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.

Multipronged Approach Necessary to Avoid Serious Physician Shortage

Recent statistical reports indicate that the medical field is experiencing a shortage of both primary care and specialty physicians, increasing the likelihood of a widespread serious physician shortage in the United States.  A physician shortage, as calculated by the AAMC, is a calculation of the gap between physician supply and demand. According to the Association of American Medical Colleges’ Center for Workforce Studies, the physician shortage is expected to approach 104,900 physicians by 2030. By physician category, the AAMC predicts a shortage of between 7,300 and 41,300 for primary care physicians, as compared to a shortage of between 33,500 and 61,800 for non-primary physicians.^[1] The latter category includes physicians categorized under specialty services, under which anesthesiology is housed. Note that the AAMC projections are variable to account for a variety of elastic conditions implicit in physician supply and demand calculation. The lower end of the spectrum provides estimates for an optimistic calculation, referencing several policy approaches to ameliorate the physician shortage. However, the higher end of the range represents a final sum based on inaction on the part of healthcare providers, anesthesia management services, and medical educators alike.

A multipronged approach is necessary to avoid a serious physician shortage in 2030, particularly in specialized fields such as anesthesia services. In sum, a multipronged approach may be comprised of the intersection between innovative medical technologies, modernized medical education policies, and optimized collaborative delivery practices. Innovative medical technologies will provide an incentive for physicians to enter a specialized field by minimizing time spent on administrative services. For example, many novel medical database applications streamline the documentation process, allowing physicians to focus on diagnostic and therapeutic work above clerical tasks. In addition, a push for modernized medical education policies will encourage students to pursue 

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careers, specifically in anesthesiology and other specialty fields. These policies may be advocated via support for post-medical school training at the federal level; an increased emphasis on medical specialization in the medical school curriculum; or other such policy levers that add incentives for medical students to specialize and thus reduce the projected physician shortage. Finally, the optimization of collaborative delivery practices will minimize physician shortage by effectively applying assets towards medical cases. In practice, this will require maximizing the use of Certified Registered Nurse Anesthetists (CRNAs) in anesthesiology practices, as well as a reconfiguration of other key members of the medical team. In this way, anesthesiologists will be supported throughout the duration of each medical cases, ensuring the longevity of physicians in the field.

Taken together, the above multipronged approach is one potential mechanism to address serious physician shortage. However, anesthesiologists, anesthesia management companies, and medical educators must share knowledge to develop further techniques to address a physician shortage in anesthesia, thus minimizing the threat of a serious and impactful shortage in the United States.

Telehealth Increases Access to Healthcare

A new study found that direct-to-consumer telehealth often initiates new use of medical services and may increase medical spending instead of decreasing it. The use of telehealth, in which a patient has access to a physician via telephone or videoconferencing, is projected to increase access to health care while reducing costs and saving time.

The Rand Corp. analyzed 2011 to 2013 claims information for 300,000 beneficiaries of a health plan provided by CalPERS, a large California public employee benefit organization, which began offering telehealth services to selected members in 2012. They examined the per episode cost of telehealth and physical visits for acute respiratory infections and estimated what fraction of telehealth visits represented substitution versus new utilization.

One of their key findings was that the cost of telehealth visits was 50 percent lower than a visit to the physician’s office and less than five percent of the cost of an emergency department (ED) visit. Although there were cost savings, these were outweighed by the increase in spending from new utilization. Net annual spending on acute respiratory infection actually increased by $45 for every telehealth patient due to new use of medical services. Only 12 percent of all telehealth visits were substitutions for visits to other providers, while the other 88 percent represented new utilization.

The researchers suggest that innovative policies could help telehealth services reach their cost-saving potential. Insurers who want to increase direct-to-consumer telehealth services may consider raising copays for telehealth and encouraging frequent ED users to utilize telehealth services instead.

Although these new findings seem to overturn the common belief that telehealth is cost-saving, the authors acknowledge that their study was subject to several limitations that may mean that their results are not universally generalizable. First, the patient population studied had generous commercial insurance, and utilization patterns among the uninsured and those with government insurance may differ. Secondly, the overall uptake of telehealth in the population was low, so it is difficult to predict how utilization might change when telehealth becomes more popular. Finally, telehealth utilization may vary among conditions, and the breakdown of spending per episode may change when other conditions are considered.

Overall, these findings begin to shed light on the question of whether telehealth tends to substitute or supplement in-person care. At this time, it appears that telehealth services are primarily increasing overall access to care without replacing physical visits to a meaningful extent.

 Anesthesia management company

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.

Optimizing the Anesthesia RFP Process (Request for Proposal)

Hospitals looking to change their anesthesia service providers will likely need to create a request for proposal document (RFP) to send to new potential vendors. RFPs can be time-consuming for both the buyer and the vendor, so it is in both parties’ best interests to make the process as straightforward as possible. While this may seem like a daunting task, there are a couple tactics that can be implemented to optimize the anesthesia RFP process and to create the best match between the vendor and hospital.

1. Hospitals should know what their needs are and convey them clearly.

A hospital will likely choose to change vendors based on concerns regarding the cost and/or service of the current vendor. The hospital should identify where the current vendor is falling short and gear a portion of the RFP to understanding how other vendors approach those areas. In general, RFPs are most effective when they are specific and allow for standardized comparisons of vendor responses during the evaluation portion of the selection process. Some hospitals will allow vendors to contribute to the RFP, a tactic that reduces the time spent by the buyer, but potentially biases the RFP towards a specific vendor and reduces its specificity to the hospital’s needs. In the interest of developing a fair and representative RFP, the hospital should handle the RFP creation process independently. However, the vendors do not need to be completely blind in the selection process; according to the TechRepublic, providing the evaluation criteria of the hospital may help vendors provide responses better geared towards the hospital’s priorities.

2. Representatives from the teams affected by the change should be included in the discussion.

Changing health service vendors not only affects the business end of the hospital but also the health care aspect. As a result, it is important to include a diverse group of stakeholders in the conversation prior to and during the vendor change. Different teams within the hospital will have different requirements for the anesthesia service. According to the Becker’s Health IT and CIO Review, addressing the stakeholders’ concerns early on in the vendor selection process will ease the implementation and transition phases. Additionally, while the current vendor should not be included in the RFP drafting process, the hospital should have a discussion with that vendor regarding their performance months before collecting RFP responses to avoid pressure to renew services.

3. Make sure that vendors follow through with their claims.

The hospital should make sure to hold the vendor to the specific standards and claims described in the vendor’s response to the RFP. If additional promises were made by the vendor before the selection committee, they must be added to the written contract or they may not be viewed as commitments by the vendor. The hospital also should request a list of references from the top candidatesand follow up with them; in some cases, a site visit could be beneficial in understanding how the service is being implemented in other locations.