The quality of anesthesia can affect patient satisfaction, quality outcomes and finances in a surgery center. Richard P. Dutton, MD, executive director of the Anesthesia Quality Institute, discusses five ways ambulatory surgery centers could improve anesthesia quality — on behalf of their individual facilities and the industry as a whole.
1. Track adverse anesthesia events. According to Dr. Dutton, anesthesia has a long history of quality outcomes and patient safety. In most facilities, the anesthesia process happens without any safety issues or adverse events, a trend that Dr. Dutton calls "a blessing and a curse." On one hand, a lack of patient safety issues is wholeheartedly positive compared to specialties that are rife with potential complications. On the other hand, a lack of issues means that facilities struggle to collect data and document results.
"If your rate of myocardial infarction is already one in hundreds of thousands, you have to study a lot of patients and get a huge amount of data to even know you have a problem," he says. In ASCs, where patients are generally healthy and most procedures occur without complications, pinpointing areas of weakness is even more difficult.
Dr. Dutton says surgery centers can help identify problem areas in anesthesia provision by answering a few basic questions on every procedure. "You can always make it a binary by asking, "Did something bad happen?" and answering, 'Yes' or 'No,'" he says. By recording every time a patient has a major allergic reaction to an anesthetic or an unexpected respiratory or cardiac event during an anesthetic, surgery centers can contribute to a volume of data that will show trends in anesthesia safety. He says most ASCs probably implement a review every time a serious adverse event occurs, but on a national level, those reviews need to be aggregated to determine when and why adverse events occur.
2. Work to reduce post-operative nausea and vomiting. If surgery centers want to improve anesthesia provision from the perspective of the patient, they need to improve their identification, prevention and treatment of post-operative nausea and vomiting, Dr. Dutton says. He says PONV often suffers from a lack of attention because the issue seems trivial when compared to other measures, such as mortality following aortic valve repair. Still, PONV has undergone significant research by the academic community, and anesthesia providers have access to strong evidence on how PONV should be identified and treated.
The issue is also significant for surgery centers because PONV contributes to decreased patient satisfaction. "It's a big dissatisfier, and in ASCs, it's even more important because safety is assumed and the discriminator is whether or not the anesthetic made the patient sick," he says.
He says PONV also has a negative impact on center finances. If a patient experiences sickness, he or she is less likely to return to the center, and the extra time spent in the recovery room slows down ASC processes and costs more money. Dr. Dutton says surgery centers should carefully screen every patient for PONV risk factors. For example, centers should ask whether the patient has experienced PONV before and whether the patient smokes; a history of PONV can increase the likelihood of a re-occurrence, and smoking actually decreases the likelihood of PONV. Females are also more likely to experience symptoms, and some operations are more commonly associated with patient sickness.
Patients with risk factors should receive prophylactic treatment with one of the four classes of medication that are known to be effective in preventing PONV. Finally, the surgery center needs a good protocol for how to react when a patient gets sick in the PACU.
3. Find out how patients feel about pain management efficacy. Pain also plays a significant role in ASC patient satisfaction, though it is harder to predict and treat because "best practices" are less established for pain management than for PONV. Pain is more complicated because risk factors have much greater variability based on procedure and individual patient. "It's a much harder area to work in scientifically, and clearly one of the things we need to measure is 'did we adequately manage the patient's pain?" Dr. Dutton says. He says a lack of national data means ASCs may find it difficult to benchmark against other facilities; instead, centers should track data over time and look for internal improvement. Surgery centers can determine the efficacy of pain management by asking patients 24 hours after surgery, "Over the past 24 hours, on a scale of 1-10, how often has your pain been managed?"
4. Consider changes to traditional anesthesia practices. New developments in anesthesia provision can decrease the likelihood of patient pain, Dr. Dutton says, but these developments may require some adaptation from the ASC. For example, if a surgery center performs an epidural on a total knee patient and leaves the epidural catheter in, the patient will go home pain-free, whereas general anesthesia will leave the patient in a lot of pain when they wake up. "The ability to send patients home with catheter-based nerve blocks has made a huge change in this business, but with 5,000 surgery centers out there, some have caught on and some haven't," he says. "It's one of those major changes in practice that takes 10 years to get to everybody."
He says surgery centers should consider whether they want to implement some of these technological advancements, based on the amount of time and capital available at the facility. For example, ultrasound-guided regional anesthesia is increasingly popular but requires significant physician training and the purchase of an ultrasound machine. He says while placing a continuous femoral nerve catheter may be just as easy to perform with ultrasound if providers are used to the procedure, the staff must still be trained on talking to the patient and answering questions about the catheter after surgery. Surgery centers should evaluate the necessary finances and provider buy-in before implementing regional anesthesia.
5. Track overall patient satisfaction with anesthesia provision. In addition to tracking satisfaction with pain management and PONV, Dr. Dutton says ASCs should measure overall patient satisfaction with anesthesia. Satisfaction can be affected by a number of factors, including provider attitude, case delays, patient warmth and patient comfort. "ASCs actually do this much better than anybody else," he says. "We've been paying attention to this for much longer than anybody else, including in actually gathering and having the data."
He says ASCs should continue to gather data on overall satisfaction by asking, "On a scale of 1-10, how would you rate your anesthesia experience?" The patient can then elaborate on any reasons for dissatisfaction.
Learn more about the Anesthesia Quality Institute.
Related Articles on Anesthesia:
Automated Alerts May Increase Anesthesiologists' Use of Low Tidal Volume
ASA Joins Obama Administration's "Partnership for Patients"
10 Recent Anesthesia Findings
1. Track adverse anesthesia events. According to Dr. Dutton, anesthesia has a long history of quality outcomes and patient safety. In most facilities, the anesthesia process happens without any safety issues or adverse events, a trend that Dr. Dutton calls "a blessing and a curse." On one hand, a lack of patient safety issues is wholeheartedly positive compared to specialties that are rife with potential complications. On the other hand, a lack of issues means that facilities struggle to collect data and document results.
"If your rate of myocardial infarction is already one in hundreds of thousands, you have to study a lot of patients and get a huge amount of data to even know you have a problem," he says. In ASCs, where patients are generally healthy and most procedures occur without complications, pinpointing areas of weakness is even more difficult.
Dr. Dutton says surgery centers can help identify problem areas in anesthesia provision by answering a few basic questions on every procedure. "You can always make it a binary by asking, "Did something bad happen?" and answering, 'Yes' or 'No,'" he says. By recording every time a patient has a major allergic reaction to an anesthetic or an unexpected respiratory or cardiac event during an anesthetic, surgery centers can contribute to a volume of data that will show trends in anesthesia safety. He says most ASCs probably implement a review every time a serious adverse event occurs, but on a national level, those reviews need to be aggregated to determine when and why adverse events occur.
2. Work to reduce post-operative nausea and vomiting. If surgery centers want to improve anesthesia provision from the perspective of the patient, they need to improve their identification, prevention and treatment of post-operative nausea and vomiting, Dr. Dutton says. He says PONV often suffers from a lack of attention because the issue seems trivial when compared to other measures, such as mortality following aortic valve repair. Still, PONV has undergone significant research by the academic community, and anesthesia providers have access to strong evidence on how PONV should be identified and treated.
The issue is also significant for surgery centers because PONV contributes to decreased patient satisfaction. "It's a big dissatisfier, and in ASCs, it's even more important because safety is assumed and the discriminator is whether or not the anesthetic made the patient sick," he says.
He says PONV also has a negative impact on center finances. If a patient experiences sickness, he or she is less likely to return to the center, and the extra time spent in the recovery room slows down ASC processes and costs more money. Dr. Dutton says surgery centers should carefully screen every patient for PONV risk factors. For example, centers should ask whether the patient has experienced PONV before and whether the patient smokes; a history of PONV can increase the likelihood of a re-occurrence, and smoking actually decreases the likelihood of PONV. Females are also more likely to experience symptoms, and some operations are more commonly associated with patient sickness.
Patients with risk factors should receive prophylactic treatment with one of the four classes of medication that are known to be effective in preventing PONV. Finally, the surgery center needs a good protocol for how to react when a patient gets sick in the PACU.
3. Find out how patients feel about pain management efficacy. Pain also plays a significant role in ASC patient satisfaction, though it is harder to predict and treat because "best practices" are less established for pain management than for PONV. Pain is more complicated because risk factors have much greater variability based on procedure and individual patient. "It's a much harder area to work in scientifically, and clearly one of the things we need to measure is 'did we adequately manage the patient's pain?" Dr. Dutton says. He says a lack of national data means ASCs may find it difficult to benchmark against other facilities; instead, centers should track data over time and look for internal improvement. Surgery centers can determine the efficacy of pain management by asking patients 24 hours after surgery, "Over the past 24 hours, on a scale of 1-10, how often has your pain been managed?"
4. Consider changes to traditional anesthesia practices. New developments in anesthesia provision can decrease the likelihood of patient pain, Dr. Dutton says, but these developments may require some adaptation from the ASC. For example, if a surgery center performs an epidural on a total knee patient and leaves the epidural catheter in, the patient will go home pain-free, whereas general anesthesia will leave the patient in a lot of pain when they wake up. "The ability to send patients home with catheter-based nerve blocks has made a huge change in this business, but with 5,000 surgery centers out there, some have caught on and some haven't," he says. "It's one of those major changes in practice that takes 10 years to get to everybody."
He says surgery centers should consider whether they want to implement some of these technological advancements, based on the amount of time and capital available at the facility. For example, ultrasound-guided regional anesthesia is increasingly popular but requires significant physician training and the purchase of an ultrasound machine. He says while placing a continuous femoral nerve catheter may be just as easy to perform with ultrasound if providers are used to the procedure, the staff must still be trained on talking to the patient and answering questions about the catheter after surgery. Surgery centers should evaluate the necessary finances and provider buy-in before implementing regional anesthesia.
5. Track overall patient satisfaction with anesthesia provision. In addition to tracking satisfaction with pain management and PONV, Dr. Dutton says ASCs should measure overall patient satisfaction with anesthesia. Satisfaction can be affected by a number of factors, including provider attitude, case delays, patient warmth and patient comfort. "ASCs actually do this much better than anybody else," he says. "We've been paying attention to this for much longer than anybody else, including in actually gathering and having the data."
He says ASCs should continue to gather data on overall satisfaction by asking, "On a scale of 1-10, how would you rate your anesthesia experience?" The patient can then elaborate on any reasons for dissatisfaction.
Learn more about the Anesthesia Quality Institute.
Related Articles on Anesthesia:
Automated Alerts May Increase Anesthesiologists' Use of Low Tidal Volume
ASA Joins Obama Administration's "Partnership for Patients"
10 Recent Anesthesia Findings