By Morris Wortman,MD
We are witnessing a “perfect storm” for the growth of office-based surgery (OBS) across the country. The combination of decreasing physician revenue, enhanced reimbursement for OBS and innovative technology have all stimulated the growth of minimally invasive procedures in the office setting. Many specialties offer a host of procedures in an office environment; these include upper and lower endoscopies, vasectomies, cystoscopies, many plastic surgical procedures, female sterilization, endometrial ablation and even removal of fibroids and endometrial polyps.
Office-based surgery (OBS) offers many unique advantages to patients, physicians and the office staff. Until recently there were few regulations that governed officebased surgery-in some cases with tragic consequences. In this brief article I’d like to review the advantages of OBS, the NYS regulations that govern it and offer suggestions for providing the highest standards of care.
The Benefits Are Clear
The patient benefits are clear. Your patient is in comfortable and familiar surroundings, enjoys simplified scheduling, lower co-pays and the familiarity with members of your office O.R. Crew. Typically, patients spend only a fraction of the time in your office when compared to the same procedure performed in a hospital O.R. or ASC and are less likely to be “bumped” unforeseeable quirks of a busy O.R.
Physicians also benefit from easier and more flexible scheduling procedures and greater control over all aspects of peri-operative care. Importantly, we are present for the entire duration of a patient’s postoperative care-a luxury often not found in a hospital or ASC setting. Financial benefits arise either from increased insurance reimbursement or from the more efficient use of our time in an office-setting. Finally, an OBS setting allows physicians far greater control over the selection and training of specific members of the O.R. Crew for specific procedures.
The office O.R. Crew also enjoys significant rewards compared to their hospital counterparts as they enjoy dual roles-caregivers both in and out of the O.R. The same nurse practitioner who asks me to consult on her patient will also assist during the patient’s operative procedure. This allows members of our O.R. Crew to participate in preoperative decision making, intraoperative care and postoperative management. Not only is this comforting for the patient but it provides individual members of our team and our patients with the kind of continuity of care not seen in other settings.
Our own office O.R. Crew enjoys another potential benefit-a culture that stresses mutual cooperation and respect. Their training and error-avoidance procedures, know as Crew Resource Management ( CRM) has been used in the aviation industry for the past 3 decades. CRM encourages the input of all members of the O.R. Crew and encourages collegiality and mutual support in their devotion to patient safety. We meet regularly, as a team, exploring potential ‘weaknesses’ in our system to develop and institute solutions. Patient safety is the responsibility of every single member of our Crew. One example is our “timeouts”. Hospital “time-outs”, are often perfunctory and limited. Our “time-outs” often take 5-10 minutes to perform and include a complete presentation of the patient’s chief complaint, past medical history, allergies, pertinent social issues and particular concerns specific to this particular patient. The CRM approach allows us to tailor procedures to the individual-not the other way around.
Understanding the Regulations
Physicians considering OBS must be aware of current NYS DOH regulations. Since January 14, 2008 the DOH requires (see NYS Public Health Law Section 230-d) the reporting of any “adverse event” that occurs in an office setting within one business day of a reportable event. This includes an unplanned transfer to a hospital, an unscheduled hospital admission within 24 hours of OBS, a serious or lifethreatening event or a death.
Since July 14, 2009 offices which provide other than minimal sedation are required to be accredited by one of 3 nationally recognized agencies -The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Accreditation Association for Ambulatory Health Care (AAAHC) or the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF). Additionally,accreditation is required for all but “minor procedures.” These are procedures “that can be performed safely with a minimum of discomfort where the likelihood of complications requiring hospitalization is minimal. .. procedures performed with local or topical anesthesia; or. .. liposuction with removal of less than 500 cc of fat under unsupplemented local anesthesia.” (http://www.health.state.ny.us/professionaIs/office-based_surgery/1aw/230-d.htm). In summary, there are 2 thresholds which require accreditation-performing other than “minor procedures” or ones that require the use of moderate or deeper levels of sedation and analgesia.
It is imperative that physicians understand that the level of sedation achieved, not the route of administration or the agent used -is what determines the need for accreditation. Whether given orally or parenterally, narcotics and sedatives pose similar risks. Minimal sedation may be achievedand does not require accreditation-with intravenous narcotics and sedatives as long as the results fall within the definitions set forth under NYS Public Health Law Section 230-d. It is also possible to induce a level of moderate conscious sedation by the injudicious use of oral agents. Some physicians, in an effort to avoid the requirements of accreditation, may perform procedures in an OBS without adequately managing pain or anxiety. As physicians we have an ethical responsibility to not compromise patient comfort in an office environment.
Before undertaking any OBS procedures one should develop a list of ‘potential’ procedures that you would like to consider in your office. After assessing the nature of the procedures and its anesthesia requirements you must determine whether or not you will require formal accreditation.
Finally, whether or not your office requires accreditation you should consider the following suggestions:
- Designate a medical director with specific patient safety responsibilities.
- Create a training manual and checklist for every procedure.
- Simulate and practice emergencies.
- Institute training and credentialing for all staff members
- Develop protocols for analgesia/sedation for all procedures.
The commitment to teamwork, ongoing quality improvement and a culture of safety results in improved outcomes for your patients and enhanced professional pride.