Cut your costs and reduce your stress: Select appropriate patients for SDS

Insurer reports guidelines reduce average claims from $78,477 to $5,207

It’s the scenario that every same-day surgery manager wants to avoid: A patient has ambulatory surgery, experiences problems in the postoperative recovery — problems that should have been identified before surgery — and has to be admitted to the hospital.

"It’s very cost inefficient and stressful for everyone involved," says Andrew M. Green, MD, chief of anesthesiology at Carroll County General Hospital and medical director at Dixon Surgery Center, both in Westminster, MD.

And that’s not the only problem. When an inappropriate patient is selected for an approach such as the laparoscopic technique, litigation can result, says Pam Lockowitz, president of MMI Risk Management Resources in Deerfield, IL. MMI insures health care organizations and offers risk management products and services.

"In looking at the details of these cases, we sometimes see patients who were selected had other issues that should have been dealt with. So, one, they are appropriate candidates for the laparoscopic approach, or two, they are appropriate for the outpatient setting," Lockowitz says.

MMI has worked with the ambulatory surgery clients it insures to develop patient evaluation and selection criteria that have resulted in a .06% rate of unplanned returns to surgery within 48 hours and a .17% rate of injuries to organs resulting from the use of an endoscope during surgery. These figures compare with a .54% rate of unplanned returns to surgery within 48 hours of inpatient surgery and a .54% rate of injuries to organs resulting from the use of an endoscope during inpatient surgery.

Clients who use MMI’s perioperative guidelines to match patients to the appropriate care setting and surgical technique have reduced average cost per malpractice claim from $78,477 to $5,207, according to company reports.

"If a patient for some reason is dissatisfied with the outcome and sues, providers can generally stand behind having followed a good set of practice guidelines and meeting standards of care," Lockowitz says.

More than likely, providers can have the case dismissed or will win the verdict, she says. "They may only have to pay the cost of defense," Lockowitz adds.

Don’t simply look at ASA class or procedure

Despite liability concerns, it’s no longer necessary to limit outpatient surgery based on the American Society of Anesthesiologists (ASA) classification or type of procedure, Green says. But he adds this caveat: "as long as you have an ability to screen for high-risk patients . . . as long as there’s a screening process to rule out patients who might need more intensive medical follow-up in the hospital in the perioperative period, despite having surgery that most people can have and go home the same day."

For example, a patient with stable congestive heart failure can undergo outpatient surgery, but someone who has a more severe case of heart failure and is more unstable might need a longer period for observation after surgery, he says.

A good nursing and medical assessment that includes surgeons, nursing, and anesthesia staff is critical for identifying such patients, says Jane Kusler-Jensen, RN, CNOR, nurse manager at Surgicenter of Greater Milwaukee.

Surgicenter conducts a "health survey" that questions patients about aspirin use, blood thinner use, latex allergies, previous anesthesia problems, history of asthma, and TB symptoms. For pediatric patients, the survey covers issues such as exposure to chickenpox. Some patients are given simple instructions, such as stop using aspirin; others undergo additional lab work to determine bleeding times, for example. Still others might need clearance from their surgeons or primary care physician, Kusler-Jensen says.

Green’s surgery center also looks for red flags based on a preadmission screening process, which he adapted from one he helped develop at Yale University. Patients are called and asked a series of questions. (See PAT Phone Interview form, p. 43.) A subset of questions identifies patients at risk for anesthesia difficulties with airway management, cardiopulmonary problems, or bleeding problems, for example. (See conditions on the form that are indented.) Any patient who responds positively in these areas is asked to come to the center for an interview with an anesthesiologist.

After conducting a history and physical, the anesthesiologist determines if further consultations are needed or whether discussions with the primary care physician are warranted. For example, patients might need to be optimized on their medications for conditions such as asthma or hypertension.

By performing the assessment one to two weeks before surgery, there is time to maximize the patient’s medical condition, Green says. The surgery program can work with consultants via fax, phone, or e-mail. "The main point isn’t to try to get patients not to have same-day surgery," he emphasizes.

Providers aren’t the only ones finding ways to identify potential problems in same-day surgery before they start. Insurance companies also are developing guidelines for selecting appropriate patients and approaches.

MMI examines malpractice cases and examines areas of potential problems for health care providers, including same-day surgery programs. For example, MMI has developed preoperative guidelines for endoscopic procedures. The guidelines indicate that patients with certain conditions should be evaluated on an individual basis as to whether they are more appropriate for an open procedure or the endoscopic approach, Lockowitz says. The list includes ASA classification 4 or higher, congestive heart failure, chronic ventilator dependency, and pregnancy.

"That is the guideline, that given those conditions, you could run into trouble," she says.

Documenting the rationale is critical for providers who decide to proceed with the endoscopic approach on such patients, Lockowitz emphasizes. "What we’re saying is that this should be a very thoughtful practice."

Guidelines alone aren’t enough

Keep in mind that policies, procedures, and guidelines alone aren’t sufficient, experts emphasize. Lockowitz points to an incident at Beth Israel Medical Center in New York City in which investigators say a patient died after surgeons made gross medical errors and a salesman performed part of what should have been a routine procedure. (For more information, see Same-Day Surgery, February 1999, p. 19.)

Beth Israel probably had protocols in place for issues that were critical to this case, such as training on new equipment, fluid overload, and informed consent, Lockowitz says. "It comes down to: Do providers get comfortable and take short cuts here and there?" she asks.

Companies such as MMI help same-day surgery managers remember that there are reasons for the safety nets, she says.

"Don’t get too comfortable," Lockowitz warns. Help your staff remember that precautions in the inpatient suite shouldn’t be lost as procedures are moved to the outpatient setting, particularly since many of these cases involve general anesthesia. "If you don’t get their attention in the first place and change behavior, you don’t achieve what you want, which is to improve patient care," she says.

Screening is critical to ensuring quality patient care, Kusler-Jensen emphasizes. "We owe it to ourselves and to our patients to give the best care possible, and if we can prepare on the front end, we’ll do a better job in the long run."