A comparison of anesthesia closed claims from ambulatory surgery centers (ASCs) and hospital operating rooms (HORs) has found some noteworthy differences, and also spotlights areas where underperforming can result in liability.
Procedures performed in ASCs have become markedly more common since the 1980s. The researchers, including Richard D. Urman, MD, MBA, of the Center for Perioperative Research at Brigham and Women’s Hospital, in Boston, and Darrell Ranum, JD, vice president for patient safety and risk management at The Doctors Company, in Napa, Calif., noted that there was a tripling of visits to freestanding ASCs between 1996 and 2006. According to the Ambulatory Surgery Center Association, they added, at least 23 million procedures were performed in at least 5,400 ASCs annually by 2011, a figure that no doubt has grown considerably in more recent years.
The researchers aimed to examine anesthesia liability specific to the setting of the ASC. They reviewed closed claims data from The Doctors Company, a private medical malpractice company that insures about 80,000 clinicians in multiple specialties, of which about 2,900 are anesthesiologists and 2,400 are CRNAs.
Anesthesiologists focusing on pain medicine and interventional pain medicine procedures were excluded from the study, as were claims from office-based surgery and those arising in specialty hospitals (e.g., psychiatry), and also claims from diagnostic and treatment clinics. The study, which will be published in the Journal of Patient Safety, consisted of anesthesia claims that were closed between 2007 and 2014.
The Doctors Company’s expert reviewers determined injury severity based on the National Association of Insurance Commissioners Injury Severity Scale, which grades from 1 (emotional only) to 9 (death). For purposes of the study, severity was grouped into low (1-2), moderate (3-5) and high (6-9) for injuries. Claims often included more than one injury. Physician analysts from The Doctors Company also reviewed each claim to determine whether injuries were known to the patient as risks of the procedure, were based on errors in clinical judgment or were system-based failures (e.g., proper equipment was not available).
Differences Between Care Settings
The researchers found 944 anesthesiology claims from all practice settings that were closed during the study period. In the ASC setting, there were 290 closed claims, and in the HOR setting, there were 528 closed claims: less than 100 hospital beds, 36 claims; 100 to 299 beds, 263 claims; and 300 or more beds, 229 claims.
The most frequent procedures from closed claims in the ASC setting involved shoulder (18%), knee (8%), cataract (7%) and nose (7%) surgeries. Injury severity of closed claims varied between ASCs and HORs. Medium-severity claims proved significantly more likely to occur in an ASC (P=0.019). High-severity claims were more frequent in the HOR setting, but the overall difference was not significant, although 11% of ASC claims were for death compared with 20.7% of HOR claims, which was significant (P<0.001). The most common claims in the ASC and HOR settings are shown in the Table. Dental damage (P=0.045) and pain (P=0.044) were significantly more likely to be ASC rather than HOR claims, whereas death (P<0.001), organ damage (P=0.003), and respiratory or cardiac arrest (P=0.004) were significantly less likely in the ASC setting.
|Table. Most Common Claims by Setting|
|Respiratory or cardiac arrest||13.3|
|ASC, ambulatory surgery center; HOR, hospital operating room|
Comorbidities as contributing factors in closed claims were similar in the ASC and HOR settings. Obesity was the most common of these conditions (ASC, 13%; HOR, 20.3%) and the difference was significant. Other comorbidities included hypertension, smoking, diabetes and obstructive sleep apnea, but the differences were not significant.
“Obesity is the number one comorbidity when looking at the codes we have,” said Mr. Ranum in an interview with Anesthesiology News, “primarily because it complicates the administration of general anesthesia, intubations and finding landmarks when doing regional anesthesia.” He noted, however, that this association has decreased in their claims over the past eight years because more and more anesthesiologists are using ultrasound-guided needle placement.
A deep dive into the data reveals three areas in which anesthesiologists should focus their efforts on improving clinical care in the ASC setting: preassessment, informed consent and OR teamwork.
“Preassessment is essential,” Mr. Ranum said. “We hear from some anesthesiologists that there is a lot of production pressure to move patients through, but from our perspective the most successful anesthesiology groups are the ones that build adequate assessment time into their patient relationships. Some of these are doing them a week ahead of when anesthesia is given, rather than just moments before the patient is taken to the OR.
“The reason for that is, number one, there could be problems with patient selection—is this an appropriate patient for the ambulatory surgery setting—and number two, you need to understand the risks and comorbidities associated with this particular patient,” he said.
Examples may include difficult airway anatomy, the presence of obstructive sleep apnea, or such conditions as diabetes and high blood pressure.
“It is really important to get a complete history and evaluate the airway, even if you are not going to do intubation for general anesthesia,” Mr. Ranum said. “The reason is because sometimespatients arrest on the table or have other complications and intubation becomes essential, and if they have not prepared for a difficult airway, we have seen them lose patients that otherwise might have been saved.”
Ditch the Pro Forma Informed Consent
Informed consent is often just a pro forma “sign on the dotted line,” but that is not good enough. “We often try to get physicians to do better informed consents. I believe the informed consent process is extremely important because of the value of bringing the patient into the health careteam and making them part of the decision-making process,” Mr. Ranum said. “We also recognize that patients often don’t have a comprehensive understanding of what the surgeon or the anesthesiologist is talking about. So sometimes there is a limit to understanding. Also, patients often don’t want to focus on potential complications. As soon as patients agree to proceed, they don’t want to think about it anymore, and I think their ability to retain information is limited.
“When a patient does experience a complication, it is important for the clinician to meet with the patient, hear their concerns, help them understand what they experienced and why, and explain how that will impact their care going forward. If the physician then takes the step of linking that conversation back to the original informed consent process—particularly if there are materials that have been shared with the patient—then the patient may still not be happy with the outcome but will have a better understanding of the whole process and possibly make them less inclined to feel they need to get an attorney to help them address their concerns.”
Distractions Impair Teamwork
Mr. Ranum noted that good teamwork is extremely challenging. “You have anesthesiologists working with a variety of surgeons and different OR staff; it is unusual to get to work with the same staff over a long period of time. So communication becomes especially important. If everyone is using the same communication tools—like closed-loop communication, for example—then they are more likely to be communicating effectively, even if they are unfamiliar with each other as clinicians.” Closed-loop communication is the practice of acknowledging instructions, repeating back orders to confirm them, and using names to eliminate vagaries in who is supposed to accomplish a task.
“We have had surgeons who have said, ‘Yeah, the anesthesiologist mentioned his blood pressure was decreasing but I didn’t realize it was at a critical level, so I went ahead and finished the procedure.’ You have to convey concrete information that everyone can process and provide feedback.”
Finally, poor teamwork involves poor monitoring and distractions. Mr. Ranum noted that their data had shown an increase in recent years in cases involving improper monitoring of patients under anesthesia. One factor might be longer surgeries being performed at ASCs, thus heightening the risk for complications of one kind or another. “It is harder for clinicians to maintain their focus over that period of time. In fact, we are just becoming aware of distractions in the OR. From other studies that have been done, it looks like distractions in the OR are another important reason why monitoring is an issue. We have seen some cases where there were delayed responses to alarms, so either the clinician is tied up doing something else, so that alarm is allowed to go on a little longer than normal, or the person is distracted and it is taking him longer to refocus and come back to that alarm.”
As for the anesthesiologist given to using some time in the OR to check up on internet news or take a look at Facebook, consider this: “Metadata is now coming into our claims,” Mr. Ranum warned, “so plaintiffs are able to get a hold of [a] physician’s phone records and their internet access records and determine what that clinician was doing at the time that may be unrelated to the patient care.”
In other words, if an anesthesiologist is found to have been on the internet instead of monitoring his or her patient, then that liability claim is, well, problematic.