Minimal sedation cuts costs, improves outcomes

Choose patients carefully and have a hand holder’

Thinking "outside the box" enabled the manager and medical director of the Elmira (NY) ASC to not only cut the cost of their procedure for patients, but also to make the patients’ recovery more comfortable and quicker.

Elmira won a 2005 Innovations in Quality Improvement Award from the Accreditation Association for Ambulatory Health Care’s Institute for Quality Improvement for its solution to an anesthesia coverage challenge.

"Anesthesia coverage for our facility was iffy,’" says Tom Friedrich, administrator of the surgery center. "Because we only handle ophthalmology procedures, the anesthesiology group that provided coverage was losing money on the procedures they handled due to the Medicare reimbursement level." In addition, the anesthesiology group had concerns about being able to guarantee staff to cover the center, he adds.

"The anesthesiology contract was due for renewal, and we were told that they could not continue to provide coverage unless we subsidized their reimbursement," says Friedrich. "We renewed the contract for a short time with the subsidy in place as we studied our other options."

The other option that was chosen after careful evaluation was to eliminate the need for anesthesiologists by using only minimal sedation in the center. "Over 70% of our procedures are cataract surgeries," Friedrich reports. After reviewing studies and recommendations for reducing risks of anesthesia, the center’s managers decided to pilot a project in which they used diazepam, an oral sedative, instead of intravenous (IV) sedation.

"Initially, some of our nurses were reluctant to make the change, and we did give them the option of not participating in the pilot project," he notes. Reasons for the reluctance included a concern that an anesthesiologist would not be available as a medical crisis manager, he says. Friedrich addressed this concern by making sure that a nurse trained in advanced cardiac life support is always on-site when there is a surgical patient in the facility.

"The surgeon prescribes the sedative, and nurses in the pre-op area administer it," he says. Monitoring and discharge protocols for conscious sedation that existed when anesthesiologists were on-site are still in place, with nurses monitoring the patient, he adds. Note that requirements for monitoring differ from state to state, Friedrich suggests.

Richard Rosenberg, MD, medical director of the center says, "I piloted the project, but soon all of the surgeons were using minimal sedation on all of their patients." The most difficult and surprising aspect of the change is that you are treating a patient who is awake, Rosenberg says. "Once a surgeon gets over the psychological aspect of talking to your patient during surgery, there are many benefits to minimal sedation," he says. "Patients are not asleep or lethargic, so they can look up or down as you need."

Physicians also can improve the patient-physician bond by talking through the procedure and explaining what they are doing, and what the patients may hear, Rosenberg says. Patients stay calmer during the procedure when they know what to expect, he adds.

Hand-holder calms patients

Because the staff and physicians did not know what to expect in terms of patient anxiety when they first tried minimal sedation, a new position in the operating room was created to address anxiety.

"The most important part of this switch to minimal sedation is the hand-holder," says Friedrich. An employee with good interpersonal skills sits next to the patient and holds his or her hand, he says. The hand-holder will talk to the patient and explain what is happening, especially if the patient is showing signs of anxiety by squeezing the employee’s hand a little more tightly, Friedrich adds. "We started with only registered nurses as hand-holders, but now we’re letting surgical techs with the skills and knowledge needed to explain things to the patient fill the position as well," he says.

"When you use minimal sedation, it requires more communication with the patient throughout the procedure, but the combination of the surgeon and the hand-holder has produced very good feedback from our patients," says Friedrich. Knowing that someone will be sitting with them during the procedure to explain everything and just to be with them reduces patients’ preoperative anxiety, he says. "When you reduce anxiety, the patient is more comfortable during both the procedure and the recovery," he adds.

The cost-savings to switch to minimal sedation is not related to drug costs, points out Friedrich. "The cost of the drugs for IV sedation compared to minimal sedation is similar, but we are not having to subsidize the anesthesiologists $100 per hour as their contract specified," he says.

There are other benefits, Friedrich says. "Our patients are not exposed to the risks of anesthesia, so we don’t have the potential for medical complications related to anesthesia, especially with our older patients," he points out.

Cancellation rates dropped after the switch to minimal sedation because it is easier to obtain medical clearance for patients, Friedrich points out. "Patients also appreciate the fact that they don’t have to make a separate visit to their primary care physician for medical clearance because our surgeons perform the pre-op evaluation," he says.

When performing the pre-op evaluation, you do have to be aware that some patients might not be appropriate candidates for minimal sedation, points out Rosenberg. "Patients who are claustrophobic may not be able to tolerate being awake during the procedure, and patients who are in the early stages of senility and can’t control their anxiety are not appropriate candidates for minimal sedation," he explains. "You can also get a sense of how cooperative the patient might be during the procedure and if they are prone to panic during your pre-op exam."

Patients who are not appropriate for minimal sedation have their procedures scheduled at the hospital, says Rosenberg. "We’ve scheduled just a handful of patients for the hospital since we switched to minimal sedation, and we are actually able to schedule more at the freestanding facility because we can see patients with medical conditions that made them high risk ambulatory patients when we were administering anesthesia."


For more information about switching to minimal sedation, contact:

  • Tom Friedrich, Administrator, Elmira ASC, 207 Madison Ave., Elmira, NY 14901. Telephone: (607) 734-2984. E-mail: