Novel Staffing Coverage for Anesthesia Outside the Operating Room

The demand for non–operating room anesthesia (NORA) services is expanding rapidly and for diverse reasons. NORA procedures are often less invasive; many of these minimally or even noninvasive procedures are either no longer adaptable or not able to be performed in traditional operating rooms, or they do not need to be performed in expensive and highly staffed operating rooms. The growth in procedures that no longer routinely need to be performed in operating rooms encompasses practices ranging from radiology (e.g., radiofrequency tumor ablation, radiation seed implantation, transhepatic biliary duct stent placement) to gastroenterology (e.g., endoscopic placement of biliary stents, closed gastric stapling) to interventional cardiology (e.g., transfemoral aortic valve replacement). Many simple procedures may be performed in relatively spartan procedure rooms or even at the bedside, such as dressing and pack changes. Regardless of the location of the patient’s procedural care, a pain-free, safe, and relatively inexpensive experience is the primary desired outcome for both the patient and proceduralist. New anesthesia and sedation care models are needed to support the new procedural practices that are NORA cases.

The main goal of anesthesia delivery in any setting is to ensure safe, high-quality care. This can be challenging in operating settings where resources are often readily available and support staff and colleagues are nearby. It can be even more challenging outside the operating room environment. In best-case scenarios, distance from extra knowledgeable hands and resources requires additional planning and raises concerns. In worst-case scenarios, anesthesia providers may be unfamiliar with the environment and procedural issues, have very limited or minimal resources, and lack support if unanticipated complications or extraordinary needs arise.

Complexity as the Norm

Unless institutional processes and facilities are specifically adapted to support NORA, the delivery of safe anesthesia care is both administratively and medically difficult. Preplanning and standardization reduce complexity and the risks inherent in one-off activities. If sufficient numbers of non–operating room procedures are to be done, it may be possible to group them into specific locations. These locations can then be appropriately resourced with personnel, supplies, and emergency equipment. Standardized processes of care can be implemented and metrics of their success tracked as in other surgical or procedural environments. For example, sufficient numbers of unique gastroenterological endoscopy procedures may be done in a facility to support standard practices. These would include scheduling systems, quality-improvement processes, specific recovery areas, and staff who are trained and knowledgeable about the many procedures that take place in such facilities. In settings that allow consolidation of typical NORA procedures, care within the context of healthy patients undergoing complex procedures or medically compromised patients undergoing simple procedures can be fairly routine. This care becomes more challenging when medically compromised patients undergo complex procedures.

Administrative difficulties arise, however, when it is not possible to develop consolidated practice areas for typical and atypical procedures outside the operating room. For example, in many settings the provision of anesthesia care for patients undergoing radiation therapy is infrequent and inconsistent. This scenario requires deliberate review and planning. Radiation therapy environments are often distant from regular operating room settings and thus isolate anesthesia providers from colleagues. Many providers are not comfortable caring for seriously ill patients or providing care to medically complex patients in emergency rooms or isolated interventional radiology or endoscopy sites. These locations all require careful planning and creation of myriad well-defined collaborative arrangements among services and staff to ensure cooperation and patient safety. These agreements need to be written, readily available, and reviewed periodically so that providers involved in these experiences understand their roles and responsibilities when working in isolated non–operating room sites. Box 24-1 lists examples of the issues to be identified and documented.

Box 24-1

Agreements and Arrangements Necessary for Procedures and Anesthesia Services Outside the Operating Room

Appointment of a director of anesthesia services
Establishment of a work group to oversee the procedural practices
Development of policies and processes that address:
- Prioritization and scheduling of patients, providers, and procedures
- Qualifications of providers
- Options of provider models
- Triage criteria for patients based on medical and procedural complexity
- Standardization of anesthetic and procedural processes of care
- Preprocedural evaluation and preparation of patients
- Intraprocedural and postprocedural management of patients
- Communication plans
- Emergency procedures

Medical complexity is a major challenge for many non–operating room procedures. Anesthesia personnel are typically requested when a patient’s condition is medically challenging, a procedure is complex, or both. Patients who are sick or compromised clearly increase periprocedural risks. Metzner et al reviewed the American Society of Anesthesiologists (ASA) Closed Claims database entries from 1990 to 2009 and found that non–operating room locations were more likely to involve older and sicker patients ( p <0.01) undergoing emergency procedures than were operating rooms. Not surprisingly, monitored anesthesia care was eight times more likely to be the anesthesia technique used rather than general anesthesia in the operating room setting. The severity of injuries in these remote locations was greater, with a significant increase in death in contrast to procedures performed in the operating room ( p <0.001). The most common respiratory event in remote locations was inadequate oxygenation or ventilation. For respiratory depression and most other injuries in this population, an impartial team of database reviewers determined that many injuries in these settings would have been preventable with increased or better monitoring ( p <0.001).

Personnel for Anesthesia Services

It is not always possible for anesthesia-trained providers to provide anesthesia services in non–operating room locations. An insufficient number of anesthesia providers are available to serve many facilities’ complete procedural sedation needs. As the aging population, which has a high level of procedure use, continues to grow, the demand for procedures of all kinds will expand rapidly. A recent article in The Journal of the American Medical Association outlined how total knee arthroplasty (TKA) volume in the elderly has increased 161.5% from 1991 to 2010. Revision TKA similarly increased by 105.9% during the same period. These increases were due to an increase in per capita usage.

One solution to the delivery of cost-effective safe sedation and anesthesia care is to develop new and innovative staffing models. Throughout this chapter, various staffing models will be discussed. It is recognized that a specific model may not work for every practice because the models need to be appropriate for practice size, patient characteristics, and available resources.

Roles of Anesthesiologists

For the sake of simplicity, the term anesthesia services will be used throughout this chapter to imply all anesthesia and sedation services in health care facilities. In accredited health care facilities, anesthesiologists are most likely to serve as directors of anesthesia services. In the absence of anesthesiologists, other appropriately qualified physicians are potential directors of anesthesia services. In their 2010 Interpretive Guidelines, the Centers for Medicare and Medicaid Services (CMS) defined the role of anesthesiologists in organizing all anesthesia services under one oversight umbrella and stated that directors of the anesthesia services must be physicians. Specifically, “anesthesia services must be organized under the direction of a Director who is a qualified doctor of medicine (MD) or doctor of osteopathy (DO) . . . the head of anesthesia services has the authority and responsibility for directing the administration of all anesthesia services, including anesthesia and analgesia, throughout the hospital (including all departments in all campuses and off-site locations where anesthesia services are provided).” Therefore it is the responsibility of these directors to grant anesthesia and sedation privileges only to providers who have met specific criteria that have been approved by the health care facilities.

Anesthesiologists and other physicians who are named directors of anesthesia services within health care facilities must be confident that the various anesthesia and sedation providers in their facilities are the most appropriate providers for all patients. Practice guidelines and procedures must be in place to facilitate the use of appropriately trained providers. In general, the directors of anesthesia services should ensure that all members of the anesthesia team are current in regard to educational and certification requirements. They must participate in or develop processes to properly train and educate all nonanesthesia providers who wish to participate in sedation care. They must establish the anesthesia service policies and guidelines for use in all practices outside the operating room. They should ensure that each provider has undergone the required training and should play an integral role in establishing quality monitoring metrics. Of course, anesthesiologists may personally deliver non–operating room anesthesia and sedation services, but they practice under the oversight of the designated physician directors of anesthesia services in accredited health care facilities.

Roles of Other Physicians

Anesthesia services for many patients undergoing NORA are provided by physicians who are not anesthesiologists. Physicians typically involved in providing these services are emergency medicine doctors, hospitalists, and intensivists. Although these physicians are independent practitioners, when they provide or supervise anesthesia or sedation care in accredited health care facilities, they also fall under the oversight authority of the directors of anesthesia services. They thus must meet the qualifications and currency requirements established by their facilities. The directors of anesthesia services are responsible to ensure that these nonanesthesiologists are appropriately qualified and follow facility-approved practice guidelines. These physicians often may provide direct supervision of others, including nurse anesthetists, specifically trained and designated sedation nurses, and nurses who are otherwise trained and approved to provide sedation care.

Roles of Nurse Anesthetists

Nurse anesthetists are independent anesthesia providers in some states. In other states they practice under physician oversight. Their degree of oversight depends on individual state laws and federal regulations. Regardless of their independence, their anesthesia and sedation activities, like those of all anesthesia providers, fall under the oversight of the directors of anesthesia services in accredited health care facilities. Nurse anesthetists also may supervise, as may designated sedation nurses and nurses who are otherwise trained and approved to provide sedation care in settings where they have independent practice authority.

Roles of Anesthesiologist Assistants

Anesthesiologist assistants are anesthesia providers trained specifically to work directly under the supervision of anesthesiologists. From a federal perspective, the CMS considers them equivalent to nurse anesthetists for billing purposes. However, anesthesiologist assistants do not have independent practice authority in any state or in federal health care facilities. Like nurse anesthetists and other anesthesia providers, the anesthesia services that anesthesiologist assistants provide fall under the oversight of the directors of anesthesia services in accredited health care facilities. Because they do not hold independent practice authority, anesthesiologist assistants are not able to provide services under the supervision of nonanesthesiologist physicians and may not supervise sedation nurses and other appropriately trained nurses.

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