ASF_SpringSummer2008.qxp 7/30/2008 9:31 AM Page 1 ASF SOURCE - SUMMER 2008 Malignant Hyperthermia What are the First Signs? Richard J. Greco, MD A recent death by a teenager in an accredited facility undergoing corrective breast surgery has brought the condition of Malignant Hyperthermia (MH) to the front of the public's awareness. Malignant Hyperthermia is a rare, but potentially lethal, acute hypermetabolic syndrome. The use of general anesthesia can trigger these events in susceptible individuals. We originally wrote about MH in the summer newsletter in 2004. In order to reeducate and make our facilities aware of the treatment for MH we decided to update you on the topic. The first step in the treatment of this disease is to understand it and its genetic transmission. MH, occurs when a susceptible patient is exposed to a "triggering" agent. The main, well documented triggering agents are the potent inhalational anesthetics: halothane, enflurane, isoflurane, sevoflurane, desflurane and the depolarizing muscle relaxant Succinylcholine. It is important to elicit a personal or family history of difficulties with general anesthesia. All patients with a positive family history should be managed as susceptible to MH. Elective ambulatory surgery is not contraindicated, but the patient should be managed with regional anesthesia or general anesthesia using non-triggering anesthetic agents. After an uneventful anesthetic, patients should be observed for 3-5 hours and, upon discharge, provided with an emergency telephone number to contact if problems arise. There have been discussions regarding the use of prophylactic pre-treatment with oral or IV Dantrolene, however, the current recommendation from the Malignant Hyperthermia Association of the United States (MHAUS) is that prophylactic treatment is not necessary with non-triggering agents, appropriate monitoring, and an adequate supply of Dantrolene. The key is to avoid the use of triggering agents. Anesthetic techniques that are considered safe include: local or regional anesthesia and monitored anesthesia care, nitrous oxide, and deeper anesthesia using intravenous Continued on page 10 PAGE 8 New Study from AAAASF Data Also In This Issue... Malignant Hyperthermia.................. Board of Directors.............................. 1 2 Big Apple M.D. Blues......................... 3 Legislative Update.............................. 4 AAAASF President’s Message......... 5 Emergency Therapy For MH......... Safe Surgeries/New Study................ 7 8 Education Update............................... 9 AAAASF Committees........................ 11 Newly Accredited Facilities.............. 13 SFR Global Accreditation.................. 14 ASF Deadlines and Feedback........... 15 News You Can Use, Fee Schedule... 16 A PUBLICATION OF THE AMERICAN ASSOCIATION FOR ACCREDITATION OF AMBULATORY SURGERY FACILITIES, INC. ® ASF_SpringSummer2008.qxp 7/30/2008 9:31 AM Page 2 American Association for Accreditation of Ambulatory Surgery Facilities, Inc. 2008-2009 Board of Directors Alan H. Gold, M.D., President Lawrence S. Reed, M.D., Vice President Harlan Pollock, M.D., Secretary/Treasurer James A. Yates, M.D., Past President Richard D’Amico, M.D. Richard J. Greco, M.D. Phil C. Haeck, M.D. Ronald E. Iverson, M.D. Geoffrey R. Keyes, M.D. Michael F. McGuire, M.D. Dennis P. Thompson, M.D. Edward S. Truppman, M.D. TRUSTEES Gustavo A. Colon, M.D. Daniel C. Morello, M.D. Robert Singer, M.D. ® ® Jeff Pearcy, MPA, CAE, Executive Director ASF Editor Richard J. Greco, M.D. Publications Committee Chairman ASF Design/Production Director Jaime Trevino - Communications Director The ASF Source is published on a tri-annual basis. Contributions to the ASF Source are welcome, but may be edited for clarity and placement purposes. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, electrostatic, magnetic tape, photocopying, recording, or otherwise, without the full written permission from the publisher. The opinions expressed within are those of the contributors to the ASF Source and do not necessarily reflect the opinions or views of the AAAASF. AAAASF Mission Statement: It is the mission of the Association to develop and implement standards of excellence for quality patient care through an accreditation system for ambulatory surgery facilities and to serve the public interest by providing accurate and timely information regarding surgery in ambulatory surgery facilities and ASCs. AAAASF Patient Safety Brochure Order Form $35 (Pkg. of 25) $100 (Pkg. of 100) Quantity _______ AA AAS F The American Association for Accreditation of Ambulatory Surgery Facilities, Inc. Total Cost $_______ To view the brochure, visit our web site: www.aaaasf.org/ps.pdf Patient Safety First Facility Name ____________________________________________________ Address _________________________________________________________ AAAASF Office P.O. Box 9500 5101 Washington Street, Suite 2F Gurnee, IL 60031 1-888-545-5222 (toll free) 847-775-1970 • Fax: 847-775-1985 Web Site: www.aaaasf.org 2 City____________________________State_______ Zip __________________ Name on Credit Card _____________________________________________ Credit Card #_____________________________________________________ Exp. Date___________ Signature_____________________________________ Faxes must include a credit card number (Visa, Mastercard, or American Express) the card’s expiration date, and written authorization to charge the amount shown or mail to: AAAASF - P.O. BOX 9500-Gurnee, IL 60031 Or fax to: 847-775-1985 ASF_SpringSummer2008.qxp 7/30/2008 9:31 AM Page 3 Big Apple M.D. Blues Lawrence Reed, M.D. - New York, NY Understandably, when word of the state mandated accreditation of all medical facilities which utilize more than mild sedation for their procedures began its unwelcome dissemination, there was confusion, anger, disbelief, denial, resentment, posturing, protestation and a prevailing atmosphere of malaise and procrastination. This was from the doctors. Others, however, with prescience and perspicacity found within this morass a verdant field that needed some fertilization and nurturing, a little watering and some not so gentle stoking of the growing flames of discontent. Enter the lawyers, consultants, money lenders and office management groups... "If you don't get accredited by July 14th of 2009 you will be out of practice as you know it, or subject to severe penalties and fines," the doctors were told. "But don't worry because we can take care of the whole thing for you." The faces of the doctors that attended the many meetings in New York City set up by the lawyers, consultants, banks and others revealed a sense of anguish and despair that is normally, sacredly, reserved for the end of the baseball season when the Yankees once again go off to "Mudville" after a promising start. AAAASF was also present and unlike our competitors, we brought to the table almost 26 years of experience as a doctor run, not for profit, accrediting agency that specialized in office based surgical facilities. We had in our group over five times the number of accredited OBS facilities as our competitors combined. We also had a knowledgeable and supportive executive staff which was readily available to help the doctors through the process. If you wanted to hire consultants and lawyers and financial planners and medical mangers, by all means, go to it. If you wanted a simple and much less costly approach well then, AAAASF was ready to serve. AAAASF created a Procedural Standards Manual tailored just for the needs of the non-surgeons. Gastroenterologists and nurses with experience in the non-surgical specialties provided great assistance. Help also came from other sources so that we could fully understand the needs of the different specialties. We also listened carefully to the concerns of our potential applicants and worked to resolve these problems. The New York State Department of Health has wisely made it known that they are not pleased by, nor will they permit overt solicitation by any of the groups that have tried to capitalize on mandatory accreditation. The doctors already have enough to contend with and do not need the additional trauma of solicitation. So where are we now? The Procedural Standards Manual is a success and I see amongst my colleagues in New York a greater understanding of the value of accreditation and recognition of the expertise that AAAASF brings to the table. A lot of people worked really hard to achieve this level of appreciation and clearly there is much more to do. But, of course, that is what AAAASF does, and has done since l982. That is our only business. Big Apple M.D. Blues? Fuhgetaboutit! Dr. Alan Gold – New President of ASAPS Dr. Alan H. Gold is the new president of the American Society for Aesthetic Plastic Surgery (ASAPS). The Society is the leading national organization of board-certified plastic surgeons specializing in cosmetic surgery of the face and body. ASAPS elected its new set of officers on May 4, 2008 during the ASAPS 2008 Annual Meeting in San Diego, CA. Dr. Gold has been a member of the ASAPS since 1985. He is currently in private practice, holding an academic appointment as Clinical Associate Professor of Surgery at the Weill Cornell Medical College. Prior to his new responsibility as President of the Society, Gold has served as the Society’s Historian, Secretary, Treasurer, and Vice-President. He is also currently serving as the Society’s representative to the American Society of Plastic Surgeons Board of Directors. Other credentials of Dr. Gold include holding responsibilities as the immediate past-president of both the Aesthetic Surgery Education and Research Foundation (ASERF) and current president for the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF). Gold was also the Co-Chair of the Joint Silicone Implant Task Force. He is a Clinical Editor of the Aesthetic Surgery Journal and serves on the Journal's task force. 3 ASF_SpringSummer2008.qxp 7/30/2008 9:32 AM Page 4 Legislative Committee Update Theresa J. Griffin-Rossi, CAE - Director of Legislative Affairs and Education AAAASF continues to work diligently with State legislators and regulators throughout the country on issues that impact patient safety and the ambulatory care environment. On April 21, 2008, Jeff Pearcy, MPA, CAE, AAAASF Executive Director and Theresa GriffinRossi, CAE, AAAASF Director of Legislative Affairs attended and gave testimony before the Nevada Legislative Committee on Health Care at the committee's request. The full day meeting addressed the patient safety issues surrounding patient exposure to Hepatitis C in Nevada. AAAASF also participated on a conference call with the Nevada Department of Health prior to the hearing to discuss the patient safety concerns in Nevada and the infection control standards currently enforced by the national accrediting agencies. In December 2007, AAAASF staff attended a two day CASCA meeting in Colorado that laid the ground work with the Department of Health and State legislators for CO-HB1234, enacted on May 27, 2008, that recognizes AAAASF as a deeming authority. AAAASF continues to monitor over 50 bills introduced in 2008 related to ambulatory surgery. We Need Your Eyes and Ears Many of our facilities are the first to hear about legislative changes that may affect all of our facilities, please call Theresa Griffin-Rossi, CAE, Director of Legislative Affairs & Education (888-545-5222) or email her at: [email protected] In addition, you may hear about significant adverse events that have occurred in other facilities in your area. Please call Pamela Baker, Director of Accreditation (888-545-5222) or email her at: [email protected] so that we can evaluate and help resolve these problems for the best interest of the patients and our facilities. We heard you. (Did we mention we also have fast delivery?) Now Available in a Minimum Order of 6 On Your GPO Contract as a Dropship Via the Wholesalers www.usworldmeds.com/dm or 502.403.1891 for more information 4010 Dupont Circle, Suite L-07 | Louisville, KY 40207 | 502.403.1886 | www.usworldmeds.com DSI-014; ISS 2-08 4 ASF_SpringSummer2008.qxp 7/30/2008 9:32 AM Page 5 AAAASF President’s Message required peer review submission as a stanAs my final year as Board President of dard. Dr. Geoffrey Keyes, who has promulAAAASF comes to an end, I have the opporgated this effort over the many years, was tunity to reflect on the challenges and opporonce again lead author of an article that was tunities presented to our association in published in the July issue of Plastic and recent years. The job of the President is to Reconstructive Surgery®. "Mortality in provide consistent and knowledgeable overOutpatient Surgery" was derived from a sight and strategic guidance and decision study of over one million cases during a five making regarding those challenges and and one-half year period that demonstrates opportunities on a weekly, if not daily, basis. the importance of accreditation in the I have tried to fulfill that role to the best of ambulatory surgery environment. In this my ability. Working with our tireless Board review of data collected, using the IBQAP and staff, we developed numerous new inifrom January of 2001 through June of 2006, tiatives in my two years and made solid conthere were 23 deaths in 1,141,418 outpatient tributions to lingering issues, such as the procedures performed. Pulmonary ever-growing complexities of CMS compliembolism caused 13 of the 23 deaths. Only ance and the Medicare accreditation proone death occurred as the result of an intragram administration. operative adverse event during that period. I believe that one of the most important One death, of course, is one too many, and and complex projects I initiated was the we hope that this study and article usher in restructuring of the Board of Directors. I a new perspective on quality improvement am certain that the recently adopted ALAN H. GOLD, M.D. in surgical practice in the ambulatory surrestructuring will help future presidents PRESIDENT gery environment. and Executive Committee members expeThe fact that AAAASF has been collecting this data since dite decision making and facilitate progress. A reconstituted 2001 is testimony to our foresight in this area. Unfortunately, and expanded Advisory Board will draw on the talents of even today, many medical societies, healthcare associations, physicians from a variety of disciplines, representatives of legislators, insurance companies and healthcare media struggle other allied medical organizations, and even non-medical repto collect data, and fail to present facts to substantiate the effecresentatives to offer their expertise on important standards and tiveness of medical programs or of existing or proposed legislasafety issues concerning our diverse group of facilities, and tion. With the inclusion of more diverse ambulatory facilities help provide an expanded knowledge base to render recominto our expanding accreditation fold, I see continued growth mendations to the Board. and success in this revolutionary AAAASF program. I comAn additional critical initiative, the creation of new mend Dr. Keyes for his years of dedication to this program and Procedural Standards to accommodate non-surgical facilities, his diligence and detail-mindedness in accomplishing this such as gastroenterology, pain management, and fertility clintremendous task. We hope it opens some eyes and encourages ics, has proven to be a valuable and well-received addition to some new thinking in how to effectively monitor and improve our product line. ambulatory surgery safety and outcomes though a program of Yet another highly visible initiative was the revision and inspection and accreditation. This effort exemplifies the unique expansion of our educational programs. The number of accredcontributions provided by volunteer physicians working ited facilities and trained inspectors has expanded steadily over together to improve the quality of patient care. As a peer to peer the last two years. There are a growing number of talented and association, we have stayed true to our mission and trust that committed physicians who now actively participate in committhe next generation of volunteer physicians will continue this tee activities, ensuring our stability and future progress. high level of commitment and service. Through their dedication and vision, we have totally recreated It has truly been both an honor and a privilege to have our inspector training programs, have produced instructional served as AAAASF President for the past two years. In the fall, DVDs, including one on insurance reimbursement, and have I will leave my post as President of the Board of AAAASF and made available new Policy and Procedure templates, also in dedicate myself to the Presidency of the American Society for DVD format. Aesthetic Plastic Surgery (ASAPS). I will, however, still remain I am confident and pleased to report that there is expandengaged in AAAASF activities while still serving on the Board ed recognition of AAAASF as an accrediting agency by my and the Board of SFR. I feel confident in the direction in which home state of New York, as well as increased solicitation by the Association is headed, and in the abilities of the incoming various states for AAAASF to comment on, or assistance in, President, Dr. Lawrence Reed. Dr. Reed, through his many drafting accreditation legislation. We have also witnessed years of work with AAAASF, has an excellent understanding of increased recognition of Surgical Facilities Resources (SFR), all aspects of ambulatory surgery and the needs of both the and our important relationship with the International Society physician and the patient. I am certain that with his clarity of for Aesthetic Plastic Surgery (ISAPS) in establishing internavision, superb administrative skills, attention to detail, and tional patient safety standards in ambulatory surgery facilities. absolute commitment, he will provide the guidance to our Expanded media recognition has been evidenced by multiple extremely talented and tireless staff that will ensure continued requests for board member interviews and story contributions. success for AAAASF. Our Internet-Based Quality Assurance and Peer Review (IBQAP) reporting system has shown once again the value of 5 ASF_SpringSummer2008.qxp 7/30/2008 9:32 AM Page 6 New & Refurbished Anesthesia Equipment New PM8000 New PM9000 $3,450 $5,450 w/EtCO2 w/EtCO2/agent ID $10,450 New Philips MP5 Touchscreen $7,950 ! w e N Refurbished Excel 210SE/CC5 New Philips MP20 w/EtCO2/agent ID $12,950 Refurbished Narkomed 2B NEW! Platinum SC430 with Color Touch Screen, Volume, Pressure & Pressure Support Modes. Heated absorber. Two year warranty. Free Standing Surgery Centers Only. $32,900 Lease for only $650/ month. New Iso/Sevo Vaporizers $1,895 Dealer price $1,395 Top dollar paid for used/trade-in Aestiva, Aespire, Narkomed GS and Fabius GS. Paragon Service 800-448-0814 6 www.ParagonService.com Zoll M-Series Defibrillator $3,995 Fax 734-429-3197 ASF_SpringSummer2008.qxp 7/30/2008 9:32 AM Page 7 Awareness, Preparation and Training Essential to Prevent a Tragic Outcome For more information or a MH Protocol Poster PDF visit www.mhaus.org http://medical.mhaus.org/PubData/PDFs/treatmentposter.pdf 7 ASF_SpringSummer2008.qxp 7/30/2008 9:32 AM Page 8 Safe Surgeries Performed in Accredited Facilities The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) has developed a new study which analyzes data submitted by accredited ambulatory surgery facilities from January 2001 through June 2006. An article, “Mortality in Outpatient Surgery,” derived from the study was published in the July issue of Plastic and Reconstructive Surgery® and demonstrates that surgery in accredited ambulatory facilities can be as safe as inpatient surgery. The key fact extrapolated is that only one death occurred, out of 1,141,418 outpatient procedures performed, as a result of an intraoperative adverse event. AAAASF has reported statistics on morbidity and mortality for facilities that it accredits based on an analysis of unanticipated sequelae and surgical mortality. Data acquired through the first ever Internet Based Quality Assurance and Peer Review reporting system (IBQAP) were first reviewed and published in 2004. "The Internet has provided us with a wonderful tool to improve patient safety and document surgical practice," says Geoffrey R. Keyes, M.D., Quality Improvement/Peer Review Committee Chair and AAAASF board member. He has been integral in the establishment of the IBQAP system and the new study. This article based on the study reports the accumulated data in the IBQAP through June of 2006, analyzing death associated with procedures performed in facilities accredited by the AAAASF. With the exception of some statistics on the Medicare aged population, there are few data reported in the literature related to deaths in outpatient surgery. The study also shows that 13 of the deaths that occurred (there were 23 deaths in 1,141,418 outpatient procedures performed during the five and one-half years of the study) were due to pulmonary embolism. "Any death is one too many, but until we elucidate the etiology of pulmonary embolism, we are faced with this grave potential sequelae of surgery regardless of whether the procedure is performed in a hospital or an outpatient surgery facility," says Dr. Keyes. The Cases: Postoperative Medication Abuse Three patients died as a result of abuse of postoperative pain medications. The first patient was a 53-year-old hispanic woman who underwent a mastopexy and removal of breast implants under intravenous sedation. She was seen on the first and fourth postoperative days. There was no indication of postoperative sequelae during those visits. On the fifth postoperative day, she was found dead in her bedroom. There was a history of drug abuse. The suspected cause of death was a pain medication overdose. The second patient was a 57-year-old Caucasian woman, who also had a history of drug abuse. She was found dead on the second postoperative day. She had been wearing a fentanyl patch and postoperatively took an unknown quantity of Vicodin orally. The third patient was a 62-year-old Caucasian woman who died on the second postoperative day after having a face lift with multiple associated procedures. The nurse responsible for her care noted the patient to be somnolent on the evening of her operation. The patient’s pain management consisted of the administration of Vicodin and a fentanyl patch. She stopped breathing on the morning of the second postoperative day. She was admitted to the intensive care unit at a nearby hospital, but died as a result of respiratory failure. The suspected cause of her death was a drug overdose leading to respiratory failure. Myocardial Infarction A 54-year-old Caucasian woman died days after having an abdominoplasty and liposuction of the back. An autopsy revealed a myocardial infarction. A second patient, a 45-year-old Caucasian woman, died three weeks after abdominoplasty and breast augmentation from ischemic heart disease. There was no known history of cardiac disease before surgery. Continued on page 12. 8 ASF_SpringSummer2008.qxp 7/30/2008 9:32 AM Page 9 Education Committee Update Theresa J. Griffin-Rossi, CAE - Director of Legislative Affairs and Education The inspector training course held at the ASAPS meeting on May 2, 2008 in San Diego was well attended. AAAASF certified 48 physician inspectors and 20 nurse inspectors and 29 Medicare inspectors. The next inspector training course will be held at the ASPS meeting this Fall in Chicago on October 31, 2008. Registration forms will be mailed out to all AAAASF Facility Directors approximately two months prior to the meeting. AAAASF inspectors must be re-certified every three years. If you are an inspector and have not attended a training course recently, please check the date on your inspector certificate or call the AAAASF office at 1-888-545-5222 to ensure that your certification does not lapse. Education Committee Co-chair David Watts, M.D. and Committee Staff Liaison Theresa Griffin-Rossi, CAE have completed a second DVD project titled, “Preparing for Accreditation.” The DVD is designed to assist new facilities in preparation for the accreditation process. A companion CD is being developed that will include sample policy and procedure documents in Microsoft Word format that can be customized by facility staff to streamline the process and make the AAAASF accreditation program even more user friendly. Packaged along with the first DVD titled, "Inspector Training Overview", the two DVD and CD set will be available later this summer. VenaFlow System ® The Ultimate in DVT Prevention The VenaFlow system combines two proven technologies, rapid inflation and graduated, sequential compression to 2,3,4 increase venous velocity and enhance fibrinolysis “A protocol for the prevention of DVT or PE should be developed by each facility” – AORN Guidelines, 2007 1 800.336.6569 www.aircast.com 1 AORN Guideline for Prevention of Venous Stasis, March 2007, Vol 85, No. 3, AORN Journal; 2Gardner AMN, Fox RH: The Return of Blood to the Heart Venous Pumps in Health and Disease. Second Edition, London, John Libbey & company Ltd, 1993; 3Kamm RD, Butcher R, Froelich J, et al: Optimisation of Indices of External Pneumatic Compression for Prophylaxis Against Deep Vein Thrombosis: Radionuclide Gated Imaging Studies. Cardiovascular Research 20(8): 588-596, 1986.; 4Nicolaides AN, Fernandes e Fernandes J, Pollock AV: Intermittent Sequential Compression of the Legs in the Prevention of Venous Stasis and Postoperative Deep Vein Thrombosis. Surgery 87(1): 69-76, 1980 © 2008 DJO, LLC 9 ASF_SpringSummer2008.qxp From page 1... 7/30/2008 9:32 AM Page 10 Malignant Hyperthermia drugs include propofol, ketamine, barbiturates, benzodiazepines, narcotics, etomidate, non-depolarizing neuromuscular blockers, anticholinesterases, anticholinergics, and non-steroidal anti-inflammatory drugs. The potent inhalational agents and Succinylcholine are unsafe. The FDA currently recommends that Succinylcholine should not be used routinely. It is important to note, that by our AAAASF standards, the facility must have Dantrolene present even if the only triggering agent in the facility is Succinylcholine. Some patients do not have a family history of MH and one should be aware of the first signs of difficulties. Typically, MH will manifest itself during the first 2 hours of anesthesia. However, cases of MH have been reported during prolonged anesthesia and even during recovery; therefore, the 12 hours immediately after surgery are considered a critical time for MH-susceptible patients. Masseter spasm is often the first sign of an impending MH crisis. Masseter spasm is "jaw muscle rigidity in association with limb muscle flaccidity after administration of succinylcholine." It is not simply inadequate relaxation or "stiffness." Any patient who has masseter spasm upon induction of anesthesia should be observed overnight for a possible MH episode. Even patients who experience mild increases in jaw tension should be observed for signs of MH for at least 12 hours. Other early symptoms of an impending MH crisis during anesthesia are sinus tachycardia, hypertension and tachypnea. Because these signs are often misinterpreted as signals of inadequate anesthetic depth, they are treated by increasing concentrations of inhaled anesthetic agents. Increased temperature is usually a late sign. The skin becomes mottled with cyanotic areas and patches of bright red flushing. Generalized skeletal muscle rigidity is observed in approximately 70% of patients. Central thermoregulation remains intact during a MH crisis; temperature increases only after continuous muscle contraction generates more heat than the body can dissipate. Temperature can rise at a rate greater than 1.5 C in less than 5 minutes and can go as high as 110 F or 46 C. Ventricular tachycardia and fibrillation may become evident. Early management includes cessation of all inhalation agents and triggering agents, finishing the surgery as quickly as possible, hyperventilating with 100% Oxygen, initiating Dantolene 2.5 mg/kg IV and using cooling blankets and ice packs as necessary. Immediate transfer to a hospital facility should be considered. Cold intravenous fluids, lidocaine for arrhythmias, and sodium bicarbonate for metabolic acidosis would be used as necessary. All of our facilities that utilize general anesthetics that can trigger MH must be equipped with a kit or cart to manage MH. It should include dantrolene, sterile water sufficient to dilute dantrolene, D50, antiarrhythmics, mannitol, calcium chloride, sodium bicarbonate, insulin, and furosemide. This is true even if the only triggering agent preset is SuMH. Drills may be useful for your facility and it is recommended that you consider practicing the dilution of Dantrolene with your outdated vials because some find the drug difficult to dilute. Patients should be monitored for EKG, blood pressure, temperature, pulse oximeter, and capnograph. An ice machine and a refrigerator should be nearby. Advice regarding acute emergencies can be obtained through the MHAUS hotline 1-800-MH-HYPER. Susceptible patients and their families should be given the contact information so that they can learn more about the risks of MH. The phone number for the MHAUS office is 1-800-98MHAUS; the e-mail address is [email protected] 10 ASF_SpringSummer2008.qxp 7/30/2008 9:32 AM Page 11 Get Involved In One Of Our Committees Many of the important projects and initiatives are introduced by way of committee recommendations. We have seen dramatic changes and development in our inspector training via the Education Committee, a major Standards revision developed by the Standards Committee, and the development of a third party reimbursement guide by the Reimbursement Committee. You can make a difference by contributing to one of the AAAASF committees, so please get involved. If you are interested in a committee... Complete the form below and fax or mail it to the AAAASF Office, call 888-545-5222 or send an email to [email protected] Interested in Serving on an AAAASF Committee? We are also interested in getting more nurses and younger surgeons from our accredited facilities involved in all our committees in order to broaden our perspectives, get new ideas, and develop future leaders of the Association. If you are interested in participating on a committee, please complete this form and mail/fax to: AAAASF Office P.O. BOX 9500 • 5101 Washington Street, Suite 2F • Gurnee, IL 60031 Fax: 847-775-1985 Name and Title: ________________________________________________________________________________________________________ Years in Practice: ________________________________________________________________________________________________________ AAAASF Facility Name or #: ____________________________________________________________________________________________ Address: ______________________________________________________________________________________________________________ City: ________________________________________________________State: __________________________________Zip: ______________ Telephone:__________________________________Fax: ______________________________E-mail:__________________________________ Check the box next to the Committee that you are interested in: If selected, you will be contacted by AAAASF staff. Thank you for your interest in serving as an AAAASF Committee member! Standards Technology Reimbursement Education Legislative Publications Investigative Inspectors Accreditation QA/Peer Review Another Way You Can Help: If you are a trained inspector please reassess your commitment to patient safety and say "yes" next time you are contacted to perform an inspection. If you have refused several inspections, you may not be on our active list. Please call or email the AAAASF Office to let us know you are available. If you would like to be an inspector, the next training will be held in Chicago at the ASPS Annual Meeting. Visit our web site or call the AAAASF Office for the registration form. If you are called and cannot perform an inspection, please let our staff know why you are unavailable and how we can help you with future inspection requests. The next time you are inspected, please be sure to thank your inspectors for their dedication to patient safety. Visit Our Web Site www.aaaasf.org and Click Contact Us! 11 ASF_SpringSummer2008.qxp 7/30/2008 9:32 AM Page 12 Mortality In Outpatient Surgery Continued from page 8. Arrhythmia A 65-year-old Caucasian woman developed an arrhythmia 24 hours after surgery. An autopsy revealed no evidence of myocardial infarction, pulmonary embolism, or medication overdose. There was no history of cardiac arrhythmia before surgery. Intraoperative Anesthetic Adverse Event A 67-year-old Caucasian woman underwent a face-lift procedure under intravenous sedation. The operating surgeon, without the assistance of a certified registered nurse anesthetist or anesthesiologist, administered propofol, fentanyl, and midazolam. During the procedure, the patient developed hypotension and bradycardia. She underwent resuscitation and was transferred to a hospital, dying 15 days after admission. On April 14, 2004, the American Association of Nurse Anesthetists and the American Society of Anesthesiologists made the following statement jointly: “Whenever Propofol is used for sedation/ anesthesia, it should be administered only by persons trained in the administration of general anesthesia, who are not simultaneously involved in these surgical or diagnostic procedures. This restriction is concordant with specific language in the Propofol package insert, and failure to follow these recommendations could put patients at increased risk of significant injury or death.” AAAASF standards now require that the use of propofol be limited to class C facilities accredited for the administration of general anesthesia, or those accredited for the provision of the use of Propofol under the direct supervision of an anesthesiologist or certified registered nurse anesthetist. Asthma On the evening of her surgery, a 32-year-old Caucasian woman died after a breast augmentation. She had a history of asthma. While sitting at the dinner table, she became dyspneic with wheezing. She was taken to the emergency room, where she died after unsuccessful resuscitative efforts. An autopsy was not performed. Sleep Apnea Respiratory Arrest A 67-year-old Caucasian woman underwent a face-lift procedure. She was reported to have been stable, alert, and oriented in the recovery room 1.5 hours after surgery. She was discharged to her home with a pulse oximeter, which apparently was never placed on the patient. She was found dead the next morning. This case is currently under review. Respiratory Failure Unrelated to Surgery A 32-year-old Caucasian woman had a nasal fracture reduced under general anesthesia. Two weeks postoperatively, she developed respiratory distress, presumably caused by chronic obstructive lung disease. She died after having thoracic surgery. The cause of death was lung cancer. The AAAASF standards require all deaths that occur within a 30-day period after surgery to be reported to the central office. This case is included in the study because of that standard. For a PDF version of the complete article, contact Jaime Trevino, [email protected]. 12 ASF_SpringSummer2008.qxp 7/30/2008 9:32 AM Page 13 Newly Accredited Facilities Class Code Examples: M7C = Medicare, 7 Physicians, Class C R2B = Regular, 2 Physicians, Class B R1C-M = Regular, 1 Physician, Class C-Modified Facility Director Facility Evan Cohn M.D. Victoria Vitale-Lewis M.D. Gregory Michael Bazell M.D. Central Ohio Urology Surgery Center Columbus OH M4B Cosmetic Plastic Surgery Center Melbourne FL R1C The Aesthetic Plastic Surgery Center of Barrington, LLC South Barrington IL R1C Hilton Becker, M.D. Boca Raton FL R1C Kent V. Hasen, M.D., PA - Aesthetic Plastic Surgery of Naples Naples FL R1C Central Coast Institute for Plastic Surgery San Luis Obispo CA R1C Advance Gastroenterology Forest Hills NY R1C-M Waccamaw Endoscopy Center, LLC Georgetown SC R1B Women's Wellness Institute of Dallas Dallas TX R1C South Miami Surgery Center, LLC South Miami FL R1C Napa Valley Plastic Surgery, Inc. Napa CA M1C Advanced Aesthetics Fayetteville GA R2C Cobble Hill Ambulatory Facility Brooklyn NY R1C The Boyd Gillard Institute of Aesthetic & Dermatologic Surgery Ypsilanti MI R1C Walnut Creek Medical Center Pembroke Pines FL R1C-M Ralph R. Garramone, M.D., P.A. Fort Myers FL R1C The Plastic Surgery Group, PC Rockville Centre NY R2C Southlake Center for Cosmetic Surgery Southlake TX R1C VIP Plastic Surgery Los Angeles CA R1C-M Gold Coast Surgery Center, LLC d/b/a Gulf Comprehensive Surgery Center Englewood FL M1C McKenna Cosmetic Surgery Center Cincinatti OH R1C Center for Breast and Body Contouring Grand Rapids MI R1C Buckingham Plastic Surgery Doylestown PA R1C-M Naples Surgical Center Naples FL R1C South Shore Plastic Surgery, Inc./ DBA Boston Plastic Surgery Quincy MA R1C Jefferson Obstetrics & Gynecology, LTD Charlottesville VA R4A Digestive Wellness Center, LLC Norton OH M2B Renvance Cosmetic Surgery Center Murrieta CA R1C South Bay Surgical and Spine Institute Long Beach CA M1C Aestique Ambulatory Surgical Center Greensburg PA R7C Gastroenterology Group of Rochester, LLP Rochester NY R2B Humboldt Bay Surgery Co-Op Eureka CA M1C Premiere Center for Cosmetic Surgery Coconut Grove FL R1C Premiere Center for Cosmetic Surgery Tampa FL R1C Women Medical Wellness of Westchester Mount Vernon NY R2C Specialty Surgical Center of Thousand Oaks Westlake Village CA M7C Westchester Putnam Gastroenterology Carmel NY R2C-M Ocean Park Surgical Center, Inc. Venice CA M2C Southeastern Fertility Center Mount Pleasant SC R2C-M Monterey Park Surgical Suite West Covina CA R1C Hilton Becker M.D. Kent V. Hasen M.D. Gary R. Donath M.D. Azeem Khan M.D. Laurence Ballou M.D. Wesley Anne Brady M.D. Eduardo Barroso M.D. WilliamJ. McClure M.D. Paul D. Feldman M.D. Pedro Canals-Ferrat M.D. Charles Boyd M.D. Jeffrey A. Steiner M.D. Ralph R. Garramone M.D. Antonio L. Uria M.D. Michael Bogdan M.D. Andrew K. Choi M.D. Anthony DiTomaso M.D. Peter J. McKenna M.D. Dennis Hammond M.D. MichaelA. Giuffrida M.D. Stanley P. Gulin M.D. Fouad Samaha M.D. Michael Arnold M.D. Ghulam Mir M.D. Brian J. Eichenberg M.D. Munir Uwaydah M.D. Theodore A. Lazzaro M.D. Howard Merzel M.D. Robert M. Green M.D. Howard Robinson M.D . Herbert Stern M.D. Guirlaine Agnant M.D. Glenn Cohen M.D. Michael Kushner M.D. Anoush Ehya M.D. John Schnorr M.D. Alejandro M. Sanchez M.D. City & State Class 13 ASF_SpringSummer2008.qxp 7/30/2008 9:33 AM Page 14 New SFR Global Accreditation Certification Program As an added benefit to those AAAASF Facility Directors who are members of ISAPS, SFR would like to extend to you an offer to certify your facility as a globally accredited facility. This added certification will enhance your status in the global marketplace. As you may know, SFR (Surgery Facilities Resources, a wholly owned subsidiary of AAAASF) and ISAPS have partnered to offer a global program of inspection and accreditation available to ISAPS members and we want to include your facility in an expeditious manner. For a nominal application fee of $250, AAAASF will automatically extend this global accreditation certification to your AAAASF accredited facility. No additional inspection is required as long as your facility is in good standing with AAAASF. This can be an excellent way to promote your facility and attract new business from outside the United States as the patient safety awareness level and the importance of inspection and accreditation increases around the world. If you are an ISAPS member and an AAAASF Facility Director and wish to join this list of Globally Accredited Facilities, please contact the AAAASF Office. Facility Name Gold Ambulatory Surgery Center Lenox Hill Ambulatory Surgery, PC Atlantic Plastic Surgery Center Dana Care Surgery Center Ambulatory Surgery Center - Bethesda Plastic Surgery Institute of South California The Plastic & Reconstructive Surgery Center Pacific Clinic Director Alan Gold, M.D. Darrick E. Antell, M.D. Lawrence Gray, M.D. Henry M. Spinelli, M.D., F.A.C.S. Bahman Teimourian, M.D. Edward Terino, M.D. Ronald E. Iverson, M.D. Brunno Ristow, M.D. City, State Great Neck, NY New York, NY Portsmouth, NH New York, NY Bethesda, MD Thousand Oaks, CA Pleasanton, CA San Francisco, CA Prevent Medical Errors, Monitor and Document Safe Surgical Practices, Ensure Ongoing Regulatory Compliance And Reduce Costs! www.surgimetrix.com 888-863-8749 14 ASF_SpringSummer2008.qxp 7/30/2008 9:33 AM Page 15 ASF Source Newsletter Submission Deadlines For Articles, Advertising and Photos Fall/Winter 2008 Issue Deadline - September 5th, 2008 Articles on patient safety issues and quality care practices within the outpatient surgery environment are accepted any time throughout the year. Please email your articles or ideas for articles to Jaime Trevino, Communications Director at [email protected] and you will be notified if the Publications Committee decides to use your article. ASF Source Newsletter Advertising 2007 Rates CAMERA READY Full page 1/2 page 1/4 page 1/8 page 1/COLOR(Black) $700 $450 $225 $110 MECHANICAL REQUIREMENTS: Full page 1/2 page 1/4 page 1/8 page Black With SPOT COLOR $825 $625 $425 $325 LIVE AREA 7.5” X 10” 7.5”X 5” 3.75”X 5” 3.75”X 2.5 4/COLOR $1,350 $850 $550 $450 BLEED 8.75”X 11.25” 8.75”X 5.5” N/A N/A Reimbursement Guide Available to Accredited Facilities John Pitman III, M.D., Reimbursement Committee Chair Dr. Pitman has produced the “Guide For Third Party Reimbursement Of Facility Fees” to help assist physicians through the quagmire that is today’s reimbursement landscape. This information will evolve as the environment changes, so Dr. Pitman welcomes all comments and advice to make this booklet the best it can be. As you know, the culture that envelopes this area of practice is continually changing, making it extremely difficult to anticipate every aspect. We hope that you gain some insight from this guide, and we want to thank Dr. Pitman for all the time and energy spent on this project.The Reimbursement Guide is currently only available in PDF format, and is free to accredited facilities. To order, visit www.aaaasf.org Products and Services Desired By Surgery Facilities If you have a valuable product or service to sell (such as custom packs of surgical tools) or know of a great company that does, email [email protected] Request for a Newsletter If you wish to be included on our mailing list or you know of a medical specialist that has requested to be included, please complete this form and fax or mail to the AAAASF Office. Name ________________________________________________________________________________________ Title or Specialty ________________________________________________________________________________________ Facility Name ________________________________________________________________________________________ Facility Address ________________________________________________________________________________________ Telephone ________________________________________________________________________________________ Fax ________________________________________________________________________________________ E-mail ________________________________________________________________________________________ Web Site ________________________________________________________________________________________ Fax to: 847-775-1985 or email all required information to: [email protected] 15 ASF_SpringSummer2008.qxp 7/30/2008 9:33 AM Page 16 ASF Source News You Can Use Standards Reminder - Version 11 is the current Standards edition. You will receive your copy of these Standards upon receipt of renewal fees or with the purchase of a General Information Packet ($250). ANNUAL FEES FOR REGULAR ACCREDITATION CLASS Specialists Specialties A B, C, C-M 1-2 1 - 2 specialties $750 $1,105 3-5 1 - 2 specialties $1,045 $1,545 3-5 3 or more specialties $1,325 $1,820 6-9 1 - 2 specialties $3,390 $4,100 6-9 3 or more specialties $3,655 $4,360 10 1 - 2 specialties $4,785 $6,045 10 3 or more specialties $5,045 $6,885 ANNUAL FEES FOR MEDICARE CERTIFICATION CLASS Specialists Specialties B, C 1-2 1 - 2 specialties $1,655 3-5 1 - 2 specialties $2,095 3-5 3 or more specialties $2,370 6-9 1 - 2 specialties $4,625 6-9 3 or more specialties $4,885 10 1 - 2 specialties $6,570 10 3 or more specialties $7,410 Inspection Fees: $500 for provisional, $950 for regular, and $1400 for Medicare inspections in addition to the annual fees shown above. PRSRT STD U.S. POSTAGE PAID PERMIT NO. 195 LIBERTYVILLE, IL P.O. BOX 9500 Gurnee, IL 60031 1-888-545-5222 (toll free) 847-775-1970 Fax: 847-775-1985
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