Volume 2, No. 1 • Spring 1987

Outpatient Anesthesia: No Double Standard

Bernard V. Wetchler, M.D.

As we in anesthesia are being removed from the safety of our traditional operating room cocoon, we should not change our obligation to our patients and to ourselves. Whenever we provide anesthesia services, the equipment, the staff and the facility must meet currently acceptable standards of cam There can be no double standards of anesthesia care.

In the area of ambulatory surgery, anesthesia practitioners have to be like cat burglars–getting our patients in and out without touching any of the alarms. When managing the outpatient, we should never allow ourselves to become so enamored of new surgical procedures, new anesthetic agents, or the ambiance of the facility that we forget the basics: selection of appropriate patients and appropriate procedures. The anesthesiologist is the watchdog of ambulatory surgery and as such, must take an active role in the necessarily compacted perianesthetic management of the outpatient.

It is our task to educate the surgeon and the surgeon’s office staff, the initial contacts for the patient, as to what is considered an acceptable patient and an acceptable ambulatory procedure in 1987. So-called healthy patients for so-called short surgical procedures should undergo a thorough history and physical examination by the surgeon and a complete screening questionnaire

In addition to what takes place at the surgeon’s office, every facility should develop its own method of preoperative screening. This can be accomplished by the patient visiting the facility several days before the scheduled procedure or this screening ran take place by way of telephone interview. Preoperative screening gives us necessary information about the patient, provides the patient with instructions, and can determine Laboratory tests that should be ordered. Also discovered are the necessity of consultation with other physicians, how far in advance the patient should be evaluated by an anesthesiologist, and the need for additional psychological support. Effective screening will not only help limit last minute cancellations but may affect patient safety and morbidity.

Initially, the majority of ambulatory facilities accepted only ASA physical status I and 11 patients. As we have be-come more experienced and selection criteria have become increasingly more liberal, we find that we are now accepting more physical status III patients. For any physical status III patient, the medical condition that classified them as a III must be in stable and good condition before that patient can he considered acceptable for an ambulatory procedure.

Patient age per se should not be a limiting factor. Each patient must be considered individually. High risk infants, however, are best handled in an inpatient setting. The infant with a low hemoglobin or hematocrit is at risk. The infant presenting with a history of respiratory distress syndrome, prematurity, apnea or aspiration with feeding is also at risk. It is generally accepted that the ex-premature should not be operated on as an outpatient until they are at least 46 weeks post conceptual age (gestational age plus postnatal age). The ex-premature less than 46 weeks post conceptual age must be apnea monitored for 24 hours post operatively as an inpatient. Al the 1985 ASA meeting, Children’s Hospital of Philadelphia presented a study which established their post conceptual age of acceptability for the outpatient ex-premature as greater than 60 weeks. At the 24th Clinical Conference in Pediatric Anesthesiology, Frederick Berry, M.D. stated “infants under 50-55 weeks post conceptual age need to be carefully monitored for the development of apnea after surgery even if they have had an apnea-free interval before surgery.” Children’s Hospital National Medical Center (Washington, DC) prospectively studied the incidence of post anesthetic apnea and periodic breathing in infants less than twelve months postnatal age undergoing general anesthesia for hernioorrhaphy. They concluded it is probably best to delay nonessential surgery for preterm infants until they are beyond 44 weeks post conceptual age. Although there appears to be no universal agreement as to what constitutes an acceptable post conceptual age for the outpatient ex-premature, there is agreement that caution must be exercised before the ex-premature is considered acceptable for any ambulatory surgical procedure.

At the opposite end of the age scale, we find the geriatric patient. Patients with multiple medical problems and on multiple medications must be carefully evaluated before being accepted as candidates for ambulatory surgery. This is dependent upon: physiologic age, physical status, surgical procedure, proposed type of anesthesia, and quality of home cam Physical status, surgical procedure and anesthetic technique must be addressed individually and collectively before the anesthesiologist accepts or rejects the geriatric outpatient. Chronologic age should be neither a consideration nor a deterrent.

Every outpatient other than those having local anesthesia, must have a responsible person take them home and monitor their needs after surgery and anesthesia. A responsible person is defined as someone who is physically and intellectually capable of taking care of the patient at home. If the person does not meet this criterion, the facility has an obligation to make other arrangements for the patient.

With the rapid changes taking place in ambulatory surgical care, lists of acceptable procedures or specific sets of characteristics rapidly become obsolete. We must be particularly cautious of the laundry lists provided by government, industry, and third party payers. The intents of these lists is to let us know that reimbursement for a particular procedure will be either limited or nonexistent unless the procedure is performed on an ambulatory basis. Third party lists must never substitute for sound, flexible, and progressive medical judgment. Neither the patient nor the

procedure can be viewed separately from the other when determining acceptability for ambulatory surgery.

Frederick Orkin, M.D. has stated, “the actual list of acceptable procedures in a given ambulatory unit is established in an evolutionary process” with the medical director on a daily basis deciding which procedures are acceptable for the facility, “Given its equipment, its staff and their capabilities, the ability and reliability of the given surgeon, and the medical condition of the particular patient.”

Although the risks to the patient associated with so-caged minor surgery are generally less than those associated with so-called major surgery, the risks relating to anesthesia remain relatively constant. At the Federated Ambulatory Surgery Association Meeting in Boston last April, mortality statistics reported from 135 of FASA’s member facilities revealed 17 deaths in approximately 1. I million procedures. If we, as anesthesiologists, don’t start thinking of standards of care for the outpatient, someone else is going to do it for us, and in their minds, with good reason.

In 1986 we were performing 30% of all surgeries in the United States on an outpatient basis; by 1990 it is projected that number will approach or exceed 50% of all surgeries. Although there are similarities in the manner in which anesthesiologists manage their inpatients and outpatients, the differences are sufficient that we should take an active role in developing standards of anesthesia care and methods of assessing quality of care that are specific for the outpatient. With quality of care having to be balanced against cost effectiveness, each outpatient center must develop its own quality assessment program to assure that selection decisions as well as other aspects of care, provide the patient with a safe ambulatory surgical experience. On a regular basis, data should be reviewed to determine if morbidity or unexpected hospitalization is due to a particular procedure, a particular physician, a particular patient population, or to a particular type of anesthesia.

Quality assessment studies will allow us to modify decisions on patient, procedure, and anesthesia selection based on our own experiences. The basic mission of quality assessment is to achieve improvement in both the quality of care provided and patient safety.

Dr. Wetchler of Medthodist Medical Center of Illinois, Peoria, is President of the Society for Ambulatory Anesthesia and a member of the Newsletter Editorial Board.