Anesthesia Delays

[Triple AAA]

This is something I've wondered about since the start of my CA-1 year. One of the most frustrating parts of my daily routine was (and in some instances, continues to be) the fact that we are expected to curtail a thorough H + P, explanation of risk, benefits, etc. of anesthesia, etc. for the sake of time, while the surgeons/proceduralists may take their sweet time doing so. To cause of a delay would further incur punishment, almost universally, in both private practice and academics.

Yes, I understand that 'that's just the way it is'. But does anybody know why such rules were ever enacted in the first place? Or why it is frowned upon to cancel/delay a case that is legitimately unsafe?

---

Members don't see this ad.

 

[deleted171991]

Because you are just a servant of the mighty surgeon.

 

[Triple AAA]

Is that really all there is to it? Surgeons made this rule on their own, without any say given to anesthesiologists? And everyone just followed it blindly?

 

[psychbender]

We don't bring patients (and their insurance dollars) to the OR, the surgeons do. Therefore, any delay on our part to properly care for the patient and limit the risk to patient/surgeon/us/hospital, is viewed as eating into the bottom line.

 

[deleted171991]

Is that really all there is to it? Surgeons made this rule on their own, without any say given to anesthesiologists? And everyone just followed it blindly?

Safety comes after profit. If this were not the case, nobody would dare to push for faster, borderline unsafe, turnovers.

For the facility, OR time is money, non-OR time is lost money. For the surgeons, generally, the profit is per procedure; the more they can operate, the more money they make. Nobody makes money between cases, not even anesthesiologists. And for the beancounters, that's ALL that matters.

Now if you want proof that you are like a servant (and not an independent professional), see what happens when a surgery is delayed by you versus the surgeon/proceduralist, especially in private practice.

 

[Triple AAA]

We don't bring patients (and their insurance dollars) to the OR, the surgeons do. Therefore, any delay on our part to properly care for the patient and limit the risk to patient/surgeon/us/hospital, is viewed as eating into the bottom line.

Safety comes after profit. If this were not the case, nobody would dare to push for faster, borderline unsafe, turnovers.

For the facility, OR time is money, non-OR time is lost money. For the surgeons, generally, the profit is per procedure; the more they can operate, the more money they make. Nobody makes money between cases, not even anesthesiologists. And for the beancounters, that's ALL that matters.

Now if you want proof that you are like a servant (and not an independent professional), see what happens when a surgery is delayed by you versus the surgeon/proceduralist, especially in private practice.

Ethical issues aside, I would have no problem with the policy IF any of this was even a remotely acceptable defense in a court of law. I ask this of many of you more experienced than myself, who may have dealt with these issues before. How are we to protect ourselves from liability with these inane policies?

 

[Euripides]

This is something I've wondered about since the start of my CA-1 year. One of the most frustrating parts of my daily routine was (and in some instances, continues to be) the fact that we are expected to curtail a thorough H + P, explanation of risk, benefits, etc. of anesthesia, etc. for the sake of time, while the surgeons/proceduralists may take their sweet time doing so. To cause of a delay would further incur punishment, almost universally, in both private practice and academics.

Yes, I understand that 'that's just the way it is'. But does anybody know why such rules were ever enacted in the first place? Or why it is frowned upon to cancel/delay a case that is legitimately unsafe?

With respect, you aren't asking the right question. The better question is why are you (or we) getting the information and communication opportunity so late in the process. This is a workflow issue and is related to systems theory thinking which all of the MBAs of the world take as second nature. In my experience surgeons don't mind at all when a case is rescheduled if I made an attempt to intervene so as to minimize the disruption to the patient and surgeon. What irritates them the most is when anesthesiologists don't try to improve the system and just casually cancel or delay cases that could have been rescheduled or started on time with just a little advance work.

A better designed preop preparation process will mitigate this issue and this is the value creation strategy that ASA is hoping catches on with us as perioperative physicians. Most of our fellow physician colleagues don't want to expend the effort to fix the problem unfortunately because it requires extra effort on our part and more than meeting the patient five minutes ahead of schedule. The larger practices and AMCs are now starting to put PAs and even hospitalists/primary care docs in clinics and to use technologies like telemedicine to streamline the preop process and reduce cancellations and delays. My practice has done the former with great effect and has spoken with some of telemedicine vendors about doing the latter.

I suspect that this issue is at least a partial explanation for why Mednax bought the consulting firm Surgical Directions which they announced on their last earnings call. (I am not affiliated with Mednax or Surgical Directions btw).

Finally, academic anesthesiology is woefully behind in teaching workflow and systems skills to anesthesia residents. I believe that because they have a closed shop with no fear of competition (the "contract" going out to bid) the academic programs feel that a focus on service isn't necessary.

 

[Noyac]

Or you could look at it another way. If you delay all your cases 5-10min so that you can adequately review the H&P then you have lost anywhere from 20-60 mins. That is significant in my book. If I were in an "eat what you kill" type practice, that is enough to pick up another case at the end of the schedule. Or even better yet, this means I have another hour of daylight to enjoy when the work is done.

It may seem intimidating now to have to review so much history prior to surgery in a short amount of time but trust me the longer you do this job the easier and more efficient you will be. You will be asking "what's taking so long".

 

[pgg]

I take as much time as I think I need to eval the chart and talk to the patient to give a safe anesthetic to a reasonably informed patient. I don't think I need very much time at all, 98% of the time, because all of the places I've worked since residency have had a solid preop process ... with few exceptions, mostly connected to a specific handful of bad surgeons.

 

[IlDestriero]

My academic practice takes adding value and reducing AVOIDABLE delays and long turnovers very seriously.
We have NPs in a pre op clinic that screen and schedule in house visits for complex patients. They then make sure tests, records, etc. are ordered as needed. We have a physician assigned as their contact person every day. That physician is also responsible for preassigning the most complex patients so that the attending anesthesiologist has a heads up and plenty of time to review things and develop an appropriate plan.
That efficiency and pathway adds value to the system and improves throughput. That translates to more dollars for everyone and probably improved safety.