Episode #43 Anesthesia Patient Safety in the Office: Part 1

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 venturing outside the operating rooms and outside the hospital…but don’t get worry we won’t be outside for too long.

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

That’s right today we are headed into the office to talk about keeping patients safe during anesthesia care for office-based surgery. Our featured article today comes from the June 2020 APSF Newsletter. It is called, “Educating the Next Generation: A Curriculum for Providing Safe Anesthesia in Office-Based Surgery” by Brian Osman and Fred Shapiro. To follow along with us, head over to APSF.org and click on the Newsletter heading. Fourth one down is Newsletter Archives. From here, click on June 2020. Then, look over at the left hand column and scroll down until you see the featured article today. Before we get into the article, we have some exclusive content for the show today. We will be hearing from one of the authors. I am going to let him introduce himself now.

[Shapiro] Hello, my name is Fred Shapiro and I am an associate professor of anesthesia at Harvard Medical School.

[Bechtel] To help kick off the show, I asked Shapiro why he wrote this article. Let’s take a listen to what he had to say.

[Shapiro] Over the past 25 years, there’s been an exponential growth in complexity of both patients and procedures in the office-based anesthesia surgical and procedural setting. There remains a need to maintain the educational curriculum consistent with the current standards and best practices. We present evidence-based literature that supports this. This includes multi-disciplinary approach with consensus statements and guidelines including all personnel during the perioperative care period that includes nurses, surgeons, and anesthesia providers. We also include the use of technology based simulation education in consideration of the needs of the next generation who are most familiar and comfortable with these modes of assimilating information. We included recommendations for safe office based anesthesia in the Covid-Era, algorithms for screening, testing, and choosing appropriate patients, procedures and personal protective equipment. This comes from our recent publication in Best Practices in Anesthesiology December 2020.

[Bechtel] Thank you so much to Fred Shapiro for kicking off the show. I don’t know about you, but I can’t wait to get into this article. Let’s get started with the summary. The first office-based anesthesia resident curriculum was developed by the Society for Ambulatory Anesthesia or SAMBA in 2010 to provide education about anesthesia care for patients undergoing outpatient surgical procedures in an office-based setting. So many more procedures are being performed in the office-based setting now for so many patients and there have been a lot of changes for anesthesia practice in this area. This article provides an important update so today we are indeed bringing you the latest in perioperative anesthesia care for office-based anesthesia practice.

Let’s set the scene with some history. 40 years ago, the vast majority of surgical procedures were inpatient surgeries and less than 10% of procedures were planned discharge home on the same day. By around 2005, 70% of surgical procedures could be performed outside of the standard hospital operating rooms and there had been growth of office-based procedures that accounted for about 15-20%. Most anesthesia professionals are now familiar with the Society for Ambulatory Anesthesia or SAMBA and this society was founded in 1985 with the mission statement to “strive to be the leader in perioperative care of the ambulatory surgical patient.” SAMBA is dedicated to patient care, medical education, patient safety, research, and practice management for anesthesia in ambulatory settings, non-operating room anesthesia, office-based  anesthesia practices. With the massive growth of office-based anesthesia practices, SAMBA worked to develop an education curriculum for anesthesia residents in training. In 2006, our guest speaker today, Fred Shapiro created the first Harvard Medical School office-based anesthesia Continuing Medical Education course. This course was called “The Manual of Office-Based Anesthesia Procedures and it became part of the SAMBA national program. Several years later, Shapiro and his colleague, Shireen Ahmad co-authored the SAMBA Anesthesia office-based anesthesia Curriculum which served as an educational resource for a one-month specialty rotation for anesthesia residents in their final year of training. 10 years later, there has been continued massive growth in the area of office-based anesthesia with changes in the available literature, practice management, accreditation requirements and even office-based practice legislation. As a result, the curriculum was updated in 2020 to provide the latest standards and guidelines for safe office based anesthesia care. I will also include a link to the SAMBA Office-based anesthesia website in our show notes which includes the updated 2020 curriculum.

So, what were the updates to the literature from 2010 to 2020? Before we even get there, we need to talk about the literature before 2010. It is important to keep in mind that adverse event reporting for office-based anesthesia was not routine and there were no randomized-controlled trials to evaluate patient morbidity and mortality for office surgical procedures and anesthesia care. To get some information, we will need to first look at retrospective studies. That’s right, it is time for a literature review.

[Literature Review Music]

The authors provide a table in the article that reviews the most important articles before 2010. Just because we are not providing anesthesia in a hospital OR or ambulatory surgery center does not mean that it is time to let down our guard. Some of the earlier literature revealed safety concerns for office-based anesthesia including a 2001 study by Domino and colleagues that reviewed complications in the ASA Closed Claims Database and found that office-based claims were about three times more severe than those from ambulatory surgery centers. Another study in 2003 by Vila and colleagues found that there was a 10 time greater risk for complications and death for office-based practices compared to ambulatory surgery centers. Not all of the studies found an increased risk of complications. Some of the complications reported in these studies included respiratory depression which could have been prevented by improved monitoring. This is from the 2006 article by Bhanaker and colleagues that also looked at the ASA Closed Claims Database and reported that more than 40% of the claims related to monitored anesthesia care were for death and permanent brain injury. The respiratory depression complication occurred in about 21% of the total claims. I encourage you to check out the table for more information.

What have we learned since 2010? The good news is that safety and outcomes have improved for patients undergoing office-based procedures. How did this happen? A 2014 comprehensive literature review by Shapiro and colleagues reported that the improved safety was likely due to appropriate credentialing of office-based facilities and practitioners, increased accreditation, better adherence to national society guidelines, use of safety checklists, and increased oversight at the state and federal levels. By 2019, additional literature reviews revealed further increases in patient safety that was attributed to better patient selection for office-based procedures reported by Seligson and colleagues. I encourage you to check out Table 2 in the article for a review of the literature between 2010 to 2019. The authors also highlight the 2017 study by Gupta and colleagues which was a large database study of more than 180,000 plastic surgery procedures performed at accredited facilities between 2008 and 2013 which revealed complications rates in office-based surgery centers to be 1.3% compared to the complication rates at ambulatory surgery centers and hospitals which were 1.9% and 2.4%, respectively. The important findings from this decade of literature includes:

• Office-based surgical procedures and anesthesia is becoming safer
• Safe patient care starts with appropriate patient and procedure selection
• Systemic approaches for safer patient care include the following:
  • Safety checklists and emergency protocols
  • Published guidelines and position statements
  • Medication management
  • Surgical risk reduction
  • New regulations
  • Accreditation measures

[End literature review music]

Now, that we have completed this literature review. Let’s dive into the updated curriculum starting with Practice Management. This is a time for anesthesia professionals to be leaders in their office-based setting by evaluating the administration, facility engineering, equipment, and facility accreditation to make sure that the practice follows an adequate standard of care. Kurrek and Twersky created a checklist that includes elements that should be evaluated prior to providing anesthesia care in an office-based practice. Over the past 20 years or so, the ASA has worked to help improve anesthesia patient safety in this setting with recommendations for proper patient and procedure selection. The ASA also recommends that there is a medical director for the office-based practice who is responsible for ensuring that current regulations are followed and that the healthcare providers are trained and credentialed, and that the facility remains in compliance with local and national legislation. The ASA recommendations were amended in 2009 and reaffirmed in 2014. Other recommendations are now available to help guide safe office-based anesthesia care including the Guidelines for Ambulatory Anesthesia and a multi-disciplinary collaboration for the 2018 Practice Guidelines for Moderate Procedural Sedation. This collaboration included the ASA, American Association of Oral and Maxillofacial Surgery, the American College of Radiology, the American Dental Association, the American Society of Dentist Anesthesiologists, and the Society of Interventional Radiology. These guidelines are a must read for anesthesia professionals who practice in an office-based setting. Checklists may be used to help improve patient safety and outcomes and to help decrease medical errors. In 2010, the Institute for Safety in Office-Based Surgery developed a patient safety checklist that could be used for office-based practice and incorporated important points from the World Health Organization Surgical Safety Checklist. There is an updated safety checklist that was developed in 2017 by the Institute for Safety in Office-Based Surgery. This checklist is now part of the American Academy of Healthcare Risk Management resource manual for Office-based surgery. I hope that you will check it out at ASHRM.org and I will include the link in the show notes.

We will review the checklist in more detail during our next show. Plus, I hope that you will check back in as we discuss important considerations for accreditation and legislation for office-based practices that provide anesthesia care. And that’s not all, we will have more exclusive content from Fred Shapiro. You will not want to miss our next show as we continue on our journey towards safe anesthesia care in office-based practices.

If you have any questions or comments from today’s show, please email us at [email protected].

Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice.

Did you know that the anesthesia patient safety foundation has launched our first-ever crowdfunding initiative and we would love for you to join the #APSFcrowd. Head over to APSF.org and click on the Our Donors heading. Then click on Make a Donation and the third one down is crowdfunding donation. Just $15 can go a long way to support our vision.

We’ll be back next week for more about office-based anesthesia patient safety.

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

© 2021, The Anesthesia Patient Safety Foundation