Patient Safety and Production Pressure: Private Practice

Casey D. Blitt, MD

You are running late, the surgeon is waiting impatiently; the patient is also waiting in the preoperative holding area. Can this scenario provide an opportunity for erosion of patient safety? You bet it can! The necessity (or perceived necessity) to perform more and more operations in a given period of time invites the potential for errors by the anesthesiologist, the surgeon, as well as the operating room staff.

There are several areas in which production pressure can diminish patient safety. These include: 1) preoperative work-up and preanesthetic evaluation, 2) preparing for the case, and 3) reluctance to cancel or reschedule. More patients are being scheduled for surgery than ever before. An increasing number of these operations are being performed on an ambulatory or same-day-admit surgical basis. Preoperative work up of the patient is frequently suboptimal and sometimes inadequate. In many cases, the anesthesiologist is dependent upon the surgeon and consultants (internists, cardiologists, pulmonologists) to perform the patient’s preoperative work-up. These physicians may be overburdened by a large patient volume.

For many patients the preanesthetic evaluation is performed immediately before the case by the anesthesiologist in a holding area. An adequate preanesthetic evaluation can often be performed in this fashion and this is successfully and appropriately done daily. Some practices have been successful in establishing preoperative clinics specifically to accomplish the preoperative work up and preanesthetic evaluation prior to the day of surgery. Some of these clinics have helped in improving the quality of the preoperative work up, improving the adequacy of preanesthetic evaluation, and decreasing cancellations. Manpower/reimbursement issues have prevented the widespread use of preoperative clinics in private practice settings. As our patient population continues to age with greater number and variety of coexisting medical conditions, preanesthetic evaluation and preoperative work-up become more involved and more complex. The increased number of cases and the pressures of managed care entities may result in "cutting corners" by all personnel involved in the care of the patient, causing a potential erosion of patient safety.

Production pressure also can adversely impact the anesthesia professional’s preparation to perform an anesthetic, an important part of which is the anticipation of potential problems and preparation to intervene and/or rescue when necessary. Preparing for the anesthetic includes assembling necessary equipment and medications and "preflight" checklists of important equipment. Time and "efficiency" pressure can certainly result in hasty preparation and checkout that omit or gloss over key elements as well as failure to anticipate potential problems.

Perhaps most important is the reluctance to cancel or reschedule a case when the preanesthetic evaluation indicates that more information is necessary in order for the anesthetic proceed safely. The range of issues is extremely broad and encompasses many areas. Recent oral intake by the patient may come into play with a tendency to fudge the generally accepted time constraints regarding oral intake, especially for solid food. The anesthesia professional who recommends rescheduling of an operation because of abnormal laboratory values, lack of appropriate consultation (cardiac, pulmonary, etc.), or for other valid medical considerations is often looked upon as not being a team player and only wanting to "dodge the case." Cancelling or rescheduling of the case of a hospitalized patient, particularly, brings down the wrath of insurance companies and managed care organizations who are concerned primarily about the excess cost of additional lengths of stay.

It is important to realize that all of the ancillary and support services for surgery and anesthesia are also under the same production pressures. This includes nurses, laboratory technicians, x-ray personnel, anesthesia technicians, and even the orderlies and housekeeping personnel. It is clear to this author from experience that production pressures in the private practice setting have been contributory to the erosion of anesthesia patient safety.

What can we do to minimize the negative impact of production pressure on safety? First, realistic and honest scheduling is important. It is important from the surgeon’s standpoint; it is important from the operating room standpoint; it is important to the anesthesia professional. I truly believe that honest and realistic surgical scheduling can play a major role in improving patient safety. It is sometimes difficult for surgeons to admit how long it actually will take them to do a case, but they must be honest, accurate, and ethical in surgery scheduling. All of us must be vigilant and not buckle under the pressure to "get the case going" until we feel that the patient’s interests have been best served. In doing so it must be assured that all personnel involved are comfortable in proceeding with the case in an appropriate time frame. We must also be ever vigilant to avoid accepting poor preoperative work-ups and/or inadequate preanesthetic evaluations. This is particularly true with patients with multiple co-morbidities. Only by adhering to good medical practice can we overcome the erosion of patient safety by the ever-increasing pressure to produce.

Dr. Blitt is Treasurer of the APSF and a private practice anesthesiologist in Tucson, Arizona.