Episode #44 Anesthesia Patient Safety in the Office: Part 2

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. It is not time to return to the hospital operating rooms just yet because today we have part 2 of our series on safe anesthesia in Office-Based Surgery.

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

Last week we talked about keeping patients safe during anesthesia care for office-based surgery by reviewing an article 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. If you haven’t listened to our show from last week, I encourage you to check out Episode #43 for Part 1 of this series which includes a literature review of studies that evaluated the safety of anesthesia in office-based practices over the past 20 years. We are so glad that you are back for Part 2 today as we continue the discussion. Now, 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. At the end of the show, we have more exclusive from one of the authors, Fred Shapiro, to look forward to as well.

We are going to start today where we ended last week by talking about available checklists to help improve patient safety and outcomes with decreased medical errors. In 2010, the Institute for Safety in Office-Based Surgery or ISOBS 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. The safety checklist was updated 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.

Let’s go through the ISOBS checklist. There are 5 columns in the checklist and each column represents the initials I-S-O-B-S. The I stands for Introduction which includes the preoperative evaluation with the practitioner and the patient. Important questions include the following:

• Is the patient medically optimized for the procedure?
• Does the patient have DVT risk factors?
• Has the procedure complexity as well as the plan for sedation and analgesia been reviewed?
• Were NPO instructions given to the patient?
• Does the patient have an escort home and has the post-procedure plan been reviewed?

Next up, the S stands for Setting which represents the physical space where the procedure will take place, but before the patient is in the room and this part involves the practitioner and any additional personnel. Important questions to ask include:

• Has the Emergency equipment check been completed? Emergency equipment may include airway supplies, an AED, a code cart, and an MH kit.
• Is EMS available to responds in the event of an emergency?
• Has the oxygen sources been confirmed and is suction available and functioning?
• What is the anticipated duration of the procedure? Ideally, procedures that are performed in office-based setting will be less than 6 hours, but for longer procedures it is important to discuss this with personnel in the room and make sure that appropriate equipment and monitoring are available.

The O in the Checklist stands for Operation and this part also involves the practitioner and personnel and should take place prior to initiation of sedation or analgesia. Here are the questions to consider:

• Has the patient identity, procedures, and consent been confirmed?
• Us the site marked and correct side confirmed?
• Has DVT prophylaxis been administered if appropriate?
• Has antibiotic prophylaxis been administered within 60 minutes prior to incision?
• Is essential imaging displayed?

Next, it is time for the practitioner to discuss the local anesthetic toxicity precautions for the case, what is the plan for patient monitoring, which needs to be in-line with institutional policy, any anticipated critical events. Finally, this is a good time to make sure that each member of the team has been addressed by name is ready to proceed. This part of the Safety Checklist goes a long way towards creating a culture of safety in the office procedure room and allows all members of the team to feel safe to speak up with any safety concerns.

Now we are in the column represented by the letter B which represents Before Discharge. This is another vital time at the end of the procedure when the patient arrives to the recovery area and should take place between the practitioner and personnel. Here are the questions for consideration:

• Is the patient having any pain or nausea and vomiting?
• Are recovery personnel available?

And just prior to discharging the patient home, it is important to evaluate the following between the patient and personnel:

• Has the patient met discharge criteria?
• Has the patient been given appropriate education and instructions?
• What is the plan for post-discharge follow-up?
• Does the patient have an appropriate escort for discharge from the office?

Once the procedure has been completed and the patient is ready for discharge home safely, the check list continues with the final column which is the S column which stands for Satisfaction and this evaluation takes place between the practitioner and personnel asking:

• Were any unanticipated events documented?
• Has the patient’s satisfaction been assessed?
• Has the provider’s satisfaction been assessed? This is a good time to ask about what went well during the procedure and what are the opportunities for improvement.

Another important resource includes emergency manuals that are geared towards providing these services in the office rather than the hospital or even an ambulatory surgery center. When seconds count, these emergency manuals and cognitive aids can mean the difference between life and death. The ISOBS developed an Office-Based emergency manual in 2017 to provide easy to use cognitive aids and treatment algorithms for 26 of the most common scenarios in office-based anesthesia practice. The scenarios includes ACLS and PALS events as well as emergency situations including fire or loss of power as well as LAST and MH. You can find this manual on the Emergency Manuals Implementation Collaborative website and I will include a link in the show notes.

Another important component of practice management involves anesthesia techniques and the 2020 updated curriculum includes an evidence-based review of the literature pertaining to patient outcomes and satisfaction. Before 2010, studies related to anesthesia techniques for office-based procedures supported general anesthesia, total intravenous anesthesia (TIVA), local anesthesia with moderate sedation, and conscious sedation as safe for office based procedures. More recent studies provide additional information about Enhanced Recovery After Surgery techniques that may be appropriate for the office with multimodal therapies for pain management and postop nausea and vomiting prophylaxis leading to improved patient satisfaction and decreased pain, nausea and vomiting, opioid medication use, and length of stay. Adjuncts for improved pain management include regional blocks, oral and IV non-opioid therapies such as steroids, pregabalin, NSAIDs, acetaminophen, clonidine, intravenous lidocaine, and intraoperative injection of long-acting liposomal bupivacaine.

Another component for practice management in the office-based setting includes decision aids for the patient which provide education to patients, even before they arrive on the day of the procedure, related to the surgery and anesthesia plan and options. The ASA has several of these tools on their website and some examples include decision aids for epidural and spinal anesthesia and regional nerve block as well as monitored anesthesia care. These practice management tools from safety checklists to emergency manuals to evidenced-based reviews for anesthesia techniques to decision aids can help to keep patients safe in the office and provide vital information to patient so that they can make informed consent and be an active member of their own healthcare team.

The next area that we are going to review is Accreditation for Office-based practices. There are 3 major nationally recognized accrediting organizations:

1. Accreditation Association for Ambulatory Health Care
2. The Joint Commission
3. American Association for Accreditation of Ambulatory Surgery Facilities.

As of 2020, 33 states required offices receive accreditation if they perform medical and surgical procedures and hopefully, this number will continue to increase. There are some differences between the accreditation received from the 3 organizations. Some of these differences include:

• Facility maintenance
• Qualification of the personnel in the facility
• Infection control
• Cleaning and maintenance of equipment
• Emergency preparedness
• Credentialing and privileging
• Documentation
• Quality Improvement

Accreditation is another way to help keep patients safe because it allows a third party to evaluate the practice setting and make sure that it is following a nationally recommended standard of care.

We have one more important area to talk about before we hear from Fred Shapiro again and that is Legislation. This area is notable for the many changes that have occurred in the past 25 years. 25 years ago, office-based practices were almost unregulated while now there is legislation or regulation in every state across the country. Office-based surgery legislation is made and enforced on the state level and there is a lot of variability depending on the state. The authors provide the example that some states do not require the practice to register or obtain licensure and other states require registration for the practice. The states with the highest level of regulation require that office-based practices follow similar rules as ambulatory surgery centers and hospitals. For more information about state legislative and regulatory activities, you can check out the Joint Commission quick references tool which takes you through all of the state specific requirements. I will include a link in the show notes as well. Legislation for office-based practices helps to keep patients safe by keeping the office accountable with standardization of safe anesthesia and surgery practices.

[Bechtel] Before we wrap up for today, we are going to hear more from Fred Shapiro. I asked him to share with us what’s next for his research. Get ready to hear about the latest research in this area.

[Shapiro] The implementation of the electronic health records enabled a recent examination of retrospective data of nearly 90,000 procedures performed between 2016 and 2019 in a mobile anesthesia practice. The data was extracted from administrative claims and an anesthesia-specific electronic medical record system and divided into 2 groups, procedures performed in an ambulatory surgery center and procedures performed in physician offices. We compared age, ASA status, types of anesthesia, and patient outcomes. The availability of a complete coherent data for substantial period of time allowed the creation of a profile of this practice. We founds some very interesting results, but this is only the beginning, /our field must continue to pursue similar research within multiple practices across the USA. This combined with the ASA national anesthesia clinical outcomes registry or NACOR data will be essential in establishing bench marks, standardization of practice and ultimately define safe practices in the office-based anesthesia setting.

[Bechtel] The future sounds very promising for working towards even safer anesthesia care in the office-based setting. Thank you so much to Fred Shapiro for his contributions to the show today and we are looking forward to learning more about the interesting results you that you found in your study.

Over the past 25 years, there have been a lot of changes for office-based anesthesia and surgery practices along with a massive growth in this area in terms of increased procedures, complexity, and variety of cases as well as increased complexity of patients presenting to the office. It is so important to keep this educational curriculum up to date with safe practices and standards of care, especially since the legislation and regulations are not consistent across the country and around the world. This article serves as a resource to ensure that offices continue to maintain appropriate standard of care and utilize current best practices to help keep patients safe during anesthesia care in the office.

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. Have you joined the conversation on twitter? If so, we would love for you to tag us in a tweet using #ASPF podcast and tag some of your friends and colleagues while you are at it. Help up continue to build our community of patient safety advocates. Thanks for listening.

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

© 2021, The Anesthesia Patient Safety Foundation