Many medical procedures are moving from the operating room to the doctor’s office, and a Forum held Oct. 9 at the Simches Research Center at Massachusetts General Hospital provided full and illuminating discussion of the significant trend.

Four speakers presented on a variety of topics, including “Office-based gynecologic procedures,” “Office-based anesthesia,” “Technology implications of office-based anesthesia safety,” and “Regional anesthesia in the office-based setting.”

Keith Isaacson, MD, medical director of the Minimally Invasive Gynecological Surgery Unit at Newton Wellesley Hospital, and CIMIT site miner at that institution, said that many gynecologists are moving toward office procedures because the net rate of reimbursement is greater.

He said that the federal Center for Medicare and Medicaid Services (CMS) is “directing” doctors to office procedures because that venue is less expensive than an OR. But there is less regulation in such facilities, and he warned that office-based medicine could become “the wild West of medicine” if it is continues to develop with a minimum of oversight.

Fred Shapiro, DO, who is with the Department of Anesthesiology, Critical Care and Pain Medicine Unit of Beth Israel Deaconess Medical Center, said that the use of anesthesia in an office setting is increasing rapidly because in the past 10 years, the number of office-based procedures has grown from 5 to 10 million cases. He noted that only 22 states have any regulations regarding office-based anesthesia, and he said that patient care could be compromised if medical professionals are not vigilant.

Beverly Philip, MD, director of the Day Surgery Unit at Brigham and Women’s Hospital, said there are both opportunities and challenges associated with OBA. She said that doctors must choose their patients carefully, and train in emergency procedures should an incident occur. She said that office-based medical personnel must excel in information management so that appropriate patients are chosen, and adequate data is available should doctors need it. Dr. Philip concurred that reimbursement is significant for those who practice outside of an operating room.

Lisa Warren, MD, director of ambulatory anesthesia at MGH’s Department of Anesthesia and Critical Care, said that regional anesthesia could be better utilized by those who use the office setting. Noting that about 25 percent of all elective surgery procedures in the U.S. are done in the office now, she suggested that doctors consider greater use of regional procedures.

The office environment is not designed for surgery, yet it is the site of millions of procedures, many performed without an anesthesiologist.  With few regulations in place, practitioners must hold themselves responsible for safety. 

It is crucial that all office surgeons have the correct equipment to monitor the anesthetized patient.  Many anesthesia machines used in private practice are old, and guidelines should be established that delineate when machines become obsolete.  Patient information (vital signs, etc.) should be collected and stored in a useful format.  Often, the riskiest time for a patient is right before and right after surgery, when the patient is not necessarily receiving a doctor’s full attention, so improved patient monitoring is needed during these times as well.

Above all, the office-based practice should be able to cope with emergencies.  It is not uncommon for small surgeries to lead to dire complications.  All staff must be trained to respond appropriately to an emergency.  Dialing 911 should not be the back-up plan.  The practice must possess emergency equipment.  A defibrillator and a reliable two-way communications device, for example, should always be on hand.  There must be a reliable source of oxygen, a reliable source of suction, emergency drugs, and an electrical generator in case the power fails.  The building must have a clear path of egress for a patient on a stretcher.  Perhaps the greatest danger posed by office-based surgery lies in the presumption that no serious problems will occur.

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