September 27, 2010

Current anesthesia records tell us rather little about the postoperative phase of a patient’s experience, and less about the quality of post-anesthesia care in a hospital generally. True, the Medicare Part A Hospital Conditions of Participation Interpretive Guidelines last updated in May mandated a post-anesthesia evaluation that must be performed by an individual qualified to administer anesthesia within 48 hours of the patient’s arrival in the PACU. Some of the elements that the anesthesia provider must document are controversial, but until CMS revises the Interpretive Guidelines, the medical record should provide the results of post-anesthesia assessment of the following:

• Respiratory function, including respiratory rate, airway patency, and oxygen saturation;
• Cardiovascular function, including pulse rate and blood pressure;
• Mental status;
• Temperature;
• Pain;
• Nausea and vomiting;
• Postoperative hydration, and
• Depending on the specific surgery or procedure performed, additional types of monitoring and assessment may be necessary.

The anesthesiologist, CRNA, AA or resident notes these elements of a single post-anesthesia evaluation in the individual patient’s hospital record. That may tell a hospital surveyor that the facility satisfies the Part A Conditions of Participation, but unless values for each element of interest are collected in a database of all patients and practitioners, none of the items listed above will help with systematic quality measurement or improvement.

If, however, the anesthesia practice captures quantifiable data on each of the post-anesthesia evaluation elements in an electronic health record so that the data can be linked to patient demographics, procedure and diagnosis codes, physical status, surgeon, anesthesiologist and/or CRNA, and clinical and time data from the pre- and intra-phases of the patient’s surgical care in an anesthesia information management system (AIMS), it will have at least the tools to benchmark and learn from experience.

The Interpretive Guidelines to the Conditions of Participation only yield information up until the post-anesthesia evaluation is completed, which may be as soon as “the patient is sufficiently recovered from the acute administration of the anesthesia so as to participate in the evaluation, e.g., answer questions appropriately, perform simple tasks, etc. ”Medicare, and in turn hospitals, will require that the anesthesiology department record the elements in the list above, so it makes sense to include them in the clinical care database, but other information obtained both before the patient leaves the PACU and post-discharge to home will be more pertinent to the value proposition.

Beyond the Conditions of Participation – Objective Measures

Avoiding anesthetic complications is a major measure of quality as well as a way of keeping costs down – the health policy definition of “value.” In addition to keeping the values for the mandatory post-anesthesia elements within normal limits, anesthesiologists can demonstrate good outcomes in the form of the absence of the following complications (among others):

In the PACU:

• Death MI, cardiac arrest, stroke
• Excessive pain
• Prolonged nausea and vomiting

• Reintubation
• Airway obstruction requiring intervention

• Unplanned mechanical ventilation
• CNS injury

• Peripheral nerve injury

• Postdural puncture headache

• Eye injury/visual loss

• Awareness

• Anaphylaxis

• Hypothermia requiring warming measures

• Arrhythmia, angina, hyper- or hypotension requiring physician intervention

• Medication error

• Unplanned hospital/ICU admission

Efficiency:

Prolonged PACU stay attributable to anesthesia
Prolonged PACU stay not attributable to anesthesia
Factors:

• Awaiting ICU bed
• Awaiting surgical floor bed
• Patient not in condition to be discharged to floor
• Awaiting surgeon
• Other

The duration of the patient’s stay in the PACU or in the facility may be particularly important in outpatient departments or ambulatory surgical centers. Whether or not it is “prolonged” will be documented by time of arrival and of discharge in the OR record or anesthesia record (and ideally the times in the two records will coincide). Few AIMS or anesthesia forms currently allow check-off of non-anesthesia factors causing delays in PACU discharges, but gathering the data may support key OR management decisions.

Post-surgical infection, whether from general or regional anesthesia, is a major adverse outcome that may become evident after the patient leaves the PACU. Linking this data point to the hospital’s Surgical Care Improvement Project (SCIP) records and/or the anesthesia record will allow the department to determine whether the infection occurred despite antibiotic prophylaxis, despite adherence to the protocol for avoiding catheter-related bloodstream infections, and/or despite the maintenance of normothermia. This linkage is of course the missing step in current reporting to the Physician Quality Reporting Initiative (PQRI), but we are only a few years away from using outcomes and not just process measures.

Subjective Measures

The subjective patient experience does not end upon discharge from the hospital or ASC. Patient satisfaction may influence the course of individual recovery as well as the reputation of the hospital and its anesthesia group in the community.

The value of patient satisfaction surveys is conjectural at this point. “Patient-centered” care being the goal of healthcare reform, and many hundreds of millions having been spent on measuring patient satisfaction over the last decade, the role of patient surveys in establishing the standing of providers is a given, however.

The federal Agency for Healthcare Research and Quality within Department of Health and Human Services first fielded its hospital-experience questionnaire in October 2006 after four years of development and testing. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS, www.hcahpsonline.org ) contains 27 questions about the patient’s recent hospital stay. The survey includes 18 core questions about critical aspects of patients’ hospital experiences (communication with nurses and doctors, the responsiveness of hospital staff, the cleanliness and quietness of the hospital environment, pain management, communication about medicines, discharge information, overall rating of hospital, and would they recommend the hospital). It is administered by mail, telephone, mail with telephone follow-up or interactive voice recognition, to a random sample of adult patients between 48 hours and six weeks after discharge.

The Medicare Hospital Quality Initiative uses HCAHPS and other measures to rate individual hospitals’ performance. If aggregate scores fall below a certain level, the hospital’s annual payment update is reduced. There is an important opportunity here for anesthesiologists to demonstrate that they contribute to their hospitals’ revenues.

Three of the HCAHPS survey questionnaires directly concern the behavior of the patient’s doctors. We can apply all three to anesthesiologists, asking patients to check the box next to the words “never,” “sometimes,” “usually” or “always:”

1. During this hospital stay, how often did doctors treat you with courtesy and respect?
2. During this hospital stay, how often did doctors listen carefully to you?
3. During this hospital stay, how often did doctors explain things in a way you could understand?

(Underlining in original HCAHPS Instrument.) Similar questions might include:

1. Did you have confidence and trust in the doctors treating you?
2. During this hospital stay, did your doctor spend adequate time with you? 
3. During this hospital stay, did your doctor clearly communicate the anesthesia options? 
4. Did your family or someone else close to you have enough opportunity to talk to your doctor?
5. Do you know when your next appointment with your doctor will be? Can we help you with that?

HCAHPS also asks whether the patient would recommend the hospital to others, a question common to all the anesthesia patient satisfaction surveys we have seen. Almost as ubiquitous is an open-ended request for comments.

The starter lists of both process and outcome measures in the Anesthesia Quality Institute’s National Anesthesia Clinical Outcomes Registry (NACOR) include patient satisfaction and “number of patient complaints.”

The Integration/Interoperability Issues

Anesthesiologists and hospitals and ASCs are already capturing a considerable number of variables that can be used to measure the quality of post-anesthesia care are already. Often the information is scattered across multiple record-keeping systems; or, just as bad, different versions of the data appear in different systems. Using the data fully means constructing measures out of combinations of elements in the various databases managed by the hospital and by the group. Integrating the data in Operating Room Management Systems (ORMS) and AIMS will depend on advances in the interoperability of information systems. For a detailed discussion, see the chapter by Marisa Wilson and Christine Doyle in Anesthesia Informatics, J. Stonemetz and K. Ruskin (eds.) (Springer, 2008).

Anesthesiology groups can–and many do–collect their own quality statistics, including subjective patient satisfaction survey results. Ideally, it would be both less burdensome and more informative if the groups could reliably exchange data with the hospitals. ePREOP, Integrated Preoperative Services out of Southern California, ABC’s newest partner, recently launched ePreop™, an EHR designed to coordinate the selection and recording of preoperative information among surgeon, anesthesiologist and hospital. We hope to identify efforts underway elsewhere to integrate the data collected by the various providers in intra- and post-operative systems. We will be delighted to help improve the measurement and management of perioperative care by introducing solid products to the anesthesia community.

With best wishes,

Tony Mira
President and CEO



If you have any questions or would like additional information please call 517-787-6440 x 4113, send an email to info@anesthesiallc.com, or visit our website at www.anesthesiallc.com.