Leaving Anesthesiology to the Experts

Leaving Anesthesiology to the Experts: 
Urology Practice Finds Outsourcing Anesthesiology to be the Best Option

Like the other three physicians who practice at Northwest Suburban Urology Associates, Geoffery Engel, MD, is extremely confident in his abilities as an urologist. He doesn’t, however, have any desire to become equally versed in anesthesiology.

“I am an urologist and I believe that I know enough and have the equipment to provide my patients with state-of-the-art urology treatment,” Engel says. “But I am not an anesthesiologist. It would be extraordinarily difficult for me to stay on top of all the trends in anesthesiology and do what an anesthesiologist does.”

When Engel entered the field of medicine some 25 years ago, he didn’t even think about trying to learn to do what an anesthesiologist does. He, like all other urologists, performed all of his surgeries in the hospital, where a hospital anesthesiologist provided all anesthesia for patients.

In recent years, however, urologists, like many other specialists, have been performing a growing number of surgical procedures in the outpatient setting. Office-based surgeries have increased approximately 93 percent from 1996 to 2004, according to a 2004 Outpatient Surgery Center Market Report. In 2005, the total number of outpatient surgeries in the United States was expected to hit approximately 40 million, of which 20 million will be performed in the hospital outpatient department and other 20 million will be equally divided between ambulatory surgery centers and physician offices.

Indeed, over the past several years, a number of factors have prompted Northwest — which is based in Elk Grove Village, Ill. and has three other outpatient offices in the Chicago area — to jump on the outpatient bandwagon. For instance, more patients are requesting outpatient surgeries because the environment is more convenient and less intimidating. In addition, insurers have been pushing healthcare providers to offer more surgeries in the outpatient setting, in an effort to reduce costs. With the pressure to move more procedures to the office, Northwest has been performing a wide variety of surgeries such as cystoscopies, transurethral needle ablation of the prostate (TUNA) and vasectomies on an outpatient basis.

What’s more, urologists are no longer just performing the relatively simply procedures that require local anesthetics but now are performing more complex surgeries that require general anesthesia in the office setting.

“We are doing many procedures that would be too difficult or time-consuming to perform with just a local anesthetic. In addition, some of the patients are just too nervous to have their procedures performed with a local anesthetic. They need general anesthesia,” Engel says As a result, a Pandora’s Box has been opened. Now, instead of simply showing up for surgery and having a hospital-based anesthesiologist assigned to the case, surgeons have to think about how they can best provide anesthesiology services while performing surgeries in the outpatient setting. “We are now doing more procedures in the outpatient setting than we are doing in the hospital.

As a result, we frequently need to put patients under general anesthesia to provide the best care. And, we have to find the best way to do that,” Engel says.

The challenge for Northwest, and many other surgical practices across the country, has been to find a cost-effective way to offer state-of-the-art anesthesiology services while providing the optimal surgical experience to patients. When considering their options, the doctors quickly realized that they could not perform surgeries that require general anesthesiology without having a dedicated healthcare professional taking charge of the anesthesiology administration.

“Someone has to mind the other end of the store so, as surgeons, we can concentrate on what we do best and not have to split our attention and worry about whether the patient’s consciousness is appropriate,” Engel says.

One option that the doctors considered was hiring a certified registered nurse anesthetist (CRNA) to provide anesthesia during surgeries. While the doctors thought that CRNAs certainly have the skill to handle anesthesia administration, the surgeon would still have to supervise the nurse — and take responsibility for the anesthesia. As a matter of fact, a recent Illinois appellate court decision stipulates that surgeons must supervise CRNAs during all surgeries.

“The concern we had with using a nurse, however, would be that the surgeon would still be responsible and liable for what happened with respect to anesthesia during the surgery,” Engel says.

As such, the doctors would have to stay on top of anesthesiology standards, best practices and technology. And, adding these tasks to their already full agendas was simply something that the Northwest doctors didn’t have the time to do, Engel says.

So, the doctors decided to search for another option. Serendipitously, Engel discovered a viable alternative when he personally had a colonoscopy performed in the outpatient setting. When he arrived at the gastroenterologist’s office, he was told that a team from Mobile Anesthesiologists, an office-based anesthesiology practice headquartered in Chicago, would be handling the anesthesiology.

“I actually found it comforting to know that an anesthesiologist would be there, knowing that the gastrointestinal surgeon would be busy performing the surgery,” Engel says.

Satisfied with this outpatient anesthesiology experience, Engel decided to learn more about the possibility of tapping into providing anesthesiology via an outsourced anesthesiology practice for Northwest. When he investigated the alternative, he discovered that the service would work like this: When Northwest has surgeries scheduled, the anesthesiology practice would then dispatch an anesthesiologist and nurse to the Northwest office. The Mobile team would bring along everything needed to safely anesthetize and recover the patients in the office setting including drugs, supplies and emergency equipment.

The anesthesiologist and nurse would handle all of the anesthesia related matters from preoperative preparation of the patient to post-operative follow-up. As such, the urologists could focus exclusively on the surgery itself.

What’s more, the anesthesiologists are skilled in administering all types of anesthesia including general, regional and IV sedation. And, because the anesthesiologists are trained specifically in outpatient anesthesiology, they know how to handle emergency situations in the isolated outpatient environment. As a matter of fact, Mobile Anesthesiologists is the only anesthesiology provider in the Midwest that is accredited by the Accreditation Association for Ambulatory Health Care (AAAHC).

Because the service seemed to offer everything that Northwest was looking for — that is, an anesthesiology alternative that makes it possible for the urologists to concentrate solely on surgeries just as if they were performing them in a hospital — Northwest decided to team up with Mobile in February 2003.

Outsourcing the entire anesthesiology function to Mobile has turned out to be the right alternative for Northwest. Since teaming up with the anesthesiology group, the urology practice has realized a number of benefits such as enhanced clinical quality. With an anesthesiologist present during surgery, the urologists can concentrate on the actual surgical procedures.

“As surgeons, we can concentrate on what we do best — and not have to split our attention.

We don’t have to worry about whether or not the level of the patient’s consciousness is appropriate because we have a qualified, skilled anesthesiologist doing that,” Engel says.

“I know that an anesthesiologist can do it better than I can in terms of the mechanics of working with a patient and getting the optimum amount of anesthesia at all times,” Engel adds. “I — or any urologist — would have a very difficult time doing what they do well.”

Another benefit is more comprehensive outpatient surgical offerings. With Mobile Anesthesiologists as a partner, Northwest is comfortable offering a wide range of surgeries in the office setting. Without an anesthesiologist in the office, however, the urologists might still schedule some difficult surgeries — or apprehensive patients — in the hospital.

A third benefit is increased safety and reduced liability. Patients are dying of anesthesiology complications in office-based settings. In addition, malpractice claims related to office-based anesthesiology are on the rise, according to the American Society of Anesthesiologists Closed Claims Project. Ambulatory anesthesia claims represented 20 percent of all anesthesia claims from 1985 to 1989, 26 percent from 1990 to 1995, and 33 percent from 1996 to 2001.

Because the anesthesiologist is handling all pre- and post-operative anesthesiology matters, the urologists can more efficiently complete their surgeries. In addition, because the anesthesiologists are highly skilled, they are able to quickly provide an optimal amount of anesthesia to patients, making it possible for the urologists to perform surgeries with minimal disruptions from sub-optimally anesthetized patients. Groups typically are able to schedule as much as 40 to 50 percent more surgeries per day due to the fact that the anesthesiologists are able to use the most effective drugs and methods to quickly and effectively anesthetize and recover patients.

Outsourcing also provides improved access to technology. Anesthesia requires specialized equipment. Purchasing and staying on top of the latest equipment trends would, of course, be onerous from a time and money perspective for the urologists.

“The anesthesiology team brings a whole truckload of technology and equipment with them. I am confident that they are using the state of the art technology and don’t have to worry about it at all,” Engel says.