Ambulatory Anesthesia Care: Strategies to Mitigate Risk and Improve Patient Safety

Ambulatory Surgery Center (ASC) surgical volume and scope continue to grow.¹ While anesthesia risks exist regardless of the surgical setting, planning for emergencies is crucial to reducing their impact when encountered in the ASC. It is important to appreciate that the standards of anesthesia care expected to be met in the care delivery of patients do not vary based on care setting. Understanding and communicating these standards can improve patient safety. Proof that these standards were met can also assist in the defense of a claim. This article uses case studies based on closed claims to propose risk reduction strategies for avoiding and responding to ASC anesthesia emergencies.

Case One: Anesthesia Emergency Preparedness

A patient presented to an ASC for elective Lap-Band system insertion with possible hiatal hernia repair. His preop anesthesia assessment was completed by the anesthesiologist on the morning of surgery. The patient was classified as a Mallampati Class III and an American Society of Anesthesiologists (ASA) Class III.

Anesthesia was initiated and intubation was eventually successful on the fourth attempt. The surgery was performed without complication, and the patient was transferred to the post-anesthesia care unit. Nursing notes indicated the patient arrived with a dusky appearance and shallow breathing.

For the next hour and a half, multiple techniques were attempted to assist with the patient’s breathing. When these efforts failed and the patient’s condition continued to deteriorate, the anesthesiologist reintubated the patient and transported him back to the operating room (OR) where he was ventilated. Attempts to transfer the patient to a higher level of care were initiated but delayed as there was no transfer agreement in place.

The patient remained sedated on the ventilator in the OR under the anesthesiologist’s care, awaiting transfer for five hours until emergency medical services (EMS) arrived. Upon loading the patient into the ambulance his cardiac rhythm converted to asystole, and advanced cardiac life support (ACLS) was initiated by paramedics. The patient was rerouted to the nearest hospital emergency department where life-saving efforts continued. He passed away shortly after arriving at the hospital.

Discussion

Experts were unsupportive of multiple aspects of the anesthesiologist’s care. Criticisms included lack of documentation of a thorough pre-operative evaluation and physical exam to ensure readiness for surgery in an ASC setting. With a more thorough understanding of the patient’s medical picture, experts agreed that the patient’s ASA classification would have changed and required a hospital surgical setting.

Additional criticisms were centered around the lack of preparedness to handle a difficult airway, which affected this patient at multiple stages of care. Experts agreed that a more active approach should have been taken to transfer the patient to a higher level of care when he met the definition of being critically ill requiring mechanical ventilation.

Risk Reduction Strategies

• Utilize American Society of Anesthesiologists² and Society for Ambulatory Anesthesia³ guidelines to support efforts in developing policies and procedures.
• Define patient selection criteria protocols. Determine criteria requiring referral to the inpatient surgical setting.
• Avoid making exceptions to your policies and procedures regardless of a patient’s desire to accept additional risks.
• Ensure there is a well-documented pre-anesthesia evaluation performed or verified by an anesthesiologist within 30 days of surgery.
• Make sure pre-operative testing including medical clearances are ordered, obtained, and reviewed prior to surgery.

Case Two: Emergency Identification and Response

After induction with monitored anesthesia care in an ASC, the surgeon began hernia repair surgery on a 52-year-old male. During the surgery the CRNA misinterpreted the abrupt drop in the patient’s heart rate as a vasovagal response due to tugging on the spermatic cord. Attempts were made to reposition the O2 saturation monitor and the surgical drain near the cord. Five minutes passed, and there was no improvement in the patient’s status, prompting the CRNA to check the patient’s airway. He noted airway obstruction and so attempted jaw thrust and chin maneuvers as well as bag-valve-mask ventilation, which failed. The CRNA then called in his supervising anesthesiologist. The patient was ultimately intubated and coded one minute later. ACLS was initiated, and the surgeon placed bilateral chest tubes, suspecting bilateral pneumothorax as the cause of cardiac arrest. The patient’s cardiopulmonary status improved, and he was transferred by EMS to the hospital. Neurological imaging studies were ultimately consistent with brain death.

Discussion

Experts were unsupportive of the anesthesia care. Criticisms were centered on the CRNA not recognizing the signs of a true hypoxic event which led to a delayed and inappropriate response. Additionally, the anesthesiologist was criticized for failure to ensure proper performance of MAC anesthesia and for failure to adequately supervise the CRNA.

Risk Reduction Strategies

• Understand and follow CRNA supervisory requirements⁴ by state, care model, and practice setting.
• Conduct a risk assessment to identify and plan for a wide range of anesthesia emergencies.
• Assess basic life support (BLS) and ACLS certification status of ASC clinicians upon hire. Consider offering access to American Heart Association accredited courses⁵ periodically to ensure certification continuity.
• Utilize cognitive aids such as the Stanford Anesthesia Emergency Manual for Perioperative Critical Events⁶ to promote a standardized response to multiple crises.
• Use emergency carts to enhance your response.
• Run drills to maximize staff response to a variety of emergencies.
• Regularly test equipment to ensure it is in working order.

While anesthesia emergencies can be difficult to manage regardless of the care setting, the case examples in this article highlight strategies for addressing the challenges and considerations unique to the delivery of ambulatory anesthesia care.

References

1. Medicare Payment Advisory Commission (MedPAC), “March 2023 Report to the Congress: Medicare Payment Policy, Chapter 5: Ambulatory Surgical Center Services: Status Report.” March 15, 2023, https://www.medpac.gov/document/march-2023-report-to-the-congress-medicare-payment-policy/
2. American Society of Anesthesiologists, “Statement on Ambulatory Anesthesia and Surgery,” October 17, 2018. https://www.asahq.org/standards-and-practice-parameters/statement-on-ambulatory-anesthesia-and-surgery
3. Society for Ambulatory Anesthesia, “SAMBA’s Clinical Practice Guidelines,” accessed August 9, 2023 (membership required). https://www.sambahq.org/clinical-guidelines
4. Rebecca Munday, “CRNA Supervision Requirements by State,” NurseJournal, updated November 16. 2023. https://nursejournal.org/nurse-anesthetist/crna-supervision-requirements/
5. American Heart Association, “Looking for American Heart Association Training?” accessed August 9, 2023. https://atlas.heart.org/
6. Stanford Anesthesia Cognitive Aid Program, “Emergency Manual: Cognitive Aids for Perioperative Crises.” (available for download). version 4.4, 2021, https://emergencymanual.stanford.edu/downloads/