Anesthesia management company Archives - Page 5 of 19 - Xenon Health

Providing safe and effective anesthesia services is a full day’s work.  The physician anesthesiologist must thoroughly review each patient’s medical history and come up with an anesthesia plan that not only considers patient safety but also the surgeon’s preferences.  Oftentimes, this is achieved by speaking directly with the patient and the surgeon, whether it be in person or over the phone, the day before the surgery.

The morning of, the physician anesthesiologist is often the first person to arrive in the operating room.  Like a pilot preparing for a flight, the anesthesiologist must embark on a systematic checklist to ensure that all equipment is functioning properly and all supplies including emergency supplies are stocked and available in the room.  The anesthesia machine is checked, the suction catheter is on and readily accessible, all monitors are available and ready to connect to the patient, airway equipment is selected for the patient and double checked for leaks or malfunction, intravenous access kits and fluids are set up, and medications are drawn up with doses already calculated.

Once the anesthesia station in the operating room is ready to go, the physician anesthesiologist then meets the patient in the preoperative area to clarify his or her medical history, assuage any fears or concerns the patient may have, and discuss the benefits and risks of the anesthesia plan.  A focused review of systems and physical exam is performed, with special attention to the cardiopulmonary systems and airway exam.

The patient is then transported to the operating room.  Once monitors are in place, the anesthesiologist preoxygenates the patient and induces anesthesia.  After the patient is asleep, he or she is intubated.  If a difficult airway is encountered, additional equipment such as a Glidescope or fiberoptic scope may be utilized.  The anesthesiologist then monitors the patient closely during the surgery and, once the surgery is done, the patient is emerged and extubated before being transported to the recovery room.  If needed, the patient may remain intubated and go to the ICU.

The anesthesiologist’s responsibilities do not end there.  The patient must be carefully monitored as he or she wakes up from the effects of anesthesia.  The physician orders pain and anti-nausea medications as needed and is available if there are airway or hemodynamic concerns during this period.  Once the patient meets discharge criteria, they can return to an inpatient room or go home.  The next day, the anesthesiologist does a postoperative visit or call to address any concerns or questions that the patient had regarding their anesthesia experience.

As discussed in the British Journal of Anaesthesia, the fundamental purpose of healthcare is to achieve good health outcomes for patients (Murphy, 2012). Researchers measure and publish clinical outcomes of healthcare services to ultimately improve their quality and establish a minimum standard of care.  However, collecting data on such performance measurements renders ample costs, specifically pertaining to anesthesia services. Many believe that measuring performance of healthcare providers such as anesthesiologists, CRNAs and others is not feasible due to the large amount of accurate, high quality data that is necessary for national comparisons, the lack of which results in flawed analyses and data misrepresentation. The current incapacity to precisely, collectively capture health outcomes for anesthesia patients in addition to the misuse of data, like misrepresentation, are some examples of the costs of collecting data on healthcare performance measurement. Because individuals are seldom provided the appropriate context to interpret such measures, an information discrepancy in healthcare performance measurement arises, leaving patients unable to determine what information is relevant to their care. This discrepancy, otherwise known as healthcare asymmetry, can adversely affect professional attitudes and patient-doctor relationships.

Because anesthesiologists, CRNAs and other anesthesia service providers provide multifaceted services to complex patients, despite researchers’ ability to collect process data, little information exists on patient health outcomes after the receipt of anesthesia services. One problem with measuring such outcomes is related to the fact that modern anesthesia is relatively safe, thus, mortality is not a sensitive indicator or measure of quality in healthcare performance. Further, no consensus has been established regarding how to measure perioperative anesthesia-related mortality, as its temporal definition ranges from death within 48 hours of an anesthesia procedure, to within 30 days of a procedure, among many others observed in the literature. Researchers must define quality measures needed to understand health outcomes in anesthesia practice to identify areas of need, and ultimately lessen the burdensome costs of healthcare performance measurement in regards to anesthesia services. While the healthcare system should promote accountability and transparency, efficient data collection should accurately reflect performance of anesthesiologists, CRNAs and other anesthesia services professionals, and be distributed to consumers as it is deemed relevant to understanding their care. To overcome such costs of healthcare performance measurement for anesthesiologists, CRNAs and others involved in providing anesthesia services, measures must be defined, identified and agreed upon, so as to assure consistency in national data collection, in order to determine the most efficient and effective means of care in terms of cost, risk and health outcomes for patients undergoing anesthesia services.

Heart rate variability (HRV) is a parameter not often heard about in clinical practice, yet it has been studied for over a decade as a marker for autonomic nervous system function. Heart rate varies with respiration, a physiologic process controlled by autonomic reflexes and central autonomic input. A decrease in this physiologic variation in heart rate has been associated with impairment in the cardiovascular system’s ability to adapt to various stressors. Abnormalities in HRV have been observed in various populations and pathologies in which the autonomic nervous system has been compromised, and in many cases (such as after acute coronary syndrome or in critically ill neurosurgery patients) can predict mortality and adverse outcomes.

Measurement of HRV is commonly done via time domain analysis and frequency domain analysis of R-R intervals on EKG. Parameters calculated from these spectral analyses infer the functionality of the sympathetic and parasympathetic nervous systems.

Intellewave is an automated cardiac monitoring device that utilizes frequency domain analysis to provide real-time quantitative assessment of HRV. It uses novel artificial intelligence techniques to differentiate between high frequency (HF) and low frequency (LF) components of this spectral analysis. The HF band reflects parasympathetic activity and the LF band represents mixed input from both sympathetic and parasympathetic modulation. Interpretation of the spectral parameters has yet to be well-defined, but is the subject of ongoing study in various populations.

Intellewave’s Nerve Express algorithm was compared to the gold standard CHRONOS algorithms for power spectral analysis of R-R intervals, the latter of which was shown to predict mortality in coronary disease and to quantify physical fitness in athletes. Its advantage over CHRONOS, which relied on Holter monitoring and required skilled technicians, was designed to be a stand-alone automated system that could be used in an office setting.

The applications for HRV in general and Intellewave in particular within the perioperative theater have yet to be closely examined. From pre-operative risk stratification of patients at risk for intraoperative complications due to autonomic dysfunction, to postoperative monitoring and predicting outcomes in an intensive care setting, the possibilities are broad. There exist however confounding factors to the utilization of HRV in practice, for in the very breadth of its potential applications lies its weakness: the autonomic system affects so many variables and is affected by so many pathologies, medications, and stressors that it would be difficult to tease out what exactly is causing a change in HRV and what it could be predicting. Nevertheless, it remains an intriguing forefront of research.

Anesthesiologists commonly perform spinal blocks for a multitude of procedures, including lower body surgeries involving the genitourinary tract, orthopedic surgeries like knee replacements, lower abdominal surgeries, and cesarean sections. Spinal anesthesia involves the single injection of medication into the intrathecal space — into the fluid surrounding the spinal cord — to cause complete numbness and analgesia from the waist down.  The onset of anesthesia is only a few minutes, and the effects can last up to a couple of hours before wearing off without further intervention.  Spinal anesthesia is often supplemented with light or moderate sedation for patient comfort, though a spinal block alone is sufficient anesthesia for an operation.  Spinal blocks offer reliable and rapid onset anesthesia and are a safe and effective alternative to general anesthesia.

The technique for administering spinal anesthetics involves palpating for landmarks and identifying an appropriate space along the vertebral column, usually the L3-L4 or L4-L5 intervertebral spaces at the midline.  Once identified, the skin is numbed with local anesthetic, and then the spinal needle is inserted via an introducer needle.  When cerebrospinal fluid is aspirated to confirm correct positioning, the medication is injected, the needle is removed, and the procedure is complete.

According to startup company IntuiTap Medical, this current technique is “highly unpredictable and requires significant guesswork.”  This can be even more pronounced when the bony landmarks are difficult to palpate, such as in obese patients or patients with scoliosis or history of spinal surgeries.  As a result, multiple attempts may be necessary to correctly identify the intrathecal space, resulting in a distressing experience for the patient and physician, as well as increased risk of post-dural puncture headaches.  These complications can increase risk of readmission and threaten patient satisfaction.

IntuiTap has created a handheld device that integrates imaging of the spine with needle guidance and analytics to increase first-pass success.  The device enhances palpation by showing a real-time image of the underlying vertebrae on a handheld LCD screen and projecting, using a proprietary algorithm, exactly where the needle will end up if inserted at that location.  A digital pressure sensor confirms positioning of the needle and measures opening pressure, obviating the need for a separate and cumbersome manometer.

The company was co-founded by its CEO Jessica Traver and CTO Nicole Moskowitz, both of whom were featured in Forbes annual list of 30 under 30 for healthcare.  Over the past year, IntuiTap has started seed funding rounds and has been awarded space at Johnson & Johnson Innovation’s JLABS and taken part in TMCx and MedTech Innovator accelerator programs.

According to a recent medGadget article reporting on findings from Hexa Research, the market for ASCs is projected to increase at a compound rate of 6 percent annually between 2016 and 2024. High government expenditure, increased government initiatives focused on team-based primary care, and technological advancements are only a few key factors involved in driving market growth for ASCs. Additionally, primary care offices reported revenues upwards of $400 billion dollars in 2014, the same year North America led the market and Europe’s demand powered market growth in the area. Higher healthcare costs and more chronic conditions are expected to fuel Asia Pacific’s growth to 7 percent CAGR in 2016-2024. It is estimated that up to 50 percent of surgeries in the United States occur in an ASC facility, according to UC Davis Health. Further, a Becker’s ASC Review from earlier this year states that surgeons have moved away from hospital settings to perform higher acuity cases in ASCs, such as spinal fusions and joint replacements, due to financial incentives and patient preferences, as the outpatient setting is ideal for otherwise healthy individuals who have minimal risk of pain, nausea, and bleeding after surgery. Utilizing ambulatory surgical and anesthesia services for minimally invasive procedures are beneficial to many patients as well, as they provide a lower cost alternative and shorter procedure length. Additionally, some surgical procedures performed in ASCs are ideal for older individuals that wish to avoid costly and time-consuming hospital stays that may pose more risk for infection or other illness during recovery time.

Utilizing ASCs for outpatient surgical procedures has its benefits; according to a 2014 HealthAffairs study by Munnich and Parente, surgical procedure lengths at ASCs are an average of 25 percent shorter than those performed in hospitals, indicating one reason for ambulatory surgery centers’ ability to reduce costs and attend to the dramatic increase in demand for outpatient surgery that has been observed since 1981. Due to the rising demand for outpatient surgical procedures, anesthesia management groups often contract with ASCs, thus the market for outpatient anesthesia services has been steadily increasing in recent years as well. The Anesthesia Quality Institute’s National Anesthesia Clinical Outcomes Registry reports the number of anesthesia cases outside of hospital operating rooms increased from 2010 to 2014 from 28 percent of anesthesia cases, or 5.9 million in 2010, to 36 percent of cases, or 12.4 million by 2014. The use of outpatient anesthesia services will likely continue increasing given the projected global ASC market growth and high demand for outpatient surgical procedures in the United States. A 2012 Oschner Journal study by Sarin and colleagues found that specialized ambulatory anesthesia teams contribute to decreased recovery times, and may be a valuable asset to anesthesia management companies and healthcare institutions by increasing perioperative efficiency, as well as both surgeon and patient satisfaction. As outpatient surgery and anesthesia services become a more attractive option due to patient preferences, lower-costs and expedited, high-quality services that reduce the likelihood of patient readmission and allow for early ambulation, the demand for outpatient anesthesia management services can also be expected to increase through 2024, parallel to the overall projected market trend for ASCs.