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The role of Anaesthetist as Manager

Image !The double Role of the anesthesiologist in Day Surgery Units (DSU): a possible organization model for running an Day Surgery Department.

Jan H Eshuis, MD, anaesthesiologist, director
Day Care Centre, Academic Medical Centre at the University of Amsterdam j.h.eshuis at amc.nl

Traditionally, we know the anesthesiologist as the guy dealing in the operating room with diverse grades of consciousness, preventing patients feeling pain during surgery, handing out sophisticated injections around nerve bundles, reassuring patients or surgeons and being capable of managing the most complicated and difficult of medical and surgical situations with lifesaving skills and capable to make acute decisions. It is this most original task of anesthesiologists which is responsible for their image.
All this however is only basic, fundamental; in Day Surgery there is more.
From the early 1980’s the scope of the anesthesiologist has gradually widened. This is probably not by accident parallel with the beginning and gradual rise of Day Surgery. In this same era the concept showed up of the anesthesiologist as a perioperative physician. His or her tasks were extended out of the Operating Room (OR), to outpatient preoperative assessment, sedating on remote locations, for pain consultations, intensive care, emergency care within as well as out of the hospital, ambulatory units and so on. Especially the last few years Day Care is increasing rapidly in many countries.
In the same period the rate of ambulatory Surgery in the Netherlands increased to at least 50% of all surgical procedures. Because not all figures of private clinics are known this percentage might be as high as 55% or even more. In other countries the rise in Day Surgery was even more: in the USA it is estimated to be between 75 and 80% of all surgery. At these levels of activity many anesthesiologists have to deal with Day Surgery as part of their routine workload.
In my view, you can consider two types of role for the anaesthesiologist: one in an organizing, managing function in the DSU, as the Medical Director, and the second the role as a medical professional. A consequence of the above mentioned broadening of the scope of the anaesthesiologist and the traditional existing role of organizing an individual OR-program, both medical and managing activities of the anaesthesiologists are more and more interconnected.
With regard to Leadership: Each DSU should have a Clinical Lead or Director who has a specific interest in day case surgery and who will lead the development of local policies, guidelines, contacts in the hospital, reports with other specialists, human resources and Clinical Governance in this area.
An Anaesthesiologist with management experience and an interest in day surgery is ideally suited to such a post. No other single medical specialist has a similar constant attendance in the logistic chain of Day Surgery; this will be explained more in detail below. No other medical specialist is interacting with so many other doctors, support personnel across the patient pathway from preoperative assessment, through the OR and then in the Recovery Ward. The Anesthesiologist is also used to managing lists in the OR. This post can (and often is) filled by a surgeon but they have to overcome the lack of the day to day contact with other doctors especially those outside their own specialty and have less insight into their specific problems. The Medical Director should organise the DSU, give direction to patient selection, should create their own dedicated staff and set of equipment on the OR. Each unit also requires adequate staffing led by a senior nurse who provides the day-to-day administration of the unit in liaison with the Medical Director. Together they form the central managing team and they should organise a regular report with all surgical specialists who operate in the DSU, preferably represented by one spokesperson. They may also run the Human Resources of the Unit, organise education and take control on the Master schedule of Surgical Planning on a weekly basis. Depending on local circumstances the unit might need a third person in the managing team, a financial and administrative manager. This will largely be dependent on the structure of your facility: in a big hospital an embedded DSU usually is covered by a financial officer further in the hierarchy of the hospital. In a Freestanding Day Surgery Unit it is probably very wise to have a financial administrative colleague in the board.
What is it that makes the role of the anaesthesiologist so special? Looking at the involvement of the anesthesiologist in all phases from referral by the General Practitioner (GP) to the hospital to the final discharge home of the patient the central role played by the anaesthesiologist is striking. He is involved in almost every part of the logistic chain which is ambulatory surgery.
Referred by a GP to any surgical specialist the patient is thought to be fit for day surgery by the surgeon. The patient is sent to the preoperative assessment clinic where their fitness for day surgery are weighed by the anesthesiologist, with help of nurses and if indicated laboratory evaluation (which should never be routine). Those patients who are suitable for day surgery will then be scheduled. In some units the Medical Director is in control on the master schedule of slots for surgical specialists in order to optimize efficiency in the DSU. In many practices an anaesthesiologist is regularly involved with scheduling programs and patients.
Then eventually the procedure is performed, again with close involvement of the anaesthesiologist; his / her professional skill will greatly determine the success of Day Surgery. After the procedure is performed, the patient is either fast-tracked to the ward or admitted to the PACU (post-anesthesia care unit or recovery room), again this is usually managed by the Department of Anesthesiology. The patient is discharged by the PACU nurse to the next and final station, according to delegated care and protocols for discharge by using criteria or a scoring system. Also in the step down unit (the ward in the DSU) the patient is discharged by the nurse according to discharge criteria or with the help of the PADS - score of Francis Chung. The use of discharge scoring lists from PACU to step down according to White / Aldrete and later home from the ward according to Chung is a reliable and easy specialist-led and nurse-run way of practicing Day Care. It is the anaesthesiologist who has the responsibility. Simply by scoring 2,1, or 0 the nurse takes control on vital signs as level of consciousness, hemodynamic parameters, pain, PONV etc. Information and education is provided. Finally the patient is going home, always together with a responsible adult escort for the first 24 hours. So trained nurse personnel can safely arrange the transition from the recovery room.
If the patient meets these criteria already on the OR at the end of surgery he can safely be fast tracked to the ward bypassing the PACU. A similar system is followed by the ward nurse in case of transition from the unit back home

Some words about the professional content:

Running an individual Day Surgery list or program means being a very pro-active perioperative physician. It is essential that you plan ahead, organise your Peripheral Nerve Blocks 2 hours before scheduled time, and gain your time later on the day! Use short acting agents, give good analgesia and try to minimise the incidence of post operative nausea and vomiting (PONV). The individual anaesthesiologist has to develop the techniques that permit the patients to undergo the day procedure with minimum stress, maximum comfort and yet optimal chance for early discharge by designing a technique that maximizes speed and quality of first and second stage of recovery.
It is beyond this abstract to cover the whole medical professional content of ambulatory anaesthesia; some striking and perhaps thought provoking issues will be discussed. Let’s focus on Patient Selection for DS.
Every planned day surgery patient should be considered on the classical main issues: procedure, patient factors, social factors and facility possibilities. Each of these should be compatible with Day Surgery. From the early 80’s when Day Surgery started, we have seen a constant shift to more liberal boundaries. Ever more complicated surgery on patients with ever more co morbidities was gradually performed as day cases and times changed the boundaries of every issue. A good example is duration of procedure - duration used to be confined to 90 minutes, but nowadays 3 to 4 hours is not unusual in day surgery. Currently in my own unit we have abandoned an upper age limit, whereas with expanding obesity the BMI-limits as only selection criterion have been upgraded to 40-45.
Many doctors still think only ASA 1 or 2 are allowed. Let me take this as an example of evidence based vanishing of limits to selection of day surgery patients. In many textbooks there are quotes of allowing ASA 3 in Day Care and already in the 90’s these texts were in the books but many doctors rejected the idea.

Some of the studies that helped included
  1. In a classical Mayo study of Warner (JAMA 1993; 270:1437) major morbidity and mortality 30 days after Day Surgery was followed. A total of 38,598 patients aged 18 years and older undergoing 45,090 consecutive ambulatory procedures and anesthetics. A quarter of them were ASA 3. No patient died of a medical complication within 1 week of surgery. Major morbidity was very low: 31 patients developed major morbidity (1:1455) Myocardial infarction, central nervous deficit, pulmonary embolism were all in low figures and often after 48 hours or longer present. Conclusion : In this big ambulatory surgical population overall morbidity and mortality rates were very low, equally distributed among the ASA 1,2 and 3 group.
  2. Chung and Mazei from Toronto (BJA 1999;83:262-70) estimated the risk of perioperative adverse events in patients with pre-existing conditions undergoing daycase surgery. They studied 17,638 consecutive daycase surgical patients in a prospective study. Preoperative, intraoperative and postoperative data were collected. Eighteen pre-existing conditions were considered. After adjusting for age, sex, and duration and type of surgery, seven associations between pre-existing medical conditions and perioperative adverse events were proven statistically significant. Hypertension predicted the occurrence of any intraoperative event and intraoperative cardiovascular events. Obesity predicted intraoperative and postoperative respiratory events, and smoking and asthma predicted postoperative respiratory events. Gastro-oesophageal reflux predicted intubation-related events.
  3. Ansell and Montgomery (BJA 2004;92:71-4) carried out a retrospective case controlled review of 896 ASA III patients who had undergone day case procedures between January 1998 and June 2002 using the existing computerized patient information system. The system records admission rates, unplanned contact with healthcare services and post-operative complications in the first 24 h after discharge. No significant (differences in unplanned admission rates, unplanned contact with health care services, or post-operative complications in the first 24 h after discharge between ASA III and ASA I or II patients. Conclusion: With good pre-assessment and adequate preparation ASA III patients can be treated safely in day surgery unit.
We all use the ASA qualification, probably without realizing ourselves that this deserves a critical approach!
  1. Another example of having too many views (subjectively) (The (ASA) Physical Status Classification was tested for consistency of use by 100 anaesthesiologists. They were asked to determine ASA grades to 10 hypothetical patients. In no case was there complete agreement on ASA grade, and in only one case were responses restricted to two of the five possible grades. So much variation was observed between individual anaesthesiologists. assessments when describing common clinical problems that the ASA grade alone cannot be considered to satisfactorily describe the physical status of a patient. (Anaesthesia 1995;50: 195)

In cases of doubt you might ask yourself, e.g. an ASA 4 (cardiac) patient with a painful anal fissure,: What would make the difference between in-and out-patient treatment? Would anything be done differently?? It is unlikely that a low dose spinal technique would deteriorate the situation. Excellent pain relief during operation, little hemodynamic disturbance, little impact from the surgery, but good pain relief.
So we can say stable ASA 3 is not a contraindication for day surgery, and ASA 4 has to be carefully evaluated on an individual basis with respect to the procedure.
Crucial it is to avoid mixed lists with the clinical part of the OR. Mixed lists threaten the smooth course of a DS-list by interfering with emergency or heavy clinical cases.
What about procedures? Minimally invasive techniques have dramatically reduced tissue injury and blood loss, and with growing understanding of nature and timing of surgical complications together with the ever improved anesthetic drugs and techniques the scope of potential Day Cases has widened very much. Individual front running teams often set an example, and gradually others follow these examples gradually.

Summary

Where day Surgery was once considered as specialized care suitable for only the simplest of procedures and carefully selected patients, it is now seen as the treatment of choice for many operations with patients only excluded if there are convincing reasons. So the medical risks have to be plotted against the degree of invasiveness of the surgical procedure: low, medium or high intensity procedures, and together with the individual fitness of the patient AND the possibilities of the facility the decision day surgery is taken very well considered. With a wide variety of adequate anesthetic techniques and the before mentioned widening of selection criteria and organizational prerequisites we probably can meet the double goal set by the NHS in the UK. In the UK the NHS and the Government are very actively promoting the practice of day surgery and they launched the next two goals:
  1. Day Surgery is the default for Surgery.
  2. 75% of procedures should be performed as Day Surgery cases

References
Anesth Analg 2007;104:1380–96 White, PF, Kehlet H et al The Role of the Anesthesiologist in Fast-Track Surgery: From Multimodal Analgesia to Perioperative Medical Care
Can J Anest 2006;53:9, 858-72 Imad Awad, T, Chung F Factors affecting recovery and discharge following ambulatory surgery
Anaesthesia 2006, 61, pages 1191–1199, Smith I, Cooke T, Jackson I and Fitzpatrick R Rising to the challenges of achieving day surgery targets