Add-On Cases: Where Safety and Convenience Collide?

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  • Chamberlin, Keith, MD, MBA, FASA
| Apr 16, 2012

We all experience “add-on” cases: previously unscheduled, unplanned surgeries, some of which really need to be done, others that are just scheduled for surgical convenience. Safety is an issue in these cases, since we know after hours staffing is less than business hours staffing, and getting full support from other services, such as, radiology, blood bank, cardiology, or vendor representatives can be an issue.

I think we have all participated in a Sunday add-on case which suddenly required a piece of equipment located three hours away, while we keep an 88-year-old with AS and CHF asleep, awaiting hip repair. Worse still, is the late night add-on of a pseudo emergency—psychologically, it goes something like this (with apologies to Kubler-Ross):

The five stages of add-ons:

1.    Denial — What do you mean he has an add-on? No, no this surgeon never does these cases at night. Who is the patient? I am sure it can wait. No, it must be just Burr holes, not a full-fledged craniotomy.

2.    Anger — There is NO WAY we can do this case. This patient has been in the hospital for a week, and the surgeon wants to do it now? NO! The OR director will never approve this, because it’s not safe to start an elective case at 10 p.m. Call the CEO. This is nonsense…

3.    Bargaining — Ok, alright, here’s the deal. I can get you a 7:30 time slot tomorrow morning. Even better, I can get you a 7:15, with your favorite nurses, in the GOOD room! I will work the patient up tonight so there will be no delay. I will call the nursing team personally, and I’ll place the line tonight so there will be even less delay! This is better for you AND the patient. Safety! Quality!

4.    Depression — This can’t be. Every time I am on call this happens to me. Why me? I did a good job today, why do I have to miss my kid’s game? This is not right. I cannot keep doing this.

5.    Acceptance — SEND (for the patient)…

And while there is certainly some black humor in this, I hope you will also find the serious lesson. The issues are aptly discussed in a recent blog entitled Abuse of Anesthesia Services by William Hass, M.D., MBA. Dr. Hass outlines how in many facilities, it is “business as usual” for the hospital policy on after-hour cases to be disregarded. Among the many, many pitfalls of such a practice are, exposing the facility to significant liability, creating poor staff relations, reducing financial performance, diminishing the value of following policies in general, and making the anesthesiologist appear “lazy and/or obstructionist.”

As an anesthesiologist, committed to patient safety and quality care, I advise that you do not blindly permit this to happen to your department. Policies on how after-hours cases are handled are in place to protect patients. Make sure your administration knows the importance of safety after hours, and that you remain a vigilant voice speaking in support of the patients, the facility, the budget and the staff.

I have personally seen at least three fabulous techs and nurses quit a facility because they were worked overtime constantly, for no reason. As we get deeper into budget cuts, this type of fiscally irresponsible behavior cannot be tolerated, and as I have said before, anesthesiologists must lead the way in these initiatives: The only way to ensure that a good after hours add on policy is upheld, and cases not meeting criteria are not pushed through, is to have administrative support BEFORE you start denying cases.

In just such an instance, I had a surgeon once tell me, “Ok, YOU tell the patient why they cannot have an operation tonight!” So I did. The patient was amazing grateful when I explained that it was in her best interest to delay the surgery until morning. Not surprisingly, she preferred to have surgery under conditions where she would receive the best possible care by a well-prepared team. Her surgery was completed successfully the next day, and that surgeon no longer makes me this offer.

When you have safety and quality care on your side, how can you be wrong?

And you can read the blog while you are sending…

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