Organization and guidelines for angloitalian meeting roma 010 on non operating room anesthesia


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Non operating room anesthesia (NORA) guidelines and organization

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Organization and guidelines for angloitalian meeting roma 010 on non operating room anesthesia

  1. 1. NORA: Non Operating Room Anesthesia organization (suggestions…) and guidelines by C.Melloni Libero professionista Roma,May 2010
  2. 2. Norah Jones Nora Amile
  3. 3. Nora Ephron Harry ti presento Sally (1989),Meg Ryan & Billy Christal) This Is My Life (1992), Insonnia d'amore ( Tom Hanks & Meg Ryan), Agenzia salvagente (1994) (Steve Martin) Michael (1996), (John Travolta & Andie MacDowell.) C'è post@ per te (1998) (Tom Hanks & Meg Ryan) Magic Numbers (John Travolta & Lisa Kudrow ) Vita da strega (2005) ( Nicole Kidman ) Julie & Julia (2009) (Meryl Streep).
  4. 4. NORA classification • In hospital,but outside OR:radiology,cardiology,endoscopy etc.:NORA,but in hospital. • Efficient scheduling • resource use • emerg. • Out of hospital – day surgery center;OR! NO NORA –office:NORA
  5. 5. Procedures outside anesth? NORA • “Imaging” – – – – – CAT MRI Functional cerebral imaging Interventional neuroadiol US/CAT guided procedures:biopsies,therapies… – Radiother. – – – – Telether:children! Brachiter Radiother intraop radiochir • Gastroenterology – Sup;esofago,gastro…varici esof…. – Colon – Liver biopsies • T.I:,tracheo chir – percut,dren tor,bronch ,cs,medull.biops.,ventriculostomy • Emerg.Room;CVC,dren tor,tracheo,ICP monitor, orthop manipul,wounds…. • Surg.offices:everything: – ophtalmology:retinoscopy,tonometry,elettr oretinography,,ant chmaber surg(cataract,iridectomy ,angiofluoro… – Plastic surgery :liposuctions,blepharoplasty otoplasty,facial miniliftings – Dental chair assist:implants,max sinus ..odontostomatologia • Psichiatry – ECT • Cardiology: – Catheter. – CS – Radiofreq.ablation • Urology Laserther – ECSWLT – cistoscopy
  6. 6. Definitions • IT:ambulatorio=office – Day surgery=chirurgia di giorno=struttura attrezzata e riconosciuta:equipped and recognized • USA: office=ufficio (del chirurgo)(of the surgeon) – Ambulatory:equipped and recognized -struttura attrezzata e riconosciuta –Ufficio:non attrezzato,non riconosciuto a meno che non si abiliti per chirurgia –Not recognized,unless accredited for surgery…………….
  7. 7. Office based surgery
  8. 8. What are we taking about? National USA Plastic Surgery Statistics Cosmetic procedure trends. 400000 mastoplast addit mentoplastica dermabrasione otoplastica blefaroplastica lift facciale lift frontale trap capelli liposuz addominoplast 350000 300000 250000 200000 150000 100000 50000 0 2000 2002 2003 2004
  9. 9. 2007 %2007 Mortality:2/100.000=0,002% Nearly 11.8 million cosmetic surgery procedures were performed in 2007: up 59 % since 2000 ! %2006
  10. 10. Problem dimension • Membership Audit, American Society for Aesthetic Plastic Surgery, Inc., Spring 1993. • survey of members of the American Society for Aesthetic Plastic Surgery (ASAPS) • 48.7 % of members perform their aesthetic surgery in an office surgical facility. • Office-based surgery (OBS) accounts for 10 million of all elective procedures performed in the United States double from a decade ago. Although there are no good national registries to accurately determine the amount of surgery done in office, the projections have ranged from 17-24% of all elective ambulatory surgery • AHA.Trends affecting hospitals and health systems May 2005. AHA TrendWatch ChartBook 2009. Available at: (Accessed May 12, 2009)
  11. 11. Patient(s) • In Hosp : – The patients undergoing procedures outside the operating room are often older, medically higher-risk patients • most NORA claims involve higher-risk, elderly patients undergoing nonemergency surgery • office • Elective,clients….
  12. 12. Diagnosis: • In Hosp: • Office: • not made • You see patients during the workup………… • Unknown diseases • Unknown patients…. • Incomplete sense of what we may encounter during the procedure… • • • • Hopefully dg made Pt well known Client.. …But be aware!Dentists..Ophtal mologists …..
  13. 13. Preanesthetic preparation • Preparation for NORA should be no different from the preparation in the operating room. – – – – Preanesth.visit Fasting Premed. consent • Preanesthetic preparation is very often done by others, who may not consider the interactions between a patient’s physical condition, medications taken and the effects of anesthesia • At worst pts coming direct from home;no prep …
  14. 14. Specific conditions that warrant special care when providing anesthesia or sedation outside the operating room • • • • • • • • • • • • • • • • • Patient unable to cooperate, e.g. severe intellectually disability Severe gastroesophageal reflux Medical conditions predisposing patients to reflux, e.g. gastroparesis secondary to diabetes mellitus Orthopnea Severe increased intracranial pressure Decreased level of consciousness/depression of protective airway reflexes Known difficult intubation Dental, oral, craniofacial, neck or thoracic abnormalities that could compromise the airway Presence of respiratory tract infection or unexplained fever Obstructive sleep apnea Morbid obesity Procedures limiting access to the airway Lengthy, complex or painful procedures Uncomfortable position Prone position Acute trauma Extremes of age
  15. 15. inappropriate OBA patients • • • • • • • • • • • • • • • • • unstable ASA 3 or greater recent MI in past 6 months severe cardiomyopathy uncontrolled HTN brittle or poorly controlled diabetes active multiple sclerosis acute substance abuse (drugs and alcohol) MH history severe morbid obesity (BMI >35, if equipment and stretcher size is limited), or morbid obesity (BMI >30 with poorly controlled comorbidities) severe COPD/ obstructive sleep apnea, pacemaker or AICD end-stage renal disease sickle cell disease patient on transplant list dementia (not oriented) psychologically unstable (rage/anger problems), Recent stroke within 3 months • • myasthenia gravis lack of adult escort
  16. 16. Location/space requirements for nonoperating room anesthesia • Adequate size with good access to the patient • Uncluttered floor space • An operating table, trolley or chair which can be readily tilted into Trendelenburg position • Adequate lighting including emergency lighting • Sufficient electrical outlets including clearly marked electrical outlets connected to an emergency back-up power source • Suitable clinical area for recovery of the patient which must include oxygen, suction, resuscitation drugs and equipment • Emergency back-up call system to summon assistance from the main operating room
  17. 17. LockAlert Automatic Relocking with a motion sensor prevents the cart from locking while in use but automatically relocks it when left unattended. The system includes an adjustable timer and rechargeable batteries Keypad with Display (LockAlert IV)* allows multiple operators to have unique entry codes and can be enhanced with keyless narcotic drawers and/or auditing. This comprehensive system includes automatic relocking and keypadaccessible manager and diagnostic routines
  18. 18. • Lightweight aluminum construction, proprietary self-closing drawer slides and multiple caster options. • Complete customization available, including multiple colors, drawer sizes and accessories. • Available Entry Management system including AutoRelock, Audit Trail, ID Card Reader, Proximity Reader, Keyless Narcotic Drawer, 250 Users/ Supervisors. • Extended base for maximum stability
  19. 19. FSC Handbook Shands Florida Surgery Center: instructions for residents • Anesthesia Carts • Take a minute to review the cart and supplies. • All carts are set up with the same supplies in the same place in each room. • Anesthesia carts are stocked nightly by an anesthesia tech and NOT in between every case. • Keys can be obtained from Tammy Thomas, the FSC anesthesia tech. You can also ask the charge nurse or another CRNA to open the cart for you in the morning so you can set up. • Laryngoscope blades are stored in the carts in the rooms and additional blades can be found in the anesthesia work room. There is a container for used laryngoscope blades and reusable LMAs on the sides of each anesthesia cart. Limit opening multiple ETT’s, LMA’s. If you end up not using an opened, nonlubricated ETT, please place a date and time on the package and store in cart.
  20. 20. DEPARTMENT OF ANESTHESIOLOGY University of Florida • Stocking Anesthesia Carts and/or Emergency Carts • Anesthesia carts are standardized throughout the operating suite, radiology suite, and labor and delivery. • A list of all items to be included on these carts is used to restock them each day. • The drugs are checked once a month and outdated drugs are replaced. • Sharps disposal containers with small openings in the top, are well marked and • • • everyone is instructed to use them. They are easily accessible on the top of each cart. Florida law requires sharps containers be dated and not in service for more than 30 days. The containers on the anesthesia carts are exempt from the dating requirement because of frequent turnover. There are no emergency carts, per se, in the operating room area since an anesthesia cart from the involved room would be utilized. There are special carts for pediatric, cardiac, burn unit, MRI, OB, X-ray and cysto.
  21. 21. FSC Handbook Shands Florida Surgery Center: II • Many cases are done with an LMA. • Each OR should have one size 3, 4, and 5 LMA. • Additional LMAs are located in the anesthesia workroom and on the side of the anesthesia supply cart. • Difficult Airway Cart • This cart is located outside of OR 1 and 2 near the OR code cart. It is different from the typical Shands UF difficult airway cart. In addition, a glidescope is available next to the difficult airway cart. • Please take a moment to familiarize yourself with this equipment.
  22. 22. • International Anesthesiology Clinics: • Winter 2006 - Volume 44 - Issue 1 - pp 159177 • Anesthesia Supply Chain • Adler, Elena MD
  23. 23. Staff • A strict adherence to minimum;scrubbed+circulating nurses?2? • staff with appropriate training? • Interdepartmental cooperation and understanding – All very important when working outside the familiar environment of the operating room
  24. 24. Procedure • The anesthesiologist needs to understand the requirements of the procedure, its potential complications, its anticipated duration and the specific needs of the proceduralists. • Specific requirements differ with each type of procedure and are discussed below • New technologies… • New people …
  25. 25. SIAARTI Linee guida 2005 • …La mancata disponibilità di quanto prescritto o l’impossibilità di sanarne le carenze in tempo reale possono costituire giusta causa,al di fuori delle situazioni di emergenza e necessità inderogabile,per il rinvio della prestazione e per la riprogrammazione a carenze sanate… • The absence of what is prescribed or the impossibility of real time restocking is enough to cancel or postpone the case ,except in cases of emergency…
  26. 26. Monitoraggio durante la procedura e risveglio:intraoperative and postoperative monitoring SIAARTI • Racc.” Monitoraggio di minima durante anestesia” • Racc.”controllo dell’apparecchio di anestesia” • Racc “Per la sorveglianza postanestetica” • Racc”clinico organizzative per l’anestesia in day surgery”
  27. 27. OBA :ASA point of view • Succinctly stated, the 1999 HOD-approved guidelines for OBA state, with respect to perioperative care... “The anesthesiologist should adhere to: • Basic Standards for Preanesthesia Care, • Standards for Basic Anesthetic Monitoring, • Standards for Postanesthesia Care • Guidelines for Ambulatory Anesthesia and Surgery as promulgated by ASA.
  28. 28. Requisiti specifici per l’accreditamento delle Strutture di ...RER • Formato file: PDF • RER
  29. 29. REQUISITI SPECIFICI • • • • • • • • • • • • • • • • • • • 3.8 REQUISITO DA SODDISFARE : Per ambulatorio chirurgico (o ambulatorio per interventi chirurgici) si intende la struttura intra od extraospedaliera nella quale sono eseguite prestazioni di chirurgia ambulatoriale, ovvero procedure diagnostiche e/o terapeutiche invasive o semi-invasive, nelle situazioni che non richiedono ricovero ordinario o a ciclo diurno; tali procedure possono essere eseguite in anestesia locale o loco-regionale e non necessitano di un’osservazione post-operatoria prolungata. Criteri per la verifica del possesso del requisito Situazione attuale 3.8 Esiste la documentazione (*) formalizzata che esplicita l’organizzazione interna dell’ambulatorio chirurgico, con particolare riferimento a: organigramma; livelli di responsabilità; strutture e modalità di funzionamento; descrizione quali-quantitativa dell’attività svolta. (*) Può coincidere con la documentazione utilizzata per attestare il possesso dei requisiti della lista di controllo n. 1 SI NO
  30. 30. 3.8.1 REQUISITI MINIMI STRUTTURALI • • • • • • • • • • • • • • • • • • • • • • • • • • 3.8.1 REQUISITO DA SODDISFARE : I locali e gli spazi devono essere correlati alla tipologia e al volume delle prestazioni erogate. La dotazione minima di ambienti per l’ambulatorio chirurgico, oltre a quanto previsto per l’assistenza specialistica ambulatoriale, è la seguente: locale/spazio per la sosta del paziente al termine della prestazione chirurgica; locale/spazio spogliatoio per il personale; locale/spazio per la preparazione del personale alla prestazione chirurgica; uno o più locali/spazi per il lavaggio, la disinfezione, il confezionamento e la sterilizzazione dello strumentario chirurgico e degli altri presidi utilizzati; armadi per il deposito del materiale sterile e dello strumentario chirurgico. Nei locali ove si svolgono attività sanitarie, i pavimenti e le pareti, fino ad una altezza di due metri, devono essere lavabili e disinfettabili. Criteri per la verifica del possesso del requisito Situazione attuale Ogni ambulatorio chirurgico dispone, in aggiunta/integrazione a quanto previsto per l’assistenza specialistica ambulatoriale, almeno di: 3.8.1 - a un’area per la sosta del paziente nel periodo di sorveglianza immediatamente successivo alla prestazione stessa, collocata in prossimità dell’ambulatorio e con un numero di posti a sedere adeguato al numero di pazienti che mediamente lo frequenta (anche in comune con il locale/spazio per l’attesa);SI NO 3.8.1 - b un locale/spazio spogliatoio per il personale (anche in comune con altri ambulatori e/o aree di degenza);SI NO 3.8.1 - c un’area per la preparazione del personale alla prestazione chirurgica, dotata di un lavello a comando non manuale e costituita da un locale a sé stante, oppure da uno spazio opportunamente delimitato all’interno dello spogliatoio per il personale, oppure da uno spazio opportunamente delimitato nel locale dedicato all’esecuzione delle prestazioni sanitarie purché, nei primi due casi, siano direttamente comunicanti con il locale stesso destinato all’esecuzione delle prestazioni sanitarie; SI NO 3.8.1 - d aree per il lavaggio, la disinfezione, il confezionamento e la sterilizzazione dello strumentario chirurgico e degli altri presidi utilizzati costituite da uno o più locali a sé stanti, oppure da uno o più spazi opportunamente delimitati all’interno dello spogliatoio per il personale, oppure da uno o più spazi opportunamente delimitati nel locale dedicato all’esecuzione delle prestazioni sanitarie; SI NO 3.8.1 - e armadi per il deposito del materiale sterile e dello strumentario chirurgico. SI NO 3.8.1 - f I locali destinati ad attività sanitarie consentono il lavaggio e la disinfezione dei pavimenti e delle pareti fino a due metri.SI NO
  31. 31. 3.8.2 REQUISITI MINIMI IMPIANTISTICI E TECNOLOGICI • 3.8.2 • • REQUISITO DA SODDISFARE : La dotazione minima impiantistica e tecnologica per l’ambulatorio chirurgico, oltre a quanto previsto per l’assistenza specialistica ambulatoriale, è la seguente: lettino tecnico o tavolo operatorio; lampada scialitica o altro sistema di illuminazione del campo operatorio; apparecchiature per il lavaggio, il confezionamento, la disinfezione e la sterilizzazione dello strumentario chirurgico e degli altri presidi utilizzati. • • • • • • • • • • • • • • • • Criteri per la verifica del possesso del requisito Situazione attuale Ogni ambulatorio chirurgico dispone, in aggiunta/integrazione a quanto previsto per l’assistenza specialistica ambulatoriale, almeno di: 3.8.2 - a un lettino tecnico, una poltrona o un tavolo operatori, adeguati alle prestazioni chirurgiche erogate; SI NO 3.8.2 - b una lampada scialitica o un altro sistema di illuminazione del campo operatorio, adeguati alle prestazioni chirurgiche erogate; SI NO 3.8.2 - c apparecchiature per il lavaggio, il confezionamento, la disinfezione e la sterilizzazione efficaci e compatibili con le caratteristiche e gli impieghi dello strumentario chirurgico e degli altri presidi utilizzati. SI NO
  32. 32. 3.8.3 REQUISITI MINIMI ORGANIZZATIVI • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • 3.8.3 REQUISITO DA SODDISFARE : In ogni ambulatorio chirurgico, oltre a quanto previsto per l’assistenza specialistica ambulatoriale, sono formalizzate e applicate le seguenti procedure (cartacee o informatizzate) riguardanti: il consenso informato; l’esecuzione delle procedure chirurgiche maggiormente invasive o rischiose; la gestione delle emergenze; la compilazione del registro chirurgico ambulatoriale; il lavaggio, il confezionamento, la disinfezione e la sterilizzazione dello strumentario chirurgico e degli altri presidi utilizzati; la prevenzione del rischio infettivo per i pazienti e il personale. Criteri per la verifica del possesso del requisito Situazione attuale In ogni ambulatorio chirurgico esistono e vengono applicate, in aggiunta/integrazione a quanto previsto per l’assistenza specialistica ambulatoriale, procedure (cartacee o informatizzate) per : 3.8.3 - a - informare il paziente sulla diagnosi, sulle motivazioni scientifiche a sostegno della prestazione chirurgica proposta, sui benefici attesi, sugli effetti collaterali e sui rischi ragionevolmente prevedibili, sulle eventuali alternative possibili e, successivamente, per acquisire il consenso del paziente stesso all’esecuzione della prestazione; SI No 3.8.3 - b - eseguire, secondo le norme di buona pratica, le prestazioni chirurgiche maggiormente invasive o rischiose effettuate, definendo: il personale necessario per l’esecuzione delle prestazioni chirurgiche, comprese le eventuali presenza o pronta disponibilità dell’anestesista; le attrezzature, la strumentazione e i presidi necessari; le attività assistenziali da svolgere nella fase di preparazione del paziente, nell’esecuzione della prestazione e nel periodo di sorveglianza immediatamente successivo la prestazione stessa. SI NO 3.8.3 - c - gestire le emergenze cliniche, incluse le modalità di trasferimento del paziente in una struttura di ricovero in caso di necessità; SI NO 3.8.3 - d - compilare la scheda chirurgica ambulatoriale, nella quale sono riportati: gli elementi identificativi del paziente; la diagnosi; i nomi e il ruolo del chirurgo e degli altri professionisti coinvolti; la prestazione chirurgica eseguita; la data, l’ora di inizio e fine della prestazione; i farmaci somministrati e la via di somministrazione; gli elementi identificativi per la rintracciabilità degli eventuali impianti; le eventuali complicanze immediate. SI NO 3.8.3 - e eseguire, secondo le norme di buona pratica, il lavaggio, il confezionamento, la disinfezione e la sterilizzazione dello strumentario chirurgico e degli altri presidi utilizzati, ed i controlli sistematici per la verifica di efficacia dei processi di sterilizzazione; SI NO 3.8.3 - f - prevenire il rischio infettivo per i pazienti e il personale. SI NO
  33. 33. UK? • SURGERY AND GENERAL ANAESTHESIA IN GENERAL PRACTICE PREMISES • Published by The Association of Anaesthetists of Great Britain and Ireland • 9 Bedford Square, London WC1B 3RA • Tel: 0171 631 1650 Fax: 0171 631 4352 •1995
  34. 34. AAGBI: SURGERY AND GENERAL ANAESTHESIA IN GENERAL PRACTICE PREMISE • • Section I Introduction 1 Section II Necessary Facilities 3 – – – • Section III Specialist Services 5 – – • • (i) Anaesthetic services (ii) Surgical services Section IV Sterilisation Services 6 Section V Technical Services 8 – (i) Anaesthetic, resuscitation and monitoring equipment – – – • • • (i) Personnel (ii) Support Staff (iii) Organisational arrangements (ii) Medical gases (iii) Volatile anaesthetic agents (iv) Waste anaesthetic agents Section VI Quality, Financial and Contractual 10 Arrangements References 11
  35. 35. Anesthesiologist(s) . . . and not only, other consultants as well • The National Confidential Enquiry into perioperative deaths (UK) found that the number of yearly procedures performed by some consultant endoscopists was too low to ensure proficiency and skill. It recommended that competency in endoscopy should be assured by national guidelines. – Scoping our practice 2004 ,pub. by the National Confidential Enquiry into Patient Outcome and Death(NCEPOD),Epworth House, 25 City Road, London EC1Y 1AA . • No such recommendations exist for anesthesiologists, however, whose competency is simply assumed by the specialist diploma…..think about the skills of many Direttori/Primari…………
  36. 36. NORA special skills • NORA requires special skills and attitudes – among 25 neuroanesthesiologists, only 3 were found to administer anesthesia with the magnet inside the operating room intrinsically recognizing the need for a higher level of technical skills. – Archer DP, McTaggart Cowan RA, Falkenstein RJ, et al. Intraoperative mobile magnetic resonance imaging for craniotomy lengthens the procedure but does not increase morbidity. Can J Anesth 2002; 49:420426 • Nontechnical skills are also important since NORA also stresses other qualities, like task management, team-working capability and coordination, situation awareness, and decision-making. – Fletcher, G.,Flin, R.,McGeorge, P et al. Anaesthetists' Non-Technical Skills (ANTS): evaluation of a behavioural marker system. Br. J. Anaesth. 2003; 90:580-588. • Since NORA involves special risks and difficulties, anaesthetists that are unsafe due either to a lack of knowledge and skills or old age need to be identified – Atkinson RS. The problem of the unsafe anaesthetist. Br J Anaesth 1994;73:29–30. – Katz JD. Issues of concern for the aging anesthesiologist. Anesth Analg 2001;92:1487–1492.
  37. 37. Sedationist ………. • Nurses – Bluemke DA, Breiter SN. Sedation procedures in MR imaging: safety, effectiveness, – and nursing effect on examinations. Radiology 2000; 216:645–652. – Sury MRJ, Hatch DJ, Dicks Mireaux C, Chong WK. Development of a nurse led sedation service for paediatric magnetic resonance imaging. Lancet 1999; 353:1667–1671 • Physician – Endoscopists………. • quality of care and outcome ???Costs?? • • • Abenstein JP, Warner MA. Anesthesia providers, patient outcomes, and costs. Anesth Analg 1996; 82:1273–1283. Silber JH, Kennedy SK, Even-ShoshanO, et al. Anesthesiologist direction and patient outcomes. Anesthesiology 2000; 93:152–163. Cromwell J, Snyder K. Alternative cost-effective anesthesia care t eams. Nurs Econ 2000; 18:185–193 [13], and the cost implications of anesthesia services . . • Martin-Sheridan D, Wing P. Anesthesia providers, patient outcomes, and costs: a critique.AANA J. 1996; 64:528-34.
  38. 38. • Anesthesia is a discipline that requires the constant vigilance of well trained and experienced providers; safety derives from high-level dedicated care, teamwork,and rapid availability of physicians, especially during medical crises. • Clinical evidence supports the anesthesiologist-led anesthesia care team as the safest and most costeffective method of delivering anesthesia. – Death and failure to rescue were more frequent when care was not directed by anesthesiologists • However…….Sedation cannot be restricted to anesthesiologists.
  39. 39. Guidelines for sedation by non anesthesiologists • ASA practice guidelines for sedation and analgesia by non-anesthesiologists.American Society of Anesthesiologists Task Force on Sedation and Analgesia by NonAnesthesiologists. Anesthesiology 2002; 96:1004–1017.
  40. 40. MAC • Monitored Anesthesia Care does not describe the continuum of depth of sedation, rather it describes “a specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure.” • From Stand by to GA!
  41. 41. main questions • What would happen when a patient’s condition abruptly changes » or • the patient moves to another stage of sedation? • Who would be responsible for complications? • every patient may become unstable, every single sedation analgesic given outside the operating room should be done by • one anesthesiologist/patient/unit of time • the anaesthesiologist should be an experienced intensivist should a crisis occur.
  42. 42. Equipment in nonoperating room anesthesia • Old equipment is often kept in NORA areas – New anesthesiologists may be unfamiliar with it – Machines may no longer meet standards – Since such equipment is not used on a daily basis, it has to be carefully checked before each use and a program of maintenance should be instituted. The same considerations apply for monitors.
  43. 43. Equipment and machines in NORA • It is important that the equipment and machines used are maintained, tested and inspected on a regular basis and not become a repository for obsolete equipment ( chineobsolescense.pdf
  44. 44. Location and equipment • Wherever the sedation or anesthetic is performed, appropriate resuscitative equipment and medications for cardiopulmonary resuscitation must be immediately available • ASA.Guidelines for non operating room anesthetizing locations.Http:/ Services/sgstoc.htm • Capnography and pulse oximetry are invaluable in a setting where patient observation is limited (e.g. darkened room) or with limited access to the patient (e.g. radiation oncology,MRI…).
  45. 45. • the standard of anesthetic care does not decrease because of venue change
  46. 46. ASA guidelines for OBA • • • • 1.Adequate professional and administrative staff, as well as housekeeping and maintenance personnel. 2.Preoperative evaluation with necessary tests and consultations as medically indicated. 3.The development of an anesthesia plan acceptable to the patient, the administration or medical direction of same, as well as the discharge of the patient remain physician responsibilities. 4.Patients who receive other than unsupplemented local anesthesia must be discharged with a responsible adult and provided written postoperative and follow-up instructions. • Because the office facilities vary considerably, anesthesiologists must ensure that the facility is adequately equipped, with the following as a minimum: • 5.Sufficient space and electrical outlets plus adequate illumination must be provided, including backup power (this is listed first because space is something for which anesthesiologists frequently must fight in the office as well as the hospital or ASF). 6.A reliable source of oxygen adequate for the length of the procedure plus a backup supply, the latter to be at least equivalent to an E cylinder, and the ability to administer positive pressure ventilation. 7.Emergency cart with defibrillator and appropriate drugs. 8.A reliable source of motor-driven suction. 9.If inhaled anesthetics are to be used, an anesthesia machine equivalent to that of the hospital operating room and a system for scavenging waste anesthetic gas must be available. 10.Basic monitoring of oxygenation (pulse oximetry), ventilation (minute ventilation for general anesthesia and capnography for intubation), circulation (blood pressure every 5 min and continuous electrocardiogram display), and temperature (when clinically significant changes in temperature are intended, anticipated, or suggested) is essential. 11.All applicable building and safety codes and facility standards must be observed and federal, state, and local laws obeyed. • • • • • •
  47. 47. Equipment/monitoring requirements for nonoperating room anesthesia • Appropriate (for deep sedation, general anesthesia and a cardiorespiratory emergency) Immediately available • Regularly serviced (service date indicated on the equipment) • Same standard as in the operating room (minimum pulse oximetry, endtidal capnography, blood pressure, electrocardiogram and temperature) • Alarms activated (with appropriate settings) and sufficiently audible • Airway gas with the recognized safety devices (e.g. indexed gas connection system, reserve supply of oxygen, oxygen analyzer, oxygen supply failure alarm, multiple gas analyzer, a volatile anesthetic agent monitor, a breathing system disconnection alarm and a scavenging system) • Anesthesia work cart stocked to operating-room standard – – – – Including: appropriate anesthetic and resuscitation drugs, airway management equipment, a self-inflating hand resuscitator bag range of intravenous equipment • Suction ( be sure it reaches the patient….) • Ready access to a defibrillator and a fully stocked emergency cart
  49. 49. Obamed 1 Standard configuration of the OBA-1® SPECS: WIDTH: 16 inches (40.6 cm) DEPTH: 9.5 inches (24.1 cm) Including the following items: HEIGHT: 15 inches (38.1 cm) to top of Inspiratory/E xpiratory valves WEIGHT: 35 pounds (15.7 kg)
  50. 50. DRE Integra SP VSO2 Portable Anesthesia Machine
  51. 51. MIE Anmedic Hawk Anesthesia Machine
  52. 52. MRI Anesthesia Machine 2200 Magmedix
  53. 53. Highland ME 109
  54. 54. Anebox Shinova Systems(China)
  55. 55. How to proceed • anesthetic and monitoring equipment check • Make a plan :sedation only.sedation+analgesia ,light,deep,GA • be prepared for a change in procedure. – It is my personal opinion that sedation and analgesia with spontaneous respiration requires greater skills and experience than GA with airway control. – Monitored anesthesia care for disabled children is much less expensive in the dental rehabilitation office than GA in the operating room, but more sentinel events have been reported • All data should be obtained during the procedure, especially when the anesthesiologist is away from the patient; • this may require remote monitoring, special extension tubing, among other means. • be prepared for bad surprises, including sudden movement of the patient, allergies, anaphylactic shock, need for vasopressors.
  56. 56. Pre prepared… prepared • Pre prepared syringes: – Atropine – Effortil – Midazolam – Fentanyl – Propofol?? – Clonidine(catapresan) – Electrolytes – ???specific for the procedure???
  57. 57. Special problems of NORA • • • • • • remote locations limited working space electrical interference with monitors and phones lighting and temperature inadequacies lack of skilled personnel, drugs, and supplies. Noises …..are unsettling for the patient and disturb the anesthesiologist. As alarm • recognition occurs 34% of the time under ideal conditions [76], noisy areas like MRI centers make sound recognition and alarm perception very difficult. A presumed reason is that many alarms have similar sounds [77]..
  58. 58. • Since alarm volume and recognition rate are correlated, we suggest that alarms be set at maximum levels in NORA environments – Anesth Analg. 2007 ;105(6 Suppl):S95-9, Effective standards and regulatory tools for respiratory gas monitors and pulse oximeters: the role of the engineer and clinician.Weininger S.
  59. 59. Postoperative surveillance/transportation • Almost all the potentially preventable office-based injuries result from adverse respiratory events in the recovery or postoperative periods; therefore, strict surveillance should be exercised until full recovery. • During transportation all the equipment necessary for a safe journey should be at hand. • The ideal recovery area should be ‘near’ the location where the patient was treated. The safe solution is to place patients in the postanesthesia care unit (PACU) or recovery room, as for surgical patients.
  60. 60. Measures of outcome • Critical incidents may be more frequent in NORA; emergency treatment of airways is paradigmatic [90]. • The availability of a difficult intubation cart in the ICU or PACU that can be called upon for rescue would be optimal, but distant locations should have their emergency trolley with a reasonable choice of airways. • Since outcome is influenced by care quality specific protocols should be adopted for NORA and personnel organized accordingly. • NORA activities require time, which means adequate staffing: consider how many NORA activities should be covered every day. • An invitation is being made to schedule fixed days for different tasks in order to organize the anesthesia services.
  61. 61. Some quality indicators • a. death, cardiac or respiratory arrest • b. unplanned re-intubation • c. central nervous system or peripheral nervous system deficit appearing within two days of anesthesia • d. myocardial infarction within two days of anesthesia • e. pulmonary edema within one day of anesthesia • f. aspiration pneumonia • g. anaphylaxis or adverse drug reactions • h. post dural puncture headache within four days of spinal or epidural anesthesia • i. dental injury • j. eye injury • k. surgical infection rate • l. excessive blood loss • m.unplanned admission to a hospital or other acute care facility
  62. 62. Quality indicators II Review of quality indicators, to include measures of patient satisfaction. • The quality improvement plan should include at least an annual review and check of anesthesia equipment to ensure compliance with current safety standards and the standards for the release of waste anesthetic gases. • For each office facility at which anesthesia is provided on a regular or ongoing basis, facility quality improvement reviews should be conducted. The reviews should be performed by a group that includes, at a minimum, the medical director, a representative of the anesthesiologists currently providing patient care and a representative of the operating room or recovery nursing staff. The frequency of the reviews would be appropriate for the number of procedures performed, but they should be conducted at least annually and result in written minutes and conclusions
  64. 64. The risk and safety of anesthesia at remote locations: the US closed claims analysis .Julia Metzner, Karen L. Posner and Karen B. Domino.Current Opinion in Anaesthesiology 2009,22:502–508 • ASA Closed Claims database of 8496 claims • 87 claims associated with anesthesia in remote locations compared with 3287 operating room claims. • Patients in remote locations were older (20% >70 years and sicker (69%, ASA PS 3-5) • > 1/3 of remote location claims involved emergent procedures as compared with only 15% of OR claims • The predominant anesthetic technique in remote location claims was MAC, 8 times more frequent (50 vs. 6%) than in OR claims. • 21% of remote location claims involved no anesthesia (e.g. emergency endotracheal intubation or resuscitation )
  65. 65. The risk and safety of anesthesia at remote locations: the US closed claims analysis .Julia Metzner, Karen L. Posner and Karen B. Domino.Current Opinion in Anaesthesiology 2009,22:502–508
  66. 66. Severity of injury The risk and safety of anesthesia at remote locations: the US closed claims analysis .Julia Metzner, Karen L. Posner and Karen B. Domino.Current Opinion in Anaesthesiology 2009,22:502–508 • The severity of injuries for remote location claims was greater than those associated with operating room claims • The proportion of death was almost double in remote location claims (54 vs. 29% ) in OR claims. • OR claims were mostly associated with temporary injuries (49%.) • The proportion of claims for other nonfatal injuries showed a similar tendency in both groups, except nerve damage, which was more common among OR claims .
  67. 67. Mechanism of injury The risk and safety of anesthesia at remote locations: the US closed claims analysis .Julia Metzner, Karen L. Posner and Karen B. Domino.Current Opinion in Anaesthesiology 2009,22:502–508 • adverse respiratory events : double that of OR claims (44 vs. 20%) • Inadequate oxygenation/ventilation was the most common respiratory-related remote location claim,occurring 7 times more frequently than in OR claims (21 vs. 3%, ) • Difficult intubation , esophageal intubation and aspiration of gastric contents were the other specific respiratory events in remote location claims
  68. 68. Preventability of injury and etiology The risk and safety of anesthesia at remote locations: the US closed claims analysis .Julia Metzner, Karen L. Posner and Karen B. Domino.Current Opinion in Anaesthesiology 2009,22:502–508 • The anesthesia care was judged by the reviewers as substandard in 54% of remote location claims compared with 37% of OR claims • In addition, a large proportion of injuries in remote location claims were considered to be preventable by better monitoring (32 vs. 8% in OR claims), • Oversedation leading to respiratory depression due to an absolute or relative overdose of sedative–hypnotic– analgesic drugs was responsible
  69. 69. The risk and safety of anesthesia at remote locations: the US closed claims analysis .Julia Metzner, Karen L. Posner and Karen B. Domino.Current Opinion in Anaesthesiology 2009,22:502–508
  70. 70. Conclusion The risk and safety of anesthesia at remote locations: the US closed claims analysis .Julia Metzner, Karen L. Posner and Karen B. Domino.Current Opinion in Anaesthesiology 2009,22:502–508 • Analysis of closed claims suggests that administration of anesthesia and sedation at remote locations is associated with a significant risk of adverse effects. In spite of the relatively noninvasive nature of the procedures, our analysis suggests that anesthesia at remote locations, particularly those involving MAC, represents a growing area of liability for the anesthesiologist. Knowledge of the pharmacokinetic properties of sedative/analgesic drugs, careful monitoring using ASA standards, including continuous monitoring of respiration by capnography, and vigilance can aid in minimizing the risk of permanent injury to the patient. In addition, general anesthesia with endotracheal intubation may be safer than deep sedation in some patients and procedures
  71. 71. • These findings emphasize the seriousness of the preanesthetic assessment and the need to identify pts at risk for cardiac,respiratory and airway issues
  72. 72. Comput Assist Tomogr. 2009 Mar-Apr;33(2):312-5. Increased risk of general anesthesia for high-risk patients undergoing magnetic resonance imaging. Girshin M, Shapiro V, Rhee A, Ginsberg S, Inchiosa MA Jr. • Department of Anesthesiology, Metropolitan Hospital Medical Center, New York, NY 100129, USA. • A total of 47,389 anesthetics have been administered to pediatric patients in the Montefiore Medical Center between February 1998 and September 2007, of which 11,700 (25%) were administered for procedures performed outside the OR. • 3 deaths from general anesthesia occurring in the MRI suite, the resulting non-OR mortality rate at our institution was approximately 1 in 3900. Comparatively, in the same period, our mortality rate for procedures performed intraoperatively under general anesthesia was 1 in 7138. • Therefore, there is almost a 2-fold increased risk in mortality associated with non-OR versus OR anesthetics at our institution. • CONCLUSION: Our analysis shows that the administration of anesthesia in MRI suite possesses inherent risks that might be the same or even higher than those in the OR. .
  73. 73. Risky patients in NORA……… • Out of operating room procedure selected as a less risky alternative to an OR procedure in an extremely risky patient: • E.g. – : vascular stenting in interventional or neuroradiology vs open procedure in OR – Oesoph. Varices ligature in endoscopy…. – Gastroduodenal ulcer bleeding in endoscopy……. – Coronary stenting in cardiology………….
  75. 75. Quality issues • Quality improvement should rely on raising the standards of every location where sedation and anesthesia are possible to operating room standards. • In the meantime, the recommendations taken from the ASA guidelines for NORA locations should be followed and implemented..
  76. 76. Conclusion • NORA means challenges • providing care for more medically complex patients while adapting to fewer resources, with lack of support system commonly available in the operating room • No anesthesia or sedation performed outside the operating room should be considered minor; it requires skill, experience, and organization. • Anesthetic needs should be evaluated from a safety point of view. • Patient preparation, consent, sedation, analgesia or GA should be performed utilizing the same standards as adopted for the operating room
  77. 77. Office-Based Surgery Practices in New York State. • Alert • Practices which perform office-based surgery were required to be accredited on July 14, 2009. – To find a list of accredited practices go to OfficeBased Surgery Practices in New York State.
  78. 78. Office-Based Surgery Practices in New York State • Effective July 14, 2009, physician offices that perform surgical or invasive procedures using more than mild sedation must be accredited by one of these agencies: • Accreditation Association for Ambulatory Health Care (AAAHC) • American Association for Accreditation of Ambulatory Surgery Facilities, Inc. (AAAASF) • The Joint Commission (TJC) • Accreditation, though not the same as state regulation, is a way to ensure a level of standardization among office-based surgical practices with the goal of assuring quality of care and patient safety.
  79. 79. Consequences….. • Beginning July 14, 2009, a physician who is found to have operated in an unaccredited office is guilty of professional misconduct and risks his license. • “New York’s law has teeth,” …. • Some states that have mandated office oversight still don’t see much accreditation activity, but “in New York, people took notice because there was a penalty in the law,”
  80. 80. Joint Commission • The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™ • Guidance for health care professionals • SpeakUP
  81. 81. Conduct a pre-procedure verification process Mark the procedure site . Perform a time-out
  82. 82. Office buildings …
  83. 83. Partnership vs solo practice • partnership of surgeons (well established) from the community who have come together to provide a wide breadth of quality surgical care……….
  84. 84. Plastic Surgery of Southern Connecticut
  85. 85. • Recommendations for anesthesia and sedation in nonoperating room locations • Raccomandazioni per l’esecuzione dell’anestesia e della sedazione al di fuori dei blocchi operatori . • SIAARTI Study Group for Safety in Anesthesia and Intensive Care . • Coordinator. E. Calderini • Minerva Anestesiologica 2005;71:17-21.
  86. 86. General organization of the guideline: • Definitions and aims • Organization :model • it is suggested that every Dept of Anesth. draft a organization model for treatments outside OR’s….… • Indications • Patient selection:I & II: ASA III with limitations • Supply and communications
  87. 87. ASA Guidelines concerning OBA • • • • • • • • • Guidelines for Office-Based Anesthesia Guidelines for Qualifications of Anesthesia Providers in the Office-Based Setting Guidelines for Ambulatory Anesthesia and Surgery Guidelines for Nonoperating Room Anesthetizing Locations Position on Monitored Anesthesia Care Statement on Regional Anesthesia Statement on the Anesthesia Care Team Basic Standards for Preanesthesia Care, Standards for Basic Anesthesia Monitoring, and Standards for Postanesthesia Care fContinuum of Depth of Sedation Definition of General Anesthesia and Levels of sedation/Analgesia
  88. 88. SIAARTI guidelines useful for OBA • LINEE GUIDA PER LA SICUREZZA IN ANESTESIA LOCO-REGIONALE • Commissione SIAARTI/AAROI,sull’anestesia in day surgery. – Coordinatore: M. SOLCA • G.BETTELLI, M.LEUCCI, C.MATTIA, V.A.PEDUTO, E.RECCHIA, P.RUJU, I.SALVO, A.TERREVOLI RACCOMANDAZIONI CLINICO-ORGANIZZATIVE PER L’ANESTESIA IN DAY-SURGERY • Raccomandazioni per l’anestesia nel Day Hospital • Raccomandazioni per il monitoraggio di minima del paziente durante anestesia.I Edizione febbraio 1990,II Edizione giugno 1996. • RACCOMANDAZIONI PER LA VALUTAZIONE ANESTESIOLOGICA IN PREVISIONE DI PROCEDURE DIAGNOSTICHE - TERAPEUTICHE IN ELEZIONE Ecc,ecc Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  89. 89. Other good articles • Recommendations on minimum facilities for safe anaesthesia practice outside operating suites. Last Updated July 3, 2002. Australian and New Zealand College of Anaesthetists Professional Document T2.[Online] 2002. technical/T2_2000.htm. • Kotob F, Twersky RS. Anesthesia outside the operating room: general overview and monitoring standards. Int Anaesthesiol Clin 2003; 41:1–15.
  90. 90. • GUIDELINES FOR OFFICE-BASED ANESTHESIA • Committee of Origin: Ambulatory Surgical Care • (Approved by the ASA House of Delegates on October 13, 1999, and last affirmed on October 21, 2009) • These guidelines are intended to assist ASA members who are considering the practice of ambulatory anesthesia in the office setting: office-based anesthesia (OBA).
  91. 91. • ….ASA recognizes the unique needs of this growing practice and the increased requests for ASA members to provide OBA for health care practitioners* who have developed their own office operatories…..
  92. 92. • ..special problems that ASA members must recognize when administering anesthesia in the office setting. Compared with acute care hospitals and licensed ambulatory surgical facilities, office operatories currently have little or no regulation, oversight or control by federal, state or local laws.
  93. 93. ASA …. • …..Therefore, ASA members must satisfactorily investigate areas taken for granted in the hospital or ambulatory surgical facility such as governance, organization, construction and equipment, as well as policies and procedures, including fire, safety, drugs, emergencies, staffing, training and unanticipated patient transfers
  94. 94. NORA • • • • Governance organization construction and equipment policies and procedures, including : – – – – – – – Fire safety drugs emergencies staffing training unanticipated patient transfers
  95. 95. Expanding the role of the anesthesiologist
  96. 96. THE END
  98. 98. Risks commonly associated with gastrointestinal endoscopy • • • • • Hemodynamic instability due to: Elderly population with limited cardiovascular reserve Dehydration due to osmotic bowel preparation Vagal responses to gastrointestinal distention Risk of aspiration due to: – Ingestion of large amounts of bowel preparation – Gastric bleeding • Difficult airway access: – Shared airway in upper endoscopy – Prone positioning – Dark procedure room
  99. 99. Risks commonly associated with MRI • Emergencies?full stomach,depressed consciousness…… • Presence of the magnet…. • Anesthesiologist out of room • Telemonitoring • Mainly children with cerebral problems or claustrophobic/non cooperative adults
  100. 100. ASA recommendations 2003 • • • • • • • • • • • • (a) Reliable oxygen source including a backup supply. (b) Adequate and reliable suction. (c) Adequate and reliable scavenging system if anesthetic gases are to be used. (d) Self-inflating resuscitation bag capable of delivering an inspired oxygen fraction (FiO2) of 0.90. (e) Adequate drugs, supplies and equipment for the planned activity. (f) Adequate monitoring equipment to adhere to standards for basic anesthetic monitoring. (g) Sufficient electrical outlets, isolated electric power or electric circuits with ground fault interruption in ‘wet areas’ like cystoscopy, arthroscopy, labor and delivery suites, with access to emergency power supply. (h) Sufficient space for equipment and personnel and transportation. (i) Immediate suitability of an emergency cart with defibrillator, emergency drugs, etc. (j) Reliable two-way communication. (k) Observation of all applicable building and safety codes and facility standards. (l) Appropriate postanesthesia management.
  101. 101. Specific items: • • • • • Self inflating resusci bag (FiO2 0.90) Drugs and devices for anesthesia Monitor ECG with HR display NIBP ;sphygmomanometer….. Pulse oximeter • Cart with emergency devices and drugs + defibrillator • Anesthesia machine if GA • Capnometer or apnea monitor only when … paragraph…..or no direct patient vision • Prerequisites • Checks and maintenance to be defined appropriately
  102. 102. Anesthesia supply cart • • • • • H+H systems? What is needed.. Same content for all Cart insert and dividers easily configured Who is checking? And when?
  103. 103. Portable anesthesia machines su Travelmate
  104. 104. Office features • • • • building Spaces:parking Transportation In nearness of :highways,railways,underground, • Which services would be offered?which staff? • Demands of patients,physicians,surgeons…
  105. 105. Reasons behind office surgery • Advancements in medicine have always been made by new discoveries or technologies …. – Instead… • Day surgery originates from savings need! – Office-based anesthesia represents a potential for cost-effective approaches for many surgical procedures….. • but now the third payer ,after having pushed ambulatory surgery in order save money ,is hampering the office based option because is afraid of increasing the expenses………..
  106. 106. Which are the driving forces behind the changes in the surgical & anesthesiological approach? • Cost containment politics – USA Medicare and other Insurances • New technologies – – – – – Instrumentations:user friendly Drugs;fast on and fast off Resp. Devices less invasive Portability of equipment and monitors Minimally invasive surgical techniques • Increase in competition on the health market;the informed patient……..
  107. 107. Advantages of Office Based Anesthesia (OBA) • facility fees in a hospital can be expensive and often unpredictable, the costs in an office are more readily controllable and predictable – WETCHLER BV: Online shopping for ambulatory surgery: let the buyer beware! [Editorial].Ambulatory Surg; 8:111, 2000. – . QUATTRONE MS: Is the physician office the wild, Wild West of health care? J Ambulatory Care Manage; 23:64-73, 2000 – SCHULTZ LS: Cost analysis of office surgery clinic with comparison to hospital outpatient facilities • for laparoscopic procedures. Int Surg; 79:273-277, 1994. Patients undergoing a procedure in an office can be made aware of all costs prior to consenting to surgery:costs typically include the surgeon’s, and anesthesiologist’s fees as well as the facility fee. – • • • • • ease of scheduling, patient and surgeon convenience, maintenance of patient privacy, decrease in patient exposure to nosocomial infections improved continuity of care, since an office is often staffed by a small group of consistent personnel – • Medically necessary procedures can be reimbursed by third-party payers. BING JB, MCAULIFFE MS, LUPTON JR: Regional anesthesia with monitored anesthesia care for dermatologic laser surgery. Dermatol Clin; 20:123-134, 2002 . IVERSON RE, LYNCH DJ: ASPS Task Force on Patient Safety in Office-based Surgery Facilities. Patient safety in office-based surgery facilities: II. Patient selection. Plast Reconstr Surg; 110:1785-1790, 2002.
  108. 108. 2000/2006/2007 National Plastic Surgery Statistics Cosmetic Procedure Trends:I
  109. 109. 2000/2006/2007 National Plastic Surgery Statistics Reconstructive Procedure Trends:II 2000 2006 2007
  110. 110. • These recommendations focus on quality anesthesia care and patient safety in the office. These are minimal guidelines and may be exceeded at any time based on the judgment of the involved anesthesia personnel. Compliance with these guidelines cannot guarantee any specific outcome. These guidelines are subject to periodic revision as warranted by the evolution of federal, state and local laws as well as technology and
  111. 111. 2004 Patient Safety Principles for Office-Based Surgery Utilizing Moderate Sedation/Analgesia, Deep sedation/Analgesia, or General Anesthesia :I Courtesy, American College of Surgeons ,March, 2004 • Core Principle #1 - Guidelines or regulations should be developed by states for office-based surgery according to levels of anesthesia defined by the American Society of Anesthesiologists' (ASA's) "Continuum of Depth of Sedation" statement dated October 13, 1999, excluding local anesthesia or minimal sedation. • Core Principle #2 - Physicians should select patients by criteria, including the ASA Patient Selection Physical Status Classification System, and so document. • Core Principle #3 - Physicians who perform office-based surgery should have their facilities accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Accreditation Association for Ambulatory Health Care (AAAHC), American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF), American Osteopathic Association (AOA), or by a staterecognized entity such as the Institute for Medical Quality (IMQ), or be state licensed and/or Medicare certified.
  112. 112. 2004 Patient Safety Principles for Office-Based Surgery Utilizing Moderate Sedation/Analgesia, Deep sedation/Analgesia, or General Anesthesia :II Courtesy, American College of Surgeons ,March, 2004 • Core Principle #4 - Physicians performing office-based surgery must have admitting privileges at a nearby hospital, or a transfer agreement with another physician who has admitting privileges at a nearby hospital, or maintain an emergency transfer agreement with a nearby hospital. • Core Principle #5 - States should follow the guidelines outlined by the Federation of State Medical Boards regarding informed consent. • Core Principle #6 - States should consider legally privileged adverse incident reporting requirements as recommended by the FSMBiv and accompanied by periodic peer review and a program of Continuous Quality Improvement.
  113. 113. 2004 Patient Safety Principles for Office-Based Surgery Utilizing Moderate Sedation/Analgesia, Deep sedation/Analgesia, or General Anesthesia :III Courtesy, American College of Surgeons ,March, 2004 • Core Principle #7 - Physicians performing office-based surgery must obtain and maintain board certification by one of the boards recognized by the American Board of Medical Specialties, American Osteopathic Association, or a board with equivalent standards approved by the state medical board within five years of completing an approved residency training program. The procedure must be one that is generally recognized by that certifying board as falling within the scope of training and practice of the physician providing the care. • Core Principle #8 - Physicians performing office-based surgery may show competency by maintaining core privileges at an accredited or licensed hospital or ambulatory surgical center for the procedures they perform in the office setting. Alternatively, the governing body of the office facility is responsible for a peer review process for privileging physicians based on nationally recognized credentialing standards.
  114. 114. 2004 Patient Safety Principles for Office-Based Surgery Utilizing Moderate Sedation/Analgesia, Deep sedation/Analgesia, or General Anesthesia :IV Courtesy, American College of Surgeons ,March, 2004 • Core Principle #9 - At least one physician, who is credentialed or currently recognized as having successfully completed a course in advanced resuscitative techniques (ATLS®, ACLS, or PALS), must be present or immediately available with age and size-appropriate resuscitative equipment until the patient has met the criteria for discharge from the facility. In addition, other medical personnel with direct patient contact should at a minimum be trained in Basic Life Support (BLS). • Core Principle #10 - Physicians administering or supervising moderate sedation/analgesia, deep sedation/analgesia, or general anesthesia should have appropriate education and training
  115. 115. The risk and safety of anesthesia at remote locations: the US closed claims analysis .Julia Metzner, Karen L. Posner and Karen B. Domino.Current Opinion in Anaesthesiology 2009,22:502–508
  116. 116. The risk and safety of anesthesia at remote locations: the US closed claims analysis .Julia Metzner, Karen L. Posner and Karen B. Domino.Current Opinion in Anaesthesiology 2009,22:502–508
  117. 117. Oral Surgery Office Building and Site Design
  118. 118. Plastic Surgery in Modesto
  119. 119. Nora focal points :quality and safety Patient selection Equipment and support of the facility Surgical choices Training Complication rate
  120. 120. PRN-15 Secure digital access LED touch panel for access Multi-level administrative and user access Automatic locking mechanism Manual lock override 500 unique user IDs on each cart Solid metal construction for durability and security Low center of gravity for easy maneuvering 5" casters for quiet operations Multiple drawer configuration: 6-5.5" or 4-8.25" patient bin cassettes or 3"/6"/9"/12" x 17" metal drawers Large easy to clean work surface with SpillGuard Protect for the electronics Optional dual password Narcotic Lock Drawer Optional items include-IV Pole, pass thru trash, pill and water cu
  121. 121. Busing Co.Stock carts