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How dangerous is your anesthesia practice? What degree of risk and unpredictability exists for your patient outcomes? Some practices are predominantly full of safe, simple predictable anesthesia cases. I have colleagues whose practice is over 80% administering propofol for elective colonoscopies. Their patients are generally healthy and there are no emergency cases. These anesthesiologists rarely lose sleep over risks regarding the next day’s surgery, or whether their anesthesia work will result in a complication, a lawsuit, or a mortality. In contrast, some hospital-based anesthesia practices involve frequent emergency cases: trauma; emergency cardiac or neurosurgical procedures; and 24/7 coverage of busy obstetrical services.
RISK FACTORS FOR HIGHER MORTALITY
What factors make for a more dangerous anesthesia practice? A 2015 study in Anesthesiology analyzed 2,866,141 cases and 944 deaths (a crude mortality rate of 33 per 100,000). The independent risk factors for higher mortality were: emergency case status; surgical cases beginning between 4 p.m. and 6:59 a.m.; a patient age less than one year or greater than or equal to 65 years; and sicker patients with an increased American Society of Anesthesiologists physical status score.
ASA PHYSICAL STATUS CLASSIFICATION AND RISKS
Let’s examine the American Society of Anesthesiologists (ASA) Physical Status classification of your patients. Anesthesia-related mortality in patients without relevant systemic disease is low, at 0.4 deaths per 100,000. But patients who are ASA III (severe systemic disease that is not life-threatening), or ASA IV (severe systemic disease that is a constant threat to life) have increased medical comorbidities, and these comorbidities correlate with increased anesthetic risk. Per the chart below, an ASA III patient has 67 times the mortality risk of an ASA I patient and 5 times the mortality risk of an ASA II patient. An ASA IV patient has 137 times the mortality risk of an ASA I patient and 11 times the mortality risk of an ASA II patient.
Table 1. Association between anesthesia-related deaths and age or patients’ ASA status
| Mortality per 100,000 anesthetic procedures | ||
| ASA classification | ||
| ASA I | 0.4 | |
| ASA II | 5 | |
| ASA III | 27 | |
| ASA IV | 55 | |
A surgical population with a higher number of ASA III or ASA IV patients will pose more risk to an anesthesiologist’s practice.
CLOSED CLAIM ANALYSIS OF RISKS
The Journal of Healthcare Risk Management examined a total of 607 closed anesthesia malpractice claims. The most frequent injuries were teeth damage (20.8%), death (18.3%), nerve damage (13.5%), organ damage (12.7%), pain (10.9%), and cardiac arrest (10.7%). Obesity was most frequently identified as a contributing factor leading to a claim. Injury-to-claim rates were highest in hospitals with fewer than 100 beds, while ambulatory surgery centers had the lowest death-to-claim rate (12%).
OBESITY
Obesity is a global health epidemic. Per Miller’s Anesthesia, in 2016, 39% of adults and 18% of children and adolescents worldwide were overweight. Obesity is associated with increased rates of diabetes, hypertension, and anesthesia morbidity. If your anesthetic population hails from a geographic area with high rates of obesity, you will have a more dangerous practice. The prevalence of obesity varies by region. Colorado, Hawaii, California, D.C., New York, Vermont, Connecticut and Massachusetts have low rates of obesity, and Arkansas, West Virginia, and Mississippi have the highest rates.
GERIATRIC ANESTHESIA
A geriatric anesthesia practice represents higher risks. Per Chapter One in Miller’s Anesthesia, the number of people in the United States the aged 65 years and over is expected to exceed 78 million by the year 2030. The aging process is associated with declines in physiologic reserve and organ function, an increase in the incidence of medical comorbidities, and a higher incidence of ASA III and ASA IV status patients.
NON-OPERATING ROOM ANESTHESIA (NORA)
The movement of anesthetic procedures away from hospital operating rooms to non-operating room locations (Non-Operating Room Anesthesia, or NORA) has changed risk profiles. NORA locations are frequently remote from main operating suites and lack the typical support systems available for complex patients and unexpected crises. Per the Anesthesia Patient Safety Foundation Newsletter, “Patients undergoing NORA procedures, compared to those performed in the operating room, have a higher frequency of severe injury and death. In more than half of NORA-related claims involving deaths, patients were deemed to have received substandard anesthesia care preventable by improved monitoring techniques. . . . Most claims were related to respiratory events, specifically inadequate oxygenation and/or ventilation. . . . Oversedation leading to respiratory depression was implicated in a third of all claims.” Hospitals with careful case preparation/selection standards for NORA cases and protocols for emergency procedures will likely have lower NORA complication rates.
AMBULATORY ANESTHESIA
A full time practice of outpatient anesthesiology avoids the subsets of emergency surgery, neonatal surgery, cardiac surgery, neurosurgery, and trauma surgery, and promises a less dangerous array of cases. Ambulatory anesthesiology is defined as the administration of anesthetics for outpatient surgical procedures, which are minor procedures that don’t require hospitalization. Between 58 % and 71% of all surgeries in the US are on outpatients. Outpatient procedures such as tonsillectomy, knee arthroscopy, shoulder arthroscopy, breast biopsy, hernia repair, rhinoplasty, hand surgery, foot surgery, nasal septoplasty, colonoscopy, and upper gastrointestinal endoscopy are low-risk surgeries which don’t disturb a patient’s physiology in any significant way. Ambulatory patients are prescreened to eliminate those with significant medical problems such as morbid obesity, severe sleep apnea, or unstable cardiac, respiratory, or neurologic disease. An anesthesiologist practicing 100% in an ambulatory surgery center will likely have zero emergency anesthetics, zero weekend duty, and zero night call.
SUMMARY
A career in anesthesiology can run the gamut from high stress inpatient 2 a.m. emergency surgeries to the opposite extreme of doing carpal tunnel anesthetics at 7:30 in the morning. In my experience, early career opportunities for junior anesthesiologists are often most often limited to the acute care hospital jobs with more challenging high-risk practices. The lower-risk jobs of administering outpatient anesthetics in a dayshift Monday through Friday world promise a quality lifestyle. These jobs are highly sought after and are more likely staffed by mid-career anesthesia professionals who’ve done their time in acute care hospital settings and moved on to easier work.
In many lines of work, more dangerous labor is reimbursed at a higher rate of income than simpler lines of work. In anesthesia this isn’t always the case. Although the anesthesia Base Value for billing is higher for complex cases such as open-heart surgeries (20 Base Units) vs billing for simple cases such a finger surgery (3 Base Units), the insurance mix for many acute care emergency hospital cases is often inferior. Anesthesiologists can earn more money administering propofol to healthy patients for colonoscopies from 9 a.m. until 4 p.m. than they can for administering anesthesia for open chest surgeries from midnight until dawn. It doesn’t seem fair, but this reflects the anesthesia job market in the present day. All anesthesia employment is not equal. Some anesthesiologists simply have riskier jobs than others. When you’re seeking anesthesia employment, be aware that some practices present an easier workload than others.
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