Volume 3, Issue 12 S A M B A T A L K S - PAGE 1 May, 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:

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

REPLY:

The issue of private pay and a fee schedule can be tricky as there are many variables.  The success of the fee structure lies in reducing the variables. Each practitioner may have a different pay schedule as their "surgical time" is variable.

We have a "start up" fee for the first hour and then have a fee with each following hour. You must know the average length of time for each procedure your surgeon performs.  The flat rate fee can be derived using this average time.  Notify the surgeon and the patient that all time over the "usual" will be balance billed to the patient. Conversely you must be ready to refund a patient who is shorter than the "usual" time. Have the option to reevaluate this "usual time" on an ongoing quarterly basis. We also have a "minimum time" or "minimum fee" that is structured so that people will stack cases and/or understand that anesthesia time has value when it is reserved for them.

To address the actual fee, one must know the competition and adjust or set their fee accordingly.

I hope this fits the bill.

-- From Meena Desai, M.D., Villanova, PA

QUESTION 2:  

What are your recommendations as far as ACLS or CPR requirements for anesthesiologists in an ASC? We are requesting that our anesthesiologists take CPR or ACLS but some feel 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

REPLY:

I firmly believe that ACLS "certification" adds nothing to the abilities or resuscitation outcome of a well-trained anesthesiologist or CRNA. The ASA requirement (Office-based Surgery Core Principles. AMA report: www.ASAhq.org/Washington/AMACorePrinciples.pdf) for at least one practitioner giving moderate or greater office sedation to be ACLS trained and the rest BLS trained, is to ensure that surgeons and other perioperative personnel possess some basic airway and resuscitation skills. These skills are inherent in anesthesia training. On the other hand, all practitioners administering drugs need to be trained in acute resuscitation and the ACLS/BLS requirement is at least a step in the right direction.  A poorly-trained, anesthesia-provider may need the update that ACLS will deliver and is also less likely to impede well-trained rescuers during the resuscitation of an arrested patient. Furthermore, an ACLS-certified practitioner is less open to criticism if there is a bad outcome after an operating room disaster.

Epidemiologically, it is not reasonable to expect that ACLS protocols, which were developed to increase the survivability of sudden cardiac death in the general population, would be applicable or perhaps even useful in a perioperative arrest. The treatment of perioperative arrests is highly dependent upon what has just transpired in the operating room. Anesthetic drugs have significant physiologic effects that need broad understanding and specific skills to manage, especially when things go wrong. Yet, it would be difficult to convince a jury that anesthesia training was sufficient, even though we all know it should be more than adequate.

In summary, while I do not feel that ACLS training is necessary or even sufficient for a good outcome from perioperative resuscitation, it is almost essential that we all strive for certification to reassure the public that we are adequately trained and capable of dealing with any problems that may arise during their procedure.

-- From Peter H Norman, M.D., Houston, TX

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

REPLY:

This is an increasingly common problem. Our head of ambulatory anesthesia, Dr. Sivashankaran, does not think that electrocautery-induced burns are an issue. Another colleague, Dr. Mark Boswell, notes that the risk of a burn applies only to electrocautery applied "near" the jewelry. He suggests that the decision about removal be left to the surgeon and that this be documented. Dr. Boswell also says that tongue jewelry should come out.

It appears that there are at least 3 distinct problems here. Firstly, there is the risk of tissue burn. Jewelry may provide an alternate path to ground for electrocautery units. Although newer units have ground-referenced generators that should prevent burns, manufacturers of electrosurgery systems continue to advocate for removal of all jewelry. Certainly, if jewelry is to be retained, electrocautery should not be used in close proximity. Secondly, there is the risk that jewelry may become snagged on bedding or other items, causing damage to tissue or to the jewelry itself. Third, oral jewelry and piercings can impede airway management - there seems to be a consensus that these decorations should be removed before surgery.

It would be interesting to know what the policy is in different institutions.

-- From Gary Kantor, M.D., Cleveland, OH

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

QUESTION 1:

Does anyone know of any studies examining whether gender influences recovery
after ambulatory surgery under general anesthesia?

-- From Danilo Soto, Puerto Ordaz, Venezuela.

QUESTION 2:

What are your guidelines for pre-op lab requirements in the freestanding surgery center?

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

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