Educating the Next Generation: A Curriculum for Providing Safe Anesthesia in Office-Based Surgery

Brian M. Osman, MD; Fred E. Shapiro, DO, FASA
Summary: 

The office-based anesthesia resident curriculum was initially published by the Society for Ambulatory Anesthesia (SAMBA) in 2010 to educate residents with a comprehensive experience in the anesthetic management of ambulatory surgical patients in an office-based environment. The number of office-based procedures has grown exponentially over the last 25 years and there have been substantial changes affecting the practice. In order to remain current and provide a suitable education in office-based anesthesia (OBA), a 2020 update to the curriculum has been designed and published on the SAMBA website. The purpose is to provide educational resources for the resident with the current safety literature, system-based changes, developments in practice management and accreditation related to OBA.

Introduction

In 1979, fewer than 10% of all surgeries were performed as outpatient procedures. In just about 25 years, approximately 70% of operative procedures have evolved beyond the walls of hospitals, with 15–20% occurring in office-based practices.1 In 1985, the Society for Ambulatory Anesthesia (SAMBA) was founded as a national society with a mission statement to “strive to be the leader in the perioperative care of the ambulatory surgical patient.” Their focus includes anesthesia in the ambulatory setting, non-operating room anesthesia (NORA) and office-based anesthesiology (OBA), patient care, medical education, patient safety, research, and practice management.2

As office-based anesthesia became more popular, SAMBA recognized the importance of keeping education initiatives current and published an anesthesia resident educational curriculum designed to provide a comprehensive experience in the anesthetic management of ambulatory surgical patients in an office-based environment. The evolution of this curriculum began in 2006 with Dr. Fred Shapiro creating the first Harvard Medical School office-based anesthesia Continuing Medical Education (CME) course, ”The Manual of Office-Based Anesthesia Procedures,” presented to the Academy at Harvard Medical School, which led to the inception of an OBA curriculum, and was later incorporated into the SAMBA national program. In 2010, Dr. Shireen Ahmad and Dr. Fred Shapiro co-authored the SAMBA Anesthesia OBA Curriculum, which was reviewed by the SAMBA taskforce on Ambulatory and Office-Based Anesthesia, approved by the SAMBA Board of Directors, and added to the website.3 It was designed to be an educational guide for a one-month specialty rotation during the final (CA-III) year of residency in Anesthesiology. Since its initial inception in 2010, the number, complexity, and variety of cases in the office-based anesthesia environment has experienced exponential growth. There have been many changes to the literature, practice management, accreditation requirements and office-based practice legislation, and the new 2020 curriculum update strives to be consistent with current standards of safe practice.4

Update to the Literature 2010 to 2020

To better understand the trajectory of OBA, it is important to demonstrate a general knowledge of how the literature has changed over the last 25 years. There was a lack of uniform reporting of adverse events in the office setting and also a lack of randomized controlled trials to determine how office-based procedures and anesthesia affect patient morbidity and mortality.5 As a result, studies on this topic are retrospective in nature. Some of the early literature expressed concerns about the safety of office-based procedures and anesthesia. A 2001 study by Domino et al. examined the reported complications in the American Society of Anesthesiologists (ASA) Closed Claims Database and reported that office-based claims were approximately three times more severe than Ambulatory Surgery Centers (ASCs).6 Vila et al. concluded in 2003 that the relative risk of complications and death was 10 times greater in the office-based practices compared to ASCs.7 Other important studies prior to 2010 are listed in Table 1 and demonstrated mixed results.

Table 1. Key Studies Addressing Safety in Office-Based Anesthesia Prior to 2010*

Key Papers, Year Method Finding
Hoefflin et al, 20018 23,000 cases from single plastic surgery office No significant complications.
Vila et al, 20037 2 years of adverse events reported to Florida board 10-fold relative risk in office compared with ASC.
Koch et al., 20039 Compared 896 office-based vs. 634 hospital-based intraocular procedures performed from 1983 to 1986 No systemic complications reported in the office-based group.
Perrot et al, 200310 >34,000 oral and maxillofacial surgeries Complication rate of 0.4%–1.5% for all types of anesthesia.
Byrd et al, 200311 5316 cases from single plastic surgery office Complication rate 0.7% (mostly hematoma)
Fleisher et al., 200412 Evaluated Medicare patients (age >65 years), more than half a million outpatient procedures from 1994 to 1999. 1-week mortality rates in the office, ASC, and hospital as 0.035%, 0.025%, and 0.05% of outpatient procedures, respectively.
Bhananker et al., 200613 Reviewed closed malpractice claims in the ASA Closed Claims Database since 1990 > 40% of MAC claims involved death or permanent brain injury. Respiratory depression accounted for 21% of claims, half of which preventable by better monitoring.
Coldiron et al, 200814 Self-reported data to Florida board from 2000 to 2007 174 adverse events; 31 deaths in this time frame.
Keys et al., 200815 1,141,418 outpatient procedures performed at AAAASF facilities 23 deaths observed. PE was the cause of 13 of those deaths. Office-based abdominoplasty most commonly associated with death from PE.

Abbreviations: ASC – Ambulatory Surgical Center; ASA – American Society of Anesthesiologists; AAAASF – American Association for Accreditation of Ambulatory Surgery Facilities; MAC – Monitored Anesthesia Care; DVT – deep vein thrombosis; PE – pulmonary embolism;

*Adapted with permission from: Shapiro FE, Punwani N, Rosenberg NM, et al. Office-based anesthesia: safety and outcomes. Anesth Analg. 2014;119:276–85.

The literature since 2010 suggests that patient safety and outcomes in the office have greatly improved. Shapiro et al. concluded in 2014 that this was likely due to proper credentialing of facilities and practitioners, increased accreditation, adherence to national societies guidelines, the incorporation of safety checklists, and the implementation of additional oversight at both state and federal levels.5,16 Table 2 highlights some of the important OBA literature from 2010 to 2019.

Table 2. Key Studies Addressing Safety in Office-Based Anesthesia After 2010*

Key Papers, Year Method Finding
Twersky et al, 201317 Review of ASA Closed Claims Data from 1996-2011 Outcomes did not differ between groups, with death in 27% and permanent disabling injury in 17% of OBA claims.
Soltani et al, 201318 AAAASF data from 2000–2012; only reviewed plastic surgery offices 22,000 of 5.5 million cases; complication rate 0.4%; 94 deaths; 0.0017% death rate.
Failey et al, 201319 2611 cases from single AAAASF facility under TIVA/conscious sedation No deaths, cardiac events, transfers; 1 DVT
Shapiro et al, 20145 Comprehensive literature review Improvements in patient outcomes likely with credentialing, accreditation, safety checklists, state and federal regulation, and national societies.
Gupta et al, 201720 Compared outcomes of 183,914 plastic surgery procedures in accredited facilities Complication rates in OBSC, ASCs, and hospitals were 1.3%, 1.9%, and 2.4%, respectively. Multivariate analysis showed lower risk in OBSC when compared to ASCs or a hospital.
Young et al, 20188 Literature review and 2018 update Rates of complications from the latest publications are similar to or lower than previously reported. The number of primary literature reports is increasing, both retrospective and prospective.
Seligson et al, 20191 Updated review of the literature from 2017 to 2019 Anesthesia and surgery in the office is becoming increasingly safe, likely due to increased patient selection.
De Lima et al, 201921 Updated review of the literature from 2016 to 2019 OBA safe with proper patient selection and adequate safety protocols. Current regulations are focused on reducing surgical risk through the implementation of patient safety protocols and practice standardization. Strategies include cognitive aids for emergencies, safety checklists, facility accreditation standards.
Osman et al, 201922 Safe anesthesia for office-based plastic surgery: proceedings from the Korean society of plastic and reconstructive surgeons 2018 meeting 72% of the 16.4 million cosmetic procedures performed in 2016 were performed in the office. As of 2018, only 33 states have guidelines, policies, or position statements regarding OBS, makes gathering outcome data difficult.
Osman et al, 201923 A comprehensive review and 2019 update to OBA A review of the literature, updates on patient safety, patient and procedure selection, practice management, accreditation, quality improvement programs, and legislations and regulations.

Abbreviations: ASA – American Society of Anesthesiologists; OBA – office-based anesthesia; ASC – AAAASF – American Association for Accreditation of Ambulatory Surgery Facilities; TIVA – total intravenous anesthesia; OBSC – office-based surgery center; ASC – Ambulatory Surgical Center; OBA – Office-based anesthesia ; OBS-Office-based surgery; DVT-deep venous thrombosis.

*Adapted with permission from: Shapiro FE, Punwani N, Rosenberg NM, et al. Office-based anesthesia: safety and outcomes. Anesth Analg. 2014; 119:276-85.

In 2017, Gupta et al. analyzed a large database of over 183,914 cases from 2008 to 2013 and concluded that complication rates in Office Based Surgery Center (OBSC), ASCs, and hospitals were 1.3%, 1.9%, and 2.4%, respectively.20 This demonstrated that, at least for cosmetic procedures, accredited office-based surgery centers were a safe alternative to ASCs and hospitals. Overall, anesthesia and surgery in the office is becoming increasingly safe and the recent data suggest that it is attributable to proper patient and procedure selection, as well as adhering to adequate safety protocols.1,21 Patients treated in the office seem to be selected based on their low risk for complications.1 As the popularity of OBA continues to increase, different systematic approaches have been developed to promote the standardization of safe practices. These include published guidelines and position statements, emergency protocols, safety checklists, medication management and surgical risk reduction, new regulations and accreditation measures.21

Practice Management

The OBA curriculum highlights system-based practice changes relevant to the office environment in 2020. Ultimately, anesthesia professionals are responsible for ensuring an adequate standard of care and should thoroughly inspect the office-based practices they agree to work in, taking into consideration the administration, facility engineering, equipment, and facility accreditation. In 2010, Kurrek and Twersky responded to this by publishing a provider checklist highlighting common elements that should be reviewed before providing anesthesia services in an office-based practice.24

As the demand for OBA continues to increase, additional efforts have come forward to promote patient safety. Since 1999, the ASA has continued to offer general recommendations for proper patient and procedure selection, as well as insisting on the presence of medical directors responsible for policies that adhere to current regulations, adequately trained and credentialed health care providers, and facility compliance with local and national legislation.25 These guidelines were amended in 2009, reaffirmed in 2014, and have contributed to the creation of other important recommendations such as the Guidelines for Ambulatory Anesthesia (reaffirmed in 2018), and a multi-disciplinary collaboration (ASA, American Association of Oral and Maxillofacial Surgery, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, Society of Interventional Radiology) to create the 2018 Practice Guidelines for Moderate Procedural Sedation.25,26

In 2010, the Institute for Safety in Office-Based Surgery (ISOBS) created a patient safety checklist adapted from the World Health Organization (WHO) Surgical Safety Checklist, customizable to the office-based practice. In 2017, the ISOBS Office-Based Surgery Checklist (Figure 1) was added to the American Academy of Healthcare Risk Management (ASHRM) resource manual for Office-Based Surgery and can be found at https://www.ashrm.org/. These types of safety checklists have shown promise in the literature for the reduction of medical errors and the improvement of patient safety and outcomes.27,28

Figure 1. Institute for Safety in Office-Based Surgery Safety Checklist for Office-Based Surgery* <br />Abbreviations: AED – automated external defibrillator; DVT – deep vein thrombosis; EMS – emergency medical services; MH – malignant hyperthermia; NPO – nothing by mouth. <br />*Adapted with permission from: WHO Surgical Safety Checklist. Courtesy of the Institute for Safety in Office-Based Surgery [ISOBS], Inc., Boston, MA. <br />Developed by Alex Arriaga, MD, Richard Urman, MD, MBA, and Fred Shapiro, DO.

Figure 1. Institute for Safety in Office-Based Surgery Safety Checklist for Office-Based Surgery*
Abbreviations: AED – automated external defibrillator; DVT – deep vein thrombosis; EMS – emergency medical services; MH – malignant hyperthermia; NPO – nothing by mouth.
*Adapted with permission from: WHO Surgical Safety Checklist. Courtesy of the Institute for Safety in Office-Based Surgery [ISOBS], Inc., Boston, MA.
Developed by Alex Arriaga, MD, Richard Urman, MD, MBA, and Fred Shapiro, DO.

With the continued growth of office-based surgery, staff and practitioners should have easy access to critical information to assist with crisis management. The use of cognitive aids, tailored to the office-based practice, can prove to be effective in emergency situations. ISOBS reviewed the most common emergencies specific to the office and published an OBA emergency manual in 2017 to provide a concise and user-friendly resource tool with treatment algorithms. This emergency manual is based on principles from widely accepted crisis manuals (advanced cardiovascular life support, Malignant Hyperthermia Association of the United States, Stanford, Massachusetts General Hospital), and it offers algorithms for 26 of the most common emergency scenarios in the OBA practice.21 As of 2018, this manual is available on the Emergency Manuals Implementation Collaborative (EMIC) website (https://www.emergencymanuals.org/).

Another practice management consideration with the 2020 update to the SAMBA Office-Based Anesthesia Curriculum was to provide an evidence-based review of anesthesia techniques to improve outcomes and patient satisfaction while mitigating risk during office-based procedures. Several studies prior to 2010 concluded that procedures could safely be performed in the office and, although not clearly defined, the evidence supports success with general anesthesia, total intravenous anesthesia (TIVA), local anesthesia with moderate sedation, and conscious sedation.10,11,19 As of 2020, there are new concepts and improved methods of patient care. For example, Enhanced Recovery After Surgery (ERAS) techniques, such as multimodal therapies and non-opioid-based perioperative analgesia, can be utilized to enhance the patient perioperative experience by reducing postoperative pain, postoperative nausea and vomiting (PONV), opioid pain medication use, and length of stay for inpatient procedures and same-day surgery.23 Multimodal therapies and non-opioid-based perioperative analgesia are some of the key components of ERAS. These include procedure appropriate regional blocks, oral and intravenous non-opioid adjuncts such as steroids, pregabalin, NSAIDs, acetaminophen, clonidine, intravenous lidocaine, and intraoperative injection of long-acting liposomal bupivacaine.23 Improved pain control can be achieved while reducing the opioid-related side effects.

Other useful tools include decision aids developed to incorporate the patient in the decision-making process regarding their own anesthetic and surgical plan. These educational tools can easily be applied to the office setting and are another important aspect of ERAS. The ASA, for example, has several patient-centric decision aids available on their website, which includes decision aids for epidural and spinal anesthesia and peripheral nerve blocks, and is currently developing one for Monitored Anesthesia Care .29

These are valuable resources to guide patients through the process of making informed decisions and participating as an active member of the health care team.

Accreditation

The three major nationally recognized accrediting organizations that govern office-based practices include the Accreditation Association for Ambulatory Health Care (AAAHC), The Joint Commission (TJC), and American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF).23 All three of these agencies have similar requirements for accreditation, but there are some subtle differences. Kurrek and Twersky have a 2010 publication that highlights some of these key differences.24 Over the past 10 years, accreditation agencies have recognized some of the patient safety issues in OBS and have focused greater attention to the office. There are currently 33 states that require offices that perform medical and surgical procedures to obtain accreditation, and this number is expected to increase in the future. It is important for the resident to be familiar with these three agencies and what accreditation means to an office-based practice, as it provides valuable information about how a facility cares for their patients. Some examples include important issues about how a facility is maintained, personnel and their qualifications, infection control, cleaning and maintenance of equipment, emergency preparedness, credentialing and privileging, documentation (i.e., HIPAA), and quality improvement, among others. Accreditation of office-based facilities allows a third party to monitor activities, provide external benchmarking, validation, and acknowledgement of a nationally recommended standard of care.

Legislation

There have been significant changes to office-based legislation in the last 25 years, going from almost completely unregulated to some form of mandated legislation or regulation in all 50 states and the District of Columbia. OBS legislation falls primarily on the individual states, which regulate OBS practices with a wide degree of variability. Some states may not require an OBS practice to register or obtain facility licensure (answering to the respective state’s medical licensing board), while other states require that office-based practices register with the department of health or practitioner’s licensing board. More stringent states may hold offices to the same standard as ASCs or hospitals. As of August 1st, 2016, only 24 states and the District of Columbia had at least one law that regulated facilities that perform OBS.30 There remained 17 states that did not require adverse event reporting at that time, but several high-profile cases resulting in death or severe injury found their way to the public through media reports.23 In 2020, one of the major accreditation agencies (The Joint Commission) actively monitors state legislative and regulatory activities, and provides a quick reference tool on their website to review state specific requirements (https://www.jointcommission.org/accreditation-and-certification/state-recognition/).31 The ultimate focus of OBS legislation is to increase accountability and standardize safe practice in office-based anesthesia and surgery.

Conclusion

An update to the SAMBA Office-Based Anesthesia Curriculum was essential as office-based surgery and anesthesia has experienced exponential growth over the last 25 years. There have been many changes to the literature, practice management, accreditation requirements, and OBA legislation. With the increase in procedures, complexity, and variety of cases, and the continued lack of uniform regulation and legislation in the office-based practice, there is a need to maintain the educational curriculum consistent with the most recent safe practices and standards. The 2020 update to the curriculum is deliberately presented as goal-driven and is not prescriptive in nature. The OBA practice is dynamic, fluid, and rapidly changing, and we present the evidence to maintain standards to support the best practices as of 2020.

 

Dr. Osman is assistant professor in the Department of Anesthesiology, Perioperative Medicine and Pain Management, UHealth Tower, University of Miami Miller School of Medicine, Miami, FL.

Dr. Shapiro is associate professor of Anaesthesia, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.


The authors have no conflicts of interest.


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