Volume 3, Issue 11 S A M B A T A L K S - PAGE 1 April, 2004

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Do you have a problem case or situation in ambulatory anesthesia about which you would like some advice? Would you like to reply to questions others have raised about ambulatory anesthesia issues? Do you have any comments or opinions regarding any topic related to ambulatory anesthesia which you would like to share with other professionals? If you answered "yes" to any of the above, then "Join the Discussion" here.

To enter the Discussion with a question, reply, or other comment, please contact us. Your question/reply/comment will be published in this section of the next available issue of SAMBA TALKS. Please include your name (or initials), city, and state, if you would like these published.

Questions and responses from previous months are available on the Web site. If you have any comments regarding the previous questions, please submit them to SAMBA Discussion, and they will be published here next month.

?? - LAST MONTH'S QUESTIONS WITH REPLIES - ?? - TOP

QUESTION 1:

I am a nurse working in an Infertility office. I'd appreciate very much if you could give me feedback on which medicines should be kept in stock for emergency.  Our Anesthesia staff is currently using Versed, Fentanyl and Diprivan for IV sedation during egg retrievals.

-- From Karen R. Rich, Thousand Oaks, CA

REPLY:

 The number of procedures undertaken outside the OR suite requiring IV sedation has increased exponentially. In many instances non-anesthesiology staff are involved in rendering sedation. Needless to say, irrespective who the provider is, it is imperative that patients be adequately monitored and cared for in these situations.

The “Definition of General Anesthesia and Levels of Sedation/Analgesia”, as approved by the ASA House of Delegates on October 13, 1999, is shown in the following table.

Definition of General Anesthesia and Levels of Sedation/Analgesia

	Minimal Sedation (Anxiolysis)	Moderate Sedation/ Analgesia ("Conscious Sedation")	Deep Sedation/ Analgesia	General Anesthesia
Responsiveness	Normal response to verbal stimulation	Purposeful response to verbal or tactile stimulation	Purposeful response following repeated or painful stimulation	Unarousable even with painful stimulus
Airway	Unaffected	no intervention required	Intervention may be required	Intervention often required
Spontaneous Ventilation	Unaffected	Adequate	May be inadequate	Frequently inadequate
Cardiovascular Function	Unaffected	Usually maintained	Usually maintained	May be impaired

Individual patients differ in their response to medications and so do surgeons in their requests to keep patients “sedated”. Given this scenario it is not surprising that patients may pass from one level of sedation to the other all too quickly and only vigilant adequate monitoring and timely intervention will provide a safe environment for our patients.

In achieving this goal we need to choose appropriate patient populations who are to undergo IV sedation. We also need to ensure that the following are present:

1. Adequate IV access and monitoring, including but not limited to: NIBP, HR, SpO₂, RR and possibly end-tidal CO₂
2. Various means of delivering oxygen
3. Functioning suction
4. Equipment to deal with emergency airway management and medical personnel adept at establishing an airway
5. IV medications as required by ACLS protocols immediately available
6. Antidotes to medications used in IV sedation, including Narcan for Fentanyl, Flumazenil for Midazolam

It is today a JCAHO requirement that all staff involved in administering “Deep Sedation,” be certified. Many hospitals have and are implementing this requirement, some more expeditiously than others.

I do think that human patient simulators have a role to play in training medical personnel for deep sedation. We use them in our institution for that purpose. It would also be interesting to see what role monitors of ‘levels of consciousness’ like BIS, Entropy, etc., may play in safely sedating patients.

-- From Suhas Kalghatgi, MBBS, MD (Anes.), Iowa City, IA

QUESTION 2:

The orthopedic surgeons are building a three OR Ambulatory Surgical Center in conjunction with their new office. They want me to be the Medical Director and put my DEA on the line.

The proposed contract is technical and extensive.  The Medical Director shall have extensive responsibility with essentially no authority.  He (me) would provide the DEA number by which all scheduled drugs used in the OR and the PACU will be administered.  I would be responsible for establishing protocols throughout the ASC as well as providing anesthesia services. 

My malpractice will cover all my duties pertaining to anesthetic services, but what about HIPAA compliance, employee substance abuse, harassment issues, disgruntled employees, etc.  My guess is that my malpractice will NOT extend to these other issues. I recognize increased direct and vicarious liability. Is insurance available for me and how much will it cost?

-- From Tod Tolan, M.D.

REPLY:

In general, the position of Medical Director involves increased responsibility and liability above those normally associated with the practice of anesthesia. You should get specific recommendations from a medical practice consultant and/or appropriate legal counsel in your geographic area since state laws and local regulations will probably determine your level of risk. I strongly encourage you to seek legal advice with the contract that you state is technical and extensive.

The position of Medical Director in any freestanding surgical facility should not be without authority. Along with the title you should have a seat on the Medical Executive Board or Governing Board of the facility. You, as Medical Director, should be appropriately empowered to ensure that quality, efficient care is provided. The Medical Director's responsibility and authority should be clearly defined in the medical staff bylaws of the facility. These may not be included in the contract.

Frequently, the Medical Director is compensated for the extra work that is required to fulfill the duties of the position. The stipend, if any, and the professional fees will make up your total compensation package and should be enough to make your extra work worthwhile and to keep you motivated and enthusiastic with your role. It may be important for you to receive a fee from a regulatory standpoint. Then you can demonstrate that you are not providing free services in return for the anesthesia franchise at the facility, a practice that the federal government does not smile upon. A successful facility will be built on mutual respect, trust, and sometimes, friendship among the partners. You may want to request partial ownership of the facility in order to guarantee that all parties have a stake in the success of the organization.

With regards to your concerns about the use of your DEA number, you may want to obtain the advice of a consultant pharmacist. In some cases the Medical Director's DEA number is used for the ordering of pharmaceutical supplies. If you are present on-site full time and actively involved in the processes of the facility then you may be comfortable with this arrangement. In the long run, the facility should definitely obtain its own DEA number for the ordering of supplies since it is not reasonable to expect that each physician would bring his or her own pharmaceuticals.

With regards to administering medications to individual patients, each physician is still responsible for his or her own orders. Each doctor should be required to provide his or her own DEA number as part of the credentialing process for physicians at the facility. You should not be responsible for the prescribing orders of other independent practitioners.

Part of the duties of the Medical Director is to help establish and maintain the policies and procedures for the facility. An administrator or nurse manager will usually help by either authoring new policies or adapting policies from other sources. However the Medical Director will spend a significant amount of time reviewing and modifying what is written.

The facility should be accredited by an approved organization such as the JCAHO or AAAHC. This will help ensure that the facility functions in a manner that meets the commonly accepted standards for outpatient surgical care, including the many and various governmental rules and regulations. There should be a facility administrator who will be responsible for ensuring that federal and state regulatory requirements are met for issues such as employment, accreditation, billing, etc. The facility administrator is usually a separate position from the Medical Director and is responsible to the owners or Board of Directors. The responsibilities for this position are defined by the accrediting agency that the facility chooses to use.

The facility should definitely carry its own insurance policy for both liability and malpractice activities. This should include either a Director's insurance or omissions and errors insurance, to cover administrative liabilities. The functions of the Medical Director should be covered by these administrative policies. You can check with your malpractice carrier to see if you are covered for any of these liabilities, however, it is unlikely that you are unless you have a separate rider to your policy.

-- From Jonathan Pregler, M.D., Los Angeles, CA

?? -- THIS MONTH'S QUESTIONS -- ?? - TOP

QUESTION 1:

At our center we have flat fees for Plastic surgery cases but it seems as though the surgeons often run over on time or do more than they say they are.  We are looking at placing time limits on each plastic procedure and any time over will be billed to the patient.  Do any of you have such a fee schedule and would you share it -- I am not sure how to set it up?  This is becoming a very big issue with our anesthesiologists. 

-- From Diana McDaniel, R.N., M.S.N.,  Evansville, IN

QUESTION 2:

What are your recommendations as far as ACLS or CPR requirements for anesthesiologists in an ASC? We are requesting our anesthesiologists to take CPR or ACLS but some feel that since they had this in their schooling and they work daily with the airway, they do not need either. Any recommendations?

-- From Diana McDaniel, R.N., M.S.N., Evansville, IN

QUESTION 3:

What do you do about body jewelry? I've always had patients remove tongue rings and nose rings because they're in our field. But patients frequently object strongly to eyebrow rings and naval rings being removed. Historically, we've always said electrocautery and burns are an issue. But is this really true?

-- From David S. Rapkin, M.D., Richmond Heights, OH

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