Posts Tagged ‘patient safety’

If you think about scope-of-practice creep at all, you may think immediately of the advocacy efforts so many physicians have made to preserve physician-led care and discourage independent practice by nurse anesthetists or physician assistants.

You may not have paid as much attention to the current momentum to grant independent practice to nurse practitioners, or NPs, nationwide.

In addition to the District of Columbia, 28 states allow NPs full practice authority to treat and prescribe without formal oversight. Half of these states grant NPs full practice authority as soon as they gain their licenses; the other half allow it after the NP practices with physician oversight for a period of time.

My home state, California, is one of the states that has always required physician oversight. Last fall, however, Governor Newsom signed a bill, Assembly Bill 890, that will allow NPs to practice independently after they have completed a three-year transition period, practicing under physician supervision.

That was when I started to worry.

Preop assessments that make us laugh or cry

No doubt everyone who practices anesthesiology or surgery has encountered preoperative medical assessments, H & Ps, or “clearance” notes that have been so far off the mark they’re laughable. I’m not just talking about the three-word “cleared for surgery” note scrawled on a prescription pad. I recall in particular:

A consultation at a VA hospital that “cleared” my cirrhotic patient with massive ascites and coagulopathy for his inguinal hernia repair under spinal anesthesia but not general.

A cardiologist who opined that my patient needed a permanent pacemaker, but it could wait until after his carotid endarterectomy because “this patient has a low risk of perioperative bradycardia. If he were to develop AV block intraoperatively, a temporary transvenous pacemaker could be placed.” (Wait. What? Carotid procedures are notorious for bradycardia. We’re going to insert a transvenous pacing wire through his open neck incision?)

An H & P from a community internist that “cleared” my patient with lung cancer for lobectomy so long as it could be done under local with sedation.

Then we have to deal with the widespread misconception that “minimally invasive” is synonymous with “trivial” when it comes to surgical procedures. My husband, Steven Haddy, MD, a cardiac anesthesiologist, loves to give a lecture to an internal medicine audience on pulmonary hypertension and anesthesia, and wait for the gasps when he shows the photo of a “minimally invasive” robotic prostatectomy with the robot docked, the abdomen insufflated, and the patient in steep Trendelenburg.

If non-anesthesiologist physicians can do such an inept job with preoperative assessments, what are we to expect from nurse practitioners?

What could go wrong?

I rely with complete confidence on the H & Ps of one experienced nurse practitioner who works in the office of a thoracic surgeon. She understands thoracic surgery procedures and their risks, knows the patients and their history, and orders exactly the right preoperative tests, every time.

What causes me anxiety, as an anesthesiologist, is thinking about the accuracy and thoroughness of a preoperative assessment I might receive from a primary care NP, working in an outpatient clinic with no physician consultation. In a brief H & P, we have no way to know what information may have been omitted. If there is little understanding of the surgery or the anesthetic impact of the patient’s underlying medical problems, how would that person know what’s important to include?

Currently, there are more than 290,000 licensed NPs in the US, and Becker’s Hospital Review reports that the number of FTEs surged 109% in the past decade. More than 30,000 NPs complete their academic programs each year.

Until I read the book, Patients at Risk, by Niran Al-Agba, MD, and Rebekah Bernard, MD, I had no idea how little breadth or depth there might be to a nurse practitioner’s education. “Registered nurses who already have a bachelor’s degree in nursing can become a Family Nurse Practitioner in under two years, with coursework completed entirely online,” the authors report. “Schools are now fiercely competing for students to fill their classrooms. One of the downsides of the increased capacity for students is that the criteria for entry have declined. In fact, at least nine programs boast 100% acceptance rates – every student who applies is guaranteed acceptance.”

Since nurse practitioners can earn higher pay than registered nurses, there is an ongoing exodus of RNs into NP programs. They have the option to select a patient population focus on acute care, either for adults or children. But most students – nearly 90%, according to the American Association of Nurse Practitioners (AANP) – certify in an area of primary care. Their certification exams are specific to primary care, and require no additional education or clinical precepting in perioperative care.

Protecting patients

If you already live in a state with full practice authority for NPs, then the camel – not just the camel’s nose – is already in the tent. There will be little you can do other than to have a low threshold for questioning the information, or lack of it, in a preop H & P generated by a non-physician you don’t know personally.

In California, though AB 890 has already passed, there is work to be done in terms of scrutinizing its language and guiding its implementation.

I find it discouraging that the law’s requirements (Section 4, Article 8.5) “are intended to ensure the new category of licensed nurse practitioners has the least [emphasis mine] restrictive amount of education, training, and testing necessary to ensure competent practice.”

I find it outright alarming that one of the conditions listed that would mandate referral to a physician is “any patient with acute decomposition [sic].” My hope would be that the patient would be referred to a higher level of care before decomposition started, but you never know.

To its credit, the California Medical Association (CMA) has established an AB 890 Task Force to provide “expertise and strategic advice” regarding the implementation of AB 890, and “to make recommendations relating to the education of NPs, patient access to care, and patient safety, among other topics.” I have the honor of representing anesthesiology on this task force, and will do my best to ensure that NP independent practice is never defined to include the practice of anesthesiology, perioperative medicine, or pain medicine.

This underscores the importance of having all physicians become members also of our state and county medical associations. If you don’t join, you won’t have a voice. There is always a need for guardrails and vigilance to ensure that everyone in healthcare – physicians and nurses alike – practices within the safe limits of their knowledge and training.

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An earlier version of this article appears in the April 2021 issue of the ASA Monitor.

Is it time to unionize?

Remember the dark days of the pandemic in March and April, when the true risk of caring for COVID patients started to become clear?  Remember when you could be censured by a nursing supervisor or administrator for wearing a mask in public areas lest you frighten patients or visitors?

Right around then, a third-year resident at UCLA decided to wear a mask wherever he went in the hospital, as testing wasn’t readily available yet for patients, and visitors still had full access. Someone with a clipboard stopped him and said he couldn’t wear a mask in the hallways. The resident politely responded that yes, he could. Why? Because his union representative said so. The discussion ended there.

The resident enjoyed backup that his attendings lacked because all UCLA residents are members of the Committee on Interns and Residents/SEIU, a local of the Service Employees International Union (SEIU). This union represents more than 17,000 trainees in six states and the District of Columbia.

As CMS threatens further pay cuts for anesthesiology services and other third-party payers are likely to follow suit, many attending anesthesiologists are asking:  Why can’t we form a union? Alternatively, why can’t the ASA function like a union and negotiate on our behalf?

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When you tell anyone in healthcare that “sedation” to the point of coma is given in dentists’ and oral surgeons’ offices every day, without a separate anesthesia professional present to give the medications and monitor the patient, the response often is disbelief.

“But they can’t do that,” I’ve been told more than once.

Yes, they can. Physicians are NOT allowed to do a procedure and provide sedation or general anesthesia at the same time – whether it’s surgery or a GI endoscopy. But dental practice grew up under a completely different regulatory and legal structure, with state dental boards that are separate from medical boards.

In many states, dentists can give oral “conscious” sedation with nitrous oxide after taking a weekend course, aided only by a dental assistant with a high school diploma and no medical or nursing background. Deaths have occurred when they gave repeated sedative doses to the point that patients stopped breathing either during or after their procedures.

Oral surgeons receive a few months of education in anesthesia during the course of their residency training. They are legally able to give moderate sedation, deep sedation or general anesthesia in their offices to patients of any age, without any other qualified anesthesia professional or a registered nurse present. This is known as the “single operator-anesthetist” model, which the oral surgeons passionately defend, as it enables them to bill for anesthesia and sedation as well as oral surgery services.

Typically, oral surgeons and dentists alike argue that they are giving only sedation – as opposed to general anesthesia – if there is no breathing tube in place, regardless of whether the patient is drowsy, lightly asleep, or comatose.

The death of Caleb Sears

Against this backdrop of minimal regulation and infrequent office inspections, a healthy six-year-old child named Caleb Sears presented in 2015 for extraction of an embedded tooth. Caleb received a combination of powerful medications – including ketamine, midazolam, propofol, and fentanyl – from his oral surgeon in northern California, and stopped breathing. The oral surgeon failed to ventilate or intubate Caleb, breaking several of his front teeth in the process, and Caleb didn’t survive.

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The real surprise – to me, at least – came more than halfway through Dr. Atul Gawande’s keynote address at the opening session of the American Society of Anesthesiologists’ annual meeting in Boston.

Much of his talk on October 21 celebrated the virtues of checklists and teamwork, topics that have turned into best-selling books for the well-known surgeon and professor of public health. “We are trained, hired, and rewarded to be cowboys, but it’s pit crews we need,” he said.

Then Dr. Gawande posed this question to the packed room: “What are the outcomes that matter?”

He answered his own question somberly. “The most unsafe operation is the operation that shouldn’t be done,” Dr. Gawande said. “Does the operation serve the patient’s goals or not?”

“We’ve all been there,” he continued. “Taking people to the operating room and wondering what we’re doing.”

Those are comments I’ve heard from anesthesiologists many times before, but I never thought I’d hear them from a surgeon.

Flogging the dead

For any of us who practice anesthesiology in a major hospital – doing cardiac, thoracic, or liver cases, for instance – there are days when all our efforts are spent on behalf of a patient whose health is unsalvageable. “Flogging the dead” is a phrase sometimes used to describe prolonged and futile care in the operating room or ICU.

Sometimes aggressive interventions are driven by a family that wants “everything” done, because in their innocence the family members have no idea how terrible and dehumanizing the process of postponing death can be.

In other circumstances, however, the decision of whether to do surgery is driven by the mission and the financial motivation of the health system to provide care. If care doesn’t occur, if the surgery isn’t done, no one gets paid.

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No, I’m not talking about putting fentanyl into my own veins — a remarkably bad idea. I’m questioning the habitual, reflex use of fentanyl, a synthetic opioid, in clinical anesthesiology practice.

I’ve been teaching clinical anesthesiology, supervising residents and medical students, in the operating rooms of academic hospitals for the past 18 years. Anesthesiology residents often ask if I “like” fentanyl, wanting to know if we’ll plan to use it in an upcoming case. My response always is, “I don’t have emotional relationships with drugs. They are tools in our toolbox, to be used as appropriate.”

But I will say that my enthusiasm for using fentanyl in the operating room, as a component of routine, non-cardiac anesthesia, has rapidly waned. In fact, I think it has been months since I’ve given a patient fentanyl at all.

Here’s why.

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