Anesthesia Billing & Management

We’re already a month into 2012, but it’s not too late to take a look at what the year has in store for the world of anesthesiology. Dr. Jerry A. Cohen, President of the American Society of Anesthesiologists, recently wrote an article about what he thinks 2012 will bring, entitled “A 2012 forecast for anesthesiology.” In reality, it’s more of a longview forecast. Regardless, here are some of the highlights:

– Drug shortages will continue to pose a serious challenge for anesthesiologists. Here’s the scary truth: According to an ASA survey from last year, more than 90 percent of physicians say they experienced at least one anesthetic drug shortage. The University of Utah Drug Information Service also reported a record 267 drug shortages. What’s worse is this shortage problem is only expected get worse this year.

“It is essential that all parties, including manufacturers, distributors, pharmacists and others, come together to solve this problem to reduce the negative impact shortages have on patients,” says Dr. Cohen. “ASA will continue its support for legislative and executive efforts aimed at stifling the drug shortages pandemic.”

– As the population continues to grow and the elderly numbers also continue to rise, physician demand will be on the rise. This includes an increase in the number of patients who will who undergo surgical procedures, putting particular demand on anesthesiologists.

– The growing demand for anesthesiologists coincides with a shortage of anesthesiologists. According to a 2010 study by the RAND Corporation, there was a shortage of 3,800 anesthesiologists and 1,282 nurse anesthetists. If these trends continue, a dramatic shortage of anesthesiologists is projected by 2020.

Ludwik Fedorko, MD, PhD, staff anesthesiologist at the University Health Network’s (UHN) Toronto General Hospital in Canada, recently referred to the operating room as a “black hole of medication safety.” He did so last month at a session on OR drug safety at the 2011 American Society of Health-System Pharmacists.

Dr. Fedorko made a point of highlighting the fact that anesthesiologists are the only health care professionals in a hospital setting who can dispense, premix, repackage, relabel and administer medications without independent verification. Also, according to Fedorko the postanesthesia care unit has accounted for 81 percent of all medication error reports in hospitals.

That said, anesthesia errors are quite rare, with a rate between 0.1 to 0.85 percent, or one of every 1,000 drug-dose administrations. Most of these errors can be reversed.

“We can almost always dig ourselves out of a hole,” Dr. Fedorko said. “The event is charted, but it doesn’t always show up as an error.”

That’s not to say hospitals wouldn’t welcome improvements, especially given the uniqueness of the OR.

“Throughout the hospital, there are safety steps in place to prevent medication errors, but not in the OR.”

So an initiative was started, led by Esther Fung, RPh, director of pharmacy operations at UHN, with a pharmacy–anesthesia collaboration exploring a point-of-care, computer-aided syringe labeling, bar-coding and verification process. The system, which came about with the help of funding from the Canadian Patient Safety Institute and sponsors in the drug industry, was implemented in January 2010.

During the process, the anesthesiologist scans every drug ampoule and syringe label to verify accuracy throughout drug dispensing, premixing, administration and documentation. In five months, the bar-coding system had been used for over 60,000 doses in more than 4,000 surgeries.

Anonymous surveys were performed with the participating anesthesiologists, and 21 of the 41 surveyed reported 29 medication errors which were all intercepted by bar-code scanning. About 97 percent said they preferred using the bar-code scanning system.

Some of the benefits beyond catching medication errors were time-savings and low costs for implementing.

“They understood that it would not only prevent them from making drug errors, but also that it improved and automated workflow in terms of easier charting and documentation because they would no longer have to do it manually,” said Dr. Fedorko.

In an effort to improve patient safety, anesthesiologists should partner up with pharmacists to better the outcomes in operating rooms and improve the hospital’s bottom line. At least that was the conclusion of some attendees at last summer’s meeting of the American Society for Health-System Pharmacists.

Michael Chappell, RPh, operations supervisor at Methodist Dallas Medical Center, said he was having a difficult time reconciling what anesthesiologists say they were using and what they were actually using. So, he and his colleagues got proactive with the anesthesiology and surgery departments at his medical center, creating a universal anesthesia kit that would cover 95 percent of their surgery patients. It included various dosages of fentanyl, hydromorphone, midazolam and morphine.

“We put everything in one place,” said Mr. Chappell, lead researcher (poster 3-M), noting that anesthesia providers, pharmacists and pharmacy technicians each had clear responsibilities. “The kits would come back to us from the provider along with the anesthesia record,” he added, “so pharmacists could look at them and see what they used, what they put on the record and then reconcile any waste.” Technicians would then validate and refill the kits’ contents.

After implementation, they found that tracking medications became much more accurate. In fact, the discrepancy rate dropped from 6.8 percent to 2.7 percent. The team linked most of the discrepancies to drug waste due to mislabeling of waste syringes or lack of documentation.

Few months back, an FDA advisory panel met regarding a very important topic: whether or not anesthesia poses cognitive and learning disability risks when used in young children. Since this involves millions of medical procedures, the importance of this topic is pretty obvious.

There have been a number of animal studies on the subject which have led to this meeting. According to Dr. Bob Rappaport, the Food and Drug Administration’s director of the division of anesthesia and analgesia products, these studies have suggested that there may be a correlation between anesthesia exposure and brain cell death or learning problems.

The FDA panel will evaluate this research, consider what further research may be needed, and decide what if anything parents should be presented if their children will be going into surgery.

“How do we communicate what we do know at this point without causing undue concern in parents and in physicians?", asked Dr. Rappaport.

Taking a look at the animal studies more closely, rodents and monkeys that were exposed to anesthesia at an age that is roughly equivalent to children under the age of four experienced brain cell death. An additional study, one done by the FDA, found that exposing newborn rhesus monkeys to 24 hours of anesthesia resulted in poorer tests performances for memory, attention and learning.
 
"We don’t know what this means for children at this time," said Dr. Rappaport. "That's exactly why it’s so critical that we get all of the necessary information."

It’s difficult to do similar controlled studies with children, so when examining humans, experts look to children who have learning disabilities and trace back to see if they had anesthesia when they were younger. However, this method is not considered very reliable.

In the absence of absolutely certain evidence, ultimately the dilemma is this: most young children who are being given anesthesia absolutely need the surgery performed on them. So, what do you do?

“What we know is that not giving anesthesia and appropriate medication to manage a child’s pain during surgery does have long-term adverse affects on a child – physical as well as emotional,” said Dr. Jayant Deshpande, another committee member, pediatrician and anesthesiologist who is a senior vice president at Arkansas Children’s Hospital. “So because the child needs surgery today, we are going to use the best information that we have and use the anesthetics.”

Most of the studies so far the studies have involved the common anesthetic, ketamine. Some of the questions experts still have involve dose, age or length of exposure, and how each may relate to the risks.

According to a study presented at the 2011 annual meeting of the Society of Obstetric Anesthesia and Perinatology, women who undergo a cesarean section  may only need half of the anesthesia dosage that is currently being administered if they are given and intrathecal catheter instead of a single spinal injection.

Among the sample of 10 patients who were given an intrathecal catheter, on average they only needed 0.6 and 1.1 mL of 0.75% hyperbaric bupivacaine to experience a T4 to T6 block, an amount which is 25-50 percent less than the published notices the same medication delivered in a single spinal injection.

The study's author J. Sudharma Ranasinghe, MD, associate professor of anesthesiology at the University of Miami Miller School of Medicine, recommended that clinicians opting for intrathecal catheters use slow, incremental dosing to ensure patients don't receive excessive anesthesia.

"If an adequate block can be achieved with less local anesthetic, bolus injection of a spinal medication that was intended for single-shot spinal through a spinal catheter may lead to high spinal block with respiratory difficulty, aspiration risk and severe hypotension," said Dr. Ranasinghe.

David Wlody, MD, professor of clinical anesthesiology at the State University of New York-Downstate Medical Center, in New York City thinks that it's a good idea look further into these findings, but cautions that such a small sample size and the lack of the control group makes its premature to jump to any conclusions.

Childhood obesity is a major problem that is reaching epidemic proportions in the U.S.
and much of the developed world. There are twice as many children who are obese than
20 years ago, and three times the number of adolescents who are obese.

This, of course, has major health ramifications, but not just in the areas you might be
thinking of, such as diabetes and heart disease. If a child has to be given anesthesia for a
medical procedure, they face bigger risks than their thinner healthier counterparts.

That is why The American Society of Anesthesiologists (ASA) is raising awareness
by educating parents about the potential complications their children may face when
undergoing anesthesia.

Since children’s airways are still in the midst of development, anesthesia can be more
complicated with kids than with adults. This means their airways are more prone to
collapse during the administration of anesthesia. The risk increases when a child is obese.

“Obese children have extra tissue surrounding their airway, chest, and abdomen that can
impair breathing while under anesthesia, and limit the amount of oxygen they receive
during surgery. This can lead to a range of complications including impairment of lung
function and in severe circumstances even brain damage,” said Mark Singleton, M.D.,
ASA member and chair of the committee on pediatric anesthesia.

Here are some tips that the ASA is giving parents to optimize their children’s surgical
outcomes, not to mention their overall health:

– The first and most logical choice is to help your child lose weight before their surgery.
Even just a few pounds of weight loss can have a positive impact on the outcome of your
child’s medical procedure. You can do this by encouraging simple healthy eating habits
at home and when they are in school or elsewhere.

– Make sure that you child’s anesthesiologist has experience with obese patients,
particularly children. Speak with them about the specific risks involved.

– When you embark on helping your child get to a healthy weight, set reasonable goals.
Make an appointment with your pediatrician to set up a safe weight-loss program for
your child. Also discuss the weight loss program with your child’s anesthesiologist and
surgeon to make sure it won’t interfere with their future medical procedure.

– Remember when kids played outside rather than sitting at home playing video games
day and night? Get your back into a daily exercise that all kids should enjoy. Sign them
up for team sports or after-school physical activities. And even if that isn’t something
they are interested in, just get them outside with friends to run around.

Dr. Singleton goes on to say the following:

“As the physicians responsible for protecting the vital health of patients when they are
at their most vulnerable – before, during and after surgery – we’re urging parents and
youths alike to educate themselves about the potential risks associated with pediatric
obesity and to fight this growing trend by making changes that enable them to lose
weight while maintaining an active lifestyle.”

According to research presented at the American Society of Anesthesiologists (ASA) 2010 Annual Meeting recently held in San Diego, California, regional anesthesia gives melanoma patients their best chance for survival.

More specifically, when regional anesthesia is used during lymph node dissection, there is a better long-term prognosis than when using general anesthesia.

“We have good information from animal studies, and our understanding of the tumor [is telling us] that we should expect surgery [to be] risky for our patients,” Gerhard Brodner, MD, PhD, professor of anesthesiology at Fachklinik Hornheide in Muenster, Germany.

The researchers conducted a retrospective study using the medical records of 273 patients who underwent inguinal lymph node dissection after the diagnosis of primary malignant melanoma of the leg. The patients received either spinal or general anesthesia.

There were 52 patients who were given spinal anesthesia (bupivacaine 0.5%) and 221 patients who were given general anesthesia, which was either a balanced anesthesia with sevoflurane and sufentanil (n = 118) or as total intravenous anesthesia with propofol and remifentanil (n = 103). The analysis revealed that patients who received spinal anesthesia had a better survival rate over 10 years than those receiving general anesthesia.

The session’s moderator, Daniel Sessler, MD, professor of outcomes research at The Cleveland Clinic in Ohio, says that there have been a series of retrospective studies on the effects of regional and general anesthesia which have come up with mixed results in different tumors.

While Dr. Brodner says that anesthesiologists “should avoid everything that could harm the balance between the immune system and tumor cells,” Dr. Sessler says that “We really need to wait for prospective data. This is an intriguing theory, but it’s absolutely not a basis for altering practice. There’s good basic science, and strong animal data to support it. It’s the human data that we’re having problems with.”