Solutions to Anesthesia Waste

The United States health care sector is responsible for 10% of the nation’s greenhouse gas emissions and generates costs of up to 470,000 disability-adjusted life years in terms of excess morbidity and mortality. , Anesthesiology in particular contributes a third of health care’s greenhouse gas emissions due to inhaled anesthetic atmospheric waste, pharmaceutical waste, and solid waste. Furthermore, anesthesiologists play a crucial role in the operating room, one of the most resource-intensive and polluting care settings. For these reasons,the specialty is poised to play a significant role in promoting sustainability in their care settings, with considerable potential savings and boons to patient care.

Waste Generated by Anesthesiology:

In 2014, the American Society of Anesthesiologists Environmental Task Force published sustainability guidelines that directly target specific waste streams, including inhaled anesthetic atmospheric waste, pharmaceutical waste, electrical waste, and solid waste. The guidelines include a call for anesthesia specialists to increase their involvement in their respective communities and become sustainability leaders.

Some of the guidelines are immediately salient to anesthesiology, including those which address inhaled anesthetic gases.Of all inhaled gases, desflurane and nitrous oxide are particularly high-risk as emissions: desflurane has the largest carbon dioxide equivalence (in global warming potential)of any inhaled anesthetic gas, and nitrous oxide’s reactivity leads to toxic downstream products that are later released into the ambient air, often without treatment. What’s more, desflurane takes up to 14 years to degrade, while nitrous oxide takes 114.ASA Guidelines, along with Jeffrey Feldman, MD, of the University of Pennsylvania,advise that these high impact gases be substituted when possible for less reactive gases, or that their use be limited through semi-closed or closed circuit anesthesia. Regional techniques should also be considered whenever possible, and investments in waste anesthetic gas capture (WAG) can provide a long term solution in limiting the amount of anesthetic gas released into the atmosphere.

Another major concern relates to the waste of pharmaceuticals. For instance, infusion waste stems from two major issues: physicians do not mix infusions with scarcity in mind, and containers are not made for single-patient use. In 2017, Tera Cushman, MD, an adult cardiothoracic anesthesiology fellow from the Duke University Medical Center, found that infusions were being wasted when trainees systematically mixed infusions as a part of their training, regardless of whether they were appropriate for the patient’s condition or treatment. This practice resulted in up to 39% of primed epinephrine being wasted and 22% of primed vasopress in being wasted. The cost of wasted infusions per case was $110. Cushman sought to cut down the amount of non-recyclable infusions and to increase the rate of return of recyclable infusions through tracing of spiked and used infusions, managing a per-case waste decrease of 70%. Alternative solutions to decreasing the waste of infusions include the cost-neutral measure of favouring pre-filled syringe use and splitting large infusion vials between patients.

These strategies are not only reasonable and culminate in lives and dollars saved from environmental impact, but they can help steer healthcare institutions toward sustainability-motivated purchasing. In an age of rising costs and frequent drug shortages, allocating drugs and resources with a scarcity mindset ensures that anesthesia providers are less likely to run out of emergency drugs (e.g. epinephrine) and curbs waste generated along the upstream production and supply chain processes. That said, leadership from hospitals, practices, and management service organizations can make key systemic adjustments to facilitate waste efficiency and in the process, increase their competitiveness in an increasingly ecology-conscious market by:

1.    Where applicable, transitioning from flat-rate waste management to volume-based waste disposal to directly incentivize waste minimization;
2.    Utilizing apps such as the Yale Gassing Greener to evaluate the environmental impact of inhaled anesthetics and to collect research data so that monitoring can be conducted over time;
3.    Building institutional spaces, such as task forces and commissions, that encourage interested health practitioners to cultivate leadership in healthcare sustainability; and
4.    Being supportive of efforts to decrease waste when it is not financially onerous to do so. 

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Anesthetic Management of Trauma Patients

In the U.S., trauma is the leading cause of death for patients younger than 40 years old, and up to a third of all hospital admissions are related to trauma.  Management of trauma patients can be especially challenging due to the intensive resource requirements and multiple injuries to multiple body systems.  In a trauma center, the anesthesiologist often becomes involved as soon as the patient arrives to the ED trauma bay, beginning with airway and resuscitation management and possibly proceeding through the operating room, then postoperatively to the intensive care unit.

 The anesthesiologist must have an understanding of the design of the trauma system and what the surgical priorities are.  Trauma patients are unique in that their history is limited, they are frequently have full stomachs and cervical spine instability, and are often intoxicated. The advanced trauma life support (ATLS) course from the American College of Surgeons is a widely recognized framework for caring for injured patients, with emphasis on the ABCDE mnemonic: airway, breathing, circulation, disability, and exposure. 

The anesthesiologist is especially qualified in airway management, and ensuring an open airway and adequate respiration is of utmost importance to avoid cerebral hypoxia and death.  Rapid sequence induction should be performed and an endotracheal intubation must be confirmed by capnometry.  Intubation should be performed using in-line cervical stabilization, and a surgeon who is proficient at cricothyroidotomy should be readily available.  A bougie, Glidescope, or LMA may be necessary to manage a difficult airway.

Managing bleeding is a priority, and shock is presumed to be from hemorrhage until proven otherwise.  Administration of fluids including blood products via large bore intravenous catheters is critical in increasing cardiac output and blood pressure in a hypovolemic trauma patient.  Emergency surgery may be necessary to diagnose or control active bleeding.  The anesthesiologist can ensure the patient receives warming fluids rapidly, and assist in increasing the room temperature and covering the patient with warm blankets.  Maintaining cerebral perfusion may be critical in patients with severe traumatic brain injury and intracranial hemorrhage.  Invasive monitors such as arterial lines, central lines, and pulmonary artery catheters may be necessary but should not delay the aforementioned resuscitation priorities.

Patients of all ages and backgrounds can suffer trauma, and because of its prevalence, many anesthesiologists will have to care for trauma patients.  Because of their appropriate and specific type of training, anesthesiologists are ideally suited to care for these patients.

A Modernized Approach to Pediatric Anesthesia

To recognize Children’s Eye Health and Safety Month, The American Association of Nurse Anesthetists (AANA) has proposed an extensive list of guidelines for the administration of anesthesia for ophthalmologic procedures on children.[1] In this document, Certified Registered Nurse Anesthetists (CRNAs) are emphasized as primary practitioners of pediatric anesthesia, combining in-depth technical knowledge with a holistic approach to healing. This document exemplifies the increasing focus on pediatric anesthesia, as noted by anesthesiologists, anesthesia management companies, and CRNAs alike. From a historical standpoint, the use of anesthesia in children has typically been limited to specialists such as pediatric anesthesiologists, who undergo specific training via fellowship in order to satisfy stringent requirements for the practice. Furthermore, the use of pediatric anesthesia has also been limited to specific procedures, recognizing the increased potency of anesthesia on younger patients. Many anesthesiologists are aware of the case of Caleb Sears, a 6-year old boy who passed away soon after administration of general anesthesia in a dental setting. While Caleb’s case has been used to debate the medical ethics of pediatric anesthesia, it is also a sharp reminder of the dangers that come from not consistently updating medical approaches to anesthesia. In response to advocacy stirred up by the tragic case of Caleb, an increased focus has been placed on pediatric anesthesia in the medical community. Therefore, anesthesiologists, CRNAs, and medical researchers are approaching pediatric anesthesia with a fresh lens. Recent developments have thus concluded that a modern approach to pediatric anesthesia combines optimized team management with updated dosage recommendations, facilitating a safe and effective administration of anesthesia to young people.anesthesia for kids

The optimization of medical team management is essential in the administration of pediatric anesthesia. The American Academy of Pediatrics recommends against a “single-operator model”, in which one individual is tasked with both the sedation and the surgery itself, an event frequent in dental and oral surgery settings.[2] Instead, it is now fully recommended that there be one separate individual who can administer anesthesia, monitor vital signs, provide PALS (Pediatric Advanced Life Support) if necessary, and step in to assist the primary surgeon in case of emergency. This role can be taken by an anesthesiologist, but can also be fulfilled by a CRNA or trained midlevel medical practitioner. CRNAs with additional training or rotations in pediatrics can often have deep knowledge of the topic, and are viewed as valuable additions to a medical team working with children.

Furthermore, specific dosage requirements are in the process of review in order to ensure that administration of anesthesia to children is safe and effective. The Food and Drug Administration had previously warned that using anesthesia on children aged 3 and younger can produce developmental problems if administered at high intensity or for a sustained period of time. In response, the American Academy of Pediatrics conducted a epidemiological study of the topic, aiming to investigate the proposed conclusion in a large population-based setting. In controlled trials using humans (as opposed to primates or other model organisms), the AAP found that a short, one-time use of anesthesia in young children provoked no developmental issues.[3] This conclusion was then supported by many medical academies and professional associations, including the Society for Pediatric Anesthesia, the International Anesthesia Research Society, and the American Society for Anesthesiologists. In sum, with the proper dosage, administered by a correctly trained medical practitioner, the use of anesthesia on young children does not result in adverse developmental consequences. Researchers will continue to focus on the issue of pediatric anesthesia, to ensure that there are detailed dosage instructions for each drug utilized and thus a proper course of action for CRNAs and anesthesiologists.

Anesthesia is an invaluable tool for smoother surgeries. A specialized team model, in combination with specific and up-to-date dosage recommendations, can ensure that anesthesia remains a viable and safe option for all, including those under pediatric care.

Sharps Safety in the Perioperative Setting

Sharps injuries are an over represented problem in the peri- and intraoperative setting. Anesthesia Services providers and perioperative nursing staff are at particular risk for sustaining needle stick injuries, as their roles involve frequent administration of medications and placement of lines, often under urgent or stressful circumstances. Surgical personnel are also at risk given the use and necessary passing of sharp instruments between team members intraoperatively.

The Association of Perioperative Registered Nurses (AORM) regularly publishes guidelines and evidence-based recommendations to promote sharps safety and reduce the number of needle stick injuries in the perioperative setting.

These recommendations include implementing the use of safety-engineered devices. For scalpels, options include retractable scalpel blades, shielded or sheathed scalpel blades, and scalpel blade removal devices. Safe tissue closure devices include tissue staplers and adhesives in lieu of suturing. A systemic review of 14 randomized controlled trials found no significant difference between sutures and adhesives in regard to infection, patient and user satisfaction, and cost; however sutures were better in minimizing wound dehiscence and were faster to use.

Health care worker’s gloved hand drops syringe into hazardous waste container.

Whenever possible, needle less systems should be used for collecting blood or bodily fluids after initial access establishment. Administering medications should be done without needles whenever possible (e.g. using IV ports that don’t require puncture). When needles are required, they should have safety engineered features. These include sliding sheaths that cover needles after use, hinged needle guards, sliding needle guards, and retractable needles. Safe practices include not recapping needles, or if recapping is necessary and a safe needle device is unavailable, using a one-handed scooping technique.

Using needleless or blunt entry devices to withdraw contents from multi-dose vials is another recommendation put forward. When opening glass ampules, using a disposable or reusable ampule breaker (which could be as simple as a 4×4 gauze) can decrease injuries.

Using a puncture-resistant sharps containment device is important in sharps disposal after use. In the operating room, a neutral zone should be implemented during passing of sharp instruments – i.e. the instruments are put down and picked up rather than passed hand to hand. A no-touch technique should be used when handling sharps to reduce manual handling – i.e. not manipulating suture needles with hands while loading or repositioning, using blunt instrument holders instead.

In addition to implementing strategies to prevent sharps injuries, health care facilities should also have a plan for post-exposure care that is familiar and readily available to their workers.

Sharps safety is an important concern in the perioperative setting, and it is paramount that both providers and facilities be aware of strategies to reduce the incidence of sharps-related injuries.

Expansion of Rural Hospitals’ Medicare Reimbursement Plan

In an effort to relieve rural hospitals’ eternal battle with insufficient funding, the Center for Medicare and Medicaid Services (CMS) is expanding its alternative reimbursement plan for another 5 years for Medicare-covered treatment costs for rural hospitals. Already starved of in-demand and expensive physicians such as specialized surgeons, radiologists, and anesthesiologists, many hospitals are struggling to provide optimal care with their available resources under their shoestring budgets or deficient incomes caused by insufficient reimbursement from both Medicare and private insurers.

           

Larger, urban hospitals can sometimes rely on extra reimbursement from private insurers to cover occasional discrepancies between treatment costs and governmental payments. However for rural hospitals that provide care to lower-income, small populations, there is a lack of a competitive market for insurance that drives down prices and raises reimbursements. These hospitals then grow dependent on full Medicare reimbursement to meet operating costs, and if these costs are not met by revenue streams, private and governmental, these hospitals, the only source of care for millions of rural Americans, are forced to close—as evidenced by the 78 closures since 2010.

           

In response to this closure epidemic, CMS is inviting qualifying rural hospitals to apply to join its payment plan designed specifically for mid-sized rural hospitals—the Rural Community Hospital Demonstration. Under this reimbursement plan, the hospitals will receive reimbursement for inpatient treatments costs for Medicare-covered patients after the patient is discharged from the hospital as long as the procedure was completed at a reasonable speed and cost. The current standard method for Medicare payment is that each year hospitals are required to estimate treatment costs for different procedures and illnesses and submit them to CMS. Then based on those early predictions, CMS reimburses the hospitals for the treatments they performed for Medicare patients. Because of rising healthcare costs, outdated technology in these hospitals, and naturally arising treatment complications, these annual predictions are sometimes insufficient to cover costs, which can be devastating to a small hospital’s budget.

           

That is why the CMS is campaigning for rural hospitals to join its alternative plan. To qualify, the hospitals must have 51 beds or less but also be larger than a Critical Access Hospital. Also, they must provide 24-hour emergency care, and be situated in a designated rural area. Applications for hospitals to switch plans close May 17th with priority given to hospitals in states with the lowest 20 population densities. With more hospitals ensuring that their budgets are always met by joining this plan, more rural Americans will continue to receive the care that they need.

Trends Shaping the Future of the ASC Industry

More now than in the past, the soaring cost of hospital care is leading physicians and patients to look for different venues for medical treatment. The average cost of a hospital stay in 2010 was $9,700, whereas for Americans ages 65 to 84 that number soared to $12,300. It is not surprising that an increasing number of patients are choosing to undergo procedures in Ambulatory Surgery Centers (ASCs), rather than in typical hospital settings. Colonoscopies, for example, one of the more common services provided by ASCs, cost patients on average a co-payment of just $76. A similar operation in a hospital, meanwhile, can cost the patient $186. While ASCs offer many benefits, there are a few key trends transforming the ASC industry which physicians, from surgeons to CRNAs to anesthesiologists, and their patients should be acquainted with. 

Since the first Ambulatory Surgery Center was established in 1970, ASCs in the United States have collected less reimbursement from Medicare than hospitals have for carrying out identical procedures. ASCs collect on average only 49% of the fees earned by hospitals and hospital-affiliated centers. For example, an ASC will receive a payment of only $980 for conducting a cataract surgery, whereas a hospital which performs the same operation will earn $1,760. This could change in the near future, however. Government health officials are working to eliminate the payment disparity between hospitals and ASCs in order to foster the growth of the ASC industry. The ASC Access and Quality Act of 2017, introduced in the House of Representatives in March of 2017, seeks to ensure fair compensation for ASCs. Moreover, the newly appointed chief of the Department of Health and Human Services, Secretary Tom Price, has a track record of supporting ASCs. He once owned an ASC himself, and worked as an orthopedic surgeon before he was elected to Congress. In his new role he may try to promote ASCs as a high-quality and cost-effective health care option for patients

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            ASCs are well-known for their autonomy, but a recent trend in the medical industry could change this. Hospitals have ownership stakes in just 21 percent of ASCs, and fully own only 3 percent of ASCs, whereas 90 percent of ASCs are owned in full or in part by surgeons and physicians. Over the last few years, however, prominent insurers and hospitals have made efforts to purchase ASCs in order to extend their presence in the healthcare market. ASCs are known for being small, local businesses – almost 70% of ASCs employ 20 people or fewer. If insurers and hospitals continue to buy ASCs this could change, however. ASCs could become more profitable as a result of these mergers, though, as they would have access to more capital and be able to procure supplies at lower costs. The future of ASCs in the United States is not certain, but these developments provide clues as to how the industry will likely change in coming years.