Given the growing number of patients and increased complexity of anesthesia cases occurring outside the operating room (OR), better strategic planning and improved financial infrastructure are needed. While ORs have long had revenue and cost management control measures, consistent preprocedural guidelines are often lacking in the non-OR space, creating a strategic imperative for anesthesiologists.
“If our goal is to put together a health care delivery system that’s cohesive, patient-centric and financially sustainable, we as anesthesiologists have to solidify our position as co-proceduralists and care integrators,” said Wendy L. Gross, MD, vice chair of anesthesia for interventional medicine at Brigham and Women’s Hospital, in Boston. “In order to get that going, we need consistent patient evaluation standards and enforceable booking and scheduling rules, and we probably can’t do any of this without some kind of collaborative financial platform.”
Non-OR Procedures Soar
It’s no secret that the number of non-OR cases in hospitals is increasing dramatically. At Brigham and Women’s Hospital, for example, the number of non-OR interventional medicine cases now exceeds the number of OR cases. “In fact, doubling time for these non-OR cases is only 4.7 years, so this growth has been really fast,” Dr. Gross said. “And the doubling time for non-OR anesthesia cases is only half of that.”
As Dr. Gross explained during her presentation at the 2015 annual meeting of the American Society of Anesthesiologists (abstract JS10), not only are anesthesiologists performing more cases outside the OR, but the scope of these procedures is expanding: Disruptive percutaneous and endoscopic technologies have been incorporated into the standard repertoire.
Despite these changes in venue, however, management control measures, such as scheduling rules, patient preparation guidelines and perioperative governance committee oversight, have not extended to non-OR areas. “Those of us who work outside of the OR find ourselves negotiating the same sorts of basic principles on a case-by-case basis,” said Dr. Gross. “There are no consistently accepted preprocedural evaluation guidelines for these patients.”
Moreover, the procedures themselves are often novel and/or technically demanding, and pre- and postprocedure planning sometimes doesn’t even occur. “At times, these procedures are more unpredictable and more variable than the cases we do in the OR,” said Dr. Gross. “In terms of flow and throughput, this is really an issue, and yet we have no hard and fast scheduling rules in place for cases in this venue.”
A three-month survey of non-OR procedures at Dr. Gross’ hospital confirmed her suspicions regarding inefficiency of service. Combined data from the Brigham and Women’s Hospital’s Perioperative Governance Committee and Centers for Clinical Excellence demonstrated that overall utilization of anesthesia services in the OR was drastically different from usage outside the OR (83% in the OR vs. 51% non-OR).
The availability of current history and physicals (H&Ps) also differed dramatically. “We found that 61% of patients coming for non-OR cases had no H&Ps,” said Dr. Gross, “and I’m not talking about pre-ops. … I’m talking about missing H&Ps, which should have been done by proceduralists before we got there … necessitating that we execute them right before the case.”
Finally, Dr. Gross observed that 5% of the non-OR cases were canceled due to some unrecognized comorbidity, which only happened in 0.5% of cases in the OR.
“An additional problem with all of this, of course, is that the financial ramifications are not insignificant,” said Dr. Gross. “If we took all the time that we spent in non-OR areas doing someone else’s H&P (an average of 13 per day) and multiplied it by our usual revenue, we could have possibly billed another $167,000 for the quarter.”
Although Dr. Gross acknowledged that 100% utilization is an unattainable number, the bottom line represents a substantial amount of time squandered by inefficient resource utilization.
“If we think about the dimensions of quality that we want to aspire to … it’s pretty hard to provide that when you’re dealing with an ever-expanding number of cases, no strategic plan and a financial infrastructure that probably hurts us more than it helps us,” Dr. Gross concluded.
A new national society, SONORIA (Society of Non-OR Interventionalists and Anesthesiologists), has been formed to look into creating a collaborative platform for interdisciplinary work in this area, with a national conference planned for May 2016.
The moderator of the session, Warren Sandberg, MD, PhD, chair of the Department of Anesthesiology at Vanderbilt University Medical Center, in Nashville, Tenn., provided historical perspective for the current transition away from OR governance.
“As Dr. Gross stated, the procedure lab spaces are popular for a lot of reasons that are related to the medical care of the patients,” said Dr. Sandberg, “but there is an undercurrent of … trying to escape the governance structures of the OR, which are inconvenient for the proceduralists but actually force them into providing standardized, high-quality care. … So, there’s a desire to escape those requirements for consistency, which means the anesthesiologists often have to fix the problems—at our own expense.
“Dr. Gross provided a compelling financial argument,” Dr. Sandberg continued. “It’s basically a way to optimize the workflow and the lifestyle of the proceduralist, in addition to capturing the unique capabilities of those proceduralist spaces.
“We’re witnessing a transition from everything happening in the OR to procedures happening in multiple locations,” he concluded. “The mature state will be: Those places have requirements for patient preparation and governance structures just as robust as in the OR.”
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