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MONITORED ANESTHESIA CARE / SEDATION

• Medicines…In Stock
• Cardiac Monitoring
• Pediatric Patients

SPECIAL SITUATIONS

• High-Volume Day

ADMINISTRATION/ MEDICO-LEGAL

• Director of an Ambulatory Surgery Center
• Medical Director - DEA
• Fee Schedule
• ACLS or CPR Requirements for Anesthesiologists

MONITORED ANESTHESIA CARE / SEDATION: Medicines…In Stock - TOP

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 keptin 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

MONITORED ANESTHESIA CARE / SEDATION: Cardiac Monitoring - TOP

I am a nurse working in GI Endoscopy. We are updating our protocols and procedures. I would like information regarding cardiac monitoring during GI Endoscopy in a patient receiving moderate sedation. What does the ASA recommend?

-- From Grace Smith, R.N. B.S.N., C.G.R.N., Rochester, NY

REPLY:

This is an excellent question, and an important practical issue. The ASA has developed a set of " Practice Guidelines For Sedation And Analgesia By Non-Anesthesiologists", which can be viewed at http://www.asahq.org/publicationsAndServices/sedation1017.pdf. It was most recently amended in October 2001.

These guidelines were specifically designed to be used for moderate and deep sedation, which were defined as:

Moderate Sedation/Analgesia ("Conscious Sedation") is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

Deep Sedation/Analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

The guidelines state that electrocardiographic monitoring should be used during moderate sedation in patients with significant cardiovascular disease or those undergoing procedures where dysrhythmias are anticipated. It is recommended for all patients undergoing deep sedation.

Other monitors recommended in the guidelines for both moderate and deep sedation are: continuous pulse oximetry, observation and/or auscultation of ventilation "at regular intervals", and blood pressure measurements every 5 minutes. The level of consciousness should also be assessed "at regular intervals" throughout the sedation process. Verbal stimuli should be used for moderate sedation, and more profound stimuli can be used for deep sedation.  

-- From D. Daley, M.D., Houston, TX

MONITORED ANESTHESIA CARE / SEDATION: Pediatric Patients - TOP

I am a non-physician quality administrator working with a pediatric task force in a mid west hospital. Several questions have come up that I thought I would pose to your group: What does the SAMBA &/or ASA say about administration of chloral hydrate to pediatric patients for the purposes of sedation during or prior to OP procedures?  Are there guidelines which address specific agents like chloral hydrate for the purposes of sedation and what do their guidelines look like?

-- From Steven C. Thayer, Grand Rapids, MI 

REPLY:

The ASA and SAMBA have no policy statements or guidelines concerning the use of specific sedatives such as chloral hydrate. However, the ASA and the American Academy of Pediatrics both have guidelines that govern the administration of sedatives to children. These guidelines are based on the intended level of sedation, and focus on the types of personnel that must be present, and the types of safety monitoring. In general, there are 3 levels of altered consciousness: moderate sedation, deep sedation, and general anesthesia. If one chooses to sedate a child, then they have to be prepared to rescue that child from a level of consciousness beyond that intended. The most common scenario being the intention of moderate sedation, with the credentials for rescuing a child from deep sedation.

For further information please see the following:

1. Committee on Drugs, American Academy of Pediatrics: Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics 1992; 89: 1110-1115
2. American Society of Anesthesiologists, Task Force on Sedation and Analgesia by Non-Anesthesiologists: Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 1996; 84: 459-471
3. http://www.jcaho.org/accredited+organizations/ambulatory+care/standards/

-- From Ron Litman, D.O., Merion Station, PA

SPECIAL SITUATIONS: High-Volume Day - TOP

I work in an ambulatory facility which occasionally has special surgical days. On those days, three to five times the regular daily number of surgeries are done in order to decrease the waiting list of patients (pediatrics, general surgery, and ENT). Does SAMBA have any guidelines or suggestions for this high-volume day?

-- From Celina Beatriz Contreras, MD, Merida, Venezuela

REPLY:

This sounds like a real challenge! The "special surgical day" is not, as far as I know, something done in North American hospitals. Nor have I seen anything in the literature to describe how best to organize for such a day. The practice here is generally to try to even out the flow of cases and make things as predictable as possible. The obvious issues, such as increasing proportionately the number of anesthesia providers, OR nurses, and recovery personnel I am sure you've already thought of. You will need extra supplies, drugs and disposables. You will need to have all your care processes very streamlined, and here I imagine that preparation and planning with all the staff will be key. You will also need a good breakfast and probably a lot of coffee!

I would suggest sitting down with your administrator, and at least one representative from nursing and from your surgical group, to discuss the plan. Although the goal of reducing waiting lists is laudable, your primary objective should be to ensure patient safety. Because of the large case load, you will be especially vulnerable to "production pressure", but you should emphasize to the other staff that you cannot decrease vigilance or standards.

I think that for your high volume day, you would be wise to select only your healthiest patients, and to avoid especially complex cases. It might be a good idea to have all your prospective patients seen preoperatively by a primary care person or anesthesiologist to make sure they are all in good shape, and having the right kinds of operations that are likely to go smoothly.

Good luck!

-- From Gary Kantor, MD, Cleveland, Ohio

REPLY:

I think patient safety must be the first priority.  Don't push your team's limits but always have a good safety margin.  Don't let your surgical colleagues put you under pressure.  In case of severe complications, no one will be able to help you and, be sure, you will be criticized and/or punished.

-- From Wellingto Ferreira, M.D., VitÓria, ES, Brazil

 

ADMINISTRATION/ MEDICO-LEGAL: Director of an Ambulatory Surgery Center - TOP

Our institution will soon be opening up a new Ambulatory Surgery Center. Does SAMBA have any guidelines for the job description of the Director of an Ambulatory Surgery Center?

-- Anonymous

REPLY:

SAMBA does not have any guidelines for this. Below is a description of my duties as Director of the Surgery Center at my institution. I hope this will be helpful.

The purpose of this position is to supervise all of the operational aspects of the facility. The position is a combination of Medical Director and Administrative Manager. Responsibilities include the direct supervision of the Surgery Center OR Nurse Manager, the Perioperative Nurse Manager and Surgery Center Administrative Staff. In this role the Director is responsible for all JCAHO accreditation issues, QA/QI programs, employee evaluations, counseling and education, coordination of intra and interdepartmental communication, personnel scheduling, facility and equipment maintenance, and adherence to all safety and legal requirements. Daily responsibilities include the supervision of the daily functioning of the units in order to maintain the efficient and cost-effective provision of services while maintaining a high standard of patient care. These duties include the scheduling of surgical procedures and Anesthesiologists, determination of the appropriateness of individual patients and procedures for the facility, communication with all of the physicians that practice at the facility and the maintenance of an efficiently managed unit. The position is also responsible for budget preparation, budget monitoring, the operation of the units within budgetary constraints, and the budgeting and purchase of capital equipment. The Director functions as the liaison to hospital administration and the medical staff office as the representative of the department. As such the Director serves or delegates representatives to various hospital and medical staff committees as directed by hospital administration, maintains records of unit activity and projects unit needs and activities for future planning. The Director reports to the Associate Director for Ambulatory Services for hospital functions and to the Chairman of the Department of Anesthesiology for academic functions.

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

ADMINISTRATION/ MEDICO-LEGAL: Medical Director - DEA - TOP

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 DEAon 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

ADMINISTRATION/ MEDICO-LEGAL: Fee Schedule - TOP

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

ADMINISTRATION/ MEDICO-LEGAL: ACLS or CPR Requirements for Anesthesiologists - TOP

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