In response to questions by anesthesia care providers on how to best convince those responsible for capital equipment expenditures in their institutions to fund purchase of modern anesthesia patient monitoring equipment, the following set of strategies was devised. The original recommendations referred to the malpractice insurance premium discount of 20% offered by the Massachusetts JUA to anesthesiologists who consistently use pulse oximetry and capnography as part of their compliance with the ASA Standards for Basic Intraoperative Monitoring, but the list here has been generically modified to apply nation-wide.

Strategies to Obtain Monitoring Equipment

1. The anesthesiologist should consider developing some kind of plan to avoid a fragmented, delayed request and approval process. The plan should identify the key players, particularly those individuals who have the authority to make decisions and approve the purchase of equipment. The degree of plan formality will vary from institution to institution according to the degree of resistance anticipated, i.e.; the greater the anticipated resistance, the more formal the plan.

2. The anesthesiologist alone should not attempt to secure the monitoring equipment. Traditionally, surgeons have power within the Medical Staff organization and hospital administration/corporate management group. For a surgeon, few occurrences are more devastating than performing successful surgery and then discovering that the patient has suffered a serious and/or permanent anesthesia related injury. The surgeon has a vested interest in anesthesia safety and is a natural ally. Gain the support of the Department of Surgery and other influential members of the Medical Staff.

3. The process of gaining administrative/corporate support and approval of the monitoring equipment request should be non-demanding, non-threatening and free of ultimatums. Emphasis should be on the education of management individuals who will make the decisions. The benefits, logic and importance of the monitoring equipment is self-evident and will sell itself if properly presented. Prior to initial discussions with administration/management, the anesthesiologist should provide written material designed to educate. The material should include, but not necessarily be limited to; ASA Standards, Harvard Standards, Board of Registration in Medicine Regulations if applicable, monitoring equipment information, Ward and Cheney Claim Analysis Study, and any pertinent information from the involved malpractice insurance carrier. If there is a great volume of material, consider sending it to management in two or three packets spaced several days apart. There is a greater probability of management seriously reviewing it if the quantity is reasonable and the material can be reviewed in a short period of time

4. There is a possible marketing advantage for those institutions who offer the most up-to-date clinical equipment, particularly clinical equipment designed to decrease the probability of catastrophic injury. At the very least, use of the monitoring equipment will prevent a competing institution from gaining a marketing advantas. Both patients and surgeons are very much aware of anesthesia risks and will base their decisions on where to receive or provide anesthesia care at least in part on safety factors. For institutions not providing readily available monitoring equipment, a decrease in surgical admissions is not a remote possibility. Ask anyone, including administrators and managers, “If you were to have general anesthesia tomorrow, would you want a pulse oximeter and C02 analyzer used in your anesthesia care?”

5. There will be no question that the absence of the anesthesia monitoring equipment wig adversely effect the ability of the institution to recruit anesthesiologists and CRNA!S.

6. Note in detail any possible lowered insurance premium incentives (such as in Massachusetts). At the very least, the premium discounts and eventual lowering of insurance classifications will help stabilize and/or slow the rate of increased anesthesia costs. Everyone including anesthesiologists, patients, and administration/management will benefit from the decreased cost of anesthesia care.

7. Anesthesia monitoring equipment (particularly the pulse oximeter and C02 analyzer) constitutes a safety “breakthrough” equivalent to electronic cardiac monitoring in terms of potential for preventing catastrophic outcomes of care. As no one should consider providing cardiac care without an EKG monitor, no one should consider providing anesthesia care without a pulse oximeter and C02 analyzer readily available. The cost vs. benefit equation for anesthesia monitoring equipment is highly favorable and significantly greater than the vast majority of more expensive clinical equipment commonly found in hospitals. One can always provide the benefit of something such as CAT Scan by sharing services with other hospitals, but the only way one ran provide the benefit of anesthesia monitoring equipment is to purchase or lease it.

8. It’s safe to say that all future anesthesia malpractice cases will be judged against a standard that includes pulse oximetery and end-tidal C02 monitoring. Any anesthesiologist/CRNA and hospital not using or providing such equipment will be in a very difficult situation in terms of defending themselves in any future anesthesia malpractice claim. Dr. Howard Zauder, ASA President, contends that “the courts have made the pulse oximeter a basic standard in liability litigation, even though the new ASA Standards list it only as one of several options in monitoring circulation”.

9. With increasing frequency, hospital negligence, questions of negligence, and unfortunate outcomes of care become widely known via the media. Catastrophic anesthesia injury without the use of anesthesia monitoring equipment has a higher than average probability of be-coming publicly known. Dollar loss via malpractice claim will be covered by liability insurance, but the damage to a hospital’s and anesthesiologist’s public reputation is an uncovered loss and usually takes years to repair. In many cases, it is much more serious than dollar loss because it negatively effects staff recruitment, staff morale, in-patient/out-patient census and the hospital’s relationship with accrediting and licensing agencies.

10. Anesthesiologists should seek the assistance of the hospital administration/corporate management and other anesthesiologists in exploring group/volume purchase arrangements to reduce total costs to absolute minimums.

11. Medical malpractice insurance companies’ Risk Management Services are available to assist the anesthesiologist in his/her efforts to improve anesthesia safety whenever necessary.

Mr. Cass is Manager, Risk Management Services, joint Underwriter’s Association of Massachusetts. Also participating in the development of the strategies were Mssrs. Nils Maurice and Gerald Cassidy of the JUA and Drs. Joseph Beauregard and Gerald Zeitlin.