Measure Twice, Inject Once

Variations in clinical practices often are blamed for dramatic variations in clinical outcomes and even more dramatic variations in the cost and price for healthcare services. We at Anesthesia Concepts,  a division of NorthStar Anesthesia, agree with that opinion and are doing something about it.

We provide anesthesia services at nine sites in Maryland and Virginia—seven ambulatory surgery centers, one hospital and one dental practice. We staff the nine sites with 17 full-time anesthesiologists, 30 full-time certified registered nurse anesthetists and a number of part-time anesthesiologists and CRNAs.

We have been working diligently with staff at our sites to standardize anesthesia services, measure the results and adjust as necessary to produce consistent positive clinical results at the lowest possible cost. We know that inconsistency in the delivery of anesthesia services is one of the root causes of inconsistent clinical and financial outcomes.

One big area of variation affecting clinical and financial results is when patients go home after surgery. That can be measured by length of stay in days for an inpatient procedure or measured in hours for an outpatient procedure. Two of the biggest determinants of length of stay after a surgical procedure are pain and nausea. They affect mobility, and mobility affects recovery time.

All too often, the type and amount of anesthesia given to a patient before and during surgery varies by anesthesiologist or CRNA. What each anesthesiologist or CRNA does is a reflection of how they were taught and trained—by different people at different sites at different times in different parts of the country or even different parts of the world. For example, some give short-acting pain medication upfront, which means patients need more pain medication during recovery and that leads to more nausea, less mobility and a delayed discharge until the anti-nausea medication takes effect. Others will give different amounts with different recovery results. It all depends. And we’ve accepted the inconsistency in practice and the inconsistency of the results as the status quo. That’s just how it is, and we’ve tolerated it.

We take the opposite approach. We believe that’s not the way medicine should be practiced. So what we’ve done is to develop a standardized “cocktail” of anesthesia and pain medications that we administer to patients prior to surgery. Patients at risk for nausea also get a standardized anti-nausea medication.  We measure and track how long patients are under, their level of pain after surgery and their nausea rates in recovery. We know the exact proportions of the cocktail that will produce the results we want. And what we want is for patients to come out of their anesthesia at the right time and in as little pain as possible to avoid additional pain medication that causes nausea and leads to the need for anti-nausea medication. They’re mobile, go home on time and can get some food in them before they need more pain relief.

And because we’re always measuring and tracking our results, we know that when there’s a variation in the outcomes it was because someone didn’t follow the proper anesthesia services protocols. Then we address that with the individual clinician. We know that when doctors and nurses are in the trenches, they’re not always going to follow evidenced-based protocols because no one is watching.

We’re successful because we hire the right people and manage them the right way using standardized, evidenced-based medicine and are continually measuring our results.