Where does the pressure come from to do cases?
(Editor’s note: In this second part of a two-part series on patient safety, we discuss the source of the pressure to handle more types of patients and procedures as outpatient cases. In last month’s issue, we discussed how safety can be compromised in outpatient surgery and how anesthesiologists and surgeons can agree on limits.)
One of the most significant reasons behind the pressure to handle more types of patients and procedures in outpatient surgery is the growing emphasis on the bottom line, sources say.
An ongoing web survey by The Society for Ambulatory Anesthesia (SAMBA) in Park Ridge, IL, asked whether patient safety or quality of care have been sacrificed for efficiency. Twenty percent (10) of 51 respondents said "occasionally." (See graph, below.) When asked whether they have sacrificed patient safety or quality of care to please surgeons or administrators, 21% (10) of 48 respondents said "occasionally." (See graph, below.)
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"I think one factor is that some of the surgery centers have been purchased by lay people," says Ervin Moss, MD, executive medical director NY State Society of Anesthesiologists in Verona, NY. These "lay people" are looking at the bottom line, Moss says. "They have pressured anesthesiologists to not cancel patients or to do anesthesia on patients that belong elsewhere," he says. Moss points to a recent case in which a 73-year-old patient who had a history of heart problems was scheduled for a knee operation. Moss discovered that the patient had not gone for his preoperative appointment with the cardiologist. "I said to the owners, If he shows up, I’ll cancel the case.’ The owners said, Why?’ I said, Because he has not received medical clearance.’ They look at the bottom line. You’re seeing surgery centers owned by lay people who only look at it as a business."
Even physician-owned surgery centers are putting greater emphasis on finances, "because reimbursement has decreased to the point that some are out of business," Moss says.
Another factor is the shortage of anesthesiologists. There is a 4% to 12% shortage of anesthesiologists nationwide, according to researchers at the Cleveland Clinic Foundation. The researchers estimated anesthesiologists supply in 2001 based on the number of graduating residents and fellows, and they took into account the loss of a portion of graduating residents due to temporary visa status. The estimate assumed a 2% or 3% increase in annual demand.1
"I’ve heard complaints from surgery centers near here that they race from the recovery room to the OR without the usual length of time interviewing patients beforehand," Moss says. In many cases, the emphasis is on volume, he maintains. "There is pressure to not spend time with the patient beforehand, getting a thorough history," Moss adds.
Due to fewer anesthesiologists and lower volume, Anaesthesia Associates of Massachusetts in Westwood has "shut down" three ORs at two hospitals, says Ross Musumeci, MD, vice president. "On any given day, we’re reducing the number of ORs we run in a fluctuating manner," he says. The ORs are running later in the day, he says. In addition, this past summer, his practice eliminated 50% of the physician’s vacation time, Musumeci says.
Anesthesia providers are reporting fatigue, according to the SAMBA survey. In that survey, 43% (22) of 51 respondents said they "occasionally" administer anesthesia when they are physically and/or mentally fatigued.
Anesthesiologists frequently handle outpatient cases during the day, but may be on call for inpatient cases at night, says Scott R. Springman, MD, professor of anesthesiology and director of ambulatory anesthesia services and the preoperative clinic at the University of Wisconsin Clinical Sciences Center in Madison. "Because there really are no restrictions on number of hours that anesthesiologists work, or physicians in general — other than resident trainees — it’s entirely possible you could not have a full eight hours of sleep prior to your workday," he says.
Reference
1. Eckhout G, Schubert A. Where have all the anesthesiologists gone? Analysis of the national anesthesia worker shortage. American Society of Anesthesiologists Newsletter 2001; 65.
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