Office-based anesthesia: an overview

Administrative issues to ensure safe anesthesia care in the office-based setting

PURPOSE OF REVIEW

Office-based practice is distinct from other ambulatory practices and has unique considerations for an effective administrative structure to support its operations.

RECENT FINDINGS

National guidelines have been promulgated by various entities addressing both management and clinical care aspects of the practice. Specific regulations vary by practice location, and practitioners need to comply with the pertinent accreditation and licensing requirements. Anesthesiologists have been at the forefront of promoting the culture of safety in the office-based setting. Specific practice considerations include provider credentialing, maintenance of documentation, quality assessment, professional liability, facility safety, patient health information, billing, and finance. Although there is emerging literature linking office accreditation to improved patient outcomes, more work is needed in this area.

SUMMARY

Office-based practice will continue to evolve with the national emphasis on patient safety, cost reduction, value-based care, and outcomes measurement and reporting. Each practice must comply with the state and national regulations that could limit the types of procedures being performed and who can administer sedation or anesthesia, and require the facility to be accredited by a nationally recognized accrediting agency.

Office-based anesthesia: safety and outcomes

The increasing volume of office-based medical and surgical procedures has fostered the emergence of office-based anesthesia (OBA), a subspecialty within ambulatory anesthesia. The growth of OBA has been facilitated by numerous trends, including innovations in medical and surgical procedures and anesthetic drugs, as well as improved provider reimbursement and greater convenience for patients. There is a lack of randomized controlled trials to determine how office-based procedures and anesthesia affect patient morbidity and mortality. As a result, studies on this topic are retrospective in nature. Some of the early literature broaches concerns about the safety of office-based procedures and anesthesia. However, more recent data have shown that care in ambulatory settings is comparable to hospitals and ambulatory surgery centers, especially when offices are accredited and their proceduralists are board-certified. Office-based suites can continue to enhance the quality of care that they deliver to patients by engaging in proper procedure and patient selection, provider credentialing, facility accreditation, and incorporating patient safety checklists and professional society guidelines into practice. These strategies aiming at patient morbidity and mortality in the office setting will be increasingly important as more states, and possibly the federal government, exercise regulatory authority over the ambulatory setting. We explore these trends, their implications for patient safety, strategies for minimizing patient complications and mortality in OBA, and future developments that could impact the field.

Office-based anesthesia for the urologist

This article describes office-based surgery and office-based anesthesia (OBA), including the safe setup of OBA and safety concerns regarding OBA. Also discussed are the preoperative selection and workup of a patient undergoing OBA, anesthetic options, the prevention and treatment of postoperative nausea, vomiting, and pain, and planning for safe discharge.

[Distribution of anesthesia practice, types of anesthesia, and human resources in Catalonia, Spain, in 2003]

BACKGROUND AND OBJECTIVE

The aim of this arm of the ANESCAT 2003 study was to describe the temporal distribution and types of anesthesia used in Catalonia, Spain, in 2003, along with the associated human resources used.

PATIENTS AND METHOD

Data were used from a survey of 23,136 anesthetic procedures collected on 14 randomly selected days in 2003 and an individual questionnaire was completed by 765 anesthesiologists working in Catalonia.

RESULTS

Anesthesia practice was divided into that associated with surgery (78.4%), obstetrics (11.3%), and other nonsurgical procedures (10.4%). Of all anesthetic procedures performed, 84.3% took place in operating theaters and 7.0% in obstetric areas. Emergency procedures accounted for 20.3% of the total. Most procedures (71.2%) were undertaken within 08:00 and 16:00 h, and the lowest number of procedures performed on workdays took place on Fridays. The median duration of anesthesia was 60 minutes. The most common technique was regional anesthesia (41.4%), with spinal block being the most widely used. There were an estimated 12.5 anesthesiologists per 100,000 inhabitants, with a median (10th-90th percentile) age of 45 (34-57) years; women made up 47.2% of that group. The mean number of standard working hours was 46 hours per week and 65% of anesthesiologists also undertook on duty shifts. Anesthesiologists spent 77% of their time performing anesthesia and the remainder in postoperative recovery and critical care units and pain clinics.

CONCLUSIONS

Emergency anesthesia represents 20% of the total workload and obstetrics and nonsurgical procedures another 20%. The use of regional anesthesia was very widespread. The population density of anesthesiologists is comparable to that of other European countries, but with a higher proportion of women.

Epidemiology of anesthesia-related mortality in the United States, 1999-2005

BACKGROUND

Previous research on anesthesia-related mortality in the United States was limited to data from individual hospitals. The purpose of this study was to examine the epidemiologic patterns of anesthesia-related deaths at the national level.

METHODS

The authors searched the International Classification of Diseases, 10th Revision manuals for codes specifically related to anesthesia/anesthetics. These codes were used to identify anesthesia-related deaths from the US multiple-cause-of-death data files for the years 1999-2005. Rates from anesthesia- related deaths were calculated based on population and hospital surgical discharge data.

RESULTS

The authors identified 46 anesthesia/anesthetic codes, including complications of anesthesia during pregnancy, labor, and puerperium (O29.0 -O29.9, O74.0-74.9, O89.0-O89.9), overdose of anesthetics (T41.0 -T41.4), adverse effects of anesthetics in therapeutic use (Y45.0, Y47.1, Y48.0 - Y48.4, Y55.1), and other complications of anesthesia (T88.2- T88.5, Y65.3). Of the 2,211 recorded anesthesia-related deaths in the United States during 1999-2005, 46.6% were attributable to overdose of anesthetics; 42.5% were attributable to adverse effects of anesthetics in therapeutic use; 3.6% were attributable to complications of anesthesia during pregnancy, labor, and puerperium; and 7.3% were attributable to other complications of anesthesia. Anesthesia complications were the underlying cause in 241 (10.9%) of the 2,211 deaths. The estimated rates from anesthesia-related deaths were 1.1 per million population per year (1.45 for males and 0.77 for females) and 8.2 per million hospital surgical discharges (11.7 for men and 6.5 for women). The highest death rates were found in persons aged 85 yr and older.

CONCLUSION

Each year in the United States, anesthesia/anesthetics are reported as the underlying cause in approximately 34 deaths and contributing factors in another 281 deaths, with excess mortality risk in the elderly and men.

Anesthesia outside the operating room in the office-based setting

PURPOSE OF REVIEW

The majority of anesthesia services provided outside the operating room or ambulatory surgery center is in the office-based setting. This review will focus on three areas that are critical to office-based anesthesia: safety, quality of care and patient satisfaction.

RECENT FINDINGS

Data obtained from the State of Florida office-based surgery adverse event data repository indicate that, even with The American Society of Anesthesiology I patients, there remains opportunity to improve outcomes. Careful patient selection remains critical, especially the patient with a history of sleep apnea. While general anesthesia remains the gold standard, expanded use of local anesthesia, regional blocks and variation on sedation techniques offer alternatives that may reduce risks but still maintain a high quality of care. While there is limited office-based anesthesia satisfaction data, limiting postoperative nausea and vomiting remains a major patient satisfier of which an occurrence rate of zero may be possible.

SUMMARY

There is rapid growth for the need of safe and high quality office-based anesthesia. To meet these needs, a special set of skills is required, which may require expanded exposure and experience during training. An office-based anesthesia central data repository is needed for benchmarking and identifying areas for improvement. Finally, with advances in surgical technology, there is a need for focused research in office-based anesthetic techniques and modalities and patient satisfaction.

[Survey of anesthetic techniques used in Catalonia: results of the analysis of 23,136 anesthesias (2003 ANESCAT study)]

OBJECTIVE

To examine anesthesia practice in Catalonia in 2003 and to describe the specific characteristics and distribution of the anesthesia techniques used and the patient profiles.

PATIENTS AND METHODS

We used the data from the ANESCAT epidemiological study that gathered information in questionnaire form on all anesthesias performed in Catalonia on 14 randomly selected days representative of practice in 2003.

RESULTS

All 131 hospitals authorized to perform anesthesia participated in the study. We collected 23136 questionnaires, from which we extrapolated to estimate 603189 anesthesias for the year and a rate of 9.0 anesthesias per 100 inhabitants per year. Fifty-eight percent of the patients were women and the mean age was 52 years. The physical status of the patients was as follows: ASA 1 or 2, 73.3%; ASA 3, 213%; ASA 4 or 5, 5.4%. The mean duration of anesthesia was 60 minutes. The most common form of anesthesia was a regional block (41.4%) and spinal block was the one performed most often. General anesthesia was used in 33.5% of the cases, combined anesthesia in 3.5%, and sedation in 21.6%. In descending order, orthopedics/trauma, ophthalmology, general surgery, obstetrics, cataract surgery, vaginal delivery, inguinal hernia repair, and colonoscopy were the procedures for which anesthesia was most commonly administered.

CONCLUSIONS

Almost 1 in 10 persons in Catalonia are given anesthesia each year and most of the procedures involve locoregional anesthesia or sedation. These data provide a picture of the current situation of anesthesiology and make it possible to forecast future anesthesia requirements.