A 25-year-old woman presents for liposuction of the abdomen, thighs, hips, flanks, and back in the surgeon’s office. She stands 62 inches (167 cm) tall and weighs 176 lb (80 kg). She denies any medical problems but reports snoring at night. Her only medication is an oral contraceptive, and she has not had any previous surgery. Anesthetic evaluation reveals an obese woman with a Mallampati class 3 airway.
What is office-based anesthesia?
Office-based anesthesia (OBA) is defined as the “provision of anesthesia services in an operatory or a procedure room that is specifically not licensed as an ambulatory surgery center (ASC) by the state in which it operates and which is integrated into the day to day operations of a doctor’s office” ( et al. 2003). Historically, one of the earliest references to OBA dates back more than a century ago, when Long used ether to anesthetize his patient successfully to remove a neck tumor. Since then, the practice of OBA has changed dramatically. More recent advances in surgical technology and equipment, along with improved anesthetic techniques and drugs have made this venue appropriate for a very wide array of surgeries and procedures previously suitable only for hospitals or ASCs. It is estimated that 10 million procedures are performed in offices annually. Although many surgical specialties presently use this unique venue, cosmetic surgery in particular has seen a tremendous increase in volume. According to the American Society of Plastic Surgeons, 37% of cosmetic procedures and 28% of reconstructive procedures are performed in the office-based setting.
What are the advantages and disadvantages of office-based anesthesia?
OBA continues to increase in popularity for numerous reasons. Surgical and anesthesia techniques and available pharmaceuticals continue to improve. These advances have allowed for more complex and minimally invasive procedures to be performed safely and effectively in this setting.
There are unique advantages for surgeons and proceduralists and patients in this type of practice. Economically, it is advantageous because the cost is significantly less compared with the hospital setting. This difference in cost is mainly due to the high overhead costs associated with hospital facility fees, which include hospital maintenance, equipment, and staff, all of which constitutes a large component of the patient’s overall procedure fee. In the office, this fee can be easily predicted and is often minimal compared with the hospital or an ASC. The cost savings can be passed on to the patient. In the interest of cost containment, insurance companies began offering incentives to surgeons to use their office locations. This venue also allows for greater surgeon and patient satisfaction. Scheduling is much easier in the office setting. For surgeons, an office-based practice can eliminate much of the unproductive time associated with long operating room turnovers, patient preparation, and driving between sites. Office-based surgery allows surgeons to perform nonsurgical duties such as patient consultations and follow-up examinations more easily.
For patients, office-based surgery is an attractive and convenient alternative to hospitals. It offers patients a more private and less stressful environment. There is better continuity of care because staffing in the office is more consistent. Exposure to nosocomial infections is also diminished.
However, there are numerous potential disadvantages to OBA. Office-based practices were once labeled as the “wild, wild, west of health care,” with issues regarding standard of care and patient safety in the office-based practice not always being met. Most OBA practices have little or no oversight by local, state, or federal governments regarding certification and qualification of either surgeons or anesthesiologists, peer review, performance improvement, documentation, general policies and procedures, and reporting of adverse outcomes. At the present time, many states have placed regulations on office-based practices. However, these regulations vary from state to state. Other states are steadily moving forward and have issued guidelines or policy statements. Because of anesthesiologists’ role as patient safety advocates, it is incumbent on them to insist that the standard of care achieved in hospitals or ASCs is the same in every office in which surgery and anesthesia are performed. Health care providers who wish to practice in this setting should take advantage of the office-based surgery patient safety guidelines and recommendations published by a variety of professional societies and accrediting organizations. The American Society of Anesthesiologists (ASA) created “Guidelines for Office-Based Anesthesia,” last affirmed on October 2009.
Another disadvantage of office-based practice is the limited resources available. Resources often taken for granted in the hospital, such as immediate availability of colleagues, other skilled nurses, laboratory services, and specialized equipment, are sparse or nonexistent. It is of utmost importance that we ensure that the standards of practice in the office, whether it is accredited or not, meet those of the hospital or ASC to provide patients with a safe office environment.
Discuss the important issues for consideration when setting up a safe office-based practice.
There is only one way to practice medicine, and that is the safe way. In office-based practice, where surgeries and procedures are performed in an elective manner, patient safety must never be compromised. Considerable consumer and physician pressures come into play in this setting. It is of utmost importance that anesthesiologists do not succumb to these pressures. We must always make sure that the standard of care in an office practice is no less than that of a hospital or ASC. Our level of vigilance should even be heightened in this venue because we are often alone, and resources we take for granted are limited.
There are many elements that need to be carefully considered for an office-based practice. Diligent and careful assessment of the physician or proceduralist, the physical office space, the patient’s comorbidities, and the anticipated procedure is paramount. The ASA formulated “Guidelines for Non-Operating Room Anesthetizing Locations,” “Guidelines for Office-Based Anesthesia,” and “Considerations for the Anesthesiologist in the Office-Based Settings,” which should be referred to by practitioners who are considering office-based practice for guidance.
The surgeon or proceduralist (e.g., gastroenterologist) must have the necessary and updated licensing and credentialing information, such as medical license, registration, and Drug Enforcement Agency certificate. The physician must be adequately trained, and board certification or eligibility by the American Board of Medical Specialties is preferable. The physician should have privileges to perform the proposed procedure in a hospital or have training and documented competency. The physician should participate in peer and quality review and continuing medical education. In addition, the physician must have admitting privileges and an emergency transfer agreement with a nearby hospital. The facility and the physician must also have adequate liability insurance.
The office must be a safe location no matter where it is. As previously stated, the standard of care in the office should be no less than that of a hospital or ASC. The office must be appropriately stocked with age-appropriate and size-appropriate equipment and supplies. All equipment must be regularly serviced and calibrated with documentation according to manufacturers’ suggestions. There must be a functioning waste gas scavenging system if inhaled agents or nitrous oxide are used. An adequate supply of compressed oxygen and backup supply for use in an emergency must be present. ASA standards for basic anesthetic monitoring must be implemented. These include electrocardiography, noninvasive blood pressure, pulse oximetry, end-tidal carbon dioxide monitoring, and temperature monitoring. Monitors must be routinely serviced and should have backup battery supply. All advanced cardiopulmonary life support emergency drugs should be available, including dantrolene if malignant hyperthermia triggering agents are used. A cardiac defibrillator with a battery backup must be immediately available, visible, and routinely checked. A source of suction, including a pharyngeal catheter, must be present.
Administrative issues, such as facility and personnel credentialing, development of policy and procedures manual, performance improvement, emergency and infection control protocols, and documentation, should be addressed as well.
Appropriate patient selection is a very important aspect of safe OBA. Patient selection is controversial among office-based practitioners because there are very few data to support the inclusion or exclusion of specific patient populations. The ASA “Guidelines for Office-Based Anesthesia” reads, “Patient who by reason of pre-existing medical or other conditions may be at undue risk for complications should be referred to an appropriate facility for performance of the procedure and the administration of anesthesia” (American Society of Anesthesiologists, www.asahq.org ) This statement leaves much room for interpretation. The anesthesiologist must evaluate the patient’s risk for OBA on an individual basis.
Determination of a patient’s suitability for OBA begins with a thorough preoperative history and physical examination. Coexisting medical conditions that could potentially complicate the surgical procedure and anesthetic management must be identified. Whoever examines the patient preoperatively should be familiar with the ASA physical status classifications and implications. The American Society of Plastic Surgeons (ASPS) and ASA have made similar recommendations that patients who are assigned an ASA physical status I or II are “reasonable candidates for the office-based surgery setting.” The ASPS recommends that ASA physical status III patients “may also be reasonable candidates for office-based surgery facilities when local anesthesia, with or without sedation,” is used. However, the ASA recommends that patients should be evaluated by the anesthesiologist before the day of surgery to determine their suitability for office-based surgery and anesthesia. It is imperative to consider all comorbidities when determining patient suitability. There must be clear communication between the surgeon and the anesthesia provider regarding this matter. The anesthesia provider must not succumb to physician and patient demands. The decision regarding the patient’s clearance for anesthesia ultimately depends on the anesthesiologist. The ASA has also provided a list of specific patient factors that should be taken into consideration before performing OBA. These factors include the following:
Known or suspected difficult airway
Previous anesthetic or surgical problem
Drug allergies that are of perioperative concern
Substance abuse disorders including alcoholism
Social situation that precludes having a responsible adult escort
Box 74-1 lists patients that may be excluded from OBA.