RMV->)A Hair Out of Place
Re: "The Art of Fast OR Turnover" (December, page 42). While the article contains some good ideas, the accompanying picture on page 43 is disturbing. The scrub person has loose hair hanging over a sterile field on an eye case. Whether staged or real, this is a break of sterile technique and a poor image. Does the emphasis on time come at the expense of proper technique and patient safety?

Rita M. Julius, RN, MSA, CNOR
Director, Surgical Services, Botsford General Hospital
Farmington Hills, Mich.
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Cheryl Stanley, RN, replies:
It wasn't until you called this lapse to our attention that we looked closely at the picture and noticed the hair out of place. The instrument tech and I were both mortified because we put the highest emphasis on quality. In the five years that the Medical Group Surgery Center has been open, we have not had a single eye infection.

Most Abusive Surgeons Are Usually Most Productive Ones
Re: "Dealing with Difficult Surgeons" (December, page 58). I enjoyed reading this article and I feel that it did a good job addressing the issue. The example of the difficult surgeon lost some of its validity because the surgeon in question was responsible for only about 20% of the ASC's volume. I think that in more cases than not, the surgeons who are most abusive are the ones who provide 80% of the caseload and therefore feel that they can do anything they damn well please. It would be nice to see if and how a center or hospital deals with that situation. When one brings in 80% of the revenues, he is king. And as the saying goes, "It's good to be the king."

Rodrick Stevenson, MD, FACS
General, Vascular and Laparoscopic Surgeon
Brookville, Pa.
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Did Antibiotic or Anesthetic Cause Adverse Reaction?
Re: "Debunking 6 Antibiotic Prescribing Myths" (November, page 44). It was very informative and helped to answer some of the problems plaguing our antibiotic study. In your research for the article, did you come across any incidence of anaphylactic reactions involving the antibiotic and the anesthetic drugs? This question has been posed in two separate cases at our hospital. While trying to keep the antibiotic delivery time within 30 minutes of incision, there are times when the antibiotic is pushed very close or immediately prior to anesthetic induction. This then poses the question of did the antibiotic or the anesthetic drug cause the adverse reaction. If you have any information on this issue I would greatly appreciate your point of view.

Jan Fetzer
Director Surgery
Middletown Regional Hospital
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Dr. Robert Condon replies:
Most shock-like episodes during induction of general anesthesia are due to excessive sedation or to hypoxia. If you have had two cases of apparent anaphylaxis within the last few years, it is possible that there is a problem with administration of anesthesia. In the absence of a history of hives, serum sickness or anaphylaxis in response to a specific class of drugs, truly allergic anaphylactic reactions are very rare. If such episodes do occur, a competent allergist should investigate them.

A Contractual Agreement For Anesthesiologists?
Re: "Are You Prepared for the Anesthesiologist Shortage?" (September, page 28). I am an anesthesiologist in an anesthesia group who, although not threatening to leave our locality, would like the facility administration to throw us a few bones to attract future partners, etc. We were wondering if a contractual arrangement could be considered which would guarantee our group an agreed-upon dollar amount per unit generated by anesthetic services. Are you aware of other groups attempting this kind of arrangement? If so, has it been effective?

Name withheld upon request

Dr. Alan Marco replies:
I am very leery of this type of arrangement. The big issue is anti-kickback regulations. CMS bans payments made for volume, and by tagging payment to RVUs you may cross that line. Similarly, there may be Stark issues, too (Stark legislation bans self-referral and payments to increase referrals).

I'd suggest that your group looks at what services it provides the hospital and what those services are worth. For example, 24/7 OB coverage or trauma coverage has a certain market value. And more and more specialists asking for subsidies for ER coverage. Also, if you run the OR or coordinate the schedule, a Medical Director's fee may be appropriate. You must follow several rules to make sure these types of arrangements don't violate the law, but if it's for fair market value and you can demonstrate that you provided a service, there shouldn't be a problem.

Another thing to look at is your contracts with payers and the exclusive contract with the hospital (if any). Many exclusive contracts say that the anesthesiologists will accept any third-party payer that the hospital accepts. This puts the hospital in the position of negotiating for the group. If the hospital wants to, it can accept a contract that offers the anesthesiology group below fair market value on their professional fees, and the group would have to accept the contract or breach their contract with the hospital. Look at those contracts carefully. Keep in mind that Medicare multiples are not the right measure for anesthesiology reimbursement.

Giving Anesthesiology Assistants Their Due
Re: "Are You Prepared for the Anesthesiologist Shortage?" (September, page 28). I was disappointed to read your impression of Anesthesiologist Assistants and their role on the anesthesia care team. I hope that this helps to place AAs in their proper role in the anesthesia care team - which extends well beyond providing "technical or clerical support that will permit more experienced providers to have more time to devote to the OR."

The federal government (CMS, Medicare) declared that AAs and CRNAs are equivalent providers of anesthesia services in the care team mode and are reimbursed at the same rate. All practices that employ both AAs and CRNAs use them interchangeably. Under Medicare rules, an anesthesiologist may supervise up to four operating rooms that are staffed by AAs or CRNAs in any combination from four AAs to two AAs and two CRNAs or four CRNAs. The level of AA training exceeds that of CRNAs, although the length of programs is equivalent. AAs are only trained in LCME-accredited schools of medicine at the master's level (not nursing schools or other hospital-based anesthesia programs) and in ACGME-accredited anesthesia residency training programs. CRNAs are taught by nurses; AAs are taught by physicians.

A. William Paulsen, MMSc, PhD, CCE, AAC
Associate Professor of Anesthesiology
Program Director for Academic Affairs
Emory University School of Medicine
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Propofol Ketamine
Re: "The Trouble with PK" (November, page 13). I've used PK as my routine anesthetic for the last three years. My patients appreciate the lack of PONV even without anti-emetics and the surgeons appreciate how the patients feel. I'm sure that Dr. Barry Friedberg has a tough skin, but I really appreciate the learning that I've gotten from him, and it's tough (here) doing something completely different from the others. Yes, perhaps it is a shame about the style of the messenger, but the message is...correct.

Chris Pollock, MB, ChB
Consultant in Anaesthesia and Pain Medicine
Hull and East Yorkshire Hospital Trust
England UK
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