Hospital Based Pain Practitioners: Injections in Procedure Room vs. OR?

MedZeppelin

Member
10+ Year Member
7+ Year Member
Sep 7, 2008
57
3
Status
Fellow [Any Field]
This thread only applies to hospital based pain programs, but any others feel free to comment:

There was an issue brought to light recently at my hospital-based pain facility. Apparently, there is a movement to classify all procedures as "Invasive" vs. "Non-Invasive" to require performance in an Operating Room or Procedure Room. These guidelines are published in Facility Guidelines Institute 2014 recommendations for classification of hospital and ambulatory facilities. Apparently, Joint Commission utilizes these regulations to approve accreditation.
In a nutshell, it implies that all "Invasive Procedures" (penetrates protective surface of body, eg. Pain) should be performed in an operating room, and "Non-Invasive" should be performed in procedure rooms (percutaneous I.V.'s etc)

This move has significant implications, as it basically indicates that all pain procedures are considered "Invasive" and should be done in an OR, vs. the traditional Procedure Room/Fluoro Suite. I find it hard to believe that a facet nerve block and SI joint injection requires a full surgical prep and gown and be completed in an operating room? Do any other hospital based pain physicians have input regarding this issue?

Excerpt from Facility Guidelines Institute 2014 manual:

“Invasive procedure” is a broad term often used to describe procedures from a simple injection to a major surgical operation. For the purposes of the Guidelines, however, an invasive procedure is defined as a procedure that penetrates the protective surfaces of a patient’s body (e.g., skin or mucous membranes), is performed in an aseptic surgical field, generally requires entry into a body cavity, and may involve insertion of an indwelling foreign body. Such procedures must be performed in an operating room suitable to the technical requirements of the procedure with consideration of infection prevention and anesthetic risks and goals. The intent is to provide a safe environment for procedures that carry a high risk of infection, either by exposure of a usually sterile body cavity to the external environment or by implantation of a foreign object(s) into a normally sterile site. Procedures performed through orifices normally colonized with bacteria and percutaneous procedures that do not involve an incision deeper than skin are not included in this definition.

A "procedure room" is defined as a room for the performance of procedures that do not require an aseptic field but may require use of sterile instruments or supplies. Procedure rooms are considered unrestricted areas. Local anesthesia and minimal and moderate sedation may be administered in a procedure room, but anesthetic agents used in procedure rooms must not require special ventilation or scavenging equipment.

An "operating room (OR)" is defined as a room in the surgical suite that meets the requirements of a restricted area and is designated and equipped for performing surgical operations or other invasive procedures that require an aseptic field. Any form of anesthesia may be administered in an OR as long as appropriate anesthesia gas administration devices and exhaust systems are provided.


Any thoughts? Thx
 

lobelsteve

SDN Lifetime Donor
Lifetime Donor
10+ Year Member
May 30, 2005
13,567
3,452
Canton GA
www.stevenlobel.com
Status
Attending Physician
See other thread about hospitals controlling doctors.
And of course it is stupid. As is 99% of what admin makes folks do.
 
OP
MedZeppelin

MedZeppelin

Member
10+ Year Member
7+ Year Member
Sep 7, 2008
57
3
Status
Fellow [Any Field]
I agree! My argument is that many "invasive" procedures are performed every day outside of and operating room. For example, a labor epidural is placed in the patient's room, a thoracic epidural in the preop holding area, and knee joint injection in the ortho room. Are they now going to require all these "invasive" procedures be performed in the OR? Sounds impractical and misinformed.
 

SSdoc33

10+ Year Member
Apr 23, 2007
6,218
1,576
Status
Attending Physician
shouldnt not be done in an OR. in fact, i dont know of any hospitals that do their spine injections in an OR. not cost effective. not necessary.
 

Orin

7+ Year Member
Jul 27, 2009
720
271
Status
$terility brings revenue

There's a lot of wriggle room in that guidance to delineate "invasive" and also in how to delineate "OR" so I don't see anything coming from it here. It's definitely not designed to reduce costs or complexity but that isn't the purpose anyway of those organizations.

I do injections in both settings based primarily on availability of time/fluoroscopy/need for sedation. Trials/implants in an OR.
 

lobelsteve

SDN Lifetime Donor
Lifetime Donor
10+ Year Member
May 30, 2005
13,567
3,452
Canton GA
www.stevenlobel.com
Status
Attending Physician
shouldnt not be done in an OR. in fact, i dont know of any hospitals that do their spine injections in an OR. not cost effective. not necessary.
I do kypho, SCS, and gasserian RF in OR.
 

cowboydoc

2+ Year Member
Jan 2, 2016
414
256
Status
Attending Physician
I sure hope I'm an outlier, but all my fluoro procedures are done in our HOPD surgery center. It wastes a ton of time/resources and costs a fortune compared to office based procedures. My continued employment will likely be predicated on them bringing all non-sedation procedures into an in-office suite.
 

Ducttape

SDN Lifetime Donor
Lifetime Donor
7+ Year Member
Oct 7, 2011
8,195
1,987
Status
Attending Physician
no.... it does not behoove the system to do any procedures in an in-office suite. rather, it would financially more responsible to lower level administrators to force you to do all your procedures that require imaging at an ASC.

they cant milk the system doing procedures with in-office suite, unless they can declare your office as a HOPD (SOS 22, i believe).
 
OP
MedZeppelin

MedZeppelin

Member
10+ Year Member
7+ Year Member
Sep 7, 2008
57
3
Status
Fellow [Any Field]
In my opinion, this is another example of non-clinician bureaucrats attempting to dictate medical practice. They have no idea what interventional pain docs do, or the difference between "invasive" vs. "non-invasive". For SCS implants & IT pump implants, yes, absolutely in the OR. All other procedures, not necessary. That is inefficient and costly.
 

SSdoc33

10+ Year Member
Apr 23, 2007
6,218
1,576
Status
Attending Physician
I sure hope I'm an outlier, but all my fluoro procedures are done in our HOPD surgery center. It wastes a ton of time/resources and costs a fortune compared to office based procedures. My continued employment will likely be predicated on them bringing all non-sedation procedures into an in-office suite.
is this an ASC-type of setting or a full blown OR?
 

cowboydoc

2+ Year Member
Jan 2, 2016
414
256
Status
Attending Physician
It's functionally an ASC, but there is an associated "short stay" unit that is minimally used. There is discussion of moving some total joints to the location, so I think it would fit most definitions of "full blown OR."

The worst is when the hospital's nurse call center calls my patients for "pre-op" and scare the hell out of them while going off the general surgery script and telling them "NPO after midnight, you may have to stay overnight..." like they are getting general anesthesia for a MBB. (I'll give an oral benzo for MBB/ESIs <5% of the time)

They are "running the numbers" to see what bringing injections to clinic-based procedure room looks like. Very interested to see what that analysis looks like.

If I understand the OP correctly, a dentist would have to have an OR to do anything more than a cleaning? Sure, that makes sense. Drusso must be on vacation, as this thread would likely send him into orbit...
 

lobelsteve

SDN Lifetime Donor
Lifetime Donor
10+ Year Member
May 30, 2005
13,567
3,452
Canton GA
www.stevenlobel.com
Status
Attending Physician
It's functionally an ASC, but there is an associated "short stay" unit that is minimally used. There is discussion of moving some total joints to the location, so I think it would fit most definitions of "full blown OR."

The worst is when the hospital's nurse call center calls my patients for "pre-op" and scare the hell out of them while going off the general surgery script and telling them "NPO after midnight, you may have to stay overnight..." like they are getting general anesthesia for a MBB. (I'll give an oral benzo for MBB/ESIs <5% of the time)

They are "running the numbers" to see what bringing injections to clinic-based procedure room looks like. Very interested to see what that analysis looks like.

If I understand the OP correctly, a dentist would have to have an OR to do anything more than a cleaning? Sure, that makes sense. Drusso must be on vacation, as this thread would likely send him into orbit...
drusso in a low orbit hence his wifi inoperable until he is fully outside earths atmosphere.
 

drusso

Moderator Emeritus
Lifetime Donor
20+ Year Member
Nov 21, 1998
7,958
2,838
Over the rainbow
Status
Attending Physician
  • Like
Reactions: clubdeac