Data show a big difference between hospital and office anesthesia safety

Today's healthcare consumers have more choices than ever before. When it comes to surgeries and procedures, patients have the option of having them done in an office setting or a hospital operating room. Patients also have the option of selecting a physician anesthesiologist or nurse anesthetist to provide anesthesia care, although many facilities do not present it as a choice.

Why have a procedure in an office instead of a hospital operating room?

Office and ambulatory surgery center procedures and surgeries are increasingly popular, in large part because they are more profitable for physicians and surgeons. A significant portion of insurance and Medicare reimbursement goes towards facility fees. When a procedure or surgery is done in a hospital operating room, 100% of those fees go to the hospital. Many physicians and surgeons perform outpatient procedures and surgeries in their offices and keep the facility fees for themselves. Some physicians and surgeons own all or part of ambulatory surgery centers and generate additional facility fee income that way.

Medical and surgery practices persuade patients to have their procedures or surgeries done in the office or in an ambulatory surgery center for two other reasons:

  • Convenience: It’s easier to get in and out of an office practice or surgery center than a hospital, and they’re often more conveniently located.
     
  • Price: Hospital operating rooms are more expensive.

What are the risks of having surgery outside a hospital operating room?

One of the reasons hospitals are more expensive than office or ambulatory surgery center operating rooms is that they are better equipped with staff, equipment, and supplies necessary to respond to an intraoperative emergency. That's why outpatient surgery centers are different from hospital operating rooms.

Hospitals have emergency departments, emergency physicians, surgeons, and anesthesiologists, who are airway experts, and can respond immediately when a problem occurs in a hospital operating room. In contrast, if a complication arises during an off-site procedure or operating room, the typical policy for most offices and ambulatory surgery centers is to call 911 and transport the patient to a hospital.

Who will be providing my anesthesia care?

Anesthesia care is a complex medical field. 

Anesthesiologist physicians have specialized training in administering anesthesia (induction), monitoring patient safety while under anesthesia, and bringing patients out of anesthesia (emergence).

Certified registered nurse anesthetists (CRNAs) are registered nurses with advanced anesthesia training from a nursing perspective, rather than a medical perspective. In some states, including Texas, CRNAs must be medically directed or supervised by a physician anesthesiologist. Under a medical direction model, a physician anesthesiologist can oversee the anesthesia care of up to four CRNAs simultaneously. Under medical supervision, a physician anesthesiologist can oversee five or more CRNAs at the same time. This has led to many lawsuits including where a Texas jury awarded $21 million over nurse anesthetist (CRNA) operating room care that left a 27-year-old man with brain injury.

Nationwide, nurse anesthetist professional associations and lobbying groups are making significant efforts to allow CRNAs to practice independently, without the medical direction or supervision of a physician. This strategy has been successful in numerous states, but in Texas, physicians must still be involved in overseeing the care provided by CRNAs.

Before anesthesia care can be provided, the patient must give informed consent, which requires a discussion of the risks and benefits of the proposed treatment or anesthesia plan. An important part of this discussion is the educational preparation and training of the anesthesia provider. To make an informed decision, including questions to ask on whether ambulatory an surgery center is appropriate for patient.

  • Are you a physician or nurse?
  • When did you finish your anesthesia training?
  • How long have you been licensed as a CRNA or nurse anesthetist?

As a patient, you have the right to ask who will be providing your anesthesia care in the operating room. In many situations, a physician anesthesiologist will perform the pre-anesthesia evaluation, which is a focused patient interview and physical examination to determine whether it’s safe for patient to proceed with general anesthesia and surgery. After giving the green light, it’s common for the anesthesiologist to turn operating room care over to a nurse anesthetist or CRNA.

Here are the options for operating room anesthesia care available patients:

  • Physician only care. In this model, a physician anesthesiologist personally provides all anesthesia care, rather than medically directing or supervising a nurse anesthetist.
     
  • Anesthesia team care. In this model, a CRNA provides the operating room anesthesia care. In some states, like Texas, where medical direction or supervision is still required, the physician anesthesiologist will participate in preparation of the anesthesia plan and should be physically present in the operating room for the most critical parts of the case, including putting the patient to sleep and waking patient up. Additionally, the physician should be immediately available in case of an emergency.

From a practical perspective, most facilities do not maintain physician anesthesiologist staffing level sufficient to provide patients with physician only care. Thus, if you want a physician to provide your operating room anesthesia care, you should make that request in advance to allow the staffing to be worked out.

Anesthesia medical malpractice cases outside a hospital setting The Anesthesia Patient Safety Foundation published a study of 200 closed anesthesia medical malpractice claims.  The study compared claims involving hospital operating rooms to non-operating room anesthesia (NORA) locations. The findings are interesting:

  • The average payment for NORA claims was 44% higher than for hospital OR claims.
  • NORA claims were more likely to involve catastrophic injuries, including brain injury and death, as compared to hospital OR claims.
  • The average NORA patient is older and more medically complex than the average hospital OR patient.

The last point really caught my attention. It would seem logical that younger, healthier patients might opt for a surgery or operation outside hospital setting, while higher risk patients who are older and have other medical conditions would choose the comparative safety of a hospital setting. his validates the concern that many people have expressed, that patients aren't given adequate information to make an informed choice about their anesthesia providers and where their care will be provided.

If you’ve been seriously injured because of poor anesthesia care in Texas, then contact a top-rated, experienced Texas medical malpractice attorney for a free strategy session about your potential case.

Article by

Robert Painter

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm Medical Malpractice Attorneys in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him for a free consultation and strategy session by calling 281-580-8800 or emailing him right now.