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I think this is highly irregular and a recipe for disaster. The ED docs should not provide general anesthesia, except for minutes (e.g. for reducing shoulder dislocations). If this a habit in you hospital, maybe you should create a dedicated non-OR anesthesia location, staffed by anesthesia when needed.However, they also provide GA for cases such as suturing up a hand or similar procedures.
The argument they often use is that the OR is full and it would take too long to post a case and so the plastic surgeons or whomever want the GA in the ER so they can do the case.
I am an anesthesiology-trained pain doc and am on the medical executive board at my local hospital. The Emergency docs at this hospital were providing general anesthesia in the ER for cases but that was changed recently (after a CMS review and bylaw changes). They have now applied for privileges for general anesthesia to bypass the bylaws and it is up for a vote.
I have been looking for any relevant info on pros/cons other than CMS guidelines which are now in place... Any one have anything else for this?
Thanks in advance.
The ASA has guidelines for "delineation of clinical privileges in anesthesiology", search their website under the Standards, Guidelines, and Statements section.
I think it's a bad idea to try to credential somebody for administering anesthesia that isn't trained in it (didn't complete a residency in it). What they need to stick with is "procedural sedation" and if they need to rescue their sedation with an airway (intubation), then so be it. But that would be a QA event and flagged for review IMHO.
Also pretty sure ED societies have guidelines suggesting that the person doing the procedure can't be the one doing the sedation.
so what is this guy actually doing?
is he inducing, paralyzing, intubating patients for procedures >30 min then extubating in the ED and discharging them home?
This is exactly what he is doing. Scary.
Wow.This is exactly what he is doing. Scary.
Are you all not aware that Emergency Medicine docs have no limitations in what they are experts in? If you doubt this statement, just ask them.
It is rural but fully staffed by Anesthesia who covers 24/7 in house. In addition, we have virtually all other specialties including Neurosurgery, ENT, ortho, etc.
We are a regional hospital and draw on 250,000+
Are you all not aware that Emergency Medicine docs have no limitations in what they are experts in? If you doubt this statement, just ask them.
Question for OP. Does the ED doc keep an anesthesia machine down there or is he running TIVAs?
Nobody has mentioned The Joint Commission yet, but I can imagine that this practice runs afoul of numerous Joint Commission standards.
This is wrong on so many different levels. Among other things...Thanks for the questions. I will try to provide some answers.
1. The ER docs are providing GA. He often provides the GA AND the procedure (definite issues there). However, they also provide GA for cases such as suturing up a hand or similar procedures.
2. They have capnography and full monitoring. There record keeping has been poor and that was part of the issue when CMS came.
3. They are recovering in the ER. They probably do not have an appropriate RN-to pt staffing ratio.
4. The hospital has nothing to gain and everything to lose. He main driver of this is rather head-strong and thinks he can do anything.
The argument they often use is that the OR is full and it would take too long to post a case and so the plastic surgeons or whomever want the GA in the ER so they can do the case.
Maybe I've been exposed to bad practice... But, usually when someone presents to the ED, GCS <8 or can't protect their airway the EM doc induces them, gives some roc or sux and then tubes them... right? I've definitely seen an induction/intubation and then a propofol TIVA running on someone in the ED for at least a few hours sometimes (bed issue, ICU backlogged etc etc). And, there most certainly isn't 1 on 1 nursing care. They're on a monitor of course.
If they're giving an anesthetic AND doing the TEE, then yes, that's a problem.Please read my post above about how I feel the practice of the OP's "friend" in the ED is well beyond the traditional scope of emergency medicine and certainly well beyond the scope of "typical" practice in emergency medicine before responding to this post.
However, I am starting to wonder if what is being discussed is really "that far" out there.
Do the anesthesiologists here feel CCM docs should not be intubating and then extubating for diagnostic TEE?
And if you have no problem with that, please explain how that is different than an EM doc (who likely has more airway and sedation/analgesia experience) intubating and extubating for an urgent or emergent therapeutic procedure?
HH
If they're giving an anesthetic AND doing the TEE, then yes, that's a problem.
If they're giving an anesthetic AND doing the TEE, then yes, that's a problem.
I actually prefer to call general anesthesia controlled coma. That's exactly how I describe it to my more inquisitive patients.One of my attendings described what we do very succinctly: we perform controlled poisoning of the patient, and are able to recover them from it.