The study in this issue of Anesthesia & Analgesia by Smallman et al., “Role of Communication Systems in Coordinating Supervisory Anesthesiologists’ Activities Outside of the Operating Rooms,”1 surveyed the types of pages that were sent to anesthesiologists who were physically on-site and actively supervising operating rooms (ORs), during the periods when they felt they could leave their supervisees alone. As the authors noted, supervising anesthesiologists have multiple duties to provide for the smooth care of multiple surgical cases in succession. The United States Centers for Medicare and Medicaid Services allows several exceptions to the limitations on medical direction, including but not limited to receiving new patients into the preoperative area, discharging patients from the postoperative areas, and coordinating case scheduling.
The authors did not examine specifics about supervising anesthesiologists’ productivity per se. Rather, they noted that the pages that came to supervising anesthesiologists when they were not in ORs, were largely for out-of-OR issues. Few of the messages were to request the supervising anesthesiologist to return to the OR for unexpected patient care concerns, indicating that out-of-OR concerns comprise a sizeable component of supervising physicians’ work. With these findings in mind, what overall insights can be inferred from, and what questions are raised by, this work relative to the design of future tele-anesthesiology supervisory paradigms for OR anesthesia care?
The proposed remote supervision tele-anesthesiology staffing model envisioned in the 2011 Rovenstine Lecture, “Leading into the Future,”2 was an extension of published tele-intensive care unit (ICU) models.3 It involved supervisory anesthesiologists in locations distant from the OR suite, using multiple screens to visualize the OR room, the monitors, laboratory data, fiberoptic/Glidescope® images, transesophageal or transthoracic echocardiography images, infusion pump settings, etc. Additionally, the tele-anesthesiology supervisor would use software decision-support algorithms associated currently with tele-ICU systems, to identify physiologic trends potentially earlier than the busy provider in the room, who may be distracted from the monitors by the myriad of care-giving tasks and may not be catching a trend change at the earliest moment.
Even though many vital signs changes are “caught” by the front-line providers without paging the supervising anesthesiologist,4 the tele-anesthesiology supervisor who is using technology to identify adverse trends earlier may contribute positively to less occult morbidity than the situations where the in-room provider finally catches the problem. For example, it is interesting to speculate that if a remote supervision tele-anesthesiology system were in place, with advanced analytical and decision-support software, a trend downward in SpO2 could have been noticed sooner and/or immediately acted on by the video/audio-connected remote tele-anesthesiology supervisor, without the need to wait for a page or walking to the room to investigate. If 7 of 100 hypoxic episodes are not solved in 3 minutes,4 potentially thus resulting in a page to an on-site anesthesiologist, then even after the supervisor’s arrival, he/she needs to absorb information and assess the situation before making corrections. There conceivably could be some critical additional minutes expended, pending correction of the problem, with a “physical presence” model compared with the quicker input of a remote supervisory tele-anesthesiology model. In this example, a shortened time of suboptimal oxygenation could mean less systemic inflammatory activation and less short-term and long-term morbidity.
Additionally, with the tele-anesthesiology supervisor provided with automatically generated electronic trend monitoring and decision-support advisories, he/she may be able to safely watch more than 4 rooms, providing a true increase in supervisory productivity.
A potential limitation of tele-anesthesiology as envisioned is that its technological reach may not on its own be effective for early detection/management of all critical intraoperative events. Examples such as the in-room provider noticing increased bleeding in the operative field, or noticing subtle patient movements indicating early abatement of critical neuromuscular blockade, may not be able to be first detected remotely via hemodynamic monitors or in-room cameras in all cases. The challenge for those anesthesiologists designing the future of tele-anesthesiology systems will be to provide as many interfaces for the tele-supervisor as practicable, to expand his/her capabilities to be as effective a backup and “knowledge resource” as possible for the in-room provider.
The advent of tele-anesthesiology systems can additionally allow us to consider whether physical presence with low supervisor to in-room provider ratios (one to few) is overstaffing for some cases. This could be the situation, for example, if qualified, experienced in-room providers actually need “knowledge supervision” versus physical task supervision. In a new staffing model, we could consider combining remote tele-anesthesiology knowledge supervision for ORs via availability of tele-anesthesiology supervisors, with a low number of physical presence rescue supervisors. Then for those situations where the in-room provider needs manual assistance beyond the scope of lower-level technical procedure assistants, a higher ratio (one to many) on-site rescue supervisor can rush to an OR when needed to supplement the remote tele-supervisors. These latter types of staffing models will be interesting to evaluate when such high-tech tele-equipment is available, such that safety and quality studies can be done in actual patient care situations.
The finding by Smallman et al.1 that relatively few pages were sent to ask on-site supervising anesthesiologists to return to the ORs is not surprising, because faculty are unlikely to leave an OR they are responsible for if they anticipate any aspect of instability of their patient. Thus, any “urgent, come back” pages represent either a misassessment of the supervising anesthesiologist that it was safe to leave the OR, or an unexpected unstable event. Had nights, weekends, and holidays been included in this survey study, which may have more potentially unpredictable cases, there could conceivably been more “urgent, come back” episodes on those nonstandard work times.
Another general issue in this work related to hospital B is that only 3 physicians’ pages were being contemporaneously analyzed, and that was being done by the physicians themselves, who knew the purpose of the study. Because they knew that their pages were being analyzed for “urgent, come back” messages, they may perhaps have been more conservative in leaving their ORs, to be assured of the appropriateness of leaving their supervisees alone. In general, looking at the low percentages of pages to return to the OR underestimates the value of the supervisory anesthesiologists’ impact on patient care, because they would only be willing to leave their supervisees alone in the OR if they had assessed that their patients were going to be stable for the duration of their absence. Conversely, they were likely already in the ORs whenever they anticipated any critical knowledge need or manual assistance need. Thus, from these survey results, we cannot estimate the total number of remote supervisory anesthesiologists needed per OR in a full tele-anesthesiology model. We need more information than these results can provide of the type of activities that supervising anesthesiologists engage in during the long periods of time that they were in the OR problem solving, when they were not getting paged.
It would be valuable to categorize during their time being physically present in the ORs, what proportion of the time these supervisors were providing knowledge supervision that a remote tele-anesthesiologist could alternatively provide, versus time spent either: (1) undertaking or supervising manual procedures that could have been alternatively provided by an experienced procedure technician under remote instruction from a tele-anesthesiologist or (2) undertaking or supervising a manual task that needed a fully trained anesthesiologist physically present in that OR. For example, a technician trained in central line placement could help an in-room provider place a central line, while the remote tele-anesthesiologist could interpret the central venous pressure or pulmonary artery tracing and confirm the adequacy of the location, including reviewing any tele-radiograph via remote picture archiving and communication system technology. Similarly, a trained echocardiography technician could assist in obtaining a transthoracic echocardiogram to be interpreted remotely by the tele-anesthesiologist, much like a neurophysiology technician in an OR can obtain an somatosensory-evoked potential reading and a remotely connected neurologist can advise the surgeon to release tension on the spinal cord.
Remote supervisory tele-anesthesiology is not intended to determine when an anesthesiologist should go to the OR. It is meant to provide more timely “knowledge interventions” based on continuous ability to watch rooms and get processed trended data that the busy in-room provider cannot always immediately notice in the midst of a case. The remote supervisor can provide “knowledge input” almost immediately without having to walk to or between rooms. Conceptually, they can increase productivity by overseeing more rooms than a physical presence supervisor can do. However, the continuous availability of a tele-anesthesiology supervisor will not be expected to shorten anesthesia times, because as Smallman et al. have pointed out, “‖ mean anesthesia times are relatively brief in relation to standard deviations of surgical times.”5,6
The concern expressed in the Appendix to this work,1 that more providers are needed than the simple math of covering rooms to provide breaks, is intuitive. That would apply to a remote supervisory tele-anesthesiology model as well as an on-site physical presence supervisory staffing model. The in-room providers will still need breaks, and similarly the options to provide additional personnel or spread out the cases to cover such would be the same.
The difference in the observation in Smallman et al.1 that non-OR pages were 45% vs 56% between hospital A and hospital B is attributed to the fact that in hospital A, pages for postanesthesia care unit (PACU) concerns were directed to a PACU resident, whereas in hospital B, the limited number of the 3 faculty surveyed were also responsible for running the OR schedule on those days, such that in the course of those specific duties they received more administrative pages. However, the pager results for non-OR pages without PACU contribution was 45% for hospital A, and 38% without PACU input in hospital B (56% total minus 18% from PACU).
The key of this study’s observations, namely that the work of overseeing preoperative/postoperative patient matters and perioperative administrative/coordination issues are important duties that have been placed on the supervisory anesthesiologist is, in fact, an improvement in productivity over in-room OR supervision alone, because the physicians are not only supervising anesthetics in 2 to 4 ORs, but are also covering preoperative/postoperative issues that would otherwise require another physician. The implication for tele-anesthesiology that supervising anesthesiologists are counted on to perform much problem solving related to issues not immediately pertinent to the on-going cases in the ORs is that if a remote supervisory tele-anesthesiology staffing model is used for intraoperative supervision, a plan must be made to address those notable preoperative/postoperative and administrative problem solving needs.
It would be interesting and engaging to be able to design and implement solutions within the framework of a tele-anesthesiology model, to address the issue highlighted by this survey, of the frequency of preoperative/postoperative and administrative work that would need to be covered if a remote supervisory model is used for intraoperative supervision. While some anesthesiologists take on the roles of tele-anesthesiologist supervisors to provide remote intraoperative minute-to-minute knowledge supervision of OR and procedure room anesthetics, then concomitantly, other perioperative physician anesthesiologists would apply their knowledge, wisdom, skills, and abilities to take on the out-of-OR medical and administrative perioperative responsibilities. Even then, tele-ICU technology could be applied to PACU bedside settings and tele-consultation could be provided to preoperative settings to supplement on-site providers.
If indeed we are open to designing a future of unlimited possibilities, then these considerations could engender a substantive and creative discussion about different ways to have the needed perioperative care accomplished through a variety of potential differential staffing models, rather than one size fits all. For example, institutions with a high comorbidity patient population may definitely need to have a separate on-site, preoperative/postoperative physician, with or without an additional tele-anesthesiologist as backup for when the patient throughput is high and the physically present perioperative anesthesiologist cannot be at all bedsides at once. That type of discussion could facilitate follow-up studies to address optimum staffing for preoperative/postoperative activities if a remote preoperative/postoperative tele-anesthesiology backup staffing model were to be available. Additionally, coming changes in payment methodologies may give us more leeway to consider patient acuity needs-based supervision, instead of uniform staffing patterns for every circumstance.
Other impacts of the development of tele-anesthesiology staffing capability could be that it is conceivable that surgeons at lower complexity hospitals may be willing to undertake more complex cases than they otherwise might, because of the “presence” of a tele-anesthesiologist to provide the knowledge-consultation or knowledge supervision, as the case may indicate, for the low-acuity hospitals’ anesthesiology providers. This could apply to military medical sites as well. It is also conceivable that incremental productivity benefits could accrue in anesthetizing locations of any hospital, because with tele-anesthesiology supervision capability, cases could start and transitions take place without delays caused by waiting for the arrival of a physically present anesthesiologist supervisor.
In summary, the findings of Smallman et al.1 have highlighted the large amount of “out-of-OR” tasks that supervising anesthesiologists regularly handle, which must be addressed as part of the considerations if technologically assisted, remote supervision tele-anesthesiology is to be adopted as part of an overall staffing paradigm in the future. The advantages of tele-anesthesiology systems to provide a large amount of clinically relevant information about multiple cases simultaneously to a remote supervisor, along with sophisticated decision-support software and minute-to-minute communication between supervisor and supervisee, could improve patient safety and overt/covert outcomes, as well as make a difference in supervisors’ productivity to provide quality oversight and knowledge supervision to a number of patient care sites. Tele-solutions can also be applied to preoperative and postoperative patient care locations. Exciting new considerations can be tested when this technology becomes more widely available.
Name: Patricia A. Kapur, MD.
Contribution: This author wrote the manuscript.
Attestation: Patricia Kapur, MD has approved the final manuscript.
This manuscript was handled by: Dwayne R. Westenskow, PhD.
1. Smallman B, Dexter F, Masursky D, Li F, Gorji R, George D, Epstein RH. Role of communication systems in coordinating supervising anesthesiologists’ activities outside of operating rooms. Anesth Analg. 2013;116:898–903
2. Kapur PA. Leading into the future: the 50th annual Rovenstine lecture. Anesthesiology. 2012;116:758–67
3. Lilly CM, Cody S, Zhao H, Landry K, Baker SP, McIlwaine J, Chandler MW, Irwin RSUniversity of Massachusetts Memorial Critical Care Operations Group. . Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA. 2011;305:2175–83
4. Epstein RH, Dexter F. Implications of resolved hypoxemia on the utility of desaturation alerts sent from an anesthesia decision support system to supervising anesthesiologists. Anesth Analg. 2012;115:929–33
5. Dexter F, Coffin S, Tinker JH. Decreases in anesthesia-controlled time cannot permit one additional surgical operation to be reliably scheduled during the workday. Anesth Analg. 1995;81:1263–8
6. Dexter F, Abouleish AE, Epstein RH, Whitten CW, Lubarsky DA. Use of operating room information system data to predict the impact of reducing turnover times on staffing costs. Anesth Analg. 2003;97:1119–26