of all the partiesAnesthesiologists,
in setting up their systems, are well advised to
allow for a measure of flexibility. While
adhering to a strong standard of care, reasonable
judgement in providing that care is preferable to
unyielding policies. L. Reuven Pasternak, M.D.,
Chapter 1, Screening Patients Strategies and
Studies.
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Competency/Consistency Service Quality
Indicators

• patient surgeon satisfaction
• accuracy rate on clinical records
• same day cancellation surgical cases delayed
• cost per case benchmarking
• prolonged post-op nausea/vomiting
• taking longer than 30 minutes in phase I
• near miss or reportable incident rates

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Compliance (with the policies and standards)

• Center policies
• ASA/AANA Standards
• Accrediting Body Standards
• OSHA
• CMS/Medicare
• Community Standards

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Compliance I am tired and I want to go home.

• AAAHC 2008
• Medical Discharge (9.L.)
• Physical Discharge (10.I.)
• Overnight Services (11)
• JCAHO similar standards under Provision of
  Care Standard
• Medicare/CMS Before Medical Discharge
  (416.42a)
• State Regulations do vary, so check!

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No Crap
Medical Anesthesia Staff Relations expect
(demand) help in dealing with the rogue providers

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What does an Anesthesia Group want?

• Much of the same.Clinical Input on Key
  Processes, Competent Nursing Staff, Consistent
  Schedule, Compliance w/ Standards, and No Crap.

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But what does an Anesthesia Group really want (
need)?

• Consideration
• Cases
• Compensation

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Consideration

• Input solicited
• Included as part of the team.
• Successes celebrated ( shared).

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Cases

• Minimal gaps between cases
• Vertical Schedule
• Difficult cases (or patients) at the beginning
  of day Locals at end of day.
• Minimum number to cover costs
• 40 50 units/day
• average in ASC 7 to 8 units/case
• 5 7 cases/room/day

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Compensation

• Medical Director Stipend
• Incentive Compensation or Profit sharing
• Consideration for short-term financial help to
  cover poor utilization (during start up or
  expansion).
• Favorable Payer mix

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Compensation Payer Mix
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Who provides anesthesia in the U.S?

• Anesthesiologists
• Certified Registered Nurse Anaesthetist (CRNA)
• Anesthesiologist Assistants (AA)
• Dentists/Oral Surgeons
• Physicians (moderate sedation)

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Who regulates the anesthesia providers?

• State Authorities
• Hospital Governing Bodies
• Malpractice Carriers
• Professional Societies

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Facts about Anesthesiologists

• 4 years of college, 4 years of Medical School,
  and 4 years of Residency
• 30,000 involved in about 90 of anesthesia given
  in the U.S.
• Of the 30,000, 60 are over 45 years old . 25
  over 55.
• Over 30 said they would not choose medicine
  (www.locumtenens.com )
• Over 50 of hospitals recruiting for gt 6 months

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Facts about CRNAs

• First professional group to provide anaesthesia
  services in the U.S.
• 4 year nursing, one year critical care, 2 to 3
  year anesthesia training (Master Degree program)
• Over 36,000 CRNAs care for 65 of patients
  undergoing surgical or medical interventions.
• Salaries doubled in 10 years
• High Job Satisfaction
• Typically less call than anesthesiologists.

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CRNA Clinical Practice

• Pre-anaesthetic prep and evaluation
• Anesthesia induction, maintenance and emergence
  (all techniques)
• Post-anesthesia care
• Peri-anesthetic and clinical support functions

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CRNA Actual Clinical Practice

• Depends on employment situation
• Member of Anesthesia Care Team - Supervised or
  Medically Directed by an Anesthesiologist
  (typically no more than 14)
• Directly supervised by operating surgeon,
  dentist or surgeon
• Unsupervised / Independent Practice

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Medicare Requirement of Physician Supervision of
CRNAs and Medicare Allowing States to Opt-out
of This Requirement
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While this is a complex subject, please note the
following

• This discussion ONLY refers to Medicare patients
• No states or Medicare require CRNAs to be
  supervised by anesthesiologists

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In the 1990s

• The American Association of Nurse Anesthetists
  (AANA) pursued revising the Medicare conditions
  of participation that would remove physician
  supervision of CRNAs
• Remember..
• Physician, not anesthesiologist supervision
• Instead, the AANA wanted Medicare to defer to
  state statutory rules and regulations related to
  licensure

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Reasons the AANA requested this revision included

• Historically, HCFA (now CMS) defers to states
  regarding health care practitioners
• Requiring supervision increases concerns
  regarding surgeon liability, no matter
  unwarranted
• Then, as now, surgeon liability becomes an issue
  when the he/she directs the CRNA to specifically
  deliver certain drugs or techniques
• The more closely the surgeon directs the CRNA,
  the more liability he/she assumes
• CRNAs have the education and training to practice
  without physician supervision

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Note the state laws and regulations on physician
supervision of CRNAs are complex

• Supervision language may be the states nurse
  practice act, state board of nursing rules and
  regulations, medical practice act, and/or Dept of
  Health rules
• Many states never required CRNAs to be physician
  supervised.
• Thirty-nine states do not have a physician
  "supervision" requirement for CRNAs in nursing or
  medical laws or regulations.

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Note the state laws and regulations on physician
supervision of CRNAs are complex (continued)

• If clinical "direction" requirements are
  considered in addition to "supervision," 31
  states never had a physician supervision or
  direction requirement for CRNAs in nursing or
  medical laws or regulations.
• Taking into account state hospital licensing laws
  or regulations as well, 33 states still do not
  require physician supervision.
• Taking into account state hospital licensing laws
  or regulations, 24 states still do not require
  physician supervision or direction.
• ALWAYS look closely at the individual state to
  determine if the state requires physician
  supervision of CRNAs

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Ultimately in 2001

• Medicare rules allowed states to opt- out of
  the Medicare physician supervision requirement
• Fourteen states requested to opt-out of the
  requirement that CRNA be supervised by physicians

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States That Have Opted Out From the Federal
Supervision Requirement Since Publication of the
November 13, 2001 CMS Rule Permitting Such
Opt-Outs 
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What if the state does require physician
supervision of CRNAs and the governor has not
requested the state opt-out of physician
supervision of CRNAs?
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Does Medicare (CMS) define or require hospitals
to define "supervision"?

• No. CMS does not define supervision, and
  hospitals are not required to define supervision.
  
• Defining supervision can create complicated
  compliance issues that many hospitals would
  prefer to avoid.
• See the following Gene A. Blumenreich, JD,
  "LaCroix case," AANA Journal, Oct. 1997, Vol. 65,
  No. 5 and Denton Regional Medical Center v
  LaCroix, 947 S. W.2d 941 (1997).
• Further, the AAAHC nor JCAHO does not define
  supervision or require such definition.

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Does the role of the supervising physician change
when working with a CRNA?  

• No. The responsibility of the operating or
  diagnostic physician does not change based on who
  is providing the anesthesia. Typically, the
  physician
• determines whether a patient requires a surgical
  or diagnostic procedure
• requests that an anesthetic be administered and
• determines that the patient is an appropriate
  candidate for the planned procedure and
  anesthetic.

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Does the supervising physician need to be
privileged in anesthesia?

• No. The supervising physician is not required to
  have privileges to actually administer
  anesthesia.

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Is a physician or surgeon more liable when
working with CRNAs?

• No. Surgeons are no more likely to be held liable
  for the actions of nurse anesthetists than the
  actions of anesthesiologists. The courts have not
  found physicians and surgeons to be automatically
  liable for the actions of CRNAs, nor are
  physicians/surgeons immune from liability when
  working with anesthesiologists.
• Courts generally do not look at the status of the
  anesthesia provider, but at the amount of control
  the physician/surgeon exercises over the
  anesthesia provider, regardless of credential.

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Note that in any state a hospital or ASC can
establish a rule that requires CRNAs be
supervised by a physician, including an
anesthesiologist

• An institution should carefully institute any
  rule as these rules can create many problems
  including staffing and billing problems

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For questions about CRNA practice, contact
 
American Association of Nurse AnesthetistsState
Government Affairs Divisionsga_at_aana.com847-655-1
130
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Facts about Anesthesiologist Assistants (AAs)

• 1st program in early 1970s
• Met tremendous resistance from CRNAs and
  Physician Assistants
• 4 years of college (similar to premed) 7
  continuous semesters of graduate work (2.2 years)
  Master Degree program
• Currently only Five programs Ohio, Georgia (2),
  Missouri, and Florida
• Currently allowed in 16 states DC
• In 2003, 600 AAs

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States with Anesthesia Assistants From
http//www.anesthesiaassistant.com/
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AA Clinical Practice

• Same as a CRNA
• Pre-anesthetic prep and evaluation
• Anesthesia induction, maintenance and emergence
  (all techniques)
• Post anesthesia care
• Peri-anesthetic and clinical support functions
• Always under the direct supervision of the
  attending anesthesiologist (anesthesia care team
  model)
• Unable to bill directly for services

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Anesthesia Coverage Choices
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Determinants of Anesthesia Coverage Choices

• Providers at adjacent/owner hospital (if
  applicable).
• ASC location
• State regulations
• Investors
• Local Politics

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Anesthesia Coverage Choices

• Keep it local
• Shop outside
• Piecemeal
• Employ

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Keep it local.. (Hospital Group)

• PROs
• Known entity
• Committed to the area
• Easily shift resources
• Keeps hospital owner happy (if applicable)

• CONs
• Not always big fan of ASCs
• Not able to adopt to ASC culture/model
• Resist growth
• Not able to commit to resources as needed

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Shop Outside.(Outside Group, Locums)

• PROs
• More choices
• Create local competition
• Dictate terms

• CONs
• Not committed to the area
• Need surgeon buy-in
• May alienate/hurt hospital
• Burned bridges if does not work out

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Piecemeal .(Multiple Groups or Independent
providers )

• PROs
• Plenty of providers to cover rooms
• Internal competition
• Surgeons have choices

• CONs
• Logistic nightmare
• No consistency
• Oversight difficult
• Introducing potentially problematic politics

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Employ .(MDs only or MDs/CRNAs or CRNAs only )

• PROs
• Hand select providers
• Better Control
• Able to control how/when rooms covered
• Assured that providers are part of team / adopt
  culture
• Potential for added revenue

• CONs
• ASC takes on risk
• Potentially costly
• Added headaches
• May need external oversight
• Must provide incentives
• Employment arrangements hard to dissolve
• May alienate/hurt hospital

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Contract considerations

• Provider Selection
• Room Coverage and Expansion
• Equipment Support Needs
• Administrative Expectations of Providers
• Medical Director
• Incentives

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Real Scenarios ( possible solutions)
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New 3 OR joint venture ASC in one hospital town
. group spread too thin, cannot cover all
rooms.but demands high end equipment.

• Discuss concerns and reach agreement a good 4 to
  6 months before opening.
• Address room coverage during ramp-up and
  expansion.
• Work with local hospital on room closures and
  risk sharing (much easier if partner).
• Identify a reasonable leader within group.
• Include leader in start-up phase..including
  equipment selection. .
• Educate group/leader on start-up costs and
  financial realities.
• Send individual to other ASCs
• If limited success, start shopping within 4-6
  months of opening.

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ASC wants to add 3rd room..other 2 rooms at 50 -
group wants subsidy.

• 1st Identify what group thinks they need to
  staff 3rd room..narrow to a minimally acceptable
  number
• Understand their other coverage obligations
• Identify one point person within group to handle
  discussions
• Identify current productivity in rooms 1 and 2,
  current staffing costs and how current
  productivity covers costs.
• As negotiations continue, request good faith full
  disclosure of financials
• Use surgeon/investor to help influence process.
• While negotiating , explore alternatives for ASC
  or 3rd room.

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Surgeons bring own anesthesia provider - ASC has
over 80 anesthesia providers on staff creating
daily chaos.

• Identify problems and educate surgeon/investor on
  need for improvement - Explore possibility of one
  group, better understand the groups scheduling
  and compensation issues.
• With surgeons/investor group, identify anesthesia
  leader who must be on-site majority of time.
• Enter into contract with lead provider and
  compensate for services.
• Insist Lead provider meets with anesthesia
  providers and educate them on issues at hand.
• Address urgent issues and document the agreements
  amongst providers.
• Typical issues to address
• Room coverage and fair distribution of work
• Safety and security of medications
• Selection and care of equipment
• Standardization of meds/supplies and key
  processes

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Hospital base group randomly rotates staff to ASC
poor patient outcomes.

• Document outcomes, provide data
• With surgeons/investor group, identify anesthesia
  leader who must be on-site majority of time
• Enter into contract with lead provider and
  compensate for services (directors fee)
• Work with anesthesia lead on outcomes, identify
  issues
• Better understand groups staffing and
  compensation model
• Explore possibility of a core group of providers
• Schedule regular meetings to share
  problems/outcomes and work with leader/providers
  on solutions
• Use surgeon/investor to help influence process.

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Anesthesia providers place tight restrictions on
what type of patients can be safely done in ASC
high cancellation rate and ASC losing cases to
hospital.

• Document cancellations, identify core problem,
  analyze cost to ASC and provide data to
  surgeons/investors.
• Use surgeon/investor to help influence process.
• Identify a reasonable leader within anesthesia
  group.
• Insist leader helps in refining pre-op
  preparation process, identify where process
  breaks down etc.
• Identify any short-comings that if fixed may
  raise comfort level for certain type of patients.
• Request that leader shows that restrictions are
  consistent with national standards/guidelines.
• Suggest leader visit other bust ASCs that are les
  restrictive.
• Request certain, more conservative providers not
  rotated though ASC.

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ALL MD group covers ASC, one MD for each room
controversy/discussion on how to handle PACU
problems if MDs in OR

• Identify a reasonable leader within anesthesia
  group
• Understand how similar issues handled in
  hospital.
• Work with leader on how providers hand off care
  to PACU staffdefine strict policies that must be
  adhered to..
• Discuss scenarios with leader and PACU
  staff..develop protocol acceptable to all parties
• When working out protocol, explore how scheduling
  of high risk cases can be best handled
  (ENT..Pediatrics.. High acuity plastic cases)
• Perform regular (quarterly or bi-annually) test
  of the process.

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ASC desires coverage until the last patient goes
home anesthesia refuses

• Identify a reasonable leader within anesthesia
  group
• Understand how similar issues handled in
  hospital.
• Review accreditation standards and state
  regulations
• Work with leader on how providers hand off care
  to PACU staff.
• With leader, clearly define medical discharge.
• Work out a method for documentation when
  anesthesia leaves. Documentation should include
  that PACU staff aware.
• Discuss scenarios with leader and PACU
  staff..develop protocol acceptable to all parties

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Moderate Sedation Endoscopy/Locals in afternoon
anesthesia leaves when their cases done..

• Two issues mishaps during the day and discharge
  policy.
• Identify a reasonable leader within anesthesia
  group
• Understand how similar issues handled in
  hospital.
• Does group cover emergencies or mishaps not
  related to their own care? Will they do they same
  at the ASC?
• Identify how likely this is to occur. Run
  scenarios with staff.
• Work with surgeons/investors on how cases are to
  be scheduled.
• Educate surgeons/investors on medical-legal
  responsibility
• How willing surgeons/investors to stay until
  medical discharge?
• Consider compensation incentive for anesthesia
  group
• Document and include agreement in contract.

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Questions twherry_at_surgerycentermd.com