Med Mal Confidential # 01 - Beware the Swiss Cheese Model of Anesthesia Staffing Ratios

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They help plaintiff and defense attorneys like yourself establish standard of care compliance and/or breaches in anesthesiology medical malpractice proceedings.

Contact them for assistance with any pending or ongoing litigation needs.

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Hey 👋- David here!

Happy April Fool’s Day to you and the other 6,640 insiders reading this.

Here’s what we’ll be uncovering in this first edition of MedMal Confidential …

Today’s ‘Insider Information’ At-A-Glance

Read Time : 3.6 minutes

🧠Musings: Why US Anesthesia Care is Suffering

💡Insight: The Finances Driving Anesthesiology Coverage Models

📰News: Baylor + USAP $21M Suit

⚖Litigation: 1 Person. 1 Place. 1 Time. 1 Thing.

Read on for your insider info …

🧠Musings: Why US Anesthesia Care is Suffering

What happens when you combine an aging population, an increasing volume of surgery, and an increase in locations needing staffing?

Shortages. 

And if that weren’t enough, 55% of Anesthesiologists are 50 years of age and older (according to the ASA Anesthesia Almanac).

Shortages, meet scarcity.

“There is a projected shortage of anesthesia care professionals in the next three to five years, and a third of the physician anesthesiologist workforce is older than 60,” said Lauren Nahouraii, M.D., an anesthesiology resident physician at the University of Pittsburgh Medical Center.

The combination of fewer anesthesiologists in the workforce and increases in surgical volume, if left unchecked, will result in less physician oversight of surgeries and procedures, and worsened patient outcomes.

Insider Information

• If we want to improve patient outcomes and ensure everyone gets the care they deserve, it’s important that we address this shortage.

• One way could be expanding CMS funding for additional residency positions. It won’t solve the immediate numbers crunch … but future patients will benefit.

💡Insight: The Finances Driving Anesthesiology Coverage Models

There are multiple anesthesia staffing models.

Currently, reimbursement is the primary driver of staffing implementation.

But herein lies the issue:

Medical Direction and Medical Supervision are NOT the same thing.

With Medical Direction, you have a maximum ratio of 1 anesthesiologist to 4 CRNAs (or AAs).

And that anesthesiologist must perform and document the following 7 activites:

1) Perform a pre-anesthetic examination and evaluation
2) Prescribe the anesthesia plan
3) Personally participate in the most demanding procedures in the anesthesia including induction and emergence, if applicable
4) Ensure that any procedures in the anesthesia plan that they do not perform are performed by a qualified anesthetist
5) Monitor the course of the anesthesia administration at frequent intervals
6) Remain physically present and available for immediate diagnosis and treatment of emergencies
7) Provide indicated post-anesthesia care

With Medical Supervision, you have 1 anesthesiologist supervising up to and more than 4 concurrent anesthesia procedures.

And what constitutes supervision is also very loosely defined.

But what’s the upper limit here? For most models, it is simply not known.

Is it 1-to-6?
1-to-10?
1-to-an-entire hospital?

The fulfillment of medical direction requirements can be very onerous depending on the practice model and work circumstances.

And while anesthesiology jobs with a 1-to-10 ratio of an anesthesiologist to CRNAs are being advertised, the uptake, unsurprisingly, is proving low.

Insider Information

• There’s an ongoing trend of increasing the number of sites 1 anesthesiologist is supervising.

• Spreading anesthesiologists too thin has been shown to result in worse patient outcomes.

📰News: Baylor + USAP $21M Suit

Link: https://www.wfaa.com/article/news/local/investigates/dallas-jury-awards-21m-to-patient-who-suffered-brain-injury/287-9f1c5fab-fb69-40c4-bc64-17b5f59a789a

Catastrophic outcome.

“The jury sent a message to US Anesthesia Partners and their doctors that allowing one anesthesiologist to supervise multiple CRNAs at the same time may be good for business but it’s not good for the safety of patients,” said Bruce Steckler, one of the family’s attorneys. “The consequences can be tragic.”

“It is very hard for an anesthesiologist to supervise four CRNAs at same time,” added attorney Walker.

Insider Information

• This lawsuit made special mention of staffing ratios in assigning responsibility for an adverse outcome.

• Since 1 anesthesiologist to 4 CRNAs is a baseline staffing ratio for medical supervision, this verdict should give pause and put on notice practice models that are considering increases to that ratio.

⚖Litigation: 1 Person. 1 Place. 1 Time. 1 Thing.

I’m not normally one to belabor the obvious, but in my line of work, I often have no choice.

Case in point…

An anesthesiologist is one person.

Meaning they can only be present in one place, at any one time, doing one thing.

Hence, adverse outcomes that happen under medical direction and/or medical supervision do NOT automatically fall squarely on the anesthesiologist of record.

There are several questions to be asked in situations like these:

1. What sites was the anesthesiologist covering?

2. How far apart were these sites?

3. When were they notified of the perioperative event in question?

4. How many anesthetics was the anesthesiologist covering?

5. What backup systems exist for simultaneous emergencies?

6. Was the anesthesiologist notified of the perioperative event?

7. What interventions were taken while awaiting their arrival?

It’s also important to remember this: anesthesiologists and CRNAs are bound by the same standard of care.

Should the anesthesiologist not be present, it is the job of the CRNA to act in their stead.

These are the facts you must remember when the finger-pointing starts…

One person.
One place.
One time.
One thing.

Insider Information

• When evaluating cases for merit, laser in on who specifically was present, versus who all was listed on the chart.

• Employers share in the blame if coverage models were unreasonable or could not be performed safely.

In the next issue of MedMal Confidential …

• Where surgery happens without anesthesiologist involvement: the dreaded ‘Opt-Out States’

• Why Advanced Cardiac Life Support (ACLS) is often done wrong

• How insurance companies are waging war on CRNA reimbursement

• Introducing: The MedMal Confidential VIP experts