Would you do this case?

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Would you do this case?

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Our fast surgeons don't care because they care about their patients doing well and they care about patients not clogging up pacu so they can keep doing their cases. The slow ones are always an hour behind schedule halfway through the day. Their patients stay in pacu forever getting a boatload of dilaudid, hypoventilating while complaining of pain, etc. It's seriously annoying to constantly get pacu phone calls on that surgeon's patients when you're trying to start the next case.

I would rather block in the OR when I control everything with all my supplies there. I know of a few patients who have went apneic or even coded from sedation. If they want to save 5 minutes they can close faster.
 
Has anyone done a suprascapular nerve block for these types of cases? They came up in my MOCA Minutes questions recently. They look intriguing, especially for patients that I may worry about phrenic nerve paralysis.
 
GassYous said:
Our fast surgeons don't care because they care about their patients doing well and they care about patients not clogging up pacu so they can keep doing their cases. The slow ones are always an hour behind schedule halfway through the day. Their patients stay in pacu forever getting a boatload of dilaudid, hypoventilating while complaining of pain, etc. It's seriously annoying to constantly get pacu phone calls on that surgeon's patients when you're trying to start the next case.

I would rather block in the OR when I control everything with all my supplies there. I know of a few patients who have went apneic or even coded from sedation. If they want to save 5 minutes they can close faster.
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This ! After center realized discharging patients were being delayed because of pain, they all asking for blocks. Show them the money and they will follow. Many of these ASCs guy don’t give a **** about patient , just how much RVUs they generate
 
NICMAN said:
One had an LAD aneurysm 3 cm large. The cardiologist never saw anything like it. ESRD Pt with normal labs, dialysed day before with a good functional status of 8 METS or so…

it is a numbers game. It is best to make the odds be in your favor.
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if you’re going to let one-off events influence your medical decision making on every subsequent patient you take care of, you better have CPB on standby and draw up epinephrine even on the ASA 1 patient who is having a bunionectomy.

the odds are strongly in your favor that, if you do the anesthetic your way (eg: you block the patient and run a light GA), this patient does fine and goes home an hour after the surgery ends. Can bad **** happen? Sure. Is this guy more prone to developing a complication than an ASA 1? Of course. No one can put a number on the rate of complications though.

As long as his functional status is OK and the surgeon simmers down in terms of trying to dictate the anesthetic, I would feel fine anesthetizing the dude at our outpatient facility.
 
Urzuz said:
if you’re going to let one-off events influence your medical decision making on every subsequent patient you take care of, you better have CPB on standby and draw up epinephrine even on the ASA 1 patient who is having a bunionectomy.

the odds are strongly in your favor that, if you do the anesthetic your way (eg: you block the patient and run a light GA), this patient does fine and goes home an hour after the surgery ends. Can bad **** happen? Sure. Is this guy more prone to developing a complication than an ASA 1? Of course. No one can put a number on the rate of complications though.

As long as his functional status is OK and the surgeon simmers down in terms of trying to dictate the anesthetic, I would feel fine anesthetizing the dude at our outpatient facility.
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If you want to run your shop that way then by all means. If you want RCRI 3s and 4s doing category 2 and 3 surgeries at your shop then again, that contrast to my quality numbers only helps me. You want to be doing shoulder surgery on a patient with a MACE risk of >5% at your freestanding center then ok. All I am saying is this is the way I do things and I am confident in our outcomes and track record. My surgeons don’t see me as the roadblock but the quality enforcer. Safety and quality above all else including individual scheduling convenience.

My shop is the kind of place where nearly all the physicians who know, their families and friends in this corner of the state go when they want an orthopedic total joint or sports procedure. People can judge the quality for themselves.
 
I remember the hospital President at one point wanted to generate some revenue and was looking at doing vascular access patients at one of our hospital attached ASCs.
All our director of that site had to do was ask the vascular surgeon to give his 30-day mortality and ICU admission numbers and that idea got shut down real fast. He said the look on the admin’s face was priceless when the surgeon said “not bad, something like 4 or 5% mortality”.
 
NICMAN said:
If you want to run your shop that way then by all means. If you want RCRI 3s and 4s doing category 2 and 3 surgeries at your shop then again, that contrast to my quality numbers only helps me. You want to be doing shoulder surgery on a patient with a MACE risk of >5% at your freestanding center then ok. All I am saying is this is the way I do things and I am confident in our outcomes and track record. My surgeons don’t see me as the roadblock but the quality enforcer. Safety and quality above all else including individual scheduling convenience.

My shop is the kind of place where nearly all the physicians who know, their families and friends in this corner of the state go when they want an orthopedic total joint or sports procedure. People can judge the quality for themselves.
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Got it, your ASA 1-2s have good outcomes. Must be some magical propofol in your part of the country 🙄

FWIW our outpatient center is connected to our tertiary care center, so we have the liberty of being maybe more aggressive with the patients we anesthetize here.

That being said, I would do this case with every intention of discharging him home from PACU.
 
abolt18 said:
Few weeks ago I had a patient coming for lumpectomy who also happened to have active chest pain with < 4 METS. She saw a cardiologist the week before the scheduled surgery. Patient says "the cardiologist said i was okay to have surgery". Problem is, the cardiologist also scheduled her for a chemical stress test and an echo in a month...

His clinic note was incomplete without any assessment/plan filled out. I called the cardiologist and he didn't have recollection of the details of the clinic visit. So i asked him to get her stress test and echo moved up sooner, so as to not delay surgery a whole month, and cancelled the case.

To make matters worse, she had made it through our anesthesia pre-op clinic.
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Wonder what would have happened if the patient just lied and said they didn't have chest pain?
 
watermelon master said:
Wonder what would have happened if the patient just lied and said they didn't have chest pain?
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Likely nothing.

Stress test was negative. Echo was normal. She had her surgery last week uneventfully. But that's not the point.

Undifferentiated chest pain, saw cardiology, who wanted additional studies and didn't have a complete note to qualify their assessment and plan or justify the reason for wanting additional studies.

This lady has a heart attack and dies, the question is going to be "so you mean, this was a non-urgent surgery, and you proceeded knowing full well that she had an incomplete workup of her exertional chest pain?!¡?!?"

But you're right, if she lies to me and she dies of cardiac arrest due to undiagnosed left main disease, then that's her bad, not mine. (But I'm still going to feel bad about it)
 
NICMAN said:
If you want to run your shop that way then by all means. If you want RCRI 3s and 4s doing category 2 and 3 surgeries at your shop then again, that contrast to my quality numbers only helps me. You want to be doing shoulder surgery on a patient with a MACE risk of >5% at your freestanding center then ok.
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No offense, but you don't really seem to know what you are talking about.

From a modified Goldman risk calculator, simply using insulin or having a creatinine of 2.0 or having had a TIA 10 years ago puts you at >5% risk of having MACE postoperatively. Are you telling me you have never done a shoulder scope on a diabetic that takes insulin in an outpatient surgery center?

I mean even in the highest of ivory towers they would laugh at you for that stance, let alone out here in the real world.



The thing with most postoperative bad events is that doing the case at the hospital isn't going to prevent it. Things like postop MIs almost never happen in PACU. They happen days later. We all feel better about ourselves doing a case in a hospital and getting the patient through it and then they still drop dead on POD 4 at home.

I'm not arguing we should all be crazy and do every single thing that shows up in a surgery center, but it's also idiocy to get all high and mighty and act like we are doing the world a favor and providing better care by taking every patient with hypertension and admitting them to the ICU postop.

Things that make me want to do a case at the hospital include needing invasive monitoring and likely need for postop admission/observation.
 
NICMAN said:
If you want to run your shop that way then by all means. If you want RCRI 3s and 4s doing category 2 and 3 surgeries at your shop then again, that contrast to my quality numbers only helps me. You want to be doing shoulder surgery on a patient with a MACE risk of >5% at your freestanding center then ok. All I am saying is this is the way I do things and I am confident in our outcomes and track record. My surgeons don’t see me as the roadblock but the quality enforcer. Safety and quality above all else including individual scheduling convenience.
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NICMAN said:
My shop is the kind of place where nearly all the physicians who know, their families and friends in this corner of the state go when they want an orthopedic total joint or sports procedure. People can judge the quality for themselves.
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How nice for you. The rest of us practice in the real world where cases need to get done and individual surgeons don’t give a $hit about the overall numbers of a random ASC. the question I ask myself before every case is 1. Can I handle this airway. 2. Do I think it is somewhat likely that this patient is going to have some cardiac or pulmonary event that I won’t be able to manage. If the answer to question 1 is yes and to question 2 is no, then we are going to sleep…
 
Mman said:
No offense, but you don't really seem to know what you are talking about.

From a modified Goldman risk calculator, simply using insulin or having a creatinine of 2.0 or having had a TIA 10 years ago puts you at >5% risk of having MACE postoperatively. Are you telling me you have never done a shoulder scope on a diabetic that takes insulin in an outpatient surgery center?

I mean even in the highest of ivory towers they would laugh at you for that stance, let alone out here in the real world.



The thing with most postoperative bad events is that doing the case at the hospital isn't going to prevent it. Things like postop MIs almost never happen in PACU. They happen days later. We all feel better about ourselves doing a case in a hospital and getting the patient through it and then they still drop dead on POD 4 at home.

I'm not arguing we should all be crazy and do every single thing that shows up in a surgery center, but it's also idiocy to get all high and mighty and act like we are doing the world a favor and providing better care by taking every patient with hypertension and admitting them to the ICU postop.

Things that make me want to do a case at the hospital include needing invasive monitoring and likely need for postop admission/observation.
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Are you kidding me? The patient in question had 3 risk factors which is a LOT more than a MACE rate of 5%. You are both arguing that I am grossly underestimating the risk based on published statistics and then in the same breath saying I should just do it in a freestanding ASC anyways...

I used >5% as my benchmark not because I "don't know what I am talking about" but because I think those statistics you cite are inflated for our practice. I do the statistics for my group for all adverse events for over 40,000 cases (NOT including ASC, OB or Endo) that we do at several community hospitals and a Level 1 trauma center. And you know what? Even for our level 1 trauma center where everybody is a BMI of 35 or more, on insulin, had a CVA/MI/CHF and/or has CKD3-4; EVEN at this sickest hospital in this region--the rate of MACE for noncardiac surgery from our inside statistics doesn't even come close to 3.8%--which is the risk for ZERO risk factors. And yes, we capture all the data up to 30 days post-op. Does anybody in this forum really believe that from your experience you all have 1 episode of MACE for healthy adults >45 for every 27 surgeries you do? that is, what, 1-2 per week??? Are you kidding me? Have you even logged into the NACOR registry to see what the benchmark numbers are for that? Do you even know what NACOR is? Yes I think those numbers are a bit inflated from what I see from our large database going back decades.

And this is only a part of my objection that others have also brought up--e.g., OSA and post-op narcotics, the need for aggressive PACU care that is usually not a capacity of ASCs including RT, possible post-op vent, and the fact that I have a reasonable chance of being stuck in an ASC while trying to get him admitted to the hospital should things go south.

On the other hand I keep reading these comments that keep on saying "just do the case", or "why don't you just do a block and a 'gentle' GA"????

I feel like all these anesthesiologist on this forum are just like the crappy surgeons down the street who say "what's the big deal with new-onset AFIB???, Just give a little beta blocker prop-sux-tube it--after all nothing you do here will be different from what you do there--it's all just cookie-cutter cookbook nursing protocols, right?"
 
abolt18 said:
Few weeks ago I had a patient coming for lumpectomy who also happened to have active chest pain with < 4 METS. She saw a cardiologist the week before the scheduled surgery. Patient says "the cardiologist said i was okay to have surgery". Problem is, the cardiologist also scheduled her for a chemical stress test and an echo in a month...
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That cardiologist deserves a slap upside the head... what an idiot!
 
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NICMAN said:
Are you kidding me? The patient in question had 3 risk factors which is a LOT more than a MACE rate of 5%. You are both arguing that I am grossly underestimating the risk based on published statistics and then in the same breath saying I should just do it in a freestanding ASC anyways...

I used >5% as my benchmark not because I "don't know what I am talking about" but because I think those statistics you cite are inflated for our practice. I do the statistics for my group for all adverse events for over 40,000 cases (NOT including ASC, OB or Endo) that we do at several community hospitals and a Level 1 trauma center. And you know what? Even for our level 1 trauma center where everybody is a BMI of 35 or more, on insulin, had a CVA/MI/CHF and/or has CKD3-4; EVEN at this sickest hospital in this region--the rate of MACE for noncardiac surgery from our inside statistics doesn't even come close to 3.8%--which is the risk for ZERO risk factors. And yes, we capture all the data up to 30 days post-op. Does anybody in this forum really believe that from your experience you all have 1 episode of MACE for healthy adults >45 for every 27 surgeries you do? that is, what, 1-2 per week??? Are you kidding me? Have you even logged into the NACOR registry to see what the benchmark numbers are for that? Do you even know what NACOR is? Yes I think those numbers are a bit inflated from what I see from our large database going back decades.

And this is only a part of my objection that others have also brought up--e.g., OSA and post-op narcotics, the need for aggressive PACU care that is usually not a capacity of ASCs including RT, possible post-op vent, and the fact that I have a reasonable chance of being stuck in an ASC while trying to get him admitted to the hospital should things go south.

On the other hand I keep reading these comments that keep on saying "just do the case", or "why don't you just do a block and a 'gentle' GA"????

I feel like all these anesthesiologist on this forum are just like the crappy surgeons down the street who say "what's the big deal with new-onset AFIB???, Just give a little beta blocker prop-sux-tube it--after all nothing you do here will be different from what you do there--it's all just cookie-cutter cookbook nursing protocols, right?"
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The numbers you are quoting, while interesting, should be interpreting in the context of: immediate postoperative complications. The 30-day morbidity and mortality isn't what concerns me here. Sure the guy is sick (bad protoplasm, whatever) and he is at increased risk, but if he has good follow up and is otherwise medically optimized, the 30 day/60 day/ 1 year outcome is NOT the metric you look at to differentiate between safety of ASC vs hospital OR. I want to know what is the likelihood of MACE intraop or PACU? That is the pointed question.

And what the heck is with your last paragraph about new onset AF and elective surgery?! Nobody was talking about that, and I don't think it has anything to do with the discussion at hand. Don't conflate this with that. They are not the same.
 
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coffeebythelake said:
The numbers you are quoting, while interesting, should be interpreting in the context of: immediate postoperative complications. The 30-day morbidity and mortality isn't what concerns me here. Sure the guy is sick (bad protoplasm, whatever) and he is at increased risk, but if he has good follow up and is otherwise medically optimized, the 30 day/60 day/ 1 year outcome is NOT the metric you look at to differentiate between safety of ASC vs hospital OR. I want to know what is the likelihood of MACE intraop or PACU? That is the pointed question.

And what the heck is with your last paragraph about new onset AF and elective surgery?! Nobody was talking about that, and I don't think it has anything to do with the discussion at hand. Don't conflate this with that. They are not the same.
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There are all kinds of surgical, anesthetic, and general perioperative errors and complications pertaining to quality and safety which wouldn't necessarily show up intra or in PACU but which would become apparent in 30d figures. For instance, one would never pick up a surgical site infection difference or DVT difference if we just stopped looking once we arrived at PACU discharge.
 
vector2 said:
There are all kinds of surgical, anesthetic, and general perioperative errors and complications pertaining to quality and safety which wouldn't necessarily show up intra or in PACU but which would become apparent in 30d figures. For instance, one would never pick up a surgical site infection difference or DVT difference if we just stopped looking once we arrived at PACU discharge.
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Again, is this really the difference you look for when determining whether this patient is suitable for ASC vs hospital OR? I would say no. The patient would be long gone (from ASC or the hospital PACU) before you see these things.
 
Urzuz said:
Got it, your ASA 1-2s have good outcomes. Must be some magical propofol in your part of the country 🙄

FWIW our outpatient center is connected to our tertiary care center, so we have the liberty of being maybe more aggressive with the patients we anesthetize here.

That being said, I would do this case with every intention of discharging him home from PACU.
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Hospital attached ASCs and freestanding ASCs are totally different ballgames.

We occasionally do ICU expl laps and trach/pegs in our hospital attached ASC and we would happily do the OP’s case at our hospital attached ASC. But we wouldn’t do the OP’s case at our freestanding ASC.

If you can’t wean the oxygen in pacu, it’s a gurney ride to a bed vs an ambulance ride to the ER. One is no big deal and the other is a reportable event.


 
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DrOwnage said:
Thanks for the input and healthy discussion. I personally ended up cancelling the case, telling the director he should be a main OR case for a lot of the concerns already stated. Wasn't comfortable without a day of surgery potassium either. They weren't too happy. But then again we have a history of doing sketchy cases on ASA 3.5-4s and our exemption criteria feels non-existent. I felt it necessary to somewhat draw the line. I'm a new attending (11 months out of residency) so it makes these decisions a little harder.

This was mainly to provide insight into peoples' reasoning for cancelling cases; IMO one of the hardest things we do.
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I feel bad for you / for this situation.

A group of physicians ought to have more influence on ASC inclusion/exclusion criteria. After all, no one wants badness.

And you personally, ideally you have group support where you can "load your boat" as a very junior partner with a phone call to your mentor or chief to garner support for your decision. (Also, be careful what you wish for with that phone call, you might not like the 2nd opinion you get)
 
nimbus said:
Hospital attached ASCs and freestanding ASCs are totally different ballgames.

We occasionally do ICU expl laps and trach/pegs in our hospital attached ASC and we would happily do the OP’s case at our hospital attached ASC. But we wouldn’t do the OP’s case at our freestanding ASC.

If you can’t wean the oxygen in pacu, it’s a gurney ride to a bed vs an ambulance ride to the ER. One is no big deal and the other is a reportable event.


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something bad could def happen and this patient is higher risk, but honestly I’m mostly worried about the inability to wean the O2 in the PACU after doing this case w no block.

regardless, if this patient weren’t compliant with his CPAP he wouldn’t be done in our freestanding ASC. Even if he were compliant there are other issues (the CKD and K+ with no follow up….) that would likely rule him out. In reality our surgeons wouldn’t post this guy at the ASC, and if he slipped through the cracks they’d understand if the case got moved to the hospital.
 
coffeebythelake said:
Again, is this really the difference you look for when determining whether this patient is suitable for ASC vs hospital OR? I would say no. The patient would be long gone (from ASC or the hospital PACU) before you see these things.
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No, something like those wouldn't be the factor that causes me to stratify this guy from an ASC to main. However, if I'm the quality/safety guy at my big institution and I have the data, and I saw that hypothetically 30d readmissions, MACE or all-cause mortality in matched pts was higher in ASA 3-4s done at an ASC, it would give me pause.
 
coffeebythelake said:
The numbers you are quoting, while interesting, should be interpreting in the context of: immediate postoperative complications. The 30-day morbidity and mortality isn't what concerns me here. Sure the guy is sick (bad protoplasm, whatever) and he is at increased risk, but if he has good follow up and is otherwise medically optimized, the 30 day/60 day/ 1 year outcome is NOT the metric you look at to differentiate between safety of ASC vs hospital OR. I want to know what is the likelihood of MACE intraop or PACU? That is the pointed question.

And what the heck is with your last paragraph about new onset AF and elective surgery?! Nobody was talking about that, and I don't think it has anything to do with the discussion at hand. Don't conflate this with that. They are not the same.
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I agree with you that immediate post op complications are the primary concern. Other people have articulated these concerns in detail.
my purpose here is to get people to broaden their view of their role (“practice to the full scope of your license” as some might say).

I argue that by Bayesian clinical decision making regarding the time, place, manner, and considering resource allocation, workflow efficiency, how our decisions affect the healthcare system as a whole (as the ED doc articulated earlier), concerns about ASC certification and performance, etc.

We shouldn’t be so narrow minded to just think about the PACU. Time, place, manner decisions taking into account resources and response can have a measurable effect on a range of quality indicators and simply ignoring that isn’t going to cut it in the changing healthcare environment. MACE is just one indicator, SSI, DVTs, post-op ED visits/hospitalizations. and you can’t just play the victim card by saying “oh, well good for you for not getting complications while doing surgeries on college athletes”.

We shouldn’t live below our privilege. Our focus should be on QUALITY and VALUE. Without proper patient selection there is simply no way to run an efficient 5 cases/OR/day ASC where you do 7 RCR shoulders or get total joints home within 6 hours of incision.
 
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nimbus said:
Hospital attached ASCs and freestanding ASCs are totally different ballgames.

We occasionally do ICU expl laps and trach/pegs in our hospital attached ASC and we would happily do the OP’s case at our hospital attached ASC. But we wouldn’t do the OP’s case at our freestanding ASC.

If you can’t wean the oxygen in pacu, it’s a gurney ride to a bed vs an ambulance ride to the ER. One is no big deal and the other is a reportable event.


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ICU exlaps at the asc smh
 
NICMAN said:
We shouldn’t live below our privilege. Our focus should be on QUALITY and VALUE. Without proper patient selection there is simply no way to run an efficient 5 cases/OR/day ASC where you do 7 RCR shoulders or get total joints home within 6 hours of incision.
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I see what you’re saying, but you should also recognize that there is simply no way for the vast majority of outpatient surgery centers to stay afloat only caring for college athletes and patients who have only one item on their problem list. In the “real world” the majority of us have to make concessions and care for patients under less-than-ideal circumstances, both at outpatient facilities (caring for an occasional ASA 3/4, etc) and in the inpatient setting (not have studies you may want before going back to the OR, etc).


nimbus said:
Hospital attached ASCs and freestanding ASCs are totally different ballgames.

We occasionally do ICU expl laps and trach/pegs in our hospital attached ASC and we would happily do the OP’s case at our hospital attached ASC. But we wouldn’t do the OP’s case at our freestanding ASC.

If you can’t wean the oxygen in pacu, it’s a gurney ride to a bed vs an ambulance ride to the ER. One is no big deal and the other is a reportable event.


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I completely agree it’s a different ballgame, hence why I bring it up. I feel like I may be biased when I evaluate the patients that I would happily anesthetize in our outpatient setting, subconsciously knowing that there is a hospital right next to me. That being said, even if I envision myself at a standalone surgery center, I still feel like I would feel comfortable doing this case as long as the surgeon allowed the anesthetic to be done my way.

Thanks for providing that letter, I had never seen it before. But regarding that new reportable item - it’s only reportable if the patient gets transferred to a hospital for a period exceeding 24 hours following the procedure. Again, not worried about the guy spending over a day in the hospital following a 1.5 hour shoulder scope. You can feel free to disagree — just my 2 cents.
 
NICMAN said:
Are you kidding me? The patient in question had 3 risk factors which is a LOT more than a MACE rate of 5%. You are both arguing that I am grossly underestimating the risk based on published statistics and then in the same breath saying I should just do it in a freestanding ASC anyways...
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You are the one who laughed at the idea of doing someone with a MACE risk of 5% at a surgery center, not me. I merely pointed out the silliness of making such a point.

I have said in this case I can understand why some people would refuse to do it in some situations. There are situations, however, where it can be quite appropriate to do a similar case in a surgery center, especially if you do an interscalene block and avoid narcotics.

I also think it is worth thinking about the fact that unless we are providing different care in a hospital, it often adds no benefit to the patient. Also comes with significant extra cost to the patient (although some of that may be handled by insurance). Most postop complications that we care about (death, MI, stroke, whatever) are going to happen long after the patient leaves our care. So unless you provide different intraop care or force patient to be admitted postop, location of care not going to make a bit of difference in those outcomes.
 
Urzuz said:
I see what you’re saying, but you should also recognize that there is simply no way for the vast majority of outpatient surgery centers to stay afloat only caring for college athletes and patients who have only one item on their problem list. In the “real world” the majority of us have to make concessions and care for patients under less-than-ideal circumstances, both at outpatient facilities (caring for an occasional ASA 3/4, etc) and in the inpatient setting (not have studies you may want before going back to the OR, etc).




I completely agree it’s a different ballgame, hence why I bring it up. I feel like I may be biased when I evaluate the patients that I would happily anesthetize in our outpatient setting, subconsciously knowing that there is a hospital right next to me. That being said, even if I envision myself at a standalone surgery center, I still feel like I would feel comfortable doing this case as long as the surgeon allowed the anesthetic to be done my way.

Thanks for providing that letter, I had never seen it before. But regarding that new reportable item - it’s only reportable if the patient gets transferred to a hospital for a period exceeding 24 hours following the procedure. Again, not worried about the guy spending over a day in the hospital following a 1.5 hour shoulder scope. You can feel free to disagree — just my 2 cents.
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What is the real world? I'm in a busy, high volume, ACT practice. All transfers from our ASCs are reviewed, look at by our ASC medical directors who are anesthesiologists, and our ASC health system administrators. No one wants transfers, especially admin. They hurt our accreditation. We make criteria to avoid them as much as we can without being overly restrictive. That doesn't mean only ASA 1s and 2s. It does however mean we aren't doing BMI 60 for shoulder scope at the ASC. They go to the hospital, get the same anesthetic, and go home > 90% of the time. Are you or @Mman saying we should be doing BMI 60 shoulder scopes at the ASC?

There appears a disconnect in the conversation. Just because the anesthesia received in the hospital is the same as that received in the ASC it doesn't mean it's appropriate for the ASC. I'm honestly very surprised I'm hearing this from anesthesiologists, but maybe your propofol is different than mine and no transfers occur where you are. They certainly occur where I am, and they're directly correlated to certain morbidities. So as anesthesiologists we try and do our part to ensure patients get good care, go home, and our health system and surgeons get favorable reviews and referrals.
 
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Southpaw said:
What is the real world? I'm in a busy, high volume, ACT practice. All transfers from our ASCs are reviewed, look at by both the ASC medical directors who are anesthesiologists, and our ASC health system administrators. No one wants transfers, especially admin. They hurt our accreditation. We make criteria to avoid as much as we can without being overly restrictive. That doesn't mean only ASA 1s and 2s. It does however mean we aren't doing BMI 60 for shoulder scope at the ASC. They go to the hospital, get the same anesthetic, and go home > 90% of the time. Are you or @Mman saying we should be doing BMI 60 shoulder scopes at the ASC?

There appears a disconnect in the conversation. Just because the anesthesia received in the hospital is the same as that received in the ASC it doesn't mean it's appropriate for the ASC. I'm honestly very surprised I'm hearing this from anesthesiologists, but maybe your propofol is different than mine and no transfers occur where you are. They certainly occur where I am, and they're directly correlated to certain morbidities. So as anesthesiologists we try and do our part to ensure patients get good care, go home, and our health system and surgeons get favorable reviews and referrals.
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when did his BMI become 60? He has coronary disease, diabetes, OSA, and CKD. With a block, there is zero surgical stimulation. So when I ask myself if this guy can handle the amount of anesthesia necessary to tolerate an LMA/ETT in his mouth for 1.5 hours, I say yes. Maybe if I physically saw him I would change my mind, but if I pulled up his chart and read his history, I wouldn’t automatically think “cancel.” Again, different strokes for different folks. I wouldn’t fault anyone for cancelling it, to be clear.

If his BMI was 60 he for sure gets cancelled.
 
Urzuz said:
when did his BMI become 60? He has coronary disease, diabetes, OSA, and CKD. With a block, there is zero surgical stimulation. So when I ask myself if this guy can handle the amount of anesthesia necessary to tolerate an LMA/ETT in his mouth for 1.5 hours, I say yes. Maybe if I physically saw him I would change my mind, but if I pulled up his chart and read his history, I wouldn’t automatically think “cancel.” Again, different strokes for different folks. I wouldn’t fault anyone for cancelling it, to be clear.

If his BMI was 60 he for sure gets cancelled.
Click to expand...

BMI 60 for shoulder scope is a hypothetical. Not okay by anyone’s standard in a freestanding ASC (I assume….) yet they go to the hospital, get the same anesthesia, and go home same day most of the time.
 
Southpaw said:
BMI 60 for shoulder scope is a hypothetical. Not okay by anyone’s standard in a freestanding ASC (I assume….) yet they go to the hospital, get the same anesthesia, and go home same day most of the time.
Click to expand...

Right, but the OP’s patient isn’t the patient you described. The decision to do or to cancel the OP’s case is much more nuanced.
 
Southpaw said:
BMI 60 for shoulder scope is a hypothetical. Not okay by anyone’s standard in a freestanding ASC (I assume….) yet they go to the hospital, get the same anesthesia, and go home same day most of the time.
Click to expand...

Some people on this board are treating hospital transfers like a patient death. They happen. And often they are not a big deal.

Obviously the goal is not to transfer. But if you do enough cases of decent size you will inevitably get transfers. For pain control, arrythmia, unable to wean O2, no one to help with care at home, those are pretty much the big ones.

If you were the surgical center admin, would you rather:

A: 25k cases per year, 4 hospital transfers
B: 10k cases per year and 1 hospital transfer

The badness comes when you can predict the transfer but do the case anyways.

A BMI 60 is more likely to need post op o2 weaning., sat monitoring.
An EF 25% is more likely to need post op pressors, BP checks
A big surgery that is likely to require blood, and the patient ends up hypotensive and you have to transfer to give blood
An elderly patient with dementia and poor home care..

Those are egg on your face. You knew it would LIKELY be a problem, but did the case anyways and dumped it on the hospital.
That's to the detriment of the surgeon and to the patient.

I often think, will this look bad if i end up having to transfer this person? Unless you have done a case in the face of a major red flag, NO.

This discussion reminds me a little of a pre-op nurse who tries to get me to cancel patients with an elevated HgA1c. Yes, I get that they are not healthy, but no acute reason to cancel...

And BTW there are lots of patients who prefer to have their case done at the ASC and not deal with the many issues surrounding going to the hospital, so its not as if its only done for the money. Im sure when the LMA came out there were lots of dug-in docs saying how unsafe it was, the future is in ASCs and outside of the hospital for more and more cases so we have to get on board
 
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GassYous said:
The surgeon already said no to the block, that's the patient we are discussing
Click to expand...

No block and I tell the surgeon to see you next week at the hospital. But I don't work with surgeons like that. Even if they didn't like a block I'd tell them this patient is 100% getting one or they can go elsewhere.
 
Southpaw said:
Are you or @Mman saying we should be doing BMI 60 shoulder scopes at the ASC?

There appears a disconnect in the conversation. Just because the anesthesia received in the hospital is the same as that received in the ASC it doesn't mean it's appropriate for the ASC
Click to expand...

They wouldn't get past the scale in the admissions area and would be sent home.

But the reason someone that big gets done at the hospital is higher likelihood of invasive monitoring need and significantly higher need for postop observation/admission. So yes, the care is different.
 
GassYous said:
The surgeon already said no to the block, that's the patient we are discussing
Click to expand...
The OP said the surgeon “doesn’t allow blocks” which I interpret to mean generally speaking.

I’m saying if you talk to the surgeon about your concerns and present it as block and proceed vs no block and cancel, most surgeons will change their tune real quick. As you pointed out, most of these are bad, slow surgeons who think that a five minute block will ruin their day, not realizing that their own ****ty surgical technique is what causes all the delays. That being said, if they have to cancel and reschedule the case, most will realize this will cause more wasted time and they’ll begrudgingly agree.
 
NICMAN said:
I agree with you that immediate post op complications are the primary concern.
Click to expand...

And that's the major decision to be made. Post op oxygenation and ability to get out of PACU is the #1, 2, and 3 concern here. Do we actually think his MACE is increased at an ASC vs hospital? I mean he's not a great overall candidate for elective surgery anyway, but most of the American population isn't either.

No one is arguing that this guy is healthy, and I don't think anyone is discounting any of the data you've presented or our role as consultants and taking more ownership of patients. It's just that it may not exactly apply to the decision making in this singular scenario.
 
Mman said:
They wouldn't get past the scale in the admissions area and would be sent home.

But the reason someone that big gets done at the hospital is higher likelihood of invasive monitoring need and significantly higher need for postop observation/admission. So yes, the care is different.
Click to expand...

I agree with you on the decision but I'd only say the care might be different. More often than not - it's not. Again, as I've said all along in this thread, that's not really the point. There's so much subjectivity in this thread it just underlines the need for anesthesiologist leadership at ASCs and exclusion criteria so everyone (anesthesia group, admin, surgeons) can be on the same page and know what to expect. Everyone needs to work together. My experience has been that when we just eyeball cases, like in the OP's situation, no one ends up happy.
 
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Southpaw said:
I agree with you on the decision but I'd only say the care might be different. More often than not - it's not. Again, as I've said all along in this thread, that's not really the point. There's so much subjectivity in this thread it just underlines the need for anesthesiologist leadership at ASCs and exclusion criteria so everyone (anesthesia group, admin, surgeons) can't be on the same page and know what to expect. Everyone needs to work together. My experience has been that when we just eyeball cases, like in the OP's situation, no one ends up happy.
Click to expand...
So again, with Hoya’s question, what exclusion criteria in your ASC gets this case screened out?
 
I agree, it is hard to be the one cancelling cases or saying no. I had decline a surgeon's request to bring 2 add on cases over to our ASC the other day, the patients were not good candidates for the ASC. What we do is looking out for a patient's safety that, unfortunately, can be seen as being lazy (see prior posts). It bothers me when surgeons think they know more than they do about the practice of anesthesia and second guess our motives. Ultimately, you use your clinical judgement to do what you deem safe and reasonable.
 
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