Ambulatory Surgery Center Patient Criteria and Selection

[Pages:8]Ambulatory Surgery Center Patient Criteria and Selection

James Hoell, MD, Aurora Sheboygan Memorial Medical Center

CMS interpretive Guidelines for ASC Coverage 416.42(a)(1)

"The purpose of the exam immediately before surgery is to evaluate, based on the patient's current condition, whether the risks associated with the anesthesia that will be administered and with the surgical procedure that will be performed fall within an acceptable range for a patient having that procedure in an ASC, given that the ASC does not provide services to patients requiring hospitalization. The assessment must be specific to each patient; it is not acceptable for an ASC to assume, for example, that coverage of a specific procedure by Medicare or an insurance company in an ASC setting is a sufficient basis to conclude that the risks of the anesthesia and surgery are acceptable generically for every ASC patient. The requirement for a physician to examine the patient immediately before surgery is not to be confused with the separate requirement at 42 CFR 416.52(a)(1) for a pre-admission history or physical assessment performed by a physician, although it is expected that the physician will review the materials from such pre-admission examination as part of the evaluation. However, this requirement does constitute one component of the requirement at 42 CFR 416.52(a)(2) for a pre-surgical assessment upon admission. See the interpretive guidelines for that requirement. "

Objective:

To review current data/thought processes to institute or modify patient selection criteria for ASC

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First ASC- two physicians in Phoenix, Arizona

Medicare reimburse ASC

>65% outpatient surgery 40% at ASC

1970

Mid 70s

1982

1990s

2016

50 ASCs- acceptance of a few commercial payors

20% of outpatient surgery in ASC

Taparia, Vivek. "Regent Surgical Health - Surgery Center Developers and Managers." Regent Surgical Health. N.p., 4

Mar. 2011. Web. 20 Aug. 2016.

What Determines if a Surgery Should Occur in an ASC?

Procedure Anesthetic technique Patient characteristics ASC Anesthesiologist Surgeon Social

Developing Clinical Pathways Will Have an Impact on...

Safety Unplanned admission Readmission Delayed discharge home Post discharge complications Efficiency Patient satisfaction Perioperative surgical home

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Patient Selection Criteria:

BMI OSA ASA physical status Age ICD/Pacemaker MH susceptible Miscellaneous

Selection of Obese Patient for Ambulatory Surgery

CEO Dir. of Sales

Comorbid Conditions Optimized

BMI50 kg/m2

Proceed with Surgery

Joshi GP , et al: Anesth Analg 2012; 115: 1060-8

Known or Presumed OSA

Follow OSA Recommendations

Not Suitable for Surgery

Joshi GP , et al: Anesth Analg 2013; 117: 1082-91

SAMBA- OSA Recommendations

Patient with Known OSA

Patient with Presumed Diagnosis of OSA

Optimized Comorbid Conditions and Able to Use CPAP Post Discharge

Patients with Nonoptimized

Comorbid Conditions

Optimized Comorbid Conditions and

Minimal Postoperative Narcotics

Proceed with Surgery

Not Suitable for Surgery

Proceed with Surgery

No Guidance Airway Surgery

Joshi GP , et al: Anesth Analg 2012; 115: 1060-8

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"STOP-BANG"

of 5-8 identify patients with high probability of moderate/severe OSA

Snore loudly Tired Observed apnea/gasping Pressure (HTN)

BMI > 35 kg/m2 Age >50 Neck 17/16 inch m/f Gender = male

Chung et al, 2012

ASA Classification of Physical Status

History :

1941- First classification, tried to stratify operative

risk, first speciality to attempt risk stratification Abandoned operative risk and went to preoperative

physical status only

1963- Current ASA classification of physical status 2014- examples given each ASA-PS

ASA Validity

"Subjective, but can be used as measure of preoperative health status."

Shankar, Brit J Anes 2014;424-32

"ASA-PS powerful parameter that condenses relevant clinical measures of patient risk and acuity into a single variable."

Dalton et al, Anesthesiology 2011;114:1336-44

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ASA-PS

ASA-PS 4: Severe systemic disease that is constant threat to life Examples: < 3 months- CVA,MI, CAD/Stents Ongoing cardiac ischemia Severe reduction of EF ARF Severe valve dysfunction

asahq/resources/clinical-information/asa-physical-status-classification-system

Cardiac:

New onset angina or angina at rest Decompensated CHF MI < 3 months Severe valvular disease e.g. AS Severe secondary PH

Age:

>80 has been associated with increased unplanned admission

Age alone not used at independent criteria Physiologic age more important than chronologic Postoperative cognitive dysfunction/disposition

environment

Whippy A. et al, Can J Anesthesia 2013; 60:675-83

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Medicare Case Volume by Specialty

Pacemaker/ICD

Type of device

Last evaluation Indication Programming Battery life >3

months

Pacer dependence Magnet response

Pacemaker:

Pacemaker dependent patients Significant EMI Only render asynchronous if significant

inhibition magnet usually puts pacemaker in asynchronous

mode Caution in special programing - e.g. minute

ventilation sensors

HRA/ASA Expert consensus statement on perioperative management of patients with ICD/PM

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ICD:

Surgery above umbilicus and

EMI

Yes

No

Yes

Reprogram or Short Bursts and

use Magnet

Pacemaker Dependent

Asia Lead

No

Proceed Use Magnet

Proceed Front End Lead

Neelankavil et al, Apsf Newsletter fall 2013

MH Susceptible Patients

MHAUS website does not provide recommendations on MH susceptible patients in ASC

Dr. Litman (oversees MHAUS hotline) has given his expert opinion:

2014- No medically valid reason that known MH susceptible patients cannot undergo GA in a freestanding ASC

2015- MH susceptible patient under GA in ASC-ideal if adjacent to hospital otherwise transfer protocol in place

Anesthesiology 06, 2014; vol 120: 1306-1308

C lin ic a l A n e s th e s io lo g y 0 3 /0 3 /2 0 1 5

Miscellaneous Patient Criteria:

Difficult airway Actively using

Recreational drugs

Hyperglycemia Liver disease

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Summary:

Minimal Criteria:

BMI > 50 OSA resumed/diagnoses not using CPAP and significant

postop narcotics ASA - PS of 4 (list examples) ICD in pacemaker dependant patient with significant EMI

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