Advantages of office based surgery

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Easter Turner
7 years ago
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1 Risk Assessment

2 Advantages of office based surgery! Outpatient surgeries! Hospitals! 90% to 40%! ASC " <5% to 38%! Offices " <5% to 17%! Costs are 60% to 75% lower than hospital-based settings! More intimate environment! Greater scheduling convenience! Perceived improvement in personal attention

3 How safe is dental anesthesia?! Office-Based Ambulatory Anesthesia: Outcomes of Clinical Practice of Oral and Maxillofacial Surgeons JOMS (2003)! No complications! Local anesthesia 99.6%! Conscious sedation 99.1%! Deep sedation / GA 98.5%

4 How safe is dental anesthesia?! Office-Based Ambulatory Anesthesia: Outcomes of Clinical Practice of Oral and Maxillofacial Surgeons JOMS (2003)! Parameters of Care & AAOMS office anesthesia manual! Ventilatory monitoring should include auscultation! Stethoscope 41.5%! Capnography 18%! IV access! Angiocatheter 49.8%

5 How safe is dental anesthesia?! OMSNIC! 2000 to 2013! 39,392,008 office based anesthetics! 113 cases resulted in death or brain injury! 1 per 348,602 cases! 1 per every 6.4 weeks

6 Normal accidents: living with high-risk technologies! Accidents are normal and should be expected! Perrow (1984)

7 Safety culture! Communication! Good information flow and processing! Shared perception of the importance of safety! Proactive identification of latent threats of safety! Organizational learning! Leadership

8 ! Was this a patient who might have had a better outcome in a hospital operating room?! Was the facility and its personnel functioning as safely as possible?

9 Equipment Patient preparation Staff / Team Practitioner

10 What is the limitation to pulse oximetry?! With supplemental O 2 administration! Provides no indication of ventilation!

11 Ventilatory monitoring! "During moderate or deep sedation, the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide unless precluded or invalidated by the nature of the patient, procedure or equipment."! American Society of Anesthesiologists (ASA) Basic Anesthetic Monitoring Standard, Section 3.2.4

12 Bispectral analysis! Liu: Effects of bispectral index monitoring on ambulatory anesthesia: A meta-analysis of randomized controlled trials and a cost analysis. Anesth 2004! Meta-analysis of randomized controlled trials! Ambulatory setting! Use of BIS for titration of GA! Modestly reduced anesthetic consumption (19%)! Marginally reduced N/V (6%)! Marginally reduced time spent in PACU (4 minutes)! Slightly higher cost per patient ($5.55)

13 ! Who do I treat?! What drugs do I use?! What technique do I employ?! When should I say no.

14 ! Health history! Co-morbidities! Medication! Social history! Family history Patient history

15 Preoperative history & physical examination! Determine the appropriate facility! Baseline information to manage patient

16 PONV! Female sex! h/o motion sickness! Previous N/V! Non smokers! Younger age! Agents! Volatile agents! Nitrous oxide! Opioids! Ketamine! GI blood

17 Patient factors! Age! Body mass index! Obstructive sleep apnea! ASA physical status

18 Pediatric anesthesia! Anatomic and physiologic development! What age defines a pediatric patient?

19 Patient factors! Age! Modestly increased risk of complications! Age related physiologic changes! Reduction in physiologic reserve

20 ! Body mass index! Obesity Patient factors

21 Obstructive sleep apnea! What assessment should be a component of the preoperative patient evaluation?! What level of anesthesia is appropriate for the OBS?! What agents are appropriate for OBS?! How long should the patient be monitored postoperatively?! Use of post-operative opioids?! Use of CPAP?! Is the risk the same for mild versus moderate severe OSA?

22 O 2 Sat vs. time to apnea Variability! Decreased capacity for oxygen loading!! FRC! Increased oxygen consumption

23 Patient factors! Body mass index! Obesity! Anorexia! Bulimia

24 ! ASA physical status Patient factors

25 Cardiovascular evaluation! Risk stratification based on clinical assessment! Low risk procedure! Unstable cardiac conditions! Unstable angina! Acute heart failure! Significant arrhythmias! Symptomatic valvular dx! Recent MI & residual ischemia

26 Anticoagulant medication! Continuing anticoagulant medication before surgery may place patients at increased risk for bleeding complications! Ceasing such drugs may put patients with CV conditions at risk for other thromboembolic events! Aspirin! Increased the rate of baseline bleeding 1.5-fold but had no effect on the severity of bleeding complications! Withdrawal of aspirin was observed in up to 10.2 % of all acute CV events

27 MAC liability claims! Older and sicker patients! Permanent brain damage & mortality represented > 40% of claims similar to GA claims! Most common cause of injury during MAC was severe respiratory depression (21%)! 46% of the claims were preventable by capnography, improved vigilance, and the use of audible alarms! Bhananker et al: Injury & liability associated with monitored anesthesia care: a closed claims analysis. Anesth 2006;104:228

28 Who would you treat in your office? A survey of Canadian anesthesiologists ASA III 93.9 ASA IV 17.1 AP II 96.4 AP III 66.3 Prior MI (1 6m) 15.9 Prior MI > 6m 94.8 CHF I 93.5 CHF II 70.3 CHF III 16.7 OSA (MAC) 91.5 OSA w/o post-op opioids Obesity BMI w/o CV/resp 63.4 OSA w/ post-op opioids BMI kg/m2 w/ CV/resp dx 18.1 MH susceptible 82 MH proven 49.7

29 Pre-operative laboratory testing! Preoperative laboratory testing in patients undergoing elective, low risk ambulatory surgery. Ann Surg 256:518 (2012)! National Surgical Quality Improvement Program! Pre-op testing in patients w/out co-morbidities had no effect on the rates of adverse outcomes even with an abnormal laboratory value! Routine preoperative medical testing for cataract surgery. Cochrane Database Syst Rev (2012)! Older patient population with multiple comorbidities! Routine testing did not improve safety

30 Pre-operative laboratory testing! No interventions after abnormal results! Rare changes in management! No surgery cancellations! Outcomes similar to those patients without preoperative tests

31 Females of child bearing age! Should I ask?! Should I test?! Incidence of pregnancy in ambulatory surgical adolescents between 12 & %

32 Pre-operative assessment! Risk stratification! Medical issues discovered during pre-operative appointment may have long term consequences! Lack of primary care! Role of the dentist in primary health care

33 Normal accidents: living with high-risk technologies! Accidents are normal and should be expected! Anticipate accidents & know how to respond to them! Perrow (1984)

34 The anesthetic team

35 Safety checklist! Changes in system! Changes in behavior! Communication! Teamwork! High-functioning teams achieving significantly reduced rates of adverse events

36 Emergency management preparation! What to do # task performance! Computer based simulation! Biologic simulation! High fidelity simulation! Team training! Knowledge! Stress reactions! Communication! Leadership! Workload distribution

37 Emergency management preparation! What is the appropriate frequency to ensure retention?

38 Does site accreditation increase safety?! Joint Commission! Accreditation Association of Ambulatory Health Care! American Association for Accreditation of Ambulatory Surgery Facilities! Facility s physical layout! Patient & personnel records! Peer review & quality assurance! Operating room personnel! Equipment! Operations and management! Environmental safety

39 Growing difficulties with OBS! Patient selection! Complexity of surgery! Office staff! Doctor! Staff training! Equipment available

40 MAC liability claims! Most frequent claims! Plastic surgery 26%! Operating room fires 17%! fire triad of ignition! Electrocautery! Combustible substances! Supplemental oxygen! Bhananker et al: Injury & liability associated with monitored anesthesia care: a closed claims analysis. Anesth 2006;104:228

41 Medical legal aspects of OBS! Failure to monitor & respond to recovering patients! Facility adequately equipped! Staff not properly trained! Discharging patients to early

42 ! There is a lack of randomized controlled trials that have measured patient safety outcomes of morbidity and mortality in office-based surgery / anesthesia

TABLE 2 ASA Physical Status Classification

TABLE 2 ASA Physical Status Classification ASA Class I II III IV V Description A normal, healthy patient, without organic, physiologic, or psychiatric disturbances A patient with controlled medical conditions