2012 ASA Annual Meeting: A view from, well, the middle…

by
  • Chamberlin, Keith, MD, MBA
| Nov 21, 2012

For those who have never attended, the ASA Annual Meeting is among the largest anesthesia meetings in the world and is filled with a seemingly endless array of educational lectures, panels, sessions, posters and product exhibits spanning more than a couple of football fields.

For those who have attended, you know it is also a chance to renew friendships, truly network and connect, and see how colleagues in the other parts of the country do “it.” There are many regional differences in practice and the meeting gives you an appreciation of how many approaches can resolve a given problem.

In terms of ASA governance, this is the once-a-year meeting where the ASA delegations from each state come together to elect officers and make final binding decisions on issues affecting the specialty. In addition, the work product of the individual committees and their recommendations are made to the ASA’s House of Delegates (HOD) for consideration. These committees also meet at the ASA and commence their work for the upcoming year.  

As a delegate and committee member, virtually all my time was occupied with the governance aspects of this meeting: caucuses, committees and the HOD. There were the California and Western Caucuses, Reference Committees and HOD meetings, as well as the Committee on Practice Management, and trying to find time to fit in some educational sessions. Additionally, the Opening Session, featuring the always entertaining James Carville and Mary Matalin, was not to be missed.

On the more serious side, the theme of this year’s ASA was Transforming Patient Safety Through Education and Advocacy. Let me elaborate on a few key issues discussed throughout the meeting.

There was enormous focus on how to educate patients, hospital administrators, fellow physicians and most importantly our governmental representatives about who we are, what enormous value we have, and how we are truly indispensable to the safe care of the patient and the efficient cost effective operation of a health care facility. Advocacy comes with education: every time a patient or an administrator learns something valuable about our specialty, we get promoted in their minds.

The concept of expanding our roles from admission to discharge (beyond induction to emergence) was emphasized as a crucial change in the way we think of ourselves and portray ourselves to others.  We are true peri-operative physicians, and that is where a large portion of our future lies, so the concept of the surgical home was brought up at virtually every meeting.

One of very clear differences between physician anesthesiologists and nurse anesthetists is that while nurse anesthetists are adept at carrying out a physician’s orders, anesthesiologists are the ones who diagnose, prescribe, analyze and rescue. Additionally, anesthesiologists are qualified and trained to care for the patient from admission to discharge. We, in fact, can become the patient’s peri-operative physician, not limited to just the intra-operative piece, which is all the nurse anesthetist can do.

For the issue of physician supervision of a qualified individual such as a nurse anesthetist or anesthesiologist assistant, there was extensive discussion and effort to define the term “immediately available.” It was finally decided the definition would be:

A medically directing anesthesiologist is immediately available if she/he is in a physical proximity that allows the anesthesiologist to return to re-establish direct contact with the patient to meet their medical needs and address any urgent or emergent clinical problems. These responsibilities may also be met through careful coordination among anesthesiologists of the same group or department.

Differences in the design and size of various facilities, and demands of the particular surgical procedures make it impossible to define a specific time or distance for physical proximity.

Should you practice in a medical direction model, your place of practice should consider the ASA definition of “immediately available” in terms of its own local needs.

On another front, the Federal OIG just released its 2012-2013 work plan; part of it includes looking at personally provided anesthesia.

That is all codes with the “AA” modifier, indicating the anesthesiologist performed the procedure him/herself, no nurse anesthetist, no anesthesia assistant, nobody but the physician. Why the OIG picked this specific modifier is a real mystery. The ASA’s Washington office is making gentle inquiries to understand what this is all about, and we hope to have more information in the near future. We can be certain that everyone in health care, anesthesiology included, is about to undergo more regulatory scrutiny than ever before

Another hot topic that was widely and vehemently discussed both in the Reference Committee and the HOD was the update on the  “STATEMENT ON GRANTING PRIVILEGES TO NONANESTHESIOLOGIST PHYSICIANS FOR PERSONALLY ADMINISTERING OR SUPERVISING DEEP SEDATION.” 

Ultimately, the following was adopted:

Because of the significant risk that patients who receive deep sedation may enter a state of general anesthesia, privileges for deep sedation should be granted only to nonanesthesiologist physicians who are qualified and trained in the administration medical practice of deep sedation and the recognition of and rescue from general anesthesia. 

Nonanesthesiologist physicians may neither delegate nor supervise the administration or monitoring of deep sedation by individuals who are not themselves qualified and trained to administer deep sedation, and the recognition of and rescue from general anesthesia.” 

This statement should provide guidance to anesthesiologists directing anesthesia services at hospitals in shaping deep sedation privileging criteria for non-anesthesiologists at their facilities.

In addition, the topic of whether the ASA should develop and oversee an educational program to train non-anesthesiologists to administer deep sedation was debated, since this issue had been referred back to the Committee on Quality Management and Department Administratation (QMDA) last year. Many in the HOD believe that the ASA MUST offer a rigorous program of education that would be the gold standard. Courses are already in place from ER doctors, family practice doctors, nurses and others – all offering “certification” in all types of conscious (and unconscious) sedation. If anesthesiologists are to be the leaders and recognized experts, it would follow that the Society needs to set the standard, raise the bar and offer the training that is required.

It also became clear that MOCA requirements are going to impact us all, even those with a certificate that is not time limited. Hospitals, insurers, patients and specialty societies are going to require that anesthesiologists prove they are keeping up with the changes in our specialty. I suggest you start planning now. The ASA is exploring ways to make keeping track of MOCA requirements and whether one is on track in the MOCA process simpler for members.

You will be reading about more about these and other issues from the ASA’s meeting over the new few weeks—one of the lessons I learned by attending the ASA Annual Meeting is the importance of being involved. The best way is to join the CSA and ASA and become an active member. As a member, you can also donate to the CSA’s GASPAC and ASAPAC. Having the most respected medical PAC in Washington is a big deal—people actually listen.

Get your colleagues to join—a lot goes on behind the scenes to anticipate trends in legislation and regulation and to ensure that all patients have access to physicians practicing anesthesiology.

The huge amount of work done through the CSA and ASA benefits all anesthesiologists—so all anesthesiologists should be on board, giving their time or money to help. Spread the word: Advocate through education!

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