Question: When, if ever, is it appropriate for an anesthesiologist to step outside the OR door for brief periods, such as during x-ray or fluoroscopy? How should this situation be managed regarding observation and monitoring of the patient?
Dr. Zauder replies: It is never appropriate for the anesthesiologist to leave an anesthetized patient, for any reason, or for even the briefest period unless replaced by an appropriate substitute. Appropriate shielding provides adequate protection against radiation to allay any concerns the anesthesiologist may have in that regard. Though the number of monitors employed by anesthesiologists have proliferated in recent years, they do not and cannot substitute for the personal attention of a skilled anesthesiologist. Vigilance – the byword of the specialty must be constant. There is no acceptable alternative.
Answer by Howard L. Zauder, M.D., Ph.D., Professor and Chairman, Department of Anesthesiology. SUNY Health Science Center at Syracuse; Immediate Past President, American Society of Anesthesiologists.
Dr. Jene replies:
It is not appropriate for the anesthesiologist or member of the anesthesia care team to leave a patient unattended during surgery or a procedure while under his/her anesthesia care.
If the need arises for a “break” or “absence” from the patient, appropriate measures should be taken by the responsible member of the anesthesia care team to provide continuity of care for the patient.
This may be arranged in many ways, e.g., have another member of the anesthesia care team come into the OR to cover time away. This should be brief and the surgeon should be aware of the change.
During x-ray and fluoroscopy procedures, proper shielding protection should be available from the Radiology Department to provide the needed safety for those who must stay with the patient. In some OR’s or x-ray rooms, there will be a lead shield or protected area a few feet from the patient which can be used for the brief period of exposure needed. There must be careful coordination between the anesthesia and radiology personnel so that the anesthetist can duck behind the shield for a moment. When this is not available, lead aprons should he worn and some anesthesia practitioners also squat down at the head of the table so the metal table top is between them and the x-ray beam.
When the anesthesiologist or member of the anesthesia care team agrees to provide anesthesia for a patient undergoing a surgical procedure, this is in effect an agreement/contract between two parties for a service. The patient should have Discussed this with the anesthesia care provider prior to the procedure. This conference (which covers Procedure, Alternatives, Risks PAR) should be documented on the chart prior to an elective procedure. This is part of the standard of rare all patients should receive. This agreement between physician and patient is clearly outlined in the ASA Peer Review Manual as well as by most hospitals and should be in the anesthesiology department/service guidelines for all members to follow. There is a clear understanding that this agreement with the patient includes the continuous presence of anesthesia personnel throughout the procedure.
When the ASA adopted the Standards for Basic Intra-Operative Monitoring in 1986, the homework from which EVERY anesthesia provider should function was established. Likewise, each patient and surgeon can expect no less from the member of the anesthesia care team at the head of the table. These standards have been widely publicized and should be observed routinely in ALL anesthesiology departments. The first standard states: “Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics and monitored anesthesia care.”
The anesthesia which is provided within a medical setting, (hospital, x-ray office, ambulatory surgical facility, or other) should have the same standard of care available to ALL patients. This should be a written part of departmental policy and procedure. If not the case, then the chairman of anesthesia is responsible for undertaking the proper means to establish this uniformity. It may he necessary for an ad hoc committee of anesthesiology representatives as well as members of the surgery, obstetrics, x-ray, risk management, and quality assurance departments to work toward this goal. Documentation of the standard of care, department policy and guidelines must be available, reviewed regularly, and be acknowledged by signature by each anesthesia care provider. If the standard of care is not followed, then this breach of the acknowledged policy will provide a rationale for the department chairman to confront those involved regarding the issue(s). A good example would be a practitioner leaving a patient unattended while taking a break. The written policy will provide a platform from which to address the question and then take actions or recommend solutions, which may call for limitation of privileges, monitoring of behavior, additional training, letters of reprimand, etc.
Finally a continent regarding monitors: with the advent of the current invasive and noninvasive monitors, it is even more important for the anesthesiologist or member of the anesthesia care team to understand, use, and document the information. However, just because there are numbers flashing and cardiac and respiratory tracings evident, this does not constitute permission to leave the patient unattended or delegate monitor watching to a member of the OR staff. The patient is the obligation of the anesthesia care provider and this must never be forgotten.
Answer by Joanne Jene, M.D., Portland, Oregon, who is a member of the ASA Pea Review Committee.