MedMal Confidential # 02 - Caution: Anesthesia 'Opt-Outs' and Shocked Dentists

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Hey 👋- David here!

Happy April 17th to you and the other 6,571 insiders reading this.

Here’s what we’ll be uncovering in the second edition of MedMal Confidential …

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

Read Time: 3.1 minutes

🧠Musings: State-by-State Anesthesia ‘Opt-Outs’

💡Insight: ACLS Algorithms Gone Wild

📰News: Cigna Lowers non-Medically Directed Reimbursement

⚖Litigation: CRNA Supervision by the Dentist!?

Read on for your insider info …

🧠Musings: State-by-State Anesthesia ‘Opt-Outs’

Have you ever wondered?

Who is providing the anesthesia care?

• Anesthesiologist

• Certified Registered Nurse Anesthetist (CRNA)

• Certified Anesthesiologist Assistant (CAA)

• Registered Nurse (moderate sedation only)

Who is supervising the anesthesia care?

• Anesthesiologist

• Surgeon

• Proceduralist (GI doc, Dentist, Pulmonologist, etc.)

Answer: It depends on the state.

But, what does the state have to do with this?

But, can the supervision of anesthesia care be that different?

Answer: CMS Conditions of Participation - 2001

In 2001, the Center for Medicaid and Medicare Services (CMS) adopted the conditions of participation rule.

In non opt-out states, physician supervision of nurse anesthetists is mandatory.

In opt-out states, physician supervision of nurse anesthetists is not mandatory.

Insider Information

• In 22/50 States, there is no state-required physician supervision of nurse anesthetists

• In non opt-out states (28/50), the person supervising nurse anesthetists may be an anesthesiologist … or any other physician, depending on local bylaws

• Ever wonder how much help a supervising podiatrist or dentist can provide a nurse anesthetist in a patient who just aspirated, is blue, and has chunks of turkey club dribbling down their chin?

  • Honest Answer: Not Much

  • Legal Answer: They are the “supervising physician” of record and thus share the responsibility with the nurse anesthetist

💡Insight: ACLS Algorithms Gone Wild

Advanced Cardiac Life Support is administered during cardiac arrest

There are two pathways:

1. Shockable

   a) Ventricular Fibrillation

   b) Pulseless Ventricular Tachycardia

2. Non-Shockable

   a) Pulseless Electrical Activity

   b) Asystole

ACLS is supposed to be renewed every 2 years

ACLS is supposed to be practiced and simulated

ACLS is supposed to be executed effectively as a team

But herein lies the issue:

It usually is not

… and poorly administered ACLS decreases the chances of a patient surviving the cardiac arrest

Having analyzed dozens of code blue - cardiac arrest records …

Deviations from the standard of care are seemingly endless:

1. Discrepancy in documentation

2. Delivering a shock during an asystole arrest

3. Deferring calling 911 for out-of-hospital arrest

4. Bolusing 300mg Amiodarone mid Asystole arrest

5. Randomly giving tissue plasminogen activator (TPA)

6. Not drawing an arterial blood gas during a PEA arrest

7. Administering bicarb, Calcium, and Magnesium just because

8. Administering 500mcg Epinephrine instead of 1000mcg (1mg)

9. Delaying Epinephrine administration beyond every 3-5 minutes

10. Failing to obtain automatic external defibrillator (AED) in timely fashion

Insider Information

• ACLS algorithms are evidence-based and laser-focused

• Deviations from the standard of care ACLS execution reduces the chances of a patient surviving the cardiac arrest and constitutes a “lost chance of a better outcome”

• ACLS certification of staff and the simulation, planning, equipment, availability, and execution may expose the site of the arrest to culpability

📰News: Cigna to lower reimbursements for certain CRNA procedures

Reimbursement of medicine dictates the staffing of medicine

Cigna is one of the 5 largest health insurers in the United States.

As of March 12, 2023, Cigna will reduce the reimbursement for non-medically directed CRNA-administered anesthesia care by 15%.

As you may recall from Med Mal Confidential Issue #01 - Beware the Swiss Cheese Model of Anesthesia Staffing Ratios:

• 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).

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

Well, Cigna just handed Medical Supervision a 15% pay cut

Insider Information

• A major insurer took the position that less Anesthesiologist involvement should result in lower reimbursement, thus encouraging conforming to an Anesthesiologist to CRNA staffing ratio of ≤ 1:4

• Other major insurers are likely to follow suit, providing a strong financial incentive to reduce the runaway 1:6, 1:8, or even 1:10 staffing ratios that have been floated around

⚖Litigation: CRNA Supervision by the Dentist!?

An anesthesiologist goes to medical school

A certified registered nurse anesthetist goes to nursing school

A dentist goes to dental school

All 3 are experts in their end craft

Consider the following …

Clinical Scenario:

• The Date: April 17th, 2023

• The Patient: Healthy 40-year-old male

• The State: Delaware

• The Surgery: Dental implants under general anesthesia

• The Event: Esophageal intubation + Failure to recognize + Delay in intervention + Hypoxic brain injury = Brain Death

Scenario 1

Anesthesiologist + Dentist pairing → Botched Airway

Event responsibility = Anesthesiologist

Scenario 2

CRNA + Dentist pairing → Botched Airway

Event responsibility = CRNA + Dentist

Wait, what? Why the dentist?

Explanation:

• Legally, the dentist is the supervising physician for the CRNA and thus bears responsibility for anesthesia-related outcomes.

• Alternatively, the dentist does not bear responsibility for anesthesia-related outcomes if an anesthesiologist is involved.

Insider Information

• Institutions, surgeons, and proceduralists often utilize CRNAs as opposed to anesthesiologists to reduce expenses

• In non opt-out states, surgeons and proceduralists are often unknowingly the legally supervising physicians, thus exposing them to culpability should a bad outcome occur

  • The supervising surgeons and proceduralists commonly do not know that they are the supervisor of record for CRNAs until a medical malpractice lawsuit is filed following an anesthesia adverse outcome

In the next issue of MedMal Confidential …

• The Continuum of Depth of Sedation

• Blood pressure limbo - “How low can you go?”

• Procedural sedation & the awake colonoscopy