To the Editor

A problem has arisen at our facility which may be common to other facilities and which might be best answered by members of the Anesthesia Patient Safety Foundation or other readers of the Newsletter

We have recently instituted an epidural program for laboring parturients. As in many settings, our program rapidly evolved from the use of intermittent bolus techniques to that of continuous infusions. While we have a diverse group of anesthesiologists, we are all basically following a similar protocol (dilute bupivicaine plus fentanyl mixture) and we have a standard set of orders drawn up for the obstetrical nurses and CRNAs to follow while the block is operative. We have found the success of the epidurals has been very high with no significant morbidity.

Recently, them have been questions posed by some of our anesthesiologists regarding the need for attendance in the facility by the physician after the block has been established and the patient has been monitored for a period of time to rule out untoward events or lack of success of the block. Since there is an in-house CRNA available at all times who is trained to handle any acute emergencies, it did appear that it might be a reasonable approach, especially at night when there are no other cases going on. Further, since we are only billing and being compensated for actual time in attendance with the patient, there would be considerable uncompensated time spent at & facility.

Our program was initiated using the ASA “Standards for Conduction Anesthesia in Obstetrics” as a basis. Unfortunately, Standard VIII specifically states that a physician shall remain in the facility until the patient is accepted in a recovery phase unit. This, in effect, proscribes the physician from leaving the facility. Yet, members of my Department say they are aware that this is not the case in many other facilities. Further, with this Standard in black and white, the hospital administration indicates that this poses an unacceptable liability risk to the facility, as well as to the physicians, and they will not allow us to leave in these situations.

My questions, therefore are. (1) With the general utilization of infusion techniques, is there any change contemplated in the stated Standard, or should there be any reason to change this Standard? (2) If my colleagues are correct that many other institutions are handling this differently, how can these facilities be practicing in accordance with ASA Standard VIII, as currently promulgated? (3) Again, if my colleagues are correct, is there, in effect, a new de facto Standard which might be replacing the existing standard? (4) If we must remain in the facility, is there any justification in seeking some monetary compensation from the Health Center for providing the availability of this service, and, is such a thing being done elsewhere? I don’t think it would be possible or reasonable to bill the patients any more than a “base” plus actual time in attendance. It would make the service prohibitively expensive to patients.) (5) Are there alternative methods which are in accordance with the existing Standards?

I would be interested in any responses to these questions.

Mark H. Zeitlin, M.D., Chairman Department of Anesthesiology Saint Vincent Health Center Erie, PA

Editor’s Note: It is this type of question and many other related questions that led to an intense review of the ASA Standards for Conduction Anesthesia in Obstetrics during 1990. Proposals for modification from the ASA Committee on Standards of Care and Obstetric Anesthesia could not he reconciled in time for approval at the October ASA Annual Meeting. Accordingly, the ASA House of Delegates eventually voted to change the existing obstetric anesthesia “Standards” to “Guidelines” for 1991 with the expectation that there will be a new proposal to consider in October, 1991. Therefore, now is the perfect time for Dr. Zeitlin and all other interested practitioners to address comments such as the above to the ASA for referral to both involved committees.