Handbook of Clinical Anesthesia

Chapter 2

Scope of Practice

Medical practice, including its infrastructure and functional details, is changing and evolving rapidly in the United States (Eichhorn JH: Practice and operating room management.Clinical Anesthesia. Edited by Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC. Philadelphia, Lippincott Williams & Wilkins, 2009, pp 27–56). Traditionally, anesthesia professionals were minimally involved in the management of the many components of their practice beyond the strictly medical elements.

  1. Administrative Components of All Anesthesiology Practices
  2. Operational and Information Resources
  3. The American Society of Anesthesiologists (ASA) provides extensive resource materials to its members regarding practice management (Table 2-1).
  4. These documents are updated regularly by the ASA through its committees and House of Delegates.
  5. Internet
  6. A modern anesthesiology practice must use the information resources (journals, textbooks, electronic bulletin boards) provided by the Internet.
  7. The Web site for the ASA is asahq.org.
  8. The Credentialing Process and Clinical Privileges
  9. The system of credentialing a health care professional and granting clinical privileges is motivated by the assumption that appropriate education, training, and experience, along with an absence of an excessive number of adverse patient outcomes, increase the likelihood that the health care professional will deliver high-quality care.
  10. Models for credentialing anesthesiologists are offered by the ASA.

Table 2-1 Practice Management Materials Provided by the American Society of Anesthesiologists

The Organization of an Anesthesia Department
Guidelines for Delineation of Clinical Privileges in Anesthesiology
Guidelines for a Minimally Acceptable Program of Any Continuing Education Requirement
Guidelines for the Ethical Practice of Anesthesiology
Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders or Other Directives that Limit Treatment
Guidelines for Patient Care in Anesthesiology
Guidelines for Expert Witness Qualifications and Testimony
Guidelines for Delegation of Technical Anesthesia Functions for Nonphysician Personnel
The Anesthesia Care Team
Statement on Conflict of Interest
Statement on Economic Credentialing
Statement on Member's Right to Practice
Statement on Routine Preoperative Laboratory and Diagnostic Screening

  1. P.9
  2. The National Practitioner Data Bankis a central repository of licensing and credentials information about physicians. The data bank is maintained by the federal government, and adverse events involving a physician (e.g., substance abuse, malpractice litigation, revocation or limitation of the physician's license) must be reported to it via the appropriate state board of medical registration.
  3. An important issue in granting clinical privileges, especially in procedure-oriented specialties such as anesthesiology, is whether it is reasonable to grant “blanket” privileges (i.e., the right to do everything traditionally associated with the specialty).
  4. Initial board certification after the year 2000 by the American Board of Anesthesiology is time limited and subject to periodic testing and recertification. This requirement encourages an ongoing process of continued medical education.
  5. Professional Staff Participation and Relationships
  6. Medical staff activities are increasingly important in achieving a favorable accreditation status from The Joint Commission (JC).
  7. Anesthesiologists should be active participants in medical staff activities (Table 2-2).

Table 2-2 Examples of Anesthesiologists as Participants in Medical Staff Activities

Credentialing
Peer review
Transfusion review
Operating room management
Medical direction of same-day surgery units
Medical direction of postanesthesia care units
Medical direction of intensive care units
Medical direction of pain management services and clinics

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  1. Establishing Standards of Practice and Understanding the “Standard of Care”
  2. American anesthesiology is one of the leaders in establishing practice standards that are intended to maximize the quality of patient care and help guide anesthesiologists make difficult decisions, including those about the risk–benefit and cost–benefit aspects of specific practices (Table 2-3).
  3. The standard of care is the conduct and skill of a prudent practitioner that can be expected at all times by a reasonable patient.
  4. Failure to meet the standard of care is considered malpractice.
  5. Courts have traditionally relied on medical experts to give opinions regarding what the standard of care is and whether it has been met in an individual case.
  6. Anesthesiologists have been very active in publishing standards of care (Table 2-3).
  7. A practice guideline has some of the same elements as a standard of practice but is intended more to guide judgment, largely through algorithms.
  8. Practice guidelines serve as potential vehicles for helping to eliminate unnecessary procedures and to limit costs.
  9. Guidelines do not define the standard of care, although adherence to the outlined principles should provide the anesthesiologist with a reasonably defensible position.
  10. JC standardsfocus on credentialing and privileges, verification that anesthesia services are of uniform

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quality, continuing education, and documentation of preoperative and postoperative evaluations.

Table 2-3 Materials Provided by the American Society of Anesthesiologists Designed to Establish Practice Standards

Standards (Minimum Requirements for Sound Practice)
Basic Standards for Preanesthesia Care
Standards for Basic Anesthesia Monitoring
Standards for Postanesthesia Care
Guidelines (Recommendations for Patient Management)
Guidelines for Ambulatory Surgical Facilities
Guidelines for Critical Care in Anesthesiology
Guidelines for Nonoperating Room Anesthetizing Locations
Guidelines for Regional Anesthesia in Obstetrics
Practice Guidelines
Practice Guidelines for Acute Pain Management in the Perioperative Setting
Practice Guidelines for Management of the Difficult Airway
Practice Guidelines for Pulmonary Artery Catheterization
Practice Guidelines for Difficult Airway
Practice Parameters
Pain Management
Transesophageal Echocardiography
Sedation by Nonanesthesia Personnel
Preoperative Fasting
Avoidance of Peripheral Neuropathies
Fast-Track Management of Coronary Artery Bypass Graft Patients

  1. Another type of regulatory agency is the peer review organization, whose objectives include issues related to hospital admissions and quality of care.
  2. Policy and Procedure
  3. An important organizational aspect of an anesthesia department is a policy and procedure manual.
  4. This manual includes specific protocols for areas mentioned in the JC standards, including preanesthetic evaluation, safety of the patient during anesthesia, recording of all pertinent events during anesthesia, and release of the patient from the postanesthesia care unit (PACU).
  5. A protocol for responding to an adverse event is useful (Anesthesia Patient Safety Foundation Newsletter, 2006:21:11, apsf.org).

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  1. Meetings and Case Discussion
  2. There must be regularly scheduled departmental meetings.
  3. The JC requires that there be at least monthly meetings at which risk management and quality improvement activities are documented and reported.
  4. Anesthesia Equipment and Equipment Maintenance.Compared with human error, overt equipment failure rarely causes critical intraoperative incidents. The Anesthesia Patient Safety Foundation advocates that anesthesia departments develop a process to verify that all anesthesia professionals are trained to use new technology being introduced in the operating room (OR).
  5. Malpractice Insurance
  6. Occurrencemeans that if the insurance policy was in force at the time of the occurrence of an incident resulting in a claim, the physician will be covered.
  7. Claims madeprovide coverage only for claims that are filed when the policy was in force. (“Tail coverage” is needed if the policy is not renewed annually.)
  8. A new approach in medical risk management and insurance is advocating immediate full disclosure to the victim or survivors. This shifts the culture of blame with punishment to a just culture with restitution.
  9. Response to an Adverse Event
  10. Despite the decreased incidence of anesthesia catastrophes, even with the very best practice, it is statistically likely that an anesthesia professional will be involved in a major anesthesia accident at least once in his or her professional life.
  11. A movement to implement immediate disclosure and apology reflects as shift from the “culture of blame” with punishment to a “just culture” with restitution. Laudable as the policy of immediate full disclosure and apology may sound, it would be mandatory for the anesthesia professional to confer with the involved liability insurance carrier, the practice group, and the facility administration before pursuing this policy.
  12. Practice Essentials
  13. The “job market” for anesthesia professionalsis being influenced by the number of residents being trained, the geographic maldistribution of anesthesiologists, and

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marketplace forces as reflected by managed care organizations and the real and potential impact on the numbers of surgical procedures. By 2001, it was perceived that there was a shortage of anesthesia providers.

  1. Types of practiceinclude academic practice, private practice in the marketplace, private practice as an employee, practice for a management company, and practice as a hospital employee.
  2. Billing and collectingmay be based on calculations according to units and time, a single predetermined fee independent of time, or fees bundled with all physicians involved in the surgical procedure.
  3. Billing for specific procedures becomes irrelevant in systems with prospective “capitated” payments for large numbers of patients (a fixed amount per enrolled member per month).
  4. The federal government has issued a new regulation allowing individual states to “opt out” of the requirement that a nurse anesthetist be supervised by a physician to meet Medicare billing requirements.
  5. Antitrust Considerations
  6. The law is concerned solely with the preservation of competition within a defined marketplace and the rights of consumers.
  7. The market is not threatened by the exclusion of one physician from the medical staff of a hospital.
  8. Exclusive service contractsstate that anesthesiologists seeking to practice must be members of the group holding the exclusive contract.
  9. In some instances, members of the group may be terminated by the medical staff without due process.
  10. Economic credentialing (which is opposed by the ASA) is defined as the use of economic criteria unrelated to quality of care or professional competency for granting and renewing hospital privileges.
  11. Hospital Subsidies.Modern economic realities may necessitate anesthesiology practice groups to recognize that after overhead is paid, patient care revenue does not provide sufficient compensation to attract and retain the number and quality of staff members necessary. A direct cash subsidy from the hospital may be negotiated to augment practice revenue in order to maintain benefits while increasing the pay of staff members to a market-competitive level.

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III. New Practice Arrangements

  1. Even though the impact of managed care plans has waned somewhat, various iterations still exist and have ongoing impact on anesthesiology practice.
  2. Prospective Payments.In this arrangement, each group of providers in the managed care organization receives a fixed amount per member per month and agrees, except in unusual circumstances (“carve-outs”), to provide care.
  3. Changing Paradigm.There is an emerging trend for private contracting organizations to tie their payments for professional services to the government's Medicare rate for specific CPT-4 codes.
  4. Pay for performanceis the concept supported by commercial indemnity insurance carriers and the Center for Medicaid and Medicare Services to reduce health care costs by decreasing expensive complications of medical care.
  5. HIPPA
  6. Implementation of the privacy rule of the Health Insurance Portability and Accountability Act (HIPAA) creates significant changes in how medical records and patient information are handled. Under HIPPA, patients' names may not be used on an “OR board” if there is any chance that anyone not directly involved in their care could see them.
  7. Electronic Medical Records (EMR).Basic EMR implementation has been problematic for practices (e.g., expense, obvious savings, acceptable software), but true electronic anesthesia information management systems have been even more difficult to implement.
  8. Expansion into Perioperative Medicine, Hospital Care, and Hyperbaric Medicine
  9. Formalized preoperative screening clinicsoperated and staffed by anesthesiologists may replace the historical practice of sending patients to primary care physicians or consultants for “preoperative clearance.”
  10. Anesthesiologists may become the coordinators of postoperative care, especially in the realm of providing comprehensive pain management.

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  1. Operating Room Management
  2. The current emphasis on cost containment and efficiency requires anesthesiologists to take an active role in eliminating dysfunctional aspects of OR practice (e.g., first-case morning start times).
  3. Anesthesiologists with insight, overview, and a unique perspective are best qualified to provide leadership in an OR.
  4. An important aspect of OR organization is materials management.
  5. Scheduling Cases
  6. Anesthesiologists need to participate in scheduling of cases because the number of anesthesia professionals depends on the daily caseload, including “offsite” diagnostic areas.
  7. The majority of ORs use block scheduling (preassigned guaranteed OR time with an agreed cut-off time), open scheduling (first come, first serve), or a combination.
  8. Computerizationwill likely benefit every OR.
  9. Preoperative Clinics.Use of an anesthesia preoperative evaluation clinic usually results in more efficient running of the OR and avoidance of unanticipated cancellations and delays.
  10. Anesthesiology Personnel Issues.In light of the current and future shortage of anesthesia professionals, managing and maintaining a stable supply promises to dominate the OR landscape for years.
  11. Cost and Quality Issues
  12. Health care accounts for approximately 14% of the US gross domestic product, and anesthesia (directly and indirectly) represents 3% to 5% of total health care costs.
  13. Anesthesia drug expenses represent a small portion of the total perioperative costs, but the great number of doses administered contributes substantially to the aggregate total cost to the institution.
  14. Reducing fresh gas flow from 5 to 2 L/min whenever possible would save approximately $100 million annually in the United States.
  15. More expensive techniques and drugs may reduce indirect costs (e.g., propofol is infusion more expensive but may decrease PACU time and reduce the patient's nausea and vomiting).

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  1. For long surgical procedures, newer and more expensive drugs may offer limited benefits over older and less expensive longer acting alternatives.
  2. It is estimated that the 10 highest expenditure drugs account for more than 80% of the anesthetic drug costs at some institutions.

Editors: Barash, Paul G.; Cullen, Bruce F.; Stoelting, Robert K.; Cahalan, Michael K.; Stock, M. Christine

Title: Handbook of Clinical Anesthesia, 6th Edition

Copyright ©2009 Lippincott Williams & Wilkins

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