Authors: Steven Young, M.D et al
ASA Monitor 02 2018, Vol.82, 10-13.
Over the past 20 years, office-based surgery has shown an exponential increase in both the number and complexitys of patients and types of procedures.Fortunately, serious O.R. crises are rare in the office-based surgical (OBS) setting, but when they do occur, both anesthesia and non-anesthesia practitioners must be well equipped to provide the best possible care for the patient. Given these patient safety concerns, the Centers for Medicare & Medicaid Services recently added the use of a World Health Organization (WHO)-type safe surgery checklist for routine procedures, and used before a procedure starts, as a measure of quality for ambulatory surgery centers. Another type of checklists includes emergency checklists with treatment algorithms, like the advanced cardiac life support (ACLS) algorithm, which are often encountered in the O.R. and hospital wards.
However, checklists need not only be used in O.R. settings. Checklists can be modified and carried out success-fully in the office-based setting. For example, Rosenberg et al. published the first pilot study evaluating the feasibility of educating office practitioners and personnel on crisis management.1 They adapted a 28-item perioperative checklist based on the WHO Surgical Safety Checklist in an office-based plastic surgery practice and demonstrated, via a prospective post-checklist implementation chart review, a reduction in surgical complications. From pre- to post-implementation, they saw 15.1 complications per 100 patients to 2.72 complications per 100 patients, a 12.4 percent absolute risk reduction of total number of complications.
The design of our OBS setting emergency manual (EM) was loosely based upon concepts from Dr. Atul Gawande’s “Checklist for Checklists” and the current Ariadne Labs O.R. Crisis Checklists. In designing the EM, typography of the checklist becomes important as it affects the reader’s ability to read quickly and grasp the significant points during times of crisis. To ensure good flow and readability, we chose to use sans-serif font, used larger first letters for uppercase words, avoided long strings of text in italics and used black font over white background.2 We ensured that each chapter fits on one page by minimizing the required content necessary to guide provider responses from start to finish. This ensures that providers can deliver patient care without turning the page during a crisis. In consultation with Dr. Alex Hannenberg, we modified the Ariadne manual intoa template for our office-based EM.
Bolding items in the EM meant to signify the importance and immediate nature of that item.3 In a clinical setting, this means reminding the provider of the critical nature of the item and the potential risk to the patient if it is forgotten. On the other-hand, non-boldface items form the other “normal” aspects of the response. It is tempting to bold every step; however, this can detract from the efficiency and effectiveness of the checklist. Numbering of actions to do was intended to signify order, but as is the case in an emergency, many of these actions will take place simultaneously.
As clinicians, we have often depended on algorithms to guide our delivery of care, such as the advanced cardiac life support (ACLS) decision tree on when to shock a rhythm, when to continue chest compressions or when to give medications. As critical events are generally less frequently encountered in the OBS setting, there is greater value in using a decision tree to help the anesthesia provider navigate more complex situations. Benefits of having checklists include providing patient care in a more organized manner, acting upon reminders of omitted actions in real time, confirming or expanding differential diagnoses, and reaffirming previously completed tasks.4
Because of unique features within OBS settings, which may include adult and pediatric patients, the need for an office-based EM is especially warranted. Hence, our research group at the Institute for Office-Based Surgery (ISOBS) reviewed existing checklists and EMs from various societies and collaboratives. We performed a literature search for the different existing cognitive aids. After reviewing the various topics and editing several drafts, a panel of patient safety experts came to an agreement by highlighting the most common emergencies encountered in this unique office-based setting and recommending treatment approaches.
Our focus was to develop a crisis checklist for the OBS setting, keeping in mind what limited resources the typical office would have access to. There are “must-have” emergencies, such as ACLS. However, given the large numbers of offices that see both adult and pediatric patients, it behooved us to include separate, specific algorithms and treatment plans for ACLS and PALS. Other clinical emergencies such as hypoxia, hypotension and hemorrhage can occur at any point during a procedure. If hemorrhage transpired during surgery in the hospital, the providers can call the blood bank, draw labs and transfuse blood. Our approach to hemorrhage in the OBS setting treats the situation similarly to how a first responder would handle a trauma situation, since the office-based practice does not have a massive transfusion protocol or uncrossed matched O-negative blood like a hospital or an ambulatory surgical center would have. Hence, in the face of uncontrolled bleeding during an office-based procedure, the consideration should be triage and immediate transfer to a higher-care health care facility.
“Because of unique features within OBS settings, which may include adult and pediatric patients, the need for an office-based EM is especially warranted. Hence, our research group at the Institute for Office-Based Surgery (ISOBS) reviewed existing checklists and EMs from various societies and collaboratives.”
Malignant hyperthermia (MH) is one of the deadliest, yet most treatable emergencies, seen in all settings. No anesthesia crisis checklist would be complete without this. With media attention to an office-based death due to MH, it seemed fitting to incorporate both a treatment and transfer protocol, highlighting the initiation of therapy for the MH patient in the OBS setting while simultaneously triggering transfer of the MH patient to a more appropriate tertiary care facility.5
We included fire,6 power failure7 and loss of oxygen8 as non-medical emergencies in our office-based EM, as these present unique challenges in an OBS setting. According to Federal Emergency Management Agency, between 2004 and 2006 there were an average of 6,400 fires in various medical facilities across the U.S. Of these fires, 5.3 percent occurred in clinics or doctor offices; 3.6 percent occurred in doctor, dental or oral surgeon offices; and 1.5 percent occurred in clinic and clinic-type infirmaries. According to the Accreditation Association for Ambulatory Health Care, standards of care, power and oxygen failure are critical emergencies that must be addressed in the health care setting. Facilities must operate with the highest fidelity to avoid adverse events due to power failure. In the hospital, there is often a backup generator and an alternative oxygen source, but these resources may be more limited or unavailable in the office-based environment. Consideration and preparation for these emergencies should be addressed along with the appropriate treatment and transfer plan for patients.
Office-based surgery continues to grow. With the continued shift of procedures from the inpatient to the outpatient setting, the goal of this EM is to have all critical information that an office-based practitioner would need during a crisis – an all-in-one, setting-appropriate compendium. The EM can also be used for interdisciplinary education of the entire office team. As a follow-up to our earlier publication, we envision the use of the ISOBS Safety Checklist for Office-based Anesthesia Crises to be included in future in-situ simulation programs.9 We hope that the addition and implementation of an EM specific to this unique OBS setting will improve clinical outcomes as well as patient comfort and satisfaction.
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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.