Surgery News - December 2007 - (Page 10)

10 OPINION EDITORIAL SURGERY NEWS • D E C E M B E R 2 0 0 7 Nightmare at the Office persona Aprominentl injury lawyer comes to your office for a procedure involvBY LAZAR J. GREENFIELD, ing moderate M.D., FACS sedation that you have done many times with the help of an experienced nurse anesthetist. During the procedure, the patient stops breathing and has cardiac arrest. Your resuscitative efforts continue as she is transferred to the hospital where she subsequently dies. Her death makes the front pages of the local newspaper. As reporters and photographers pester your office, family members and community leaders extol the virtues of the deceased. Other patients cancel their appointments, and your colleagues begin asking questions your lawyer tells you not to answer. Sound like a bad dream? Welcome to the real risk of office-based surgery under sedation. When this happened to a respected plastic surgeon in Arizona, reporters began looking for other cases of office-based procedural deaths, and found several over a 2-year period. As questions about safety surfaced, the Arizona Medical Board became concerned. At press time, officebased surgery rules were on the agenda for a Dec. 4 meeting of the Governor’s Regulatory Review Council. If approved, they could take effect in February 2008. What qualifications should be required for those performing such procedures? Requiring surgeons to have hospital privileges for office-based procedures would help to correct that source of patient risk. Our anesthesiology editor, Kevin Tremper, asks whether that credentialing would also obligate the surgeon to be privileged to supervise the certified registered nurse anesthetist (CRNA). My legal eagle, Ed Goldman of the University of Michigan, believes that in the office, the CRNA is an employee of the surgeon, and hospital rules would not apply. But what is the actual risk of an adverse event? In a study of unplanned postoperative hospital admissions, Fleisher et al. reviewed the Hospital Cost and Utilization Project data set for New York State containing more than 1.1 million discharges for 1997 (Arch. Surg. 2007;142:263-8). Using a modified rating system for medical conditions, they identified the following predictors for hospital admission: age 65 or older; operative time over 120 minutes; cardiac, peripheral vascular, or cerebrovascular disease; malignancy; positive HIV status; and regional or general anesthesia. The risks were not great; even with higher scores, the rate of hospital admission was 2.8% and it was not clear how many patients had originated in a hospital. Even if preoperative risk is managed, a patient may collapse during a procedure and the surgeon will be held responsible. According to the American Society of Anesthesiology, for optimal safety, anesthesia care should be monitored by an anesthesiologist for cases in which anesthesia levels may drift deeper than expected (www. asahq.org). But what about a surgeon who practices in both the hospital and the office or who chooses not to make a large facility investment? I think the proposed Arizona standards make a lot of sense: In moderate or deep sedation, the patient’s oxygenation must be monitored by pulse oximetry, circulatory function must be monitored by EKG display, and blood pressure and heart rate must be measured every 5 minutes. Temperature must also be monitored, and the licensed health care professional doing the monitoring should have no other responsibilities during the procedure. After the operation, the physician or a staff member trained in advanced cardiac life support must remain at the office to respond to an emergency until the patient is discharged. The office must be equipped with a reliable oxygen source with a monitor, suction and resuscitation equipment, emergency drugs, and appropriate cardiac monitoring equipment. Having increasingly complex procedures done in the office appeals to patients and surgeons alike. But there are no free rides. Risks must be managed to ensure patient safety. Remember what you learned as a scout: Be prepared! ■ DR. GREENFIELD is Editor in Chief of SURGERY NEWS. http://www.asahq.org http://www.infovactherapy.com

Table of Contents Feed for the Digital Edition of Surgery News - December 2007

Surgery News - December 2007 Contents Breast Radiation Boost Cuts Cancer Recurrence Mortality Soars in Some Patients With Respiratory Distress New Codes Promote Alcohol Screening New Ideas News From the College: Quality Standards General Surgery: Helping Hand Trauma: Spleen Protocol

Surgery News - December 2007

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