Fall 2017


Vol. 1, No. 3


Patient Selection in the ASC: An Ever-Changing Process


By Stanford R. Plavin, MD


As a practicing anesthesiologist with more than 20 years of clinical experience providing care in ASCs, I have noticed a dramatic change


in the patient selection process. There still seems to be a wide range of what clinicians and administrators feel is an appropriate candidate for their facilities. As patient care technologies have improved and physiologic monitoring capabilities have followed suit, we find ourselves more willing to provide care to those patients who, only a few short years ago, may not have been a suitable ASC patient.


The patient selection process should be viewed with a methodology and process that provides a comprehensive holistic approach. Factors that influence our decisions are many. These include the skill sets of the providers, the facility itself, the types of procedures, the anesthetic techniques being performed and, most importantly, the patient’s physical health issues and characteristics.


Focus on BMI and the Obese When an administrator, medical director, surgeons, staff and anesthesiologists evaluate suitability and criteria for appropriate candidates for their facility, one of the more challenging decisions is whether to provide a limit based upon a patient’s body mass index (BMI). There are a number of factors to consider when working through this process as it specifically relates to BMI.


The prevalence of obesity continues to increase worldwide. Morbid obesity poses many challenges in providing safe and appropriate care. These include


technical challenges for procedures, those impacting health care personnel and medical issues that go along with this patient population.


When we assess or measure weight, we typically think of BMI as clinicians. BMI traditionally correlates with body fat but this isn’t always the case. An increase in BMI has been shown to be a predictor of other health-related issues such as type 2 diabetes, hypertension, stroke, obstructive sleep apnea (OSA), depression, arthritis and mobility issues. The National Institutes of Health classify obesity as a BMI greater than 30. Class I obesity is a BMI of 30-34.9 kg/m2; Class II morbid obesity is a BMI of 35-39.9 kg/ m2; Class III extreme obesity is a BMI of greater than 40kg/m2; BMIs greater than 50kg/m2 are considered super morbid obesity.


In order to properly care for patients with excessive BMIs, facilities must possess necessary infrastructure and proper equipment. There is an inherent cost to provide these services, which include technical items such as larger stretchers and chairs, positioning devices and, in some cases, specific lift devices. These are typically fixed costs to the facility. Disposable costs include airway equipment, positioning items, larger gowns and blood pressure cuffs as well as higher uses of IV access materials due to technical challenges. Along with the challenges of providing this care are the risks to the staff who must be prepared and trained accordingly.


Appropriateness for the ASC There is evidence showing that BMI alone is not an independent risk factor for perioperative complications. The majority of the patients in these studies (e.g., study on knee arthroscopy) had mild to moderate obesity with


Results of a new study published in The Journal of Arthroplasty indicate that select Medicare patients who undergo total knee arthroplasty (TKA) can be safely discharged within a day of their procedure.


4 ASC PHYSICIAN FOCUS


The researchers examined data on nearly 2,300 hospital Medicare patients who underwent unilateral, primary TKAs. About 1,500 were discharged within a day of surgery. The remaining were discharged on day two or later. Shorter-stay patients did not experience


BMIs less than 40 kg/m2 and minimal comorbidities. There are studies (e.g., study on total hip arthroplasty) suggesting that super obesity (BMI > 50 kg/m2) may be associated with higher risk of postoperative complications, particularly those with comorbidities such as OSA and other cardiopulmonary sequelae.


Assigning an absolute to any situation is often challenging. In the absence of specific, high-quality evidence, decisions regarding the appropriateness of obese patients tend to be guided by what is available for review. In addition to the patient’s characteristics, weigh several factors such as surgical competence, anesthetic technique and invasiveness of the surgery when deciding whether to provide care in the ASC setting.


Data has shown that patients with BMIs less than 40 kg/m2 and limited comorbidities appear to be safe and appropriate candidates for outpatient surgeries. The super obese (BMI >50 kg/m2) may be at a higher risk of perioperative complications and should be carefully evaluated when considering them for ambulatory surgical procedures. For those patients who fall in between (BMI 40-50 kg/ m2), perform an extremely thorough preoperative assessment to assess the suitability for their care as ambulatory surgery candidates.


Stanford R. Plavin, MD, is an anesthesiologist, owner of Technical Anesthesia Strategies and Solutions and ASCA board member. Contact Dr. Plavin at splavin@technicalanesthesia.com.


The advice and opinions expressed in this column are those of the author and do not represent official Ambulatory Surgery Center Association policy or opinion.


Study: Faster Discharge of Medicare TKA Patients Safe


a higher 30-day readmission rate compared to the longer/traditional-stay patients. They also did not experience a higher rate of unplanned, 90-day readmissions.


Access the study’s abstract here.


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