Patient Monitoring, Patient Safety

Outpatient Centers vs. Hospitals: Lessons Learned from the Death of Joan Rivers

The headline of a recent Washington Post article reads “Joan Rivers’s death spurs new look at outpatient centers”.

Although ABC News reports that the outpatient center that treated Joan Rivers is losing both Medicare certification and accreditation from the American Association for Accreditation of Ambulatory Surgery Facilities (AAASF), Kenneth P. Rothfield, MD, MBA, CPE, CPPS (System Vice President, Chief Medical Officer, Saint Vincent’s Healthcare, Ascension Health) points out that the question is not whether outpatient centers are better or worse than hospitals, but whether the facility is properly equipped and personnel adequately trained:

I don’t think it’s the venue that’s the most important thing,” said Rothfield, a member of the board [of advisors] of the Physician-Patient Alliance for Health & Safety, a nonprofit group. “ASCs [ambulatory surgery centers] traditionally have done simpler procedures in healthy patients,” while hospitals have routinely dealt with a broader and sicker — mix of people. Hospitals, he said, are more likely to be fully equipped and to have staff members with greater experience handling emergencies. “Unless you have drilled for it, and trained for it, it can be hard to pull off.

In addition, the medical standards of care upheld by healthcare facilities may differ. Although hospitals typically seek accreditation from The Joint Commission, ambulatory centers can receive accreditation from a variety of organizations. For example, the AAASF accredits ambulatory surgery facilities like the one where Joan Rivers underwent her medical procedure.

How might these standards specifically differ?

In the article “Medical standards of care and the Joan Rivers death,” differing standards of monitoring patients receiving opioids are discussed:

What is instructive in terms of gained knowledge in the Joan Rivers’ death are the differing patient safety measures in place by the application of standards when a sedative is delivered to the patient.

The AAAASF standard would have monitored for oxygenation by pulse oximeter, which measures the amount of oxygen in blood. Measuring oxygenation provides a very late indicator of hypoventilation, or ineffective breathing. In other words, there would have been a delay in the detection of low blood oxygenation by pulse oximeter.

The ASA [American Society of Anesthesiologists] standards provide an extra level of patient safety by requiring that the adequacy of ventilation be monitored in addition to oxygenation. The ASA standards therefore call for the “continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide”.

Even in hospitals, however, multiple standards of care may exist. Although anesthesiologists, the recognized experts in providing safe sedation, are required to monitor adequacy of breathing by measuring exhaled carbon dioxide, non-anesthesiologists such as gastroenterologists, surgeons, and radiologists are not required to provide this extra measure of safety. For example, American Society for Gastrointestinal Endoscopy “Guidelines for safety in the gastrointestinal endoscopy unit” does not require monitoring for adequacy of ventilation by Capnography, as required by the ASA.

So, how can patients decide on which healthcare facility to undergo a surgical procedure?

The Physician-Patient Alliance for Health & Safety offers four simple points to keep in mind:

  1. Even “minor” procedures can have major risks and hidden harm

The ASA reminds us that although “anesthesia is safer than ever before, every person scheduled for a procedure or surgery must have a serious conversation with their physician anesthesiologist about their anesthesia care delivery plan ahead of time … Even ‘minor procedures’ are not risk-free.”

  1. Ask questions to fully understand the medical procedure you are to undergo

Physicians must communicate and patients need to fully understand the full nature of the medical procedure. It is often helpful to have a family member, friend or significant other with you to check if you asked all your questions and another set of “ears” to listen to what is being told or explained to you.

U.S. Department of Health and Human Services’ (HHS) Agency for Healthcare Research and Quality (AHRQ) believe “clinicians and patients [need] to engage in effective two-way communication to ensure safer care and better health outcomes.”

This type of patient engagement and education should be told to the patient, and then to ensure an adequate level of understanding the clinician should ask for verbal or written feedback from the patient..This validates the patient’s understanding and is termed ”readback feedback”.

AHRQ encourages patients to ask their medical providers questions, as illustrated in this humorous video which shows how patients ask many questions everywhere (such as in a restaurant) but not in the doctor’s office (please click on the image to view the video):

AHRQ Restaurant Ad

AHRQ Restaurant Ad

  1. Make sure you are monitored electronically, with both pulse oximetry and capnography, if you are to receive sedation, opioids or anesthesia

Even “routine” procedures may entail the use of a sedative, opioids, or anesthesia, additionally there maybe use of a combination of more than one of these medications. The endoscopic procedure performed on Ms. Rivers, which would have likely involved insertion of a large scope into her mouth, is a simple and common procedure, but, as noted by Dr. Karen Siebert, “uncomfortable enough that most patients are given sedation or, less commonly, general anesthesia.” The type of sedation given can be Monitored Anesthesia Care (MAC) or I.V. Conscious sedation.

The Anesthesia Patient Safety Foundation (APSF) believes that clinically significant drug-induced respiratory depression in the postoperative period remains a serious patient safety risk that continues to be associated with significant morbidity and mortality.

Continually evaluating and monitoring respiratory and circulatory status prior to, during, and following the procedure is essential. As a recent video released by the APSF demonstrates continuous electronic monitoring of oxygenation (the adequacy of oxygen in the blood) with pulse oximetry and ventilation (adequacy of breathing) with capnography, These combined with traditional in-depth nursing assessment and vigilance, will greatly decrease the likelihood of unrecognized, life threatening, opioid induced respiratory impairment and distress.

Virtually all proceduralists use pulse oximetry to measure blood oxygen levels as a standard of practice. Assessing ventilation is another issue. The ability to tell by simple observation if a patient is breathing adequately or not during a procedure can be tricky. Surprisingly, standards for capnography monitoring are not the same for all medical specialists.

Anesthesiologists are required by the ASA to measure the adequacy of ventilation using capnography (a device which measures exhaled carbon dioxide) to provide breath-by-breath monitoring. Other specialists, such as gastroenterologists and dentists, are not required to use this technology. Without capnography, several critical minutes can elapse after a patient stops breathing before medical professionals are alerted to the situation. Unfortunately, by this time, a serious problem or even a cardiac arrest may occur.

  1. Equipment and resources at an outpatient clinic may be different than at a hospital

If your procedure is scheduled at an outpatient clinic be sure to ask about available emergency equipment at the clinic. Just because your procedure is scheduled in an outpatient type of clinic, do not take this lightly and ask about code cart availability, emergency drugs to manage your condition and any adverse events, and lastly trained clinicians available and knowledgeable about handling potential life threatening emergencies.

As Dr. Rothfield cautions, the venue does not necessarily dictate better patient safety and health outcomes. Ensuring that the facility is properly equipped, its personnel adequately trained and whether its patients receiving opioids are continuously monitored – these are some key questions.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s