Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. Today, we are returning to our coverage of the 2022 APSF Stoelting conference, “Crucial Patient Safety Issues in Office-Based and Non-Operating Room Anesthesia (NORA).” This is the third episode in the series, and we will be picking up right where we left off last week.

Before we dive into the episode today, we’d like to recognize BD, a major corporate supporter of APSF. BD has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, BD – we wouldn’t be able to do all that we do without you!”

For the past two weeks we have reviewed the first session, “Is All NORA Created Equal? Requirements for a Safe and Effective Anesthetic Regardless of Location.” Before we move on to Session 2, we are going to answer some questions from conference participants for our Session 1 speakers. Plus, we have exclusive content from one of our speakers. So, freshen up your cup of coffee or tea because here we go!

The first question is for the proceduralists on the panel: “What are the most common misunderstandings about your practice or procedures by the anesthesia team?” The answers provide some great insight from our proceduralist colleagues and may lead to better understanding and teamwork going forward.

Some of the misunderstandings are:

• That cardiologists try to plan ahead and follow protocols especially for complex patients and time-outs, but there are times when cases started out simple or straightforward and then the patient condition changes or there is a complication during the procedure requiring a new plan and additional help. During clinical practice this looks like the procedure team having the idea that there is just a team of anesthesia professionals on standby to help at all times and the anesthesia team constantly asking why they didn’t call for help earlier.
• The idea that patients going to interventional radiology may be quite sick with multi-organ failure, hemorrhage, and requiring emergent procedures, but these are patients who need these procedures and are not chosen by the interventional radiologist.
• Communication problems when inpatients require endoscopy procedures but may not have been evaluated by the anesthesia team prior to the procedure so it is challenging to make sure that the appropriate case preparation is done.

Another question from the audience asked the speakers to weigh in about the relationship between production pressure and patient safety. This is a threat to patient safety. Productivity may be compromised due to unanticipated events, complications, and day-of procedure case cancellations. This is where planning for staffing and equipment and communication can help to avoid delays. One strategy is the use of a pre-op clinic to ensure proper patient selection and optimization and patient completion of an online questionnaire to decide if the patient needs further preoperative evaluation. The key to maintaining patient safety is to not rush to save time and just get procedures done.

Let’s take a listen to one of our conference speakers. I asked Brian Thomas why he feels so passionate about this topic and what he hopes to see going forward. Let’s take a listen now.

“Hi, my name is Brian Thomas, and I’m an attorney and the Vice President of Risk Management for Preferred Physicians Medical, the nation’s only professional liability insurance company, ensuring anesthesia professionals and their practices exclusively. I also serve on the anesthesia patient Safety Foundations board of directors, and the editorial board for the APSF.

I feel so passionate about this topic because a review of my company’s closed claims loss data has identified a troubling loss trend involving an increase of claims and lawsuits arising from complications. During Nora cases, many of these cases resulted in catastrophic patient injuries, including brain damage and death, and in most cases were prevent.

What I hope to see going forward is to continue to contribute data and specific risk management recommendations that the APS F can use to influence changes that improve patient safety and neuro practices.”

[Bechtel] Thank you so much to Thomas for contributing to the conference and to the show today.  We are moving right along now to the second session, “Appropriate Patients and Procedures” moderated by Shane Angus. Our first speaker is BobbieJean Sweitzer to talk about Ambulatory Surgery Centers. There are some important questions that anesthesia professionals who work at these locations must ask to determine the appropriate patients and procedures. What are the patient risks for noncardiac surgeries and NORA procedures? Who are high risk patients and what can we do about it? One consideration is the use of a risk calculator such as the ACS NSQUIP Calculator. To use this calculator, you input the planned procedure plus 20 patient predictors including age, ASA class, BMI, HTN, and more) to predict the patient’s risk for 18 different outcomes within 30 days following surgery. I will include a link in the show notes so that you can check it out.

Now, let’s look a little closer at cataract surgery. This is a low-risk procedure. Or is it based on the increased use of pre-op consultations and testing prior to this procedure. Even though the patients are elderly and may have significant comorbidities, the procedure may be performed with topical or regional anesthesia and minimal or no sedation. Remember, the goal here is to restore eyesight and as long as the patient is able to lie in position for the procedure, then there are very few conditions that preclude cataract surgery. Check out the recent position statement by the Society for Ambulatory Anesthesia all about Preoperative Care for Cataract Surgery in Anesthesia and Analgesia from 2021 for more information.

We have left the operating room and the hospital and the ambulatory surgery center and are heading into the office for our next talk by Fred Shapiro to talk about Office-Based Anesthesia. While this is an area that has seen significant growth in the past 30 years, there are still questions about patient safety and outcomes. Shapiro reported on this in 2014 in Anesthesia and Analgesia in his paper, “Office-based Anesthesia: Safety and Outcomes.” I will include the citation in the show notes. Several considerations to improve patient safety in these locations include proper patient and procedure selection, provider credentialing, facility accreditation, the use of patient safety checklists, and adherence to professional society guidelines.

Shapiro also discusses his research and APSF grant on the use of a smart assistant device. Here are some of the highlights of the device: It uses AI for pattern recognition of physiologic data and medical history to provide a differential diagnosis with best practices. It can be customized to the anesthesia professional and the clinical situation such as the office or an ICU. It may include visual or audio response and one of the main benefits is that it allows the clinician to keep the patient in view while capturing all of this data, instead of turning to the side to watch the monitor. We are looking forward to hearing more from Shapiro about this in the future.

Going forward, there will likely be continued growth in office-based anesthesia practices which will require increased education in this area for trainees. One example is the ambulatory anesthesia patient safety elective at Harvard which focuses on the importance of patient and procedural selection as well as the role of the anesthesia professional throughout the perioperative period as a member of a multidisciplinary team. There is a call to action to conduct research in office-based practices around the country in order to develop and then implement safe and efficient systems to keep patient safe during office-based anesthesia care.

Our final speaker for this session is Rita Agarwal to talk about Dental Anesthesia. The most important take away from this talk is that the practice of single operator model or surgeon anesthetist model is a big threat to patient safety. This is the practice where a provider who is an anesthesia permit holder directs the anesthesia and performs the surgery while a dental assistant monitors the patient. Keep in mind that the Dental Anesthesia Assistant National Certification Examination only requires 36 hours of online education.

If we look broadly at dental anesthesia, there are some significant concerns related to different standards of care and different practices in dental sedation plus state-to-state variability with a lack of transparency and very little tracking of adverse events or death during dental procedures with anesthesia leading to excessive morbidity and mortality. The lack of reporting in this area means that we don’t know what the incidence of adverse events are in dental anesthesia, but what we do know is that there is one death every 4-6 weeks for an incidence of 1 in 327,000 cases which is unacceptable and excessive. The Wake-up Safe data estimates 0 deaths in healthy children in over 2 million anesthesia events.

There have been some steps taken to improve patient safety in this area. Agarwal highlights Caleb’s Law which I will link to in the show notes. Caleb’s Law is an organization that is working to increase the safety of administering and monitoring general anesthesia and deep sedation to children during dental procedures. Caleb’s law was signed into law in California and requires the following:

1. High quality pediatric outcomes data
2. Update definitions used for sedation to follow ASA guidelines
3. Restructure the dental sedation and anesthesia permit system
4. Update equipment and records
5. Collect data that will allow future study

But this is not enough to keep patients safe and more must be done in this area.

There are other crucial patient safety considerations during dental anesthesia practice as well. Even when anesthesia professionals are present, there may be complications or death. It is also not just a pediatric problem since there have been deaths in adults following dental anesthesia. Going forward there is a call to action for the following: Education, Collaboration, Good data collection, strong NORA guidelines that apply to all practitioners and in all locations. Check out the Updated Guidelines for Monitoring and Managing Pediatric patients undergoing procedures including dental sedation from 2019 for more information. I will include a link in the show notes as well. Anesthesia professionals can have a big impact on anesthesia patient safety during dental procedures and future lives depend on it.

We have completed our tour of outside the hospital NORA locations for today. What a great session with so many considerations for keeping patients safe. Do you practice in one of these locations? Let us know by tagging us @APSForg and don’t forget to use the conference hashtag #APSF2022. Plus, did you know that you can tune in to the entire conference online for free now. That’s right, head over to APSF.org and click on the conferences and events heading. Second one down is APSF Stoelting Conference 2022. There you will find the recordings of all of these great sessions. I will include the link in the show notes, and we hope that you will check it out.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2022, The Anesthesia Patient Safety Foundation