Association of Anesthesiologist Staffing Ratio With Surgical Patient Morbidity and Mortality

[jwk]

At what point is the surgical consult note put in and the case request booked? You're telling me a patient is admitted overnight, booked, and brought to pre-op.... but a surgeon hasn't even laid eyes on them? I think you're missing some details there, but regardless, at some point they meet their surgeon...and then the surgeon they meet is the one who actually does the procedure, right?

Not missing any details - but the rest is correct.

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[vector2]

Not missing any details - but the rest is correct.

So what you're saying is an EM physician +/- an IM physician are engaging in surgical decision making without an actual general surgeon doing a consultation first. Yeah that makes sense.

 

[Dr. Rude]

Has anyone heard about a response to the publication from AANA or state society of NAs? Any Univ of Michigan folks on this board? lead author is from there. Wonder how it went over with their CRNAs.

 

[DocVapor]

So what you're saying is an EM physician +/- an IM physician are engaging in surgical decision making without an actual general surgeon doing a consultation first. Yeah that makes sense.

ER docs, after ignoring a patient with abdominal pain for 10 hours, finally do a CT at 8 pm which shows a hot appy, they call surgeon at 11 pm. Surgeon, without schlupping in to ER at midnight calls OR to post case to follow their usual OR schedule. Surgeon #1 finally rounds on them in between their first and second case it the day. Surgeon #1's partner ends up finishing first and picks up the case. Surgeon #2 sees patient in holding 5 minutes beforehand and gets new consent.

This happens frequently at my place.

Edited for spelling.

 

[vector2]

ER docs, after ignoring a patient with abdominal pain for 10 hours, finally do a CT at 8 pm which shows a hot sppy, they call surgeon at 11 pm. Surgeon, without shlupping in to ER at midnight calls OR to post case to follow their usual OR schedule. Surgeon #1 finally rounds on them in between their first and second case it the day. Surgeon #1's partner ends up finishing first and picks up the case. Surgeon #2 sees patient in holding 5 minutes beforehand and gets new consent.

This happens frequently at my place.

In your scenario, the surgeon (even though they didn't come in) has actually reviewed the ED physician's history, the labs, and the scan before finally posting the case himself. I.e. a surgeon ultimately made the surgical decision making.

Maybe I missed something but @jwk didn't make any mention that a surgeon was involved at all (even by phone) in the time the pt arrives to the ED, is admitted, booked, and then transported to pre-op in the morning. Even when I prompted that there must be some missing detail about the surgeon's involvement at the time of admission and case booking he said nope. Perhaps he can clarify whether in his scenario the surgeon is curbsiding from home and posting the case.

 

[anesussy]

Has anyone heard about a response to the publication from AANA or state society of NAs? Any Univ of Michigan folks on this board? lead author is from there. Wonder how it went over with their CRNAs.

I mean, wasn't it Beaumont that had the routine colonoscopy death a while back from a crna being "supervised" by an anesthesiologist who was "supervising" like 7 other crnas?

If the Michigan crnas are that incensed they can head over to Beaumont and play doctor I guess

 

[DocVapor]

In your scenario, the surgeon (even though they didn't come in) has actually reviewed the ED physician's history, the labs, and the scan before finally posting the case himself. I.e. a surgeon ultimately made the surgical decision making.

Maybe I missed something but @jwk didn't make any mention that a surgeon was involved at all (even by phone) in the time the pt arrives to the ED, is admitted, booked, and then transported to pre-op in the morning. Even when I prompted that there must be some missing detail about the surgeon's involvement at the time of admission and case booking he said nope. Perhaps he can clarify whether in his scenario the surgeon is curbsiding from home and posting the case.

I can see that, I may have missed that clarification in your post too.

 

[jwk]

So what you're saying is an EM physician +/- an IM physician are engaging in surgical decision making without an actual general surgeon doing a consultation first. Yeah that makes sense.

In your scenario, the surgeon (even though they didn't come in) has actually reviewed the ED physician's history, the labs, and the scan before finally posting the case himself. I.e. a surgeon ultimately made the surgical decision making.

Maybe I missed something but @jwk didn't make any mention that a surgeon was involved at all (even by phone) in the time the pt arrives to the ED, is admitted, booked, and then transported to pre-op in the morning. Even when I prompted that there must be some missing detail about the surgeon's involvement at the time of admission and case booking he said nope. Perhaps he can clarify whether in his scenario the surgeon is curbsiding from home and posting the case.

The surgeon on call overnight is probably informed about the case, tells the ER folks to admit the patient and tell them they'll have surgery in the AM - all without actually meeting the patient. We have an on-call surgery room each morning for these kinds of cases. As often as not, the case hasn't even been posted by 7am, but the OR is set aside anyway. The case is done by a different on call surgeon who comes on duty at 7am, and meets the patient for the first time in pre-op.

 

[Urzuz]

The surgeon on call overnight is probably informed about the case, tells the ER folks to admit the patient and tell them they'll have surgery in the AM - all without actually meeting the patient. We have an on-call surgery room each morning for these kinds of cases. As often as not, the case hasn't even been posted by 7am, but the OR is set aside anyway. The case is done by a different on call surgeon who comes on duty at 7am, and meets the patient for the first time in pre-op.

Yes we have a similar system when a patient has HMO insurance and comes in overnight for an urgent (but non-emergent) surgery.

Patient comes to ED at 2am with appendicitis and gets worked up by ED physician. ED doc places a call to the on-call surgeon and tells them about the patient. The on-call surgeon makes the patient NPO, calls the OR, and books the case the next morning for one of his/her partners (all from the comfort of their bed). New surgeon the next morning meets the patient in the preop holding area to go over surgery.

I’m not justifying the assembly-line approach To OR cases — in fact, my aversion to this is a huge reason why I choose to work in MD only private practice for less pay. But many physician groups have adopted this assembly-line approach to try to get cases done while maintaining some semblance of quality of life. The most egregious example of this in our hospital is with our IR guys — they have a line of cases on the board every day and will literally just go down the line, utilizing two rooms, and just churn them out as quickly as possible, knowing literally nothing about the patients they are sticking needles and tubes into. They also have an NP that will do “easy” things like thoracenteses etc by herself with “supervision” from them.

 

[coffeebythelake]

the problem is everyone thinks we are replaceable by nurses, or at least it is OKAY to replace us with nurses.

That's not true. The hospital administration and bean-counters would like to think so. For them it's all about the money.
But the vast majority of patients want physicians and physician-lead anesthesia care.

 

[vector2]

But the vast majority of patients want physicians and physician-lead anesthesia care.

I actually think the vast majority of patients (at least in my neck of the woods) are totally oblivious to whether "Jeff with Anesthesia" is a nurse or a doctor or what his training entailed...... as long as they go to sleep and wake up and nothing majorly wrong happens. And it's that way because the ASA and anesthesiologists in general continue to do a terrible job educating the public about who plays what role in their anesthesia care. Hell, when most other physicians and medical professionals have such little idea what we do, how could we possibly expect the public to do better?

 

[anbuitachi]

That's not true. The hospital administration and bean-counters would like to think so. For them it's all about the money.
But the vast majority of patients want physicians and physician-lead anesthesia care.

vast majority of the patients do not know the difference.
if one day soon crnas start introducing them as Dr blah blah, patients will not bat an eye.

 

[vector2]

Let me just reiterate that when surgeons admit appys from home over the phone, when OBs defer their 6pm section to the OB hospitalist, or when IR or GI docs meet their pts that morning and clear the procedure list de novo each day, the vast majority of those physicians made the decision *themselves* to run their respective practices that way.

That is the salient difference here. On the other hand, most anesthesiologists who supervise 1:4 are not like the docs in mman's or jwk's groups, I.e. true private practice MDs (+ probably bigwigs on all the hospital boards/committees) who get to strictly decide how they're going to structure their first starts or induction policies. It's one thing to have no problem with the CRNA calling another MD to start your room because your group is a cohesive band of carefully chosen people who all decided that's the way you all want it. It's another thing entirely to be forced to do that because your group has no control and administration doesn't care if a random MD starts the room with the CRNA, the CRNA calls a second CRNA, or they just goes to sleep solo because you were tied up. S'all I'm saying.