The original logo of the American Society of Anesthesiologists had a lighthouse, a ship at sea, and in bold letters “VIGILANCE”. Over the last few years, the logo changed to a simple clipart figure of a lighthouse and “vigilance” was dropped but assumed. I’ve always thought that VIGILANCE and “SPIDEY SENSE” (the ability to sense imminent danger, a kind of sixth sense), are the hallmarks of what being an anesthesiologist is all about. For many, many reasons (among which are cost reduction/efficiency, physician staffing shortages, and maximizing income), 1:1 operating room staffing is becoming less and less common. Is overlapping coverage and supervision responsibility for more than one room safe? And if so, if and when does the system fail? 1:2, 1:3, 1:4 or even higher overlapping coverage? Today’s PAAD attempts to answer this question or at least cause us to think about this in an open forum. But first a few words from Dr. Glaucomflecken on cost reduction. Myron Yaster MD
Original article
Burns ML, Saager L, Cassidy RB, Mentz G, Mashour GA, Kheterpal S. Association of Anesthesiologist Staffing Ratio With Surgical Patient Morbidity and Mortality. JAMA Surg. Published online July 20, 2022. doi:10.1001/ jamasurg.2022.2804 PMID: 35857304
During residency and fellowship training and as educators of several generations of anesthesiologists, CRNAs and AAs, it was drilled into us, and we drilled into our students, that constant vigilance and anesthesiologist engagement were essential to the safe delivery of intraoperative anesthesia care. With competent bedside help in each room, the attending physician anesthesiologist led care team could safely provide medical direction and safe care for children in two operating rooms. Going beyond that to a 3rd or 4th room was thought to substantially increase the risks for missing key clinical information or observations and for being able to respond in a timely manner if more than one patient needed immediate help. Do we know that this is true? What is the evidence?
We know that in adult surgery, when surgeons divide their attention with overlapping operations, problems like higher mortality, longer surgical duration, and higher postoperative complication rates may occur.1, 2 Would the risks be different in pediatric surgery and anesthesia? As we recently discussed, Olbrecht et al.3 (see PAAD July 21: “Benchmarking Quality”), pediatric anesthesia care overall has become quite safe, and death in ASA PS < 3 is exceedingly rare. Perhaps the supervision staffing ratios of ASA PS < 3 can be increased from 1:1 or 1:2 to 1:3 or 1:4 without compromising safety?
Burns et al.4 in a study of healthy adult patients, undergoing lower risk operations present an excellent retrospective report from the MPOG (Multicenter Perioperative Outcomes Group) database that compared the 30 day mortality and perioperative morbidity in adult patients in 4 groups by level of attending anesthesiologist coverage (1 room, 1-2 rooms, 2-3 rooms and 3-4 rooms). This was a retrospective, matched cohort study consisting of major noncardiac inpatient surgical procedures performed from January 1, 2010, to October 31, 2017, conducted in 23 US academic and private hospitals. A total of 866 453 adult patients (aged ≥18 years) undergoing major inpatient surgery within the Multicenter Perioperative Outcomes Group electronic health record registry were included.
Anesthesiologist sign-in and sign-out times were used to calculate a continuous time-weighted average staffing ratio variable for each operation. Propensity score–matching methods were applied to create balanced sample groups with respect to patient-, operative-, and hospital-level confounders and resulted in 4 groups based on anesthesiologist staffing ratio. Groups consisted of patients receiving care from an anesthesiologist covering 1 operation (group 1), more than 1 to no more than 2 overlapping operations (group 1-2), more than 2 to no more than 3 overlapping operations (group 2-3), and more than 3 to no more than 4 overlapping operations (group 3-4). Data analysis was performed from October 2019 to October 2021. The authors found that increasing anesthesiologist coverage responsibilities beyond 1:2 was associated with an increase in risk-adjusted surgical patient morbidity and mortality. Compared with patients in group 1-2, those in group 2-3 had a 4% relative increase in risk-adjusted mortality and morbidity (5.06% vs 5.25%; adjusted odds ratio [AOR], 1.04; 95% CI, 1.01-1.08; P = .02) and those in group 3-4 had a 14% increase in risk-adjusted mortality and morbidity (5.06% vs 5.75%; AOR, 1.15; 95% CI, 1.09-1.21; P < .001).
Thus, these results are similar to adult studies of care delivered by nursing, hospitalists, and critical care medicine that have concluded that increased clinical workload has substantial consequences to individual and organizational performance and leads to decreased quality of care and poor clinical outcomes.5
The study design is an interesting read for those who want to engage in observational studies using large databases. For others, it’s important to know that the design considered most of the confounding variables and the authors clearly recognize the limitation of this approach. Even so, this paper raises important concerns in an era where administrators and physicians often define “productivity” primarily by the RVU’s and throughput per attending.
We’ve raised a lot of issues in this PAAD and have some other questions for you to think about. Please send me your thoughts that I will post in a future reader’s response myasterster@gmail.com
1. What staffing ratio (anesthesiologist to number of ORs/anesthetizing locations) does your hospital/practice use to assess how many attending anesthesiologists you need? 1:1, 1:2, 1:3, 1:4
2. When you are short or stretched, or at the end of the day, do you cover more rooms per attending?
a. No more than 1:2
b. No more than 1:3
c. Sometimes 1:4
3. If you were the boss, what staffing ratio would you like to see? Why?
References
1. Mello MM, Livingston EH. The Evolving Story of Overlapping Surgery. JAMA. Jul 18 2017;318(3):233-234. doi:10.1001/jama.2017.8061
2. Sun E, Mello MM, Rishel CA, et al. Association of Overlapping Surgery With Perioperative Outcomes. JAMA. Feb 26 2019;321(8):762-772. doi:10.1001/jama.2019.0711
3. Olbrecht VA, Uffman JC, Morse RB, Engelhardt T, Tobias JD. Setting a universal standard: Should we benchmark quality outcomes for pediatric anesthesia care? Paediatric anaesthesia. Aug 2022;32(8):892-898. doi:10.1111/pan.14474
4. Burns ML, Saager L, Cassidy RB, Mentz G, Mashour GA, Kheterpal S. Association of Anesthesiologist Staffing Ratio With Surgical Patient Morbidity and Mortality. JAMA surgery. Jul 20 2022;doi:10.1001/jamasurg.2022.2804
5. Gershengorn HB, Harrison DA, Garland A, Wilcox ME, Rowan KM, Wunsch H. Association of Intensive Care Unit Patient-to-Intensivist Ratios With Hospital Mortality. JAMA internal medicine. Mar 1 2017;177(3):388-396. doi:10.1001/jamainternmed.2016.8457