PREOPERATIVE PROCESSING OF THE AMBULATORY PATIENT
From the American Society of Anesthesiologists’ Annual Meeting, October 13-17, 2007, San Francisco, CA
| ALTERNATIVE PRACTICE LOCATIONS, ALTERNATIVE PROCESSING PATTERNS —Meena S. Desai,
MD, President and Chief Executive Officer, Nova Anesthesia Professionals, Villanova, PA
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| Preoperative processing: includes concern for patient safety (bring as many critical elements as possible into ambulatory
setting); concern should extend to facility safety; choose practices, practitioners, and procedures before starting
(systematically, with conversations and review of facilities before starting anesthesia); ensure appropriate
equipment and supplies in place; ensure patient and practice have same expectations of anesthesia, and that these
expectations can be met; incorporate postoperative procedure (follow-up and communication afterwards) to trend
and track delivery of anesthesia and make improvements; reviewing quality of care helps avoid repeating mistakes
from one location to another
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| Facility safety: ensure elements of safety in anesthetizing location; make sure room large enough, emergency exit
available from second or higher floor, hallways large enough, stretcher fits into elevator, elevator available, secondary
power supply available, battery packs on monitoring equipment last for ≥2 hr, power outlets available for
all equipment brought to location, lighting adequate, counter space adequate for anesthesia equipment, phone access
available in room, and cellular phone reception adequate; determine length of time needed for emergency response
and which staff are educated and ready to help; determine whether patient can be admitted to nearest
hospital; speaker educates all helpers in facility about their roles; requires visiting site, identifying helpers, and educating
them before starting cases; speaker recommends yearly review of “what’s going on and who’s doing what”;
scenarios requiring backup plan (possibly printed in manual) include fire, cardiac arrest, electrical failure, intraoperative
crisis, and natural emergencies (locally appropriate)
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| Equipment and supplies: ensure everything needed present; “do not begin any case with anything missing”; in
speaker’s practice, mobile unit brings replacement if something missing or broken; essentials may include monitors,
medications (enough to maintain patient for 15-20 min while emergency medical services [EMS] arrives), disposable
supplies, and O2 and suction; determine how items to be transported (speaker has mobile package that weighs
≈35 lb); determine if safe to carry package (including drugs) on street
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| Choosing practitioners, practices, and procedures: always conduct preliminary research before promising to deliver
anesthesia care; research surgical colleagues; network with medical community; evaluate colleagues’ experience
and possibly observe their work; important to provide care that meets high standards and to be able to trust colleague
to do his or her portion of patient care; speaker recommends beginning every relationship safely, with less
aggressive procedures, “until you’re sure that you’re in the right setting and your surgeon and yourself are on the
same page”; patient selection criteria varies with facility, depending on level of care available
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| Process for evaluating and selecting patients: initial encounter in surgeon’s or medical practitioner’s office; regularly
educate surgical staff and surgical office staff on differentiating patients that can be seen in private surgical suite
from those requiring higher-acuity facility; most practices require 1 yr to attain this capability; takes patient preoperative
selection process out of surgical hands, and into anesthesia hands; also, carefully review tests in charts so
that surgical staff can begin to order tests; give yourself as much time as possible to collect information (speaker’s
institution begins to collect information “the minute the patient’s booked”); each day every office sends information
about schedule (≥2 wk ahead in most practices); list should be amended or embellished to stay up-to-date with
current anesthesiology practices (eg, in ambulatory setting, morbid obesity defined as body mass index of 45); testing
determines whether patient adequately “worked up” and whether surgery can be performed for particular procedure
while maximizing patient’s health, eg, many things may be unnecessary in patient coming for cataract
procedure; however, may need to “rediscover old information”; as long as patient healthy, <50 yr of age, with no
comorbid conditions, no specific preoperative tests indicated; current history and physical examination required;
role of anesthesia provider to ensure patient generally receiving good health care; for women of child-bearing age,
if last menstrual period shows “any missed time or periods,” offer pregnancy testing on day of surgery; for patient
>50 yr of age with comorbid condition and scheduled for minimally or moderately invasive surgery, electrocardiography
(ECG) suggested (can use preexisting one if done within 1 yr) with history of hypertension, coronary artery
disease, cardiovascular disease, or diabetes; how to capture information—provide surgical office with questionnaire
and demographic collection information, then have information transmitted to anesthesia provider; surgical office
should also have patient sign consent form; if no information available, member of anesthesia provider’s staff calls
patient; nursing staff specifically trained to obtain anesthesia-relevant information in focused way; aim to avoid all
last-minute cancellations and gaps in schedule; patient sent preoperative and postoperative anesthesia procedure information
and consent form, which is signed on day of surgery
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| New procedures and locations: include ambulatory urology procedures (eg, transurethral needle ablation [TUNA]),
gynecologic procedures (eg, diagnostic and therapeutic hysteroscopy, endometrial ablation, mini-laparotomy tubal
ligation, labial contouring), dental procedures (eg, periodontics, oral surgery, prosthodontics, endodontics), and remote
locations in hospital (eg, emergency department, diagnostic imaging)
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| Pediatric offsite anesthesia: reported that pediatric patients who undergo sedation and anesthesia for diagnostic and
therapeutic procedures at extremely high risk and have low tolerance for errors; follow all state guidelines; evaluate
child carefully; speaker cares for pediatric patient in ambulatory surgery center (ASC) only if pediatric anesthesiologist
present; ensure proper postoperative care
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| FILTERING AND COUNTERING DISINFORMATION FROM THE MEDIA, A NEW PREOPERATIVE
TASK —Douglas R. Bacon, MD, MA, Professor of Anesthesiology and History of Medicine, College of Medicine,
Mayo Clinic, Rochester, MN, and Editor, American Society of Anesthesiologists’ Newsletter
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| Sources of bad information: movies—Awake (involves awareness under anesthesia during open heart surgery and
subsequent psychologic problems); The Verdict (alcoholic attorney who takes case of woman who had cerebral anoxic
injury during cesarean delivery under general anesthesia); radio—National Public Radio recently produced
program on anesthesiologists’ experiences in Green Zone in Baghdad; local and national talk programs;
television—various shows have medical episodes, and medicine favorite topic, eg, Grey’s Anatomy (showed anesthesiologist
reacting to unexploded munition by running from room; caused strong reaction from anesthesia community,
especially when considering military colleagues who deal with live, unexploded munitions), House, 60
Minutes, and Anderson Cooper 360 (Mark Lema interviewed for 2 hr but only 30 sec of interview shown);
magazines—Newsweek (article on regional anesthesia in Gulf War and transporting wounded soldiers from Iraq to
Germany with catheters in place), Time, Men’s Health (article about “junkie in the [operating room] OR”), and Cosmopolitan;
Internet—good and bad; many Web sites provide data for patients in easy-to-understand language, but
peer review process lacking (eg, several Web sites address awareness under anesthesia; stories include people who
“are simply being aware of extubation at the end of surgery,” others aware of being transported from OR to recovery
room; few stories about true intraoperative awareness)
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| Discovering bad information: difficult to read every article, watch every broadcast, or listen to every talk radio program;
take time to talk to patient and find out source of information (speaker goes to Web site while patient present,
eg, in preoperative screening; then able to say, “here’s why you don’t need to worry about this or why this is
wrong”)
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| Countering bad information: American Society of Anesthesiologists (ASA) has helpful resources and recent press material
on its Web site; includes ASA responses to stories in press, press releases, and portable document format (PDF)
copies of available pamphlets (give to patient); further questions can be referred to ASA’s department of communications
(resources that may not be available on Web site)
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| Conclusion: considerable amount of bad information easily accessible to patient; also considerable amount of good
information that patient may not understand; popular culture has made entire anesthesia community look bad (easy
target; not as visible or as “sexy” as surgeon); correcting misperception long, tedious, and almost impossible task;
must be done “one patient at a time”; nationally, ASA responds to as many popular press issues as possible; when
possible, access material personally so you know “what’s going on”; most importantly, be reassuring to patient
(most fears rare complications) and act professionally
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| PHONES, FAMILIES, AND OTHER THREATS TO THE PRIVACY OF PATIENTS —Thomas W. Cutter, MD,
MA, Associate Professor of Anesthesiology and Associate Chair, Department of Anesthesia and Critical Care, University
of Chicago Pritzker School of Medicine, and Medical Director for Perioperative Services, University of Chicago
Medical Center, Chicago, IL
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| Privacy: Health Insurance Portability and Accountability Act (HIPAA; many consider it to be Health Information Privacy
and Accountability Act [“seemingly what it has become”]) first federal legislation to specify requirements for individual
privacy; intended to provide consolidation and ease of access; allows portability of health benefits by taking
advantage of latest electronic technology; anesthesia providers take oath to not divulge private information to anyone
who does not need to know (occasionally have elevator conversation or phone conversation in lobby, but not done intentionally);
other individuals may not have same diligence and dedication; each instance of unauthorized accidental
disclosure punishable by fines ranging from $10,000 to $25,000; if intentional, fine may be as high as $250,000
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| Definitions: covered entity—one who is obliged to follow these rules, but also entitled to access protected health information
(PHI); includes any health care provider who conducts certain transactions in electronic form, or health
care clearinghouse, or health plan; PHI—includes name, address, telephone number, fax number, e-mail address,
social security number, health plan beneficiary number, medical diagnoses, records account number, certificate and
license number, and photographs of images
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| Authorization for release of PHI: “if you want to be entirely safe, you really should get it in writing”; but not all
health information or all dissemination and distribution of health care information requires written release (known
as treatment, payment, or health care operation [TPO]), eg, sharing PHI with other treating physicians, insurance
company paying for treatment, and for operation scheduling; as people become more concerned about privacy, they
also potentially risk losing personality
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| Disclosure: must be monitored (follow release of PHI, eg, track e-mail and Web site visits); incidental disclosure of
information to family member or close friend (directly relevant to involvement with patient’s care) can be determined
by practitioner; if possible, make sure patient does not object to disclosure; if patient not present or incapacitated,
practitioner may determine that such disclosure in best interest of patient
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| Transportation of PHI: paper—“if the wrong person views the patient’s health care information, you’ll be paying for
it”; OR schedules and patient records should not be easily visible or easily distributed; make sure charts secure and PHI
disposal bins available (disposal company should be licensed, bonded, and insured); telephone—cellular phone privacy
limited (risky for transmitting PHI); ask patient to indicate in writing whether allowable for messages to be left on answering
machine and to whom PHI can be divulged; always make sure to call correct phone number; unless given permission,
do not leave additional information (eg, time of surgery); fax—speaker recommends not using fax machine;
however, if used, recommendations include not using fax machine until after attempting regular mail, and taking reasonable
steps to ensure fax transmission sent to and received by intended recipient; when fax transmission includes PHI,
reasonable steps include confirming that recipient’s fax machine located in secure area or that intended recipient waiting
by machine to receive transmission; consider preprogramming machine with recipients’ phone numbers to avoid misdialing,
and test frequently to confirm validity; when fax number entered manually, visually check recipient’s fax number
on fax machine before starting transmission; use standard fax cover sheet; check fax confirmation sheet immediately or
as soon as possible after transmission; if intended recipient notifies sender fax was not received, sender should use best
efforts to determine whether fax inadvertently transmitted to another fax number; if fax sent to wrong number, try to retrieve;
those recipients who regularly receive PHI will be periodically reminded to reveal any change; fax confirmation
sheet should be attached; never send results of HIV/AIDS, results or status of substance abuse, and mental health treatment
records; if sending fax via Internet, use secure sockets layer (SSL) or public key infrastructure (PKI) technology;
do not place patient-identifying information into any data fields; use “delete fax after completion” feature; e-mail—
include disclaimer to effect that sender trusts that if recipient received e-mail in error or if not pertinent, it will be deleted,
ignored, and not revealed to anyone else; rules do not specify which technology appropriate for preserving confidentiality
of patient records (physician’s decision), but some encryption should be applied; not considered to be secure;
third-party “cleansing” of transmission an alternative; face-to-face—dry-erase bulletin board or paper acceptable, but
must be kept secure; speaker uses computer-based system with patient information available on display screens; not directly
viewable by patients or families; in waiting area, families have pass code and can track location of family member;
in preoperative holding area, practitioner often has to speak loudly to patient and family to be heard; soft music or
white noise do not solve problem; assure patient you are concerned about their privacy; request patient’s permission to
speak candidly in front of family; sensitive questions in adolescent patients include those about pregnancy and drug usage;
ask in front of parents, then again when alone with patient; do not assume person transporting patient to and from
ASC can receive postdischarge instructions; also determine how to complete postoperative follow-up phone calls; be
concerned about vendors who have access to OR (limit access only to patient for whom vendor is caring, not other patients)
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Suggested Reading
Eisenach JC et al: Anesthesiology and the press. Anesthesiology 107:8, 2007; Haugh R: Payment. Who are you, anyway?
Hosp Health Netw 81:16, 18, 2007; Irving MA: Privacy laws and their effect on healthcare organizations. Ann
Health Law 16:335, 2007; Kent CD et al: Awareness: practice, standards, and the law. Best Pract Res Clin Anaesthesiol
21:369, 2007; Openshaw DJ: The perils of PDAs. CMAJ 168:1524, 1526; author reply 1526, 2003; Schoppmann MJ
et al: HIPAA compliance: the law, reality, and recommendations. J Am Coll Radiol 1:728, 2004; Sutton JH: Patient
privacy and health information confidentiality. Bull Am Coll Surg 86:8, 2001; Wang X et al: Integrating computerized
anesthesia charting into a hospital information system. Int J Clin Monit Comput 12:61, 1995; Weinger MB et al: Video
capture of clinical care to enhance patient safety. Qual Saf Health Care 13:136, 2004.
Educational Objectives
| The goal of this program is to improve preoperative processing of the ambulatory patient. After hearing and assimilating
this program, the participant will be better able to:
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 | 1. Identify emerging trends and practices in preoperative processing of the ambulatory patient.
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| 2. Review the process for evaluating and selecting patients for ambulatory surgery.
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| 3. Describe new procedures and locations for ambulatory surgery, and highlight pediatric offsite anesthesia.
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| 4. Identify sources of “bad” information about anesthesia care and devise ways to counter the incorrect information.
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| 5. Summarize the impact of preoperative processing of the ambulatory patient, including privacy concerns, family
participation, preoperative teaching, and practitioner-patient interaction.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and planning committee
members to disclose relevant financial relationships within the past 12 months that might create any personal conflicts
of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in
health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee
reported nothing to disclose.
Acknowledgements
Drs. Desai, Bacon, and Cutter spoke in San Francisco, CA, at the American Society of Anesthesiologists’ Annual Meeting
, held October 13-17, 2007. The Audio-Digest Foundation thanks the speakers and the ASA for their cooperation
in the production of this program.
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