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Summer 2013


A Retrospective Study of a Gastroenterology Facility: Are the Patients Sicker?

Kim Riviello DNP, MBA/HCM, CRNA
President, Anesthesia Services Group, Tipp City, OH

There has been substantial growth in the number of ambulatory surgery centers across the United States. With the advancement in technology for non-invasive procedures, and shorter-acting anesthetics, more patients are being seen in the freestanding surgery facility (FSF). However, the trend in patient co-morbidities, i.e., obesity, diabetes, cardiac, and respiratory diseases has also risen, increasing the anesthetic risk even though low risk procedures are performed. The most common malpractice claims have been associated with diagnostic procedures performed in ambulatory surgery centers under monitored anesthesia care (MAC) with patient co-morbidities as contributing factors. The morbidity and mortality of ambulatory surgery patients has led to an increased concern for patient safety in freestanding facilities. Of particular concern is sedation, specifically in gastroenterology (GI) centers. Yet, the Journal of the American Medical Association (JAMA) recently reported that two-thirds of the anesthesia procedures provided during colonoscopies and endoscopies (EGDs) were on “low-risk patients;” suggesting a lack of need for professionally administered anesthesia in GI facilities and implying that specialist-monitored anesthesia would contribute to the increased cost of these procedures (Liu, Waxman, Main, & Mattke, 2012).

In February 2006, closed claims analysis of MAC cases found that the patients who were older (> 70 years) and sicker (ASA 3-4) had higher claims associated with morbidity and mortality (40%) (Bhananker et al., 2006).

Bishop, Ryan and Casalino also examined malpractice claims, comparing outpatient (free-standing and hospitalbased) and operating room procedures from 2005 to 2009. In the outpatient setting, the most common claim was for diagnostic procedures under MAC (45.9%).

The ASA scoring system (Dripps, 1963) is a valuable tool in evidence-based anesthesia practice, helping to determine intra-operative and post-operative complications for patients based on their overall health status. It is also valuable in ascertaining quality outcome measures and patient safety indicators based on the co-morbidities presented by patients. The tracking of risk indicators in hospitals has been an important tool to improve quality of patient safety and is now an incentivized program for hospitals (CMS, “Hospital Initiatives,” 2011). However, this has not occurred in FSFs. In 2009, a study surveyed diagnosis-based risk adjustment for surgical and procedural outcomes in ambulatory surgery centers. The seven-day mortality rates for hospital based outpatient surgery (HBOS) and FSFs were examined based on the co-morbidities reported by the facilities on each patient. The study revealed that HBOS reported patient co-morbidities more frequently than FSFs: 59.64% versus 8.65% in cataract patients, and 90% versus 45% in GI patients (Chukmaitov, Harless, Menachemi, Saunders, & Brooks, 2009). Requiring this data from FSFs could be a valuable tool in determining future morbidity and mortality of patients seen in these facilities.

Studies have demonstrated that FSFs have definitive risks associated with the patient co-morbidities and the type of anesthesia provided; diagnostic centers and endoscopy centers providing MAC sedation have the most associated claims. Yet in the 2006 NSAS report there was no data on the co-morbidities of the 14.9 million people seen in the FSFs and the risk associated with anesthesia. NSAS stated that procedures in FSFs and outpatient hospital based facilities increased by 300% over a ten year span. If this trend continues, by 2016, 44.7 million people will be seen in FSFs. Six million will be over the age 65 obtaining gastrointestinal procedures (Cullen et al., 2009).

In this study over 50% of the patient population seeking GI procedures was between the ages of 51 and 70 years of age. The co-morbidities of HTN, hyperlipidemia, sleep apnea, GERD, diabetes, smoking, CAD, and COPD were the most frequently exhibited by the patient population. These co-morbidities increased over time and the increase was statistical-ly significant. However, body mass index did not change over time in a statistically significant manner.

With the continued increase in demand for FSFs, analysis and documentation of a patient’s co-morbidities needs to be tracked to get a better understanding of the type of patients being seen in these isolated locations and how to address associated patient safety issues. Administrators and federal/state agencies need to be aware of the level of risk associated with these diseases to ensure the proper clinician is determining which patients are or are not at risk for a procedure. Bishop et al. (2011) suggested that because of the high percentage of claims linked to diagnostic procedures under MAC anesthesia, safety initiatives should be developed focusing on the outpatient setting. Chukmaitov et al. (2009) recommends that federal and state agencies mandate HBOS and FSFs to provide comprehensive information on all patients related to co-morbidities to help determine patient safety guidelines and risk-adjustment measurers.

The advantage of having anesthesia during GI cases has been demonstratedthrough pre-operative screening, intra-procedural safety, and post-operative satisfaction (Hass, 2013). This study revealed that most of the patients receiving anesthesia were ASA 3. So is cost still an issue knowing that the majority of the patients are sick? According to Liu, by advocating patient safety, anesthesia is helping to decrease the cost of health care by decreasing intra-operative and post-operative complications (Liu et al., 2012). Hass found that examining cost and procedural factors alone only creates a barrier to anesthesia. It is through a comprehensive analysis of patient assessments that the societal advantages of patient safety and satisfaction can be found (Hass, 2013). Anesthesia intervention is pivotal in FSFs, including GI centers, to ensure proper evaluation of patient co-morbidities and risk factors to ensure that the appropriate anesthetics are administered and patients remain safe. Regardless of the practice environment patients should be assured they are receiving a safe and quality anesthetic from an anesthesia professional.


Kim Riviello DNP, MBA/HCM, CRNA, is President of Anesthesia Services Group in Tipp City, OH. Ms. Riviello has been a practicing CRNA for 26 years. Anesthesia Services Group provides consulting, management and anesthesia clinicians for ASCs in Ohio. She has a Doctorate of Nursing from Robert Morris University, 2013, an MBA from Wright State University, 2010, her CRNA from University of South Carolina, 1987 and a BSN from Ohio State University, 1982. Riviello is a member of The American Association of Nurse Anesthetists, The Ohio State Association of Nurse Anesthetists, Sigma Theta Tau, Honor Society of Nursing, The Society of Perioperative Assessment and Quality Improvement, Lifetime Alumni Member of The Ohio State University, President’s Club of Robert Morris University, and The American Quarter Horse Association. She can be reached by email at kim.riviello@frontier.com or (937) 287-8178.


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