Opening your doors to potentially challenging cases can boost your bottom line, but to do it safely, you've got to develop effective strategies for assessing and accommodating higher-risk patients. "But where do you draw the line?" asks anesthesiologist Philip Bilello, MD, of Paoli (Pa.) Surgery Center — a question anesthesia providers are asking with increasing frequency given today's older, heavier, sicker patients. Unfortunately, just as there's no cookbook answer to know if your providers are too conservative with patient selection, there are no hard-and-fast rules to determine which patients are good candidates for surgery in an ASC and which should be done in a hospital.

Case-by-case assessment
"Too often I get calls from surgery centers that want an absolute guideline," says Hector Villa, MD, the American Society of Anesthesiologists' section chair for subspecialties. But it all depends on the patient, the procedure, the physicians and the facility in question. "It's perfectly reasonable for one surgery center, that may not have the equipment, resources or experienced personnel to deal with a difficult airway, to choose not to do those procedures in their facility," says Dr. Villa. But he says it would be perfectly safe to host those procedures at an ASC across town "that does have the appropriate airway equipment and experienced anesthesia staff to safely perform an awake intubation."

Your medical staff must have a process in place for reviewing challenging patients on a case-by-case basis before deciding whether to host them. One way to determine whether your anesthesia providers are being too cautious is to ask for a detailed, reasoned explanation of why they believe a particular patient isn't right for your facility, and how they came to that conclusion. Your anesthesia providers should take an active role in assessing patients before they arrive at your facility and should be able to present any concerns they have about a particular case with well-researched medical evidence backing up their claims.

"It causes tensions when the patient is not looked at as an individual, but looked at simply as a class," says Los Angeles-based knee surgeon James M. Fox, MD. A good anesthesia team will treat each patient as an individual, not by their specific ASA classification or categories like "obese" or "diabetic." Dr. Bilello of Paoli Surgery Center agrees. "My job is to evaluate the patient" through phone interviews, talking to the patient's primary care physician and specialists and, if necessary, bringing the patient in for an examination and a discussion of the anesthesia plan. "At this point, you can see just what shape the patient's in," explains Dr. Bilello. "If the patient is wheezing, if he presents with acute asthma, then you can send him to be re-evaluated and treated by his primary care doctor, and then bring him back for surgery when he's healthier." A patient with acute symptoms doesn't always have to equal a cancelled case, he says.

Volume-building strategies
Here are some other steps you can take to improve your facility's preparedness for higher-risk patients.

• How good are your providers? Start with a "candid assessment of the anesthesia department's capabilities," says Clifford M. Gevirtz, MD, MPH, medical director of Somnia Pain Management in New Rochelle, N.Y. Not everyone on your team has the same level of experience and expertise. Consider bringing on what Dr. Gevirtz calls "designated hitters" — anesthesiologists specializing in pediatrics, ophthalmology, bariatric patients and other subspecialties, whom you can contract to come in 1 or 2 days a week or join your anesthesia team full-time. "Opening up your staff for these designated hitters will greatly expand your capabilities," he says. For example, while many outpatient facilities won't operate on patients with implantable cardioverter-defibrillators (ICDs), Dr. Gevirtz says these patients can be treated in an ASC if you have an anesthesia provider specially trained in both ambulatory and cardiac anesthesia and you have a product rep for the ICD device present during the procedure.
• Build a regional anesthesia program. "If you want to take care of higher-risk patients, regional anesthesia is really the way to go," says Dr. Bilello. Regional anesthesia eliminates the need to intubate and control the patient's breathing, thereby solving the airway issue in high-risk groups such as morbidly obese patients and patients with chronic pulmonary disease, while offering the benefits of a speedier recovery and less post-op pain and nausea. But for regional to have these benefits, your anesthesia providers must be proficient in the technique, says Dr. Bilello. "You need to administer a lot of blocks to get consistent results with a low complication rate." Anesthesia providers should also discuss this option with patients ahead of time and give them the choice to have the surgery done either in the ASC with regional or in the hospital with general anesthesia (if the anesthesia team doesn't feel comfortable doing general in the ASC). Having surgeons start the conversation during their office visits with patients helps educate them about what to expect from regional vs. general anesthesia.

• Have the right equipment. Want your anesthesia providers to accept more difficult airway cases? Talk to them about their equipment needs and make sure your difficult airway cart is stocked with the right mix of equipment, such as fiberoptic airway devices, intubating devices and video laryngoscopes, to give your staff the comfort level they need to handle these cases at your facility. The equipment you provide "has to be equivalent to what's in any hospital setting," says Dr. Fox, "even for patients with a class 1 risk level." Dr. Gevirtz says a full, top-of-the-line airway emergency cart will require a capital investment of about $30,000 to $40,000. And he cautions that simply having the equipment's not enough: Make sure your anesthesia team and support staff are properly trained on how to use it.
• Train your support staff. When you bring riskier patients into your facility, the onus is on everyone, not just the anesthesia providers, to ensure their safety. It's the same philosophy you apply to all patients, but keep in mind that patients with airway difficulties, diabetes, morbid obesity, cardiac conditions and other co-morbidities will require some special attention. Train your nursing staff to identify high-risk patients during pre-op phone calls and relay any concerns they may have to the medical director. Your schedulers should be aware that these cases are best reserved for the morning, in case the patient needs more time in recovery before he can be discharged, says ASA board member John Dombrowski, MD, PC.

Just as the surgeon and anesthesia provider must be able to show they are proficient at delivering care to potentially challenging patients, you must ensure that the medical staff can trust that the circulator, scrub techs and PACU nurses know what they're doing. "That trust has to be there. When I'm working at one end of the table, I can't be worried about who's working at the top of the table — it's a team," says Dr. Fox. "If they're not familiar with the procedure, then everything becomes chaotic."

Go safely
There may be a bottom-line incentive to increasing volume by taking on higher-risk patients, but Pamela Hudson, DM, administrator of Paoli Surgery Center, notes that there's also a business case to be made for taking a cautious approach. Many ASCs have begun tracking patient transfers as a quality measure, and the riskier the cases you host, the more likely you are to increase the number of transfers. Furthermore, taking the time to properly evaluate each patient and make careful, in-formed medical decisions about whether or not to accept them sends a positive message to your surgeons and other physicians in the community who may want to do business with your center. "When surgeons know you're totally looking out for the patient's safety, they can look at you and say, 'This company's not all about the money,' and they're going to send more patients there," says Dr. Hudson.