Anesthesia management Archives - Page 13 of 20 - Xenon Health

The discovery and development of pain management has allowed for safer, longer, more invasive surgeries and has dramatically reduced the pain associated with such procedures (1). Interventional pain management is a specialty of pain management that uses techniques and procedures such as implantable drug delivery systems, neurolytic blocks, and epidural infusions to alleviate pain.

Early developments in interventional pain management date back to physicians studying regional anesthesiology and nerve blockage in the late 1800s (2). Regional anesthesia and nerve blocks target specific organs or body regions and can numb pain to the targeted region (3). In 1884, Dr. Carl Koller reported that cocaine had a numbing effect on the tongue (2). Physicians then began to use cocaine to numb regions of the body during ophthalmology, urology, and general surgery. In 1899, Tuffer described the first nerve block, spinal cocaine, for pain management, and in 1901, Dr. Harvey Cushing discovered the use of caudal epidural injections for regional pain relief. Many other physicians, such as Dr. Schloesser with trigeminal alcohol blockage, continued to pioneer the field of interventional pain management and develop new advancements (4).

Dr. Von Gaza pioneered diagnostic blockage in pain management with the use of procaine for determining whether pathways of pain were sensory or sympathetic (2). This led many physicians to study interventional pain management and focus their efforts on diagnostic techniques. Dr. White in 1930, and Dr. Steindler and Dr. Luck in 1938 all developed novel applications for diagnostic interventional techniques. Dr. Steindler and Dr. Luck used procaine hydrochloride injections to identify sources of pain in lower back disorders. These advancements furthered the subspecialty of interventional pain management to include diagnostic techniques.

Many important advancements in interventional pain management were developed since the start of interventional pain management, and the publication of pain management textbooks were critical to the spread and recognition of interventional pain management as a subspecialty. In 1953, Dr. John Bonica wrote a groundbreaking textbook, The Management of Pain, which outlined many key developments in pain medicine. Bonica also later opened the first multidisciplinary pain center (4). In 1954, Dr. Vandam and Dr. Eckenhoff published an article, which offered a different perspective from Bonica’s textbook (6). Vandam and Eckenhoff’s chose to focus not only on pain relief from nerve blocks but also on the nature of pain. Dr. Privthi Raj published the Practical Management of Pain in 1986, which was considered to have “launch[ed] the era of interventional pain management” (2). These physicians and authors are considered to be some of the most important modern contributors of interventional pain management.

The term “interventional pain management” was not coined until 1996 when Dr. Steven Waldman used the term in the publication of the Atlas of Interventional Pain Management (5). Now, this subspecialty has received recognition by the United States National Uniform Billing Committee to bill under programs such as Medicare and Medicaid (1). There are currently several interventional pain management organizations for physicians practicing this subspecialty such as the Society For Pain Practice Management and American Society of Interventional Pain Physicians.
Interventional pain management has evolved to become a subspecialty in medicine and now includes many techniques (2). As seen throughout history, failures in delivery can be extremely dangerous, and proper specialization and continuous research are vital for patient safety. Current work done by physicians and researchers will no doubt continue to revolutionize medicine and offer patients more options for pain management.

Resources:
1. http://nucc.org
2. http://www.ncbi.nlm.nih.gov/pubmed/16871301
3. http://www.webmd.com/pain-management/guide/nerve-blocks
4. http://painmanagementohio.com
5. Atlas of Interventional Pain Management 3rd ed. S.D. Waldman (ed) Elsevier Philadelphia 2010
6. http://www.ncbi.nlm.nih.gov/pubmed/13124799

Despite the fact that nearly 20% of Americans live in rural areas, rural hospitals have historically faced momentous challenges that limited the centers’ ability to provide quality basic care in an efficient and affordable manner. Plagued by a lack of staff, minimal clinical and technological resources, and the unique ailments of typically poor and underserved communities, smaller rural hospitals were unable to provide the same standard of care as larger urban healthcare centers and many were forced to close due to the lack of resources or public support. For while these hospitals gave services to roughly 51 million people, governmental organizations largely ignored the financial and demographic problems that these centers faced—perhaps due to the fact that the majority of the patients were on Medicare or had no health insurance—and patients were thus required to travel great distances to receive care at an urban acute care center.

After decades of mass hospital closings in rural regions, the federal government finally realized that financial support would be required to sustain these hospitals that filled such a crucial gap in our healthcare system. The Balanced Budget Act (BBA) of 1997 authorized certain rural hospitals that presently accepted Medicare, or had recently closed, to become Critical Access Hospitals (CAHs), or small acute care centers that received cost-based reimbursement from government funds, with the hope that this financial and public support would allow the hospitals to remain open and become effective resources in local communities. However, the BBA additionally set forth some very strict eligibility requirements that would ensure that only the centers that could benefit communities and that could receive the most benefit from the reimbursements would become CAHs. For example, to become a Critical Access Hospital, the center had to be in a state that had a State Rural Health Plan, be in a rural area, and be 35 miles from the nearest hospital. The hospital had to offer 24/7 emergency care, have no more than 25 beds, and ensure that the average length of stay of a patient for acute care was less than 96 hours. These requirements were crucial for CAHs to remain cost-effective and they emphasized that a CAH would primarily offer treatment for common conditions and short overnight stays, while referring more complex cases elsewhere. The establishment of Critical Access Hospitals and the 101% Medicare reimbursement of reasonable costs incurred immensely improved the financial performance of failing rural hospitals, and the 10% bonus payment awarded to doctors practicing at a CAH in a Health Professional Shortage Area ensured that there were sufficient incentives available to staff.

In the roughly twenty years since the passage of the BBA, Critical Access Hospitals have spread across the United States, now accounting for 25% of acute care centers nationwide, becoming an absolutely essential tool in meeting the unique needs of rural communities. As of December 2015 there were 1,332 certified CAHs, with the majority being located in the Midwest and the Great Plains region, all offering a great level of flexibility in staffing and in their services, usually catering the services they offer to the specific needs of the community.

However, reliable and effective anesthesia services must be available at CAHs in order for them to be deemed operational. Anesthesia is essential to all surgical procedures and many aspects of outpatient care, making it necessary to always have an anesthesiologist available at CAHs. Certified Registered Nurse Anesthetists (CRNAs) are the primary providers of anesthesia in CAHs, with CRNAs in fact providing nearly 100% of the anesthesia in rural areas. With CRNAs being much more cost-effective than anesthesiologists and many reports concluding that the quality of care is the same between CRNAs and physicians, CRNAs are excellent providers for these rural health care centers that need to maximize cost-efficiency while supporting a lower income populace. Additionally, studies have found that there is a large shortage of anesthesiologists in rural areas and CRNAs have subsequently risen to fill this void, for now 60% of CAHs are located in the 17 states in the US that allow a CRNA to work without the observation of a physician. In order to ensure the continued cost-efficiency of anesthesia services at CAHs, several financial incentive programs have been created, namely the Anesthesia Rural Pass-Through Program. This initiative offers Medicare reimbursement payments to CRNAs and anesthesiologist assistants (AAs) who work in Critical Access Hospitals, but not to anesthesiologists, who are significantly more expensive than CRNAs or AAs.

Critical Access Hospitals comprise a vital section of our healthcare infrastructure and offer lifesaving care to frequently overlooked and underserved populations. However, it will be interesting to see how CAHs are affected by a continuing desire to decrease federal healthcare costs at every turn, while simultaneously expanding coverage to the millions uninsured.

Health and Human Services (HHS) announced goals to shift Medicare payments from quantity-based compensation toward result-based compensation for healthcare providers in January 2015 (1). The HHS set a goal of shifting 30 percent of traditional, or fee-for-service, Medicare payments to alternative payment models by the end of 2016 and 50 percent by the end of 2018. To achieve these goals, Medicare has planned to use alternative payment models such as Accountable Care Organizations (ACOs), bundled payment arrangements, and the implementation of the Affordable Care Act. In March 2016, the HHS announced that it has already reached its goal of shifting 30 percent of Medicare payments to quality-based payments (2). It attributes its early success to the tools provided by the Affordable Care Act such as the Medicare Shared Savings Program and the Center for Medicare and Medicaid Innovation.

This reform has implications for all health care providers. Previously, payment for each individual service is received regardless of the result for these patients. Under this payment system, many patients who had multiple doctors experienced difficulty due to the lack of communication between providers. According to HHS, the Affordable Care Act and shift to alternative payment models gives providers better patient information and results in better relationships with among providers (2). For anesthesia providers, this is especially important because they are likely one of many healthcare providers for any given patient, and better access to medical history and communication with the patient’s other physicians is critical. Additionally, a new payment model that incentives healthcare results will also incentivize the development of safer and more effective techniques and equipment. Anesthesia research conducted by many hospitals, universities, and other organizations worldwide will become increasingly more pertinent as the appeal for more effective methods grows.

This shift will likely be seen even outside of Medicare in many different healthcare payment methods. Dozens of insurance companies, employers, and organizations have joined the Centers for Medicare & Medicaid Services (CMS) to move toward alternative payment models. A Health Care Payment Learning and Action network was established to support efforts by the government, private sector payers, employers, and others seeking healthcare coverage to create a payment system that leads to the most affordable and best healthcare results.

Healthcare providers should be aware of how this new quality-based model with affect Medicare payments. There is an incentive to participate in the Physician Quality Reporting System (PQRS), which collects clinical data for the CMS to research the most cost effective treatments with the best results (3). Anesthesia providers can report through the National Anesthesia Clinical Outcomes Registry (NACOR) (4). NACOR collects data and outcomes of anesthesia practices such as the duration of surgery, agents used, infections, and any prolonged length of stay (5). NACOR also identifies areas for improvement for healthcare providers based on quality gaps found through reported data (4).

To keep practices financially sustainable, it is vital for healthcare providers to be familiar with changes in this new payment model. Staying up to date with the quality of techniques and equipment is now essential not only for patient care, but also for Medicare reimbursements.

Sources:

1. http://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html
2. http://www.hhs.gov/about/news/2016/03/03/hhs-reaches-goal-tying-30-percent-medicare-payments-quality-ahead-schedule.html
3. http://www.hbma.org/news/public-news/n_pqrs-measuring-value-today-and-tomorrow
4. https://www.aqihq.org/introduction-to-nacor.aspx
5. http://www.aqihq.org/files/Introduction%20to%20NACOR.pdf

Perhaps few other medical disciplines are as reliant upon, and willing to adapt to, technology in the name of advancing patient health and safety as is anesthesiology. Anesthesiologists use the anesthesia workstation to not only safely and properly deliver gases and inhalants, but also for patient monitoring. Given the important role that the anesthesia machine plays in the delivery of anesthesia services, patient safety is dependent upon keeping these machines in safe working order. Sometimes, however, anesthesia machines are rendered obsolete – meaning they are no longer considered safe for patient use.  But determining whether a particular machine is obsolete and what to do about it can be confusing.

The America Society of Anesthesiologists (ASA) has established recommended guidelines for determining anesthesia machine obsolescence. Patient safety is the primary goal for the anesthesiologist, and for this reason it is imperative that the provider have confidence in the anesthesia machine. Importantly, age of the machine alone does not provide a good indication of whether it is obsolete and unsafe to use. Rather, a machine is rendered obsolete when essential components wear out and cannot be replaced, when it is missing certain safety features, or when it is no longer compatible with current medical practice standards.  The ASA guidelines look to the presence or absence of certain criteria in determining anesthesia machine obsolescence.

Absolute Criteria

According to ASA guidelines, the presence or absence of certain features will render a machine obsolete. This means the machine should no longer be used for patient care. Absolute criteria can be broken down into three main categories: lack of essential safety features, presence of unacceptable features, or adequate maintenance is no longer available.

1. Lack of essential safety features.

Anesthesia has inherent risks, but many of these can be minimized when there are standardized safety features present on anesthesia machines. For this reason, the lack of those essential safety features that prevent a mishap with gas and anesthesia vapor levels will render the machine obsolete.  For instance, if the machine is missing an oxygen failure safety (“fail-safe”) device, is missing a minimum ratio device (nitrogen/oxygen (N2O/O2 proportioning system), or oxygen supply pressure alarm, the machine must be rendered obsolete. The guidelines list other key features that must be present if the machine is to be considered safe for patient use.

2. Presence of unacceptable features.

Just as the absence of some features makes the machine obsolete, so will the presence of other features deemed unsafe or unacceptable. Many unacceptable features involve the vaporizers on the machine. First, because they are no longer manufactured and therefore are typically unserviceable, measured-flow vaporizers are no longer acceptable on anesthesia machines. Additionally, in an effort to ensure uniformity among machines, all machines with vaporizers that have rotary concentration dials must increase vapor concentration only when the dial is turned counterclockwise.  If your machine’s rotary concentration dial increases vapor concentration with a clockwise turn, it should not be used (unless the dial can be replaced).  You can review other unacceptable features that the ASA points out here.

3. Adequate maintenance is no longer possible.

Regular maintenance of the anesthesia machine is key to ensuring patient safety. Generally, an anesthesia machine will be rendered obsolete if the manufacturer or certified service personnel is unwilling or unable to service the machine with acceptable replacement parts.  Notably, it can be difficult to obtain acceptable replacement parts, particularly when the machines are no longer manufactured. Hospitals and providers should be aware that when a manufacturer determines that it will no longer service a particular machine, the responsibility transfers to the healthcare facility or the third party.

Relative Criteria

Unlike absolute criteria, the presence of “relative criteria” does not mandate that a machine be replaced; only that it might need to be replaced.

1. Lack of certain safety features

If certain features are lacking, or are inappropriate, the machine may be obsolete. This includes the lack of an adjustable pressure-limiting (APL) valve or the lack of an airway pressure alarm.  In addition, there should not be any oxygen flow control knob that is smaller than other flow control knobs. The ASA recommends that the machine needs to have a main power switch and an anti-disconnection device at the fresh gas outlet (because, depending on the model used, the disconnection of the fresh gas hose may not be immediately noticeable).

2. Problems with maintenance

A machine that has a history of mechanical problems or frequent service demands may be considered obsolete if it is threatening patient safety.  Maintenance logs should be filled out and reviewed regularly to determine whether any machine is having recurrent problems that could be affecting anesthesia services or patients.

3. Potential for human error

The potential for human error is a real threat to patient safety, particularly if there are inconsistencies between machines being used by the provider. For instance, if features such as an alarm are present on one machine, but not on another, the user can become confused and the likelihood of operator error increases. It is recommended that anesthesia providers consider standardization of machines throughout their institution and/or practice.

4. Inability to meet practice needs

Finally, a machine may be rendered obsolete by virtue of it no longer being able to meet changing practice requirements.  This may occur when an older machine cannot accept newer inhaled volatile agents or when it cannot meet the standards of current anesthetic techniques.

What to do with an obsolete machine?

If a machine is determined to be obsolete, remove the machine from any place in which it might be used clinically.  Obsolete anesthesia machines can be destroyed, or possible donated for different use (for example, to a zoo, laboratory or even developing country). Because there may be legal liability related to the donation of these devices, it is always a good idea to seek legal advice before making any charitable donation of obsolete machines.

Recent advances in telehealth promise to improve health outcomes – and save both time and money. Using a wide variety of technological innovations, practitioners using telehealth can provide consultations, conduct check-ups, and perform procedures, all without meeting a patient face-to-face.

In former decades, “telehealth” mostly meant using a phone to call your doctor. Now, doctors can perform even complex robotic surgeries on patients who are on the opposite side of the world. With digital medical equipment, cameras, and video chatting, doctors can evaluate and treat patients without meeting them in person. These methods are not only cost-effective, but also improve upon current health procedures: recent studies of telehealth implementation show that incorporating technology into health care services can actually lead to better medical care even while cutting costs.

In rural or sparsely populated areas, where specialists are few and far between, telehealth can provide enormous benefits to long-underserved populations. In a study begun in 2014 in Sunflower County, a poor area of Mississippi, using telehealth for 100 patients led to the discovery of 18 cases of diabetic retinopathy that would otherwise have gone undiagnosed, and saved patients a collective 10,000 miles of travel.

In anesthesia services, remote consultations and procedures are already saving people time and money. Instead of meeting patients face-to-face before a procedure, anesthesiologists can conduct a full physical exam by video. In one recent study, a nurse present with the patient used an airway camera to enable doctors to conduct a full airway exam of the respiratory system, and used a digital stethoscope to enable full heart and lung auscultation. Using this equipment eliminates the need for a pre-operative meeting, so that patients and doctors meet only on the day of the procedure. By reducing the amount of in-person interaction between doctor and patient, telehealth pre-operative anesthesia services appointments have the potential to cut Medicare spending in this sector.

Doctors can even administer and manage anesthesia from afar. In one study, anesthesiologists remotely controlled intravenous anesthesia using an automated system called the “Anesthesia Cockpit.” This system controls the anesthesia’s impact on the patient by adjusting the drug level according to physiological indicators like heart rate, blood pressure, and level of consciousness.

More and more practitioners are incorporating these new technologies into their standard operations. In 2015, there was a 25% increase in total Medicare payments for telehealth from the previous year. According to a 2015 National Business Group on Health survey, in 2016, 74% of large employers expect to offer telehealth services to their employees. The latest report by business intelligence provider GBI Research claims that telehealth has the potential to yield over $6 billion in healthcare savings every year. Given the fact that, according to the Center on Budget and Policy Priorities, Medicare spending along with Medicaid, CHIP, and Affordable Care Act marketplace subsidies accounts for 25% of the federal budget (some $900 billion), the potential of telehealth to cut government health insurance spending has real significance.

But certain barriers still prevent telehealth from reaching its full potential. Communicating through video chat or other web-based means often requires sending personal medical data across a connection, and thus data security and privacy are issues. In developing countries and other areas where IT literacy is low, it is difficult to implement telehealth practices without encountering technological difficulties.

In addition to these issues inherent to telehealth, there are larger features of the medical system that have slowed its progress. Restrictions on Medicare reimbursements limit in what circumstances doctors may receive payment for conducting appointments and procedures over the Internet. Many states – including Texas, Arkansas, Mississippi, Alaska, Alabama – have recently upheld legislation that mandates face-to-face meetings in certain situations, thereby reducing the potency of telehealth solutions. Although there has been progress at the state level – just this week, the Texas State Board of Examiners of Professional Counselors rejected a proposal to mandate that therapists establish an in-person relationship with a patient before turning to telehealth – significant systemic barriers still exist.

But the federal government may lower some of these barriers soon. Just over a month ago, a bipartisan group of senators introduced a bill, the “CONNECT for Health Act,” which proposes to expand the scope of Medicare reimbursements for telehealth and remote patient monitoring services. An identical bill was introduced in the House of Representatives just a couple of days later. An independent report predicts that the bill would save the federal government $1.8 billion over the next ten years, if it passes through Congress.

Although telehealth is far from reaching its full potential, it is certainly on the rise. It’s worth keeping an eye on the news from this sector of the health care system to see what’s next in the world of digital health, and how these new techniques can both lower costs and promote good health