Politics and Medication Safety: The CSA 2014 Annual Anesthesia Meeting

  • Sibert, Karen, MD, FASA
| May 05, 2014

Chilly, rainy weather at week’s end transformed into a brilliantly sunny weekend in San Francisco, as physicians from as far away as Australia, Canada, and Saudi Arabia gathered at the Hyatt Regency Embarcadero for the CSA 2014 Annual Anesthesia Meeting and Workshops, held Apr. 24 to 27. 

Mark Rollins MD PhD, associate professor at the UCSF Department of Anesthesia and Perioperative Care, led development of the meeting’s agenda and served as program chair.

The meeting enjoyed a 60% greater attendance than last year’s in Orange County, reflecting the draw of the San Francisco location both for California anesthesiologists and for the nearly 25% of attendees who came from out of state. The CSA Board of Directors has agreed to keep the annual educational meeting in San Francisco at least for the next several years, anticipating that the meeting will eventually grow in size and scope to rival the New York State Society of Anesthesiologists’ annual PostGraduate Assembly, held each December in New York City.

Three well-attended Thursday workshops kicked off the events, directed by faculty from Stanford and UCSF. Edward Mariano MD MAS, chief of anesthesiology at the Palo Alto VA, led an interactive workshop on ultrasound-guided regional anesthesia. Dr. Mariano edits  the American Society of Regional Anesthesia and Pain Medicine (ASRA) newsletter, and recently co-authored a lead editorial in Anesthesiology on adductor canal blocks for total knee arthroplasty.

John Taylor MD of UCSF, who has a special interest in critical care, took the lead in an intensive 8-hour workshop on ultrasound for cardiac, thoracic, abdominal, and vascular assessment. Co-chairs Patricia Roth MD and Thomas Fernandez, FANZCA, MBChB, also of UCSF, headed the team of faculty members at the 8-hour difficult airway workshop; watch for an upcoming video with highlights of the difficult airway stations.

This year, for the first time, four lectures provided the opportunity for attendees to earn credits toward the ABA Maintenance of Certification in Anesthesiology (MOCA®) Part II Patient Safety requirements. Those lectures were:

  1. Bringing Safety to the OR; Adrian Gelb, MBChB, DA, FRCPC
  2. Current Antithrombotic Guidelines for Regional Anesthesia & Interventional Pain Management; Ramana Naidu MD
  3. Fluid Responsiveness Monitoring: Should this be part of my practice? Danielle Roussel MD
  4. Optimizing Your EMR to Improve Legal, Financial, and Patient Outcome Efforts; David Robinowitz, MD MHS MS.

Other lectures and problem-based learning discussions covered a wide range of topics including critical care, neuroanesthesia, pain, pediatrics, geriatrics, obstetrics, and regional anesthesia.

“The drugs we use are lethal”

One of the highest honors the CSA bestows is that of giving the annual Forrest E. Leffingwell Memorial Lecture. Dr. Leffingwell became the second president of the CSA in 1949, and went on to become ASA President in 1962; he made remarkable contributions toward improving the specialty of anesthesiology and its public image.  This year, the honor went to neuroscientist Adrian Gelb MBChB, DA, FRCPC, professor of anesthesia and perioperative care at UCSF, who has served as chair of the CSA’s Educational Programs Division for the past six years.

Dr. Gelb spoke to the audience Saturday morning on the topic: “Bringing Safety to the OR: Medication Safety.” Many of us don’t realize, Dr. Gelb said, how sophisticated fake drugs may be, and how closely the forged labels resemble genuine ones. While fake drugs are currently more of a problem in Asia, Latin America, and Europe, substandard drugs wreaked devastation in the US recently, as contaminated steroids used in epidural and intra-articular injections infected over 700 people and led to 58 patient deaths.

It’s alarming to consider that 85% of the propofol used in the US comes from foreign sources over which we have little control, Dr. Gelb pointed out. While it would be nice to have a “hard-law” solution such as a multilateral treaty to control drug manufacture, he said, the current political climate is not conducive. Instead, the Institute of Medicine recommends that a “soft-law” solution should be put forward, such as a World Health Organization code of practice to address falsified and substandard drug manufacture and distribution.

We ourselves are not immune from making medication errors, Dr. Gelb told the audience. “Errors can result from failure of a planned action to be completed as intended, or from the use of a wrong plan to achieve an aim,” he said. “They may be errors of commission or omission.” Antibiotics, analgesics, cardiovascular drugs, and electrolytes are the top classes of drugs cited in significant adverse events.

In this era of medication shortages, we may be forced to use drugs we don’t normally use, Dr. Gelb explained, and inexperience may lead to error. So can fatigue, haste, and interruptions. Though it’s hard to pin down exactly how often medication errors occur in anesthesia, estimates range from one in 572 administrations to one in 133. If you anesthetize 700 patients a year, giving 10 drugs per case over a 25-year career, you would give more than 175,000 medications, Dr. Gelb said, estimating that one or two medication errors would likely occur every six weeks.

“The drugs we use are lethal,” Dr. Gelb concluded, though the consequences of drug error are not usually fatal. He advised the audience to beware of human factors such as fatigue and haste, to look up any drug or dose if unsure, and to report and learn from medication errors.

The ACA: “Politics and mistrust remain”

Marc Leib MD JD, the chair of the ASA Committee on Economics, made a special appearance Sunday morning to update the meeting on the impact of the Affordable Care Act (ACA) on the specialty of anesthesiology. “Much of the politics and mistrust remain,” Dr. Leib said, “but some things are clearer due to court rulings.” Dr. Leib, former president of the Arizona Society of Anesthesiologists and the Arizona Medical Association, has served as chief medical officer of the Arizona Health Care Cost Containment System, and has extensive knowledge of payment and healthcare delivery models.

Though the ACA was passed in 2010, Dr. Leib explained, it wasn’t until June 2012 that the individual mandate was ruled constitutional. Implementation didn’t really get under way until 2013 because publication of regulations and standards was intentionally delayed until after the 2012 elections. “Although widespread political differences on the ACA exist,” Dr. Leib said, “little disagreement exists on the initial implementation. It was a disaster!”

“We went from Pearl Harbor to winning a world war in less time than it took to build one website,” Dr. Leib marveled. In spite of the website’s ineptitude, over 8 million individuals are now covered under various exchanges, though some disagree over who these policyholders are, whether they are newly or previously insured, and whether they will pay their premiums and remain enrolled, Dr. Leib said. “Over the next 12 to 18 months, we should know.”

The ACA should decrease uncompensated care, Dr. Leib explained, but at what rates? Exchange plans are commercial plans, but some want to pay Medicaid rates. Anesthesiologists should evaluate whether it is in their best interest to participate in those exchange plans, he advised.

Other provisions of the ACA that could affect anesthesiologists, Dr. Leib said, include:

  1. Accountable care organizations (ACOs)
  2. Bundled payments
  3. Medicaid (MediCal) audits similar to Medicare audits
  4. Increased Office of Inspector General (OIG) investigations of Medicaid
  5. Payment reductions for Provider Preventable Conditions.

The federal government wants to decrease fee-for-service payments for individual services, Dr. Leib said, and anesthesiologists will have to negotiate their portion of bundled payments and any shared savings generated. Nonetheless, he said, fee-for-service payments will continue to dominate for the foreseeable future, though alternative payment models are emerging and will increase in importance.

In the question session after Dr. Leib’s talk, Keith Chamberlin MD MBA, vice chair of the CSA Legislative and Practice Affairs Division (LPAD), pointed out that not all ACOs are like managed care organizations. Some are physician-run and focus on coordinated care. He also emphasized the pitfalls of low physician payment rates both in exchange plans and in the mirror plans that have been set up by California insurers. Dr. Leib agreed that ACOs will succeed best not by always saying “no”, but by delivering the best possible care, keeping patients out of emergency rooms, and preventing readmissions. There may eventually be litigation over mirror plans and restricted networks on antitrust grounds, he said.

Thanks to our exhibitors and sponsors

The CSA’s Educational Program Division is led by Dr. Gelb as chair and Samuel Wald MD MBA as vice chair, with the dedicated staff support of April Becerra, CME and professional development manager.  They report that this educational meeting attracted 21 exhibitors. I-Flow awarded the CSA an unrestricted educational grant to support the meeting. The list of exhibitors includes:

Anesthesia Business Consultants
B Braun
Bell Medical Inc.
Belmont Instrument Corp.
Cooperative of America Physicians
Edwards Lifesciences
GE Healthcare
Grifols US Inc.
ICU Medical Inc.
Medical Protective
Mindray North America
Mylan Inc.
ONE Management Services Co.
PPM Information Solutions Inc.
Qgenda, Inc.
Tahoe Institute for Rural Health Research

Check out the event’s complete photo album on our Facebook page!

The CSA’s next educational meeting is the Fall Anesthesia Conference, to be held Oct. 27-31 at the Fairmont Orchid, on the Kohala Coast of Hawaii. The Winter Anesthesia Conference will take place Jan. 12-16 at the Fairmont Kea Lani in Maui, Hawaii. The 2015 Annual Anesthesia Meeting and Workshops will be held again at the Hyatt Regency Embarcadero in San Francisco, from Apr. 16 to 19.

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