Patient Safety

Are These Healthcare Decisions Reasonable or Do They put Patients At-Risk?

Articles we have been reading this past week of February 19, 2018 made us ask ourselves whether recent healthcare decisions are reasonable. What do you think?

Why do patient monitoring guidelines of the American Society for Gastrointestinal Endoscopy differ from those of the American Society of Anesthesiologists?

The American Society for Gastrointestinal Endoscopy (ASGE) recently released new guidelines on sedation and anesthesia in GI endoscopic procedures, such as the commonly performed colonoscopy. As the Healio reports, the new ASGE guidelines mirror those from ASA. However, the ASGE guidelines “notably differ on the use of capnography for patient monitoring during endoscopic procedures with moderate sedation” from those of the ASA:

Regarding patient monitoring during procedures, the guideline recommends the use of pulse oximetry during all sedated endoscopic procedures. Further, the ASGE departs from the ASA on the use of capnography.

“In contrast to ASA recommendations regarding capnography, ASGE states, ‘integrating capnography into patient monitoring protocols for endoscopic procedures with moderate sedation has not been shown to improve patient safety: however, there is evidence to support its use in procedures targeting deep sedation,’” Saltzman said. “The ASGE ‘suggest(s) that capnography monitoring be considered for complex endoscopic procedures or patients with multiple medical comorbidities, or at risk for airway compromise.’ This is a pragmatic data-based recommendation of the ASGE.”

A recent consensus statement from the ASA and other leading medical organizations – American Association of Oral and Maxillofacial Surgeons, the American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology – recommend continual monitoring of ventilatory function with capnography to supplement standard monitoring by observation and pulse oximetry (more on this in another post).

However the ASGE guidelines disagree and go against the strong consensus recommendations of the ASA and the other leading medical organizations. Why?

Why do patient monitoring guidelines of the American Society for Gastrointestinal Endoscopy differ from those of the American Society of Anesthesiologists? Click To Tweet
Are tonsillectomy patients spending too much time in hospital?

According to the Register-Herald, a WVU researcher suggests hospital time for tonsillectomy patients is unnecessary:

“Our nursing staff always felt that some children could be discharged way before the six-hour arbitrary, mandatory timeframe based on how the kids were doing,” said Hassan Ramadan, a member of Zalzal’s research team and chair of the Department of Otolaryngology, Head and Neck Surgery. “After checking with half a dozen children’s hospitals in our region, none of them had any validated criteria.”

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When we read this article, we immediately thought of Logan, who died of opioid-induced respiratory depression, shortly after being discharged home  His mother Pamela Parker, who is a nurse, recommends that patients should only be discharged after a sufficient period has passed to ensure that the patient will not suffer from OIRD. Her Lesson 5 of “Six Nursing Lessons: Nurse and Mother Reflects on the Untimely Death of Her Teenage Son” states:

Lesson #5 – All Patients Should be Monitored for an Extended Period in an Unstimulated Environment Prior to Discharge

To listen to our interview with Ms. Parker on Logan and her 6 nursing lessons, please click on the image below:

Click on the image to listen to an interview with his mother, Pamela Parker

Click on the image to listen to an interview with his mother, Pamela Parker

Although no one wants to spend more time than one has to in a hospital, for the safety of patients, should they remain in hospital for the 6 hours before being discharged?

All Patients Should be Monitored for an Extended Period in an Unstimulated Environment Prior to Discharge Click To Tweet
Should The Clinician Performing the Medical Procedure Also Monitor the Sedated Patient?

NPR reports that the health insurer Anthem recently released a clinical guideline saying that

“it’s not medically necessary to have an anesthesiologist or nurse anesthetist on hand to administer and monitor sedation in most cases.” Anthem justified its decision in a statement:

“Anthem’s Medical Policy and Technology Assessment Committee, a majority of whom are external physicians, reviewed the available evidence addressing the use of general anesthesia and monitored anesthesia care for cataract surgery. According to the literature reviewed, there is no one definitive approach regarding the use of anesthesia for cataract surgery and patient-specific needs should be taken into consideration as well as potential risk of harm to individuals who are sedated during surgical procedures.”

Should The Clinician Performing the Medical Procedure Also Monitor the Sedated Patient? Click To Tweet

Dr. David Aizuss, an eye surgeon who is president-elect of the California Medical Association, thinks that the Anthem decision puts patients at-risk:

“I wouldn’t even consider doing a cataract surgery without an anesthesiologist or nurse anesthetist in the room,” says. “If you’re working inside the eye it’s a very confined space, and if the patient gets agitated and starts moving around you have to get the equipment out of the eye very quickly.”

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