Presence in C/Sec

[Neogenesis]

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How many of you routinely leave the C/sec room prior to the pt rolling out of the OR? Meaning when the surgeons are closing. I heard about a group where this is common. They will leave the OR when closing to go do an epidural or roll the next section into the other OR. Never been my practice (admittedly do not do any L&D really now), so I was a little surprised. What is everyone's practice/comfort level with that? What are legal implications?

 

[Arch Guillotti]

If I sat my own cases (I don't), I would never leave the patient before the operation is over.

 

[psychbender]

This is only a good Idea if the resident or anesthetist that you are supervising is still in the room. If you're by yourself, I would not advise it.

 

[deleted171991]

If this is in a solo practice, there might be multiple problems here:
1. Billing anybody for that time is fraud. Ending anesthesia care before the end of the procedure seems like another no-no.
2. Even if it's fixed pay per service, it's still fraud.
3. If anything happens, it's patient abandonment.
4. It probably goes against a number of guidelines, and definitely against the standard of care. Generally, it seems indefensible, unless the anesthesiologist left the room to help in an emergency in the immediate vicinity (or similarly emergent Montezuma's revenge), and left the patient under surgical/nursing supervision.

 

[urge]

Doesn't sound like a great idea but I can see some yahoos doing it. To be honest the patient is not going to be much different now vs. 30 min later where the pacu nurse checks VS q 15 while focusing on her online shopping.

 

[deleted171991]

Doesn't sound like a great idea but I can see some yahoos doing it. To be honest the patient is not going to be much different now vs. 30 min later where the pacu nurse checks VS q 15 while focusing on her online shopping.

Yes, but there is a nurse following and responsible for the patient in the PACU.

If that PACU nurse came to the OR, and followed the patient there till the end of the surgery (under anesthesiologist supervision, while the anesthesiologist is not blocked in another procedure), it would be less debatable. One could argue that a dedicated (PACU) nurse would suffice at this stage.

 

[IlDestriero]

Never even heard of it.

 

[Urzuz]

You anesthetized them, you're responsible for them until the procedure is complete and a formal handoff has been given.

Would you feel comfortable or think it is okay to leave the OR before a MAC case is done to get another one started in the room next door? That's what this is analogous to IMO.

 

[BLADEMDA]

If I sat my own cases (I don't), I would never leave the patient before the operation is over.

You anesthetized them, you're responsible for them until the procedure is complete and a formal handoff has been given.

Would you feel comfortable or think it is okay to leave the OR before a MAC case is done to get another one started in the room next door? That's what this is analogous to IMO.

It's fraud at the worst and unethical at best to leave the room before the patient gets to PACU. I think we are all in agreement here that the only way we leave the O.R. before getting to PACU is if a qualified provider is present at all times ( don't you just love that term "qualified provider")

 

[Neogenesis]

Agreed with the responses from everyone. I was floored when I first heard it. But realizing that I am relatively new in the game I just had to see if this was just one of those, "in the real world out of residency" things. I'm glad to hear that people overwhelmingly think that it's a big no no

 

[Noyac]

It's fraud at the worst and unethical at best to leave the room before the patient gets to PACU. I think we are all in agreement here that the only way we leave the O.R. before getting to PACU is if a qualified provider is present at all times ( don't you just love that term "qualified provider")

Just to be devils advocate here, what exactly changes when we cross the doors to the PACU. To be more clear, if the anesthsiologist were to leave the case during skin closure and dressing and have a qualified PACU RN come into the room to assist with the transfer to PACU and that RN received full report as if you are in PACU, what's the difference. All the anesthesiologists would need to do is document full report given to PACU RN at such and such time and end his billing cycle there.

For the record, Iam not advocating this practice.

 

[Ezekiel2517]

I don't agree with it, but I'm not surprised if it's being done. In this group there is likely one anesthesiologist covering OB and the OBGYN's want to do their sections as quickly as possible. It's most likely a PA who is actually closing and prolly takes longer to close skin than it takes to perform the c-section.
I say I'm not surprised because I have seen the lengths some anesthesiologists go for the sake of surgeon satisfaction, even if it means risking pt safety

 

[Urzuz]

Just to be devils advocate here, what exactly changes when we cross the doors to the PACU. To be more clear, if the anesthsiologist were to leave the case during skin closure and dressing and have a qualified PACU RN come into the room to assist with the transfer to PACU and that RN received full report as if you are in PACU, what's the difference. All the anesthesiologists would need to do is document full report given to PACU RN at such and such time and end his billing cycle there.

For the record, Iam not advocating this practice.

That's like saying we have an ASA 1 patient who is having a laparoscopic cholecystectomy. Let me induce the patient, put the ETT in, and have the PACU RN just come and sit with the patient. What's the difference? What can go wrong? I'll give her full signout. She will let me know if anything goes wrong. I can then go start another case and have another PACU RN come and sit with that patient. Then I can go and sit on my fat ass in the lounge drinking coffee and stuffing my face with donuts while these nurses do my work for me. Does this situation sound familiar?

It's about professional integrity. The surgical tech who has scrubbed thousands of surgeries can close skin and probably even close fascia just as well as some surgeons can. But does a surgeon leave before the case is over? No. The attitude that you can leave when the job is half done yet you still deserve a fat paycheck is what has f@#%ed this specialty royally.

 

[PainDrain]

This is super sketchy. It basically patient abandonment, you are leaving them there isn a vulnerable state which you were helping them through until which point it became inconvenient.

On a similar note, I have heard of CV practices where the anesthesiologist leaves the roof while the patient is on bypass and returns when surgeon is ready to come off. That I feel is also patient abandoement but it apparently is very common.

 

[IlDestriero]

This is super sketchy. It basically patient abandonment, you are leaving them there isn a vulnerable state which you were helping them through until which point it became inconvenient.

On a similar note, I have heard of CV practices where the anesthesiologist leaves the roof while the patient is on bypass and returns when surgeon is ready to come off. That I feel is also patient abandoement but it apparently is very common.

I've definitely seen the latter, but at least in that situation the perfusionist is monitoring the vitals and labs and making necessary changes.

 

[Noyac]

That's like saying we have an ASA 1 patient who is having a laparoscopic cholecystectomy. Let me induce the patient, put the ETT in, and have the PACU RN just come and sit with the patient. What's the difference? What can go wrong? I'll give her full signout. She will let me know if anything goes wrong. I can then go start another case and have another PACU RN come and sit with that patient. Then I can go and sit on my fat ass in the lounge drinking coffee and stuffing my face with donuts while these nurses do my work for me. Does this situation sound familiar?

It's about professional integrity. The surgical tech who has scrubbed thousands of surgeries can close skin and probably even close fascia just as well as some surgeons can. But does a surgeon leave before the case is over? No. The attitude that you can leave when the job is half done yet you still deserve a fat paycheck is what has f@#%ed this specialty royally.

Whoa dude/chick! You are talking about an extremely different situation.
The lap Chloe is still under anesthesia, not recovering from anesthesia like our PACU pts.
The c/s is no longer receiving any anesthetic. It was placed over 30minutes ago. The pt is in no different state than when you drop them off in the PACU IN 5 minutes. What's the difference? What, a couple sutures are going into the skin? How is that gonna cause a problem? Assuming the pt doesn't feel the sutures, which I hope this anesthesiologist would know before leaving it pt to the RN, what's the big deal? Judgement is what is the difference here. I doubt anyone would turn this over if the pt was uncomfortable or nauseated, etc. But the vast majority of these pts are just ready to get out of the OR and otherwise no issues.

Also, how do you think crnas became such a big part of this specialty?

Full disclosure, I have never done this and do not plan too.

 

[Noyac]

On a similar note, I have heard of CV practices where the anesthesiologist leaves the roof while the patient is on bypass and returns when surgeon is ready to come off. That I feel is also patient abandoement but it apparently is very common.

I have done this thousands of times. What's the problem?

 

[Noyac]

This is super sketchy. It basically patient abandonment, you are leaving them there isn a vulnerable state which you were helping them through until which point it became inconvenient.

Inconvenient for whom? The pt that you just went and placed an epidural for? The pt who's baby was having decels and needed to get the F*ck out of her momma? The pt that was abrupting? The footing breech?

You have to be able to assess the circumstances and react. If you are the only one providing OB services and this sh-*t happens, are you gonna sit with a completely stable mom while they close her skin instead of calling in a PACU RN so you can make real things happen? It's a lodgical question. I know many people can't react lodgically in these situations for fear of what "might" happen.

 

[Noyac]

This is super sketchy. It basically patient abandonment, you are leaving them there isn a vulnerable state which you were helping them through until which point it became inconvenient.

Inconvenient for whom? The pt that you just went and placed an epidural for? The pt who's baby was having decels and needed to get the F*ck out of her momma? The pt that was abrupting? The footing breech?

You have to be able to assess the circumstances and react. If you are the only one providing OB services and this sh-*t happens, are you gonna sit with a completely stable mom while they close her skin instead of calling in a PACU RN so you can make real things happen? It's a lodgical question. I know many people can't react lodgically in these situations for fear of what "might" happen.

 

[Noyac]

This is super sketchy. It basically patient abandonment, you are leaving them there isn a vulnerable state which you were helping them through until which point it became inconvenient.

Inconvenient for whom? The pt that you just went and placed an epidural for? The pt who's baby was having decels and needed to get the F*ck out of her momma? The pt that was abrupting? The footing breech?

You have to be able to assess the circumstances and react. If you are the only one providing OB services and this sh-*t happens, are you gonna sit with a completely stable mom while they close her skin instead of calling in a PACU RN so you can make real things happen? It's a lodgical question. I know many people can't react lodgically in these situations for fear of what "might" happen.

 

[jwk]

Yes, but there is a nurse following and responsible for the patient in the PACU.

If that PACU nurse came to the OR, and followed the patient there till the end of the surgery (under anesthesiologist supervision, while the anesthesiologist is not blocked in another procedure), it would be less debatable. One could argue that a dedicated (PACU) nurse would suffice at this stage.

Sorry - this can't possibly be justified. It's abandonment.

 

[PainDrain]

Inconvenient for whom? The pt that you just went and placed an epidural for? The pt who's baby was having decels and needed to get the F*ck out of her momma? The pt that was abrupting? The footing breech?

You have to be able to assess the circumstances and react. If you are the only one providing OB services and this sh-*t happens, are you gonna sit with a completely stable mom while they close her skin instead of calling in a PACU RN so you can make real things happen? It's a lodgical question. I know many people can't react lodgically in these situations for fear of what "might" happen.

I can see under the circumstances you describe where another case presents itself and it is a true emergency I would obviously leave the c-section patient; but to leave to place an epidural, or worse, to tee up your next c-section who is waiting in the wings so the OBs can make it out by 3pm is ridiculous. Labor epidurals are elective. Also, if you are the only one around for OB during peak hours or at a busy institution that is also a problem and a disaster waiting to happen.

 

[Noyac]

Duplicate post

 

[Noyac]

I can see under the circumstances you describe where another case presents itself and it is a true emergency I would obviously leave the c-section patient; but to leave to place an epidural, or worse, to tee up your next c-section who is waiting in the wings so the OBs can make it out by 3pm is ridiculous. Labor epidurals are elective. Also, if you are the only one around for OB during peak hours or at a busy institution that is also a problem and a disaster waiting to happen.

Agreed!

 

[Noyac]

Sorry - this can't possibly be justified. It's abandonment.

So if the case were to have finished 10 minutes earlier you would have your pt in the care of the PACU. But instead the OR crew is taking their usually 10 min to apply the dressing and move to the bed. Is there "really" a difference here?

All I'm saying is that there are circumstance that might make this acceptable. That all.

 

[Urzuz]

Whoa dude/chick! You are talking about an extremely different situation.
The lap Chloe is still under anesthesia, not recovering from anesthesia like our PACU pts.
The c/s is no longer receiving any anesthetic. It was placed over 30minutes ago. The pt is in no different state than when you drop them off in the PACU IN 5 minutes. What's the difference? What, a couple sutures are going into the skin? How is that gonna cause a problem? Assuming the pt doesn't feel the sutures, which I hope this anesthesiologist would know before leaving it pt to the RN, what's the big deal? Judgement is what is the difference here. I doubt anyone would turn this over if the pt was uncomfortable or nauseated, etc. But the vast majority of these pts are just ready to get out of the OR and otherwise no issues.

Also, how do you think crnas became such a big part of this specialty?

Full disclosure, I have never done this and do not plan too.

Haha sorry, clearly I am just a little passionate and a lot bitter about this subject. I'm in a private practice MD-only group, and it just irks me thinking back to residency how there were attendings who would skate by doing the minimum amount of work possible, content with themselves sipping their fourth and fifth cups of coffee at 10am and feasting on an assortment of pastries, barely able to do a moderate risk case on an ASA 3 patient from start to finish, not bothering to teach one iota of anesthesia knowledge, getting angry at residents if they took an extra minute to take a piss during their break -- all while collecting a handsome paycheck every month. Clearly the post has nothing to do with this but I took it in that direction for whatever reason...sorry!

But getting back to the topic at hand, I see your point, but at the same time it's a slippery slope. What constitutes the "end" of the procedure? Sewing skin? Dressing being put on? Fascia?! Whenever I deem that there won't be any further major physiologic alterations? As mentioned above, I think it's justifiable to leave if you're doing another patient-related activity that demands your immediate attention. However, leaving so you can beat the lunchtime rush in the cafeteria would be indefensible in a court of law. I also think the example I gave above still stands -- imagine you are doing a MAC case (cataract, inguinal hernia, take your pick), and it's smooth sailing. No propofol, just a little midazolam and fentanyl. Is it justified to leave after the case is "pretty much" over...ie: just a couple sutures and a dressing to apply? Most would agree that you have to finish the case. Why? Because you anesthetized the patient. Whether it's scrambling a patient's brain with midaz/fent or interrupting nociceptive pain pathways with local anesthetic, both constitute anesthetizing the patient, and in both you enter into a tacit agreement that you will be there throughout the entire procedure, ie: nothing else "surgically" needs to be done!

 

[IlDestriero]

We used to do arm blocks in the pre op block area and send the patients down to the ortho procedure room for minor stuff all the time after confirming a good block. Was that abandonment as well? We weren't there for the procedure at all.

 

[San Marzano]

We used to do arm blocks in the pre op block area and send the patients down to the ortho procedure room for minor stuff all the time after confirming a good block. Was that abandonment as well? We weren't there for the procedure at all.

Where can we draw the line? Because we need to draw a line somewhere, or someone else will draw the line for us and not in our favor. I don't have enough experience to make that call.

 

[Planktonmd]

If the volume on the OB floor is requiring the anesthesia provider to leave the operating room to place epidurals this means they are understaffed and need more people.
It's OK to be flexible and efficient and It's OK to try to accommodate the needs and wishes of others but at the end of the day there has to be certain red lines or deal breakers, and leaving a patient unattended in an operating room is one of these situations.
Next thing they might ask you to do 2 c sections simultaneously!

 

[urge]

Inconvenient for whom? The pt that you just went and placed an epidural for? The pt who's baby was having decels and needed to get the F*ck out of her momma? The pt that was abrupting? The footing breech?

You have to be able to assess the circumstances and react. If you are the only one providing OB services and this sh-*t happens, are you gonna sit with a completely stable mom while they close her skin instead of calling in a PACU RN so you can make real things happen? It's a lodgical question. I know many people can't react lodgically in these situations for fear of what "might" happen.

I'm with Noyac on this. I wouldn't recommend it, but can see how every now and then it might be the lesser evil. Closing the chart and giving report to someone being necesary.

 

[Orin]

What do you document your anesthesia end time in these scenarios as?

 

[Noyac]

What do you document your anesthesia end time in these scenarios as?

I would document end time as the time I turned over to the RN. Plus I would be off to another task and would have documented a starting time there which can't overlap.

 

[jwk]

Where can we draw the line? Because we need to draw a line somewhere, or someone else will draw the line for us and not in our favor. I don't have enough experience to make that call.

I think for any case for which you are with the patient in the OR, such as the epidural C/S we're discussing, you can't abandon the patient prior to completion of the procedure. Once the "surgery end time" is noted, I think with an epidural C/S you could then sign off/hand off to the RN, especially in a place like ours where every L&D nurse is ACLS certified and cross-trained for L&D/OB-OR/PACU. I still don't think that is ideal, and it shouldn't be done just to keep the surgeon happy, but I think you've demonstrated some ongoing continuity of care at that point. I'm not sure leaving the patient before the end of the actual surgical procedure can otherwise be justified without medico-legal risk.

 

[dhb]

This is a funny read from my perspective.

 

[B-Bone]

I'm 100% sure that this isn't a judgement call, but rather is definitely very clearly spelled out by CMS/medicare/private insurers that they will not pay for overlapping solo care. They won't pay for a labor epidural that happened while you are signed into an OR case as the only anesthesia provider. They won't pay for two cases at once, even overlapping by a single minute. Any overlap invalidates reimbursement for the entirety of all involved cases/procedures. To attempt to bill for this sort of thing constitutes fraud, which is punishable by triple damage fines (at least where CMS is concerned). The only exception permitted is the "emergency of short duration" where the overlap is intended to last <15min and/or backup has been called. This also applies to ACT care where you try to bill for medical direction with > 4 cases concurrently, or 3 cases plus blocks (not including labor epidural placement). Even one minute of overlap means they can refuse reimbursement for the entirety of all cases involved in the overlap. You may not get caught, but aside from being shoddy care, you could lose the farm. There are several notable multimillion dollar judgements from the last few years.

 

[seinfeld]

ONce the procedure in completed a sign out to a PACU nurse could be conducted. Our PACU for OB are the same nurses as the circulator in the OR. Would save me 10 minutes if done in the OR. Obviously billing would end then too. Don't see the need for the rush in a normal circumstance

 

[chfo]

I think most people here do not understand abandonment.

1. Patient abandonment is a form of medical malpractice that occurs when a physician terminates the doctor-patient relationship without reasonable notice or a reasonable excuse, and fails to provide thepatient with an opportunity to find a qualified replacement care provider.

Abandonment is when you have a duty to your patient for care, but you do not uphold the standards of that duty and do not transfer care to another provider.

What is your duty during a C-section? If you performed a spinal anesthetic, and the baby has been delivered, and patient's surgical bleeding is under control, and you have given no other medications besides the usual post-partum medications (oxytocin, etc, which are "ordered" by the OB anyways), then your duty has been fulfilled. You sign out your patient to a "PACU" nurse, which in OB means just a floor nurse who is on PACU duty that day. No patient abandonment at this point.

However, if you have done anything other than a spinal (eg general, epidural, sedation), then it is patient abandonment to sign out the care to a PACU nurse because the anesthetic is not complete. and you are not transferring care to another qualified provider.

Anesthesia stop time is not the same as procedure stop time. One can be after or before the other, depending on the circumstances. If you are involved in the anesthetic, and you are in the room (or have qualified provider in the room) the whole time, then all that time is billable. It is not fraud to sign out to a PACU nurse at closure and document end of anesthesia.

 

[Urzuz]

However, if you have done anything other than a spinal (eg general, epidural, sedation), then it is patient abandonment to sign out the care to a PACU nurse because the anesthetic is not complete. and you are not transferring care to another qualified provider.

What? Why is a spinal so special versus an epidural or sedation? Just because they have a polyurethane tube sitting in their back that means that the anesthetic isn't complete, but it is complete even if they have hyperbaric bupivacaine swirling around intrathecally? What if you don't plan on giving anything more through the epidural, you are just going to pull the catheter afterwards, and they are sewing skin? Isn't your "duty" still fulfilled? And your example of sedation makes even less sense -- just because they may have a little midazolam and fentanyl in their system that means that your duty isn't complete? In that circumstance your duty wouldn't ever finish until the patient metabolizes those drugs. Again, what if they are on skin and going to put the dressing on right afterwards? I would argue that having patients that have a spinal, can't move their legs, have a functional sympathecomy, and may be hypotensive, probably are at HIGHER risk for things going wrong than a patient under minimal sedation.

As I argued above, I don't believe you should leave the patient until the surgery is complete and you have given complete a complete handoff. To suggest that a single-shot spinal is somehow different versus an epidural or sedation makes no sense to me.

 

[Twiggidy]

[QUOTE="PainDrain, post: 16533136, member: 636804"

On a similar note, I have heard of CV practices where the anesthesiologist leaves the roof while the patient is on bypass and returns when surgeon is ready to come off. That I feel is also patient abandoement but it apparently is very common.[/QUOTE]

1000% percent disagree. Once bypass is initiated the vent is turned off and the only reason the monitor is on is so the perfusionist can monitored the arterial cannula and cardioplegia pressures (possibly CVP if venous cannula isn't giving good SVC drainage). We're there to move the table, which is something the OR nurse can do. Therefore, there is no problem with the anesthesiologist stepping out to hit the head or grabbing a quick bite if all else is normal. This is not the same as leaving a C/S with an awake patient who could still have fluctuating hemodynamics and the possibility of feeling pain or nausea. It's bad form and an embarrassment to our profession. The next C/S can wait, heck, the next epidural can wait (my apologies to all the female anesthesiologists on here who gone through labor pain. I know this is a pain I'll never understand)