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Young S, Osman B, Shapiro FE. Office-based anesthesia: a contemporary update on outcomes, incentives, and controversies. Curr Opin Anaesthesiol 2023; 36:643-648. [PMID: 37724581 DOI: 10.1097/aco.0000000000001310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
PURPOSE OF REVIEW The volume of office-based surgery (OBS) has surged over the last 25-30 years, however patients with increasing comorbidities are being considered for procedures in office locations. This review focuses on office-based surgery outcomes, financial incentives driving this change, and controversies. RECENT FINDINGS Healthcare economics appear to drive the push towards OBS with improved reimbursements, but there are rising out-of-pocket costs impacting patients. Plastic surgery has low complications, but procedures like buttock augmentation are associated with mortality. In ophthalmology, emerging controversial literature investigates the impact of anesthesia type on and whether anesthesia providers impact ophthalmology outcomes. Dental anesthesia continues to suffer occasional wrong-sided surgeries. Vascular interventions are being driven towards offices due to reimbursements, and may be safely performed. Meta-analyses of ear, nose, and throat in-office surgeries have low complication rates. SUMMARY The reported safety supports the proper selection of patients for the proper procedure in the right location. Anesthesiologists need to develop and implement safe and efficient systems to optimize patient outcomes in outpatient office settings. Further research and uniform standardized outcomes tracking are needed in the emerging specialties performing office-based surgery.
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Affiliation(s)
- Steven Young
- Instructor in Anaesthesia, Harvard Medical School, Associate Medical Director for the Medical Evaluation Center at Massachusetts Eye and Ear Infirmary, Department of Anesthesiology, Massachusetts Eye and Ear Infirmary (MGB Corporation), Boston, Massachusetts
| | - Brian Osman
- Chief of Orthopedic Anesthesia & Director of Quality Assurance at UHealth Tower, Associate Professor of Anesthesiology, Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
| | - Fred E Shapiro
- Associate Professor of Anaesthesia, Harvard Medical School, Director, Research, Faculty Development, Promotion, and Medical Student Education, Department of Anesthesiology, Massachusetts Eye and Ear Infirmary (MGB Corporation), Boston, Massachusetts, USA
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Shapiro FE, Urman RD. The paradigm of 6 P's: Defining the essence of a safe clinical office-based practice. J Clin Anesth 2023; 90:111239. [PMID: 37639749 DOI: 10.1016/j.jclinane.2023.111239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 08/20/2023] [Accepted: 08/22/2023] [Indexed: 08/31/2023]
Affiliation(s)
- Fred E Shapiro
- Department of Anesthesiology, Massachusetts Eye and Ear Infirmary, Boston, MA, United States of America
| | - Richard D Urman
- Department of Anesthesiology, The Ohio State University, Columbus, OH, United States of America.
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Young S, Osman B, Shapiro FE. Safety considerations with the current ambulatory trends: more complicated procedures and more complicated patients. Korean J Anesthesiol 2023; 76:400-412. [PMID: 36912006 PMCID: PMC10562071 DOI: 10.4097/kja.23078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/14/2023] Open
Abstract
In the last quarter of a century, the backdrop of appropriate ambulatory and office-based surgeries has changed dramatically. Procedures that were traditionally done in hospitals or patients being admitted after surgery are migrating to the outpatient setting and being discharged on the same day, respectively, at a remarkable rate. In the face of this exponential growth, anesthesiologists are constantly being challenged to maintain patient safety by understanding the appropriate patient selection, procedure, and surgical location. Recently published literature supports the trend of higher, more medically complex patients, and more complicated procedures shifting towards the outpatient arena. Several reasons that may account for this include cost incentives, advancement in anesthesia techniques, enhanced recovery after surgery (ERAS) protocols, and increased patient satisfaction. Anesthesiologists must understand that there is a lack of standardized state regulations regarding ambulatory surgery centers (ASCs) and office-based surgery (OBS) centers. Current and recently graduated anesthesiologists should be aware of the safety concerns related to the various non-hospital-based locations, the sustained growth and demand for anesthesia in the office, and the expansion of mobile anesthesia practices in the US in order to keep up and practice safely with the professional trends. Continuing procedural ambulatory shifts will require ongoing outcomes research, likely prospective in nature, on these novel outpatient procedures, in order to develop risk stratification and prediction models for the selection of the proper patient, procedure, and surgery location.
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Affiliation(s)
- Steven Young
- Department of Anesthesiology, 1Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Brian Osman
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Fred E. Shapiro
- Department of Anesthesiology, 1Massachusetts Eye and Ear Infirmary, Boston, MA, USA
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Benoit JP, Flynn J, Jowett N, Shapiro FE. Simple Means to Prevent Cuff Rupture During Nasotracheal Intubation. Laryngoscope 2022. [DOI: 10.1002/lary.30470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/22/2022] [Accepted: 10/17/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Justin P. Benoit
- Department of Otolaryngology – Head and Neck Surgery Massachusetts Eye and Ear, and Harvard Medical School Boston Massachusetts USA
| | - John Flynn
- Department of Anesthesia Massachusetts Eye and Ear, and Harvard Medical School Boston Massachusetts USA
| | - Nate Jowett
- Department of Otolaryngology – Head and Neck Surgery Massachusetts Eye and Ear, and Harvard Medical School Boston Massachusetts USA
| | - Fred E. Shapiro
- Department of Anesthesia Massachusetts Eye and Ear, and Harvard Medical School Boston Massachusetts USA
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Beight L, Pardo J, McCarthy K, Dinkel A, de Lima A, Torous J, James TA, Shapiro FE. An electronic monitored anesthesia care (MAC) decision aid for breast conserving surgery. J Clin Anesth 2022; 78:110648. [DOI: 10.1016/j.jclinane.2022.110648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/27/2021] [Accepted: 01/02/2022] [Indexed: 11/15/2022]
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Shapiro FE, Park BH, Levy TS, Osman BM. The assessment of a growing mobile anesthesia practice from 2016 to 2019: A retrospective observational cohort study of 89,999 cases comparing ambulatory surgery (ASC) and office-based surgery (OBS) centers using a high-fidelity, anesthesia-specific electronic medical record (EMR). J Healthc Risk Manag 2022; 41:27-35. [PMID: 35184355 DOI: 10.1002/jhrm.21499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 11/07/2022]
Abstract
Office-based surgery (OBS) has emerged as a significant subspecialty of ambulatory surgery. There are few clinical trials and limited published data on patient characteristics, anesthesia, or outcomes distinguishing OBS from ambulatory surgery centers (ASCs). We examined retrospective data from a large mobile anesthesia practice for 89,999 procedures from 2016 to 2019. Data was abstracted from billing and an anesthesia-specific electronic medical record, segregating procedures performed in ASCs versus OBS. The number and breadth of procedures increased substantially. Compared to ASCs, OBS patients were more likely male (52% vs. 48%), older (61 years vs. 55 years), and to have a higher American Society of Anesthesiologists (ASAs) status (33% vs. 20% ASA 3 or higher). The procedure mix varied substantially between the two settings. The major complication rate was 0.07% for the ASCs and 0.24% for OBS (p = 0.2, confidence interval [CI] -0.15 to 0.04). Minor complications were 11.2% in OBS versus 17.3% the ASCs (p < 0.0001, 95% CI 5.2-7). The practice demonstrates a low rate of complications, and despite the limitations of this study, the organization and structure of this large mobile anesthesia practice serves as a template for effective risk mitigation and patient safety.
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Affiliation(s)
- Fred E Shapiro
- Department of Anesthesiology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Brian H Park
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Tal S Levy
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Anesthesia Associates, NYU Grossman School of Medicine, New York, USA
| | - Brian M Osman
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Health System, University of Miami Miller School of Medicine, Miami, Florida, USA
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Young S, Pollard RJ, Shapiro FE. Pushing the Envelope: New Patients, Procedures, and Personal Protective Equipment in the Ambulatory Surgical Center for the COVID-19 Era. Adv Anesth 2021; 39:97-112. [PMID: 34715983 PMCID: PMC8313519 DOI: 10.1016/j.aan.2021.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Steven Young
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, 300 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School
| | - Richard J Pollard
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, 300 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School
| | - Fred E Shapiro
- Harvard Medical School; Department of Anesthesia, Mass Eye and Ear Infirmary, 243 Charles Street, Suite 712, Boston, MA 02114, USA.
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Abstract
OBJECTIVE We present a contemporary analysis of patient injury, allegations, and contributing factors of anesthesia-related closed claims, which involved cases that specifically occurred in free-standing ambulatory surgery centers (ASCs). METHODS We examined ASC-closed claims data between 2007 and 2014 from The Doctors Company, a medical malpractice insurer. Findings were coded using the Comprehensive Risk Intelligence Tool developed by CRICO Strategies. We compared coded data from ASC claims with hospital operating room (HOR) claims, in terms of injury severity category, nature of injury, nature of allegation, contributing factors identified, and contributing comorbidities and claim value. RESULTS Ambulatory surgery center claims were more likely to be classified as medium severity than HOR claims, more likely to involve dental damage or pain than HOR claims, but less likely to involve death or respiratory or cardiac arrest. Technical performance was the most common contributing factor: 47% of ASCs and 48% of HORs. Only 7% of allegations relating to technical performance were judged to be a direct result of poor technical performance. The most common anesthesia procedures resulting in ASC claims were injection of anesthesia into a peripheral nerve (34%) and intubation (29%). Obesity was the most common contributing comorbidity in both settings. Mean closed claim value was significantly lower for ASC than HOR claims, averaging US $87,888 versus $107,325. CONCLUSIONS Analysis of ASC and HOR claims demonstrates significant differences and several common sources of liability. These include improving strategies for thorough screening, preoperative assessment and risk stratifying of patients, incorporating routine dental and airway assessment and documentation, diagnosing and treating perioperative pain adequately, and improving the efficacy of communication between patients and care providers.
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Affiliation(s)
- Darrell Ranum
- From the Patient Safety, Northeast Region, The Doctors Company, Napa, California
| | - Anair Beverly
- Center for Perioperative Research, Brigham and Women's Hospital, Harvard Medical School
| | - Fred E Shapiro
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Abstract
Over the last 25 years, with an exponential growth in the complexity of patients and procedures in the office-based setting, the topic of patient safety is becoming more fundamental. Current research efforts focus on the implementation of customizable safety checklists for both the patient and provider, and an emergency manual specifically adapted to guide providers though challenging and unexpected emergencies in this unique setting. Additional efforts are focusing on legislative changes and accreditation to standardize and ensure increased accountability and patient safety.
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Affiliation(s)
- Brian M Osman
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University Health Tower, University of Miami Miller School of Medicine, 1400 Northwest 12th Avenue, Suite 3075-H, Miami, FL 33136, USA.
| | - Fred E Shapiro
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue F-407, Boston, MA 02215, USA
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Urman RD, Southerland WA, Shapiro FE, Joshi GP. Concepts for the Development of Anesthesia-Related Patient Decision Aids. Anesth Analg 2019; 128:1030-1035. [DOI: 10.1213/ane.0000000000003804] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Fernando RJ, Shapiro FE, Urman RD. Survey Analysis of an Ambulatory Surgical Checklist for Patient Use. AORN J 2016; 102:290.e1-10. [PMID: 26323231 DOI: 10.1016/j.aorn.2015.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 03/22/2015] [Accepted: 07/24/2015] [Indexed: 01/18/2023]
Abstract
Although checklists are used as tools for providers, they have not been adequately explored as tools for patients. The purpose of this study was to survey the stakeholders on the usefulness of an ambulatory surgical checklist for patients. We performed a cross-sectional study through a survey designed to include both patients and providers. Descriptive analysis of the data was performed based on responses from 35 patients and 52 providers. Overall, 94% of patients and 83% of providers thought the checklist would be beneficial for patients. In addition, 37% of providers indicated potential barriers to checklist implementation, including fear of confusing the patient, making patients doubt the care they were receiving, taking too much time, and lack of resources. Based on survey responses, the study suggests that the ambulatory surgical checklist can potentially facilitate patient education, enable more active patient participation, increase patient satisfaction, and decrease patient anxiety.
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Jani SR, Shapiro FE, Gabriel RA, Kordylewski H, Dutton RP, Urman RD. A Comparison between office and other ambulatory practices: Analysis from the National Anesthesia Clinical Outcomes Registry. J Healthc Risk Manag 2016; 35:38-47. [PMID: 27088775 DOI: 10.1002/jhrm.21223] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Ambulatory and office-based surgery is expanding rapidly. While growth continues, there are lingering patient safety concerns. To this end, the American Society of Anesthesiologists (ASA) created the Anesthesia Quality Institute (AQI), which collected patient and procedural characteristics on 23,341,130 anesthetics from all health care settings from 2010 to 2014. Of these, 179,618 office and 4,627,379 ambulatory cases were isolated and compared. Our findings show that although both settings are often grouped together, there are statistically significant differences in patient demographics, procedure types, and reported adverse events. Among these reports, inadequate postoperative pain control and nausea/vomiting are the most common issue. More serious events such as death, cardiac arrest, and vision loss occurred but were rare.
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Affiliation(s)
- Samir R Jani
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Fred E Shapiro
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Rodney A Gabriel
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA
| | | | | | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA
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Robert MC, Choi CJ, Shapiro FE, Urman RD, Melki S. Avoidance of serious medical errors in refractive surgery using a custom preoperative checklist. J Cataract Refract Surg 2015; 41:2171-8. [DOI: 10.1016/j.jcrs.2015.10.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 02/28/2015] [Accepted: 03/01/2015] [Indexed: 11/17/2022]
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Abstract
BACKGROUND Patient safety is critical for the patients, providers, and risk managers in the office-based procedural setting, and the same standard of care should be maintained regardless of the healthcare environment. Checklists may improve patient safety and potentially decrease risk. This study explored utilization of checklists in the office-based setting and the potential barriers to their implementation. METHODS A cross-sectional prospective study was performed by using a 19-question anonymous survey designed with REDCap®. Medical providers including physicians and nurses from 25 different offices that performed procedures participated, and 38 individual responses were included in the study. RESULTS Only 50% of offices surveyed use safety checklists in their practice. Only 34% had checklists or equivalent protocol for emergencies such as anaphylaxis or failed airway. As many as 23.7% of respondents indicated that they encountered barriers to implementing checklists. The top barriers identified in the study were no incentive to use a checklist (77.8%), no mandate from a local or federal regulatory agency (44.4%), being too time consuming (33.3%), and lack of training (33.3%). Reasons identified that would encourage providers to use checklists included a clear mandate (36.8%) and evidence-based research (26.3%). CONCLUSIONS Checklists are not being universally utilized in the office-based setting. There are barriers preventing their successful implementation. Risk managers may be able to improve patient safety and decrease risk by encouraging practitioners, possibly through incentives, to use customizable safety checklists.
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Affiliation(s)
- Fred E Shapiro
- Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Abstract
The increasing volume of office-based medical and surgical procedures has fostered the emergence of office-based anesthesia (OBA), a subspecialty within ambulatory anesthesia. The growth of OBA has been facilitated by numerous trends, including innovations in medical and surgical procedures and anesthetic drugs, as well as improved provider reimbursement and greater convenience for patients. There is a lack of randomized controlled trials to determine how office-based procedures and anesthesia affect patient morbidity and mortality. As a result, studies on this topic are retrospective in nature. Some of the early literature broaches concerns about the safety of office-based procedures and anesthesia. However, more recent data have shown that care in ambulatory settings is comparable to hospitals and ambulatory surgery centers, especially when offices are accredited and their proceduralists are board-certified. Office-based suites can continue to enhance the quality of care that they deliver to patients by engaging in proper procedure and patient selection, provider credentialing, facility accreditation, and incorporating patient safety checklists and professional society guidelines into practice. These strategies aiming at patient morbidity and mortality in the office setting will be increasingly important as more states, and possibly the federal government, exercise regulatory authority over the ambulatory setting. We explore these trends, their implications for patient safety, strategies for minimizing patient complications and mortality in OBA, and future developments that could impact the field.
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Affiliation(s)
- Fred E Shapiro
- From the Department of Anesthesia, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Medicine, Georgetown University Medical Center, Washington, District of Columbia; Department of Family Medicine and Community Health, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts; First Colonies Anesthesia Associates, Frederick, Maryland; Department of Anesthesiology, SUNY Downstate Medical Center, Brooklyn, New York; and Department of Anesthesiology, Brigham and Women's Hospital, Boston, Massachusetts
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Shapiro FE, Jani SR, Liu X, Dutton RP, Urman RD. Initial results from the National Anesthesia Clinical Outcomes Registry and overview of office-based anesthesia. Anesthesiol Clin 2014; 32:431-444. [PMID: 24882129 DOI: 10.1016/j.anclin.2014.02.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Safe office-based anesthesia practices dictate proper patient and procedure selection, appropriate provider qualifications, adequately equipped facilities, and effective administrative infrastructure. Analysis of patient outcomes can help reduce mortality and morbidity by identifying high-risk patients and procedures. We analyzed data from the Anesthesia Quality Institute National Anesthesia Clinical Outcomes Registry. Analysis included patient demographics and outcomes, procedure and anesthesia type and duration, and case coverage by provider. Increased regulation and standardization of care, such as the use of checklists and professional guidelines, can advance safe practices. There is increasing emphasis on continuous quality improvement, electronic health records, and outcomes data reporting.
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Affiliation(s)
- Fred E Shapiro
- Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Samir R Jani
- Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Xiaoxia Liu
- Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Richard P Dutton
- Anesthesia Quality Institute, 520 N. Northwest Highway, Park Ridge, IL 60068, USA
| | - Richard D Urman
- Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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Shapiro FE, Pawlowski JB, Rosenberg NM, Liu X, Feinstein DM, Urman RD. The use of in-situ simulation to improve safety in the plastic surgery office: a feasibility study. Eplasty 2014; 14:e2. [PMID: 24501616 PMCID: PMC3889688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Simulation-based interventions and education can potentially contribute to safer and more effective systems of care. We utilized in-situ simulation to highlight safety issues, regulatory requirements, and assess perceptions of safety processes by the plastic surgery office staff. METHODS A high-fidelity human patient simulator was brought to an office-based plastic surgery setting to enact a half-day full-scale, multidisciplinary medical emergency. Facilitated group debriefings were conducted after each scenario with special consideration of the principles of team training, communication, crisis management, and adherence to evidence-based protocols and regulatory standards. Abbreviated AHRQ Medical Office Safety Culture Survey was completed by the participants before and after the session. RESULTS The in-situ simulations had a high degree of acceptance and face validity according to the participants. Areas highlighted by the simulation sessions included rapid communication, delegation of tasks, location of emergency materials, scope of practice, and logistics of transport. The participant survey indicated greater awareness of patient safety issues following participation in simulation and debriefing exercises in 3 areas (P < 0.05): the need to change processes if there is a recognized patient safety issue (100% vs 75%), openness to ideas about improving office processes (100% vs 88%), and the need to discuss ways to prevent errors from recurring (88% vs 62%). CONCLUSIONS Issues of safety and regulatory compliance can be assessed in an office-based setting through the short-term (half-day) use of in-situ simulation with facilitated debriefing and the review of audiovisual recordings by trained facilities inspectors.
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Affiliation(s)
- Fred E. Shapiro
- Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Mass
| | - John B. Pawlowski
- Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Mass
| | | | - Xiaoxia Liu
- Harvard Medical School, Brigham and Women's Hospital, Boston, Mass
| | - David M. Feinstein
- Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Richard D. Urman
- Harvard Medical School, Brigham and Women's Hospital, Boston, Mass
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Ranum D, Ma H, Shapiro FE, Chang B, Urman RD. Analysis of patient injury based on anesthesiology closed claims data from a major malpractice insurer. J Healthc Risk Manag 2014; 34:31-42. [PMID: 25319466 DOI: 10.1002/jhrm.21156] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
INTRODUCTION The analysis of malpractice claims can provide risk managers with a detailed view of patient mortality and morbidity. The data comes from many institutions, encompasses a diverse group of practitioners and practice settings, and contains detailed clinical information. Analysis can help identify patterns of injury, risk factors, and rare and sentinel events. METHODS We examined most recent anesthesia closed claims data collected by The Doctors Company, a large national malpractice insurer. We analyzed data from claims closed between 2007 and 2012. Each claim underwent a review by physician and nurse experts, and was then coded using the Comprehensive Risk Intelligence Tool. Injury distribution and association between the injury and patient comorbidity were also examined. RESULTS A total of 607 claims were analyzed. Most frequent injuries were teeth damage (20.8%), death (18.3%), nerve damage (13.5%), organ damage (12.7%), pain (10.9%), and arrest (10.7%). Obesity was most frequently identified as a contributing factor leading to a claim. Injury-to-claim rates were highest in hospitals with fewer than 100 beds, while ambulatory surgery centers had the lowest death-to-claim rate (12%). Average indemnity for an anesthesia claim was $309 066, compared to $291 000 for all physician specialties. CONCLUSIONS The most frequent claims were death and nerve damage when teeth damage was excluded. Obesity impacted anesthesia outcomes more frequently than did other comorbidities. Although there were fewer claims from the smaller hospitals, those claims had higher rates of mortality and nerve damage compared to larger-size hospitals. Further analysis is needed to evaluate these trends as well as impact of specific patient comorbidities on anesthesia outcomes.
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Shapiro FE, Punwani N, Urman RD. Office-based surgery: embracing patient safety strategies. J Med Pract Manage 2013; 29:72-75. [PMID: 24228364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Office-based surgery continues to grow as more procedures are being performed in the outpatient setting. With this exponential growth, there is an increasing emphasis on safe and effective patient care. Current research shows both gaps in safety and opportunities for improvement. Practice managers, clinicians, and other personnel should be cognizant that office procedures are coming under intense regulatory scrutiny. Effective strategies to maintain quality and patient safety include the use of checklists, obtaining office accreditation, encouraging board-certification and proper credentialing of proceduralists, and appropriate patient and procedure selection. There is increasing regulation of ambulatory surgery on state and national levels that will likely affect the financial and care quality aspects of office-based practice. Socioeconomic and political forces will continue to shape the future of office-based surgery.
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Urman RD, Punwani N, Bombaugh M, Shapiro FE. Safety considerations for office-based obstetric and gynecologic procedures. Rev Obstet Gynecol 2013; 6:e8-e14. [PMID: 23687556 PMCID: PMC3651543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The migration of gynecologic procedures to office-based settings provides numerous advantages for patients and providers alike, including reduced patient expenses, improved scheduling convenience, favorable provider reimbursement, and enhanced continuity of care and patient satisfaction. With rising health care costs-a major concern in health care-procedures will continue to shift to practice environments that optimize care, quality, value, and efficiency. It is imperative that gynecologic offices ensure that performance and quality variations are minimized across different sites of care; physicians should strive to provide care to patients that optimizes safety and is at least equivalent to that delivered at traditional sites. The gynecologic community should nonetheless heed the Institute of Medicine's recommendations and embrace continuous quality improvement. By exercising leadership, office-based gynecologists can forge a culture of competency, teamwork, communication, and performance measurement.
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Affiliation(s)
- Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
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Rosenberg NM, Urman RD, Gallagher S, Stenglein J, Liu X, Shapiro FE. Effect of an office-based surgical safety system on patient outcomes. Eplasty 2012; 12:e59. [PMID: 23308306 PMCID: PMC3536439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To implement a customizable checklist in an interdisciplinary, team-based plastic surgery setting to reduce surgical complications. METHODS We examined the effects on patient outcomes and documentation of a customizable, office-based surgical safety checklist. On the basis of the World Health Organization Surgical Safety Checklist, we developed a 28-element, perioperative checklist for use in the office-based surgical setting. The checklist was implemented in an office-based plastic surgery practice with an already high standard of care. We recorded baseline, prechecklist rates for each checklist item and postoperative adverse outcomes via a retrospective chart review of 219 cases. After an education program and 30-day run-in period, a prospective, post-checklist implementation chart review was initiated (n = 184), with outcome data compared to the baseline. RESULTS The total number of complications per 100 patients decreased from 15.1 to 2.72 after checklist implementation (P < .0001), for an absolute risk reduction of 12.4. The proportion of patients with one or more complications decreased from 11.9% to 2.72% (P = .0006). Site and side marking increased from 69.9% prechecklist to 97.8% (P < .0001). Medical optimization increased from 90.9% to 99.5% (P < .0001). Emergency medical services (EMS) policy confirmation, case-specific equipment availability, anticipation of estimated blood loss, and verbal confirmation of local anesthetic toxicity precautions increased from 0% to 90.0% (P < .0001), 92.4% (P < .0001), 82.1% (P < .0001), and 91.3% (P < .0001), respectively. Assessment of patient satisfaction increased from 57.1% to 90.8% (P < .0001). CONCLUSIONS Implementation of a customizable checklist was associated with a reduction in surgical complications in an office-based plastic surgery practice with an already high standard of care.
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Affiliation(s)
- Noah M. Rosenberg
- aUniversity of Massachusetts Memorial Medical Center, Worcester,Correspondence:
| | | | | | - John Stenglein
- dHarvard Medical School, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Xiaoxia Liu
- bHarvard Medical School, Brigham and Women's Hospital
| | - Fred E. Shapiro
- dHarvard Medical School, Beth Israel Deaconess Medical Center, Boston, Mass
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Urman RD, Punwani N, Shapiro FE. Office-based surgical and medical procedures: educational gaps. Ochsner J 2012; 12:383-388. [PMID: 23267269 PMCID: PMC3527870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Abstract
Over the past decade, the number of procedures performed in office-based settings by a variety of practitioners-including surgeons, gastroenterologists, ophthalmologists, radiologists, dermatologists, and others-has grown significantly. At the same time, patient safety concerns have intensified and include issues such as proper patient selection, safe sedation practices, maintenance of facilities and resuscitation equipment, facility accreditation and practitioner licensing, and the office staff's ability to deal with emergencies and complications. An urgent need exists to educate practitioners about safety concerns in the office-based setting and to develop various educational strategies that can meet the continued growth of these procedures. This review outlines educational needs and possible solutions such as simulation exercises and education during residency training.
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Affiliation(s)
- Richard D. Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | | | - Fred E. Shapiro
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
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