• Emergency in the ASC: Are You Prepared?

    Written By: Leslie Burling-Phillips, Contributing Writer

    This article is from October 2007 and may contain outdated material.

    The last three decades of medical and technological breakthroughs have created a shift not only in the way that medicine is practiced but where it is practiced. Less than 40 years ago, almost all surgeries were performed in a hospital. Patients commonly waited for weeks or even months to have a surgical procedure, and postsurgical recovery time lasted from days to weeks or longer. Today, more than 50 percent of all surgical procedures—nearly 10 million surgeries—are performed at ambulatory surgery centers (ASCs), and of those, ophthalmic procedures are the most frequent. Approximately one-half of the nation’s 4,000 ASCs offer some type of ophthalmic surgery.1

    Recognizing and Resolving Emergencies

    Although ASCs have a favorable record, many or most will inevitably face a decompensating patient. Medical emergencies can occur at any time—before, during or after surgery—and the staff’s ability to respond quickly and effectively may mean the difference between a welcome or very unwelcome outcome. Several types of emergencies tend to occur more frequently than others:

    • hypoglycemic crises
    • hypertension/cardiac arrhythmia/coronary ischemia
    • respiratory distress

    Prescreening equals prevention. In many cases these crises can be prevented. “Prescreening patients by taking a thorough medical history is critical. We look for red flags within the patient’s history. For example, is the patient under another physician’s care? How is their condition being managed? Does the patient smoke, have lung problems or use oxygen? Ideally, we are aware of a patient’s medical history prior to scheduling a procedure,” explained Daniel P. Shepard, MD, of the Shepard Eye Center in Santa Maria, Calif. “We frequently proceed with the surgery even though they may have a problematic history—it does not mean that they should be denied care. This information simply increases our sensitivity to observe the patient more carefully during surgery.”

    “Don’t rely on the paperwork completed by the patient,” warned Daniel C. Simonson, CRNA, MHPA, nurse anesthetist at the Spokane Eye Surgery Center in Washington state. “Nothing serves you better than having the nurse conduct a complete history with the patient upon admission. You often find things that the patient may not have indicated on their intake form.”

    Blood glucose too low? “Hypoglycemic crises typically occur when we adjust a patient’s medication in preparation for surgery. The classic story is that we advised the patient to be NPO prior to surgery and they have had nothing to eat after midnight. Yet they still take all or part of their diabetic medication and they do not have enough glucose in their system. In these cases, the patient may present with an altered mental status, appearing lethargic or becoming disoriented, even combative,” said Dr. Shepard.

    Although patients are typically not required to be NPO for most of the procedures performed at the Spokane Eye Surgery Center in Washington, Mr. Simonson occasionally encounters the same problem: “This happens more frequently than we would like . . . patients have taken insulin and not eaten despite our instructions to the contrary. In an effort to minimize this problem, we draw blood glucose from all diabetic patients who are taking insulin. If their blood sugar is low, we give them glucose or fruit juice, and the crisis is resolved.”

    Blood pressure too high? In some cases, problems related to hypertension may be remedied as easily as those with hypoglycemia. “Sometimes patients are just anxious because of the impending surgery. With these patients, their blood pressure is typically reduced when they are sedated,” explained Mr. Simonson. “There are other patients, though, whose blood pressure does not decline to a normal range. In these cases, the first factor to consider when deciding whether or not to proceed with surgery is if the patient is having symptoms—dizziness, headache or tinnitus, for example. If the patient is symptomatic, I would not proceed with the procedure but would instead refer them to their primary care physician.”

    Know Your ABCs

    Unfortunately, not all emergencies can be prevented. In these cases, “you always refer to the fundamental ABCs that are taught in CPR and advanced cardiac life support training programs—Airway, Breathing and Circulation. Make sure the patient has an open airway,” said Dr. Shepard. “Once the airway is open, make sure the patient is breathing or oxygenating. Then assess the patient’s circulation and perform any necessary resuscitation measures.”

    Creating a plan of action. There are four broad categories of emergencies that can occur in an ASC:

    • Those that can be resolved by the ASC staff.
    • Those that require a consultation with a patient’s primary care physician.
    • Those that require a consultation with an ophthalmology subspecialist.
    • Those that require the patient to be transferred to a hospital.

    Having a predetermined plan of action with personnel trained to carry out the plan and keep adequate supplies and properly functioning equipment on hand is essential for managing an emergency. “All ASCs should have a written emergency plan that delineates the specific responsibilities unique to each staff member and their corresponding skills, detailing what measures should be taken in the event of an emergency,” said Dr. Shepard.

    Time to act it out. “Mock or simulation training is far more effective than simply reviewing the plan. Local advanced cardiac life support instructors can conduct simulations with the staff,” said Dr. Shepard. “This is a great opportunity to determine whether everyone knows their roles and to verify that they all know how to respond to an emergency as it evolves. This kind of role-play allows each person to understand their responsibility and how it fits into the overall process. It also gives the team the opportunity to find any problems with the process before actually dealing with a patient. You find holes in your system before you have a patient in front of you. It’s the most realistic way to train without putting patients at risk,” Dr. Shepard explained.

    Crash Cart Goodies

    Crash carts should include these basics:

    • Dantrolene (only if general anesthesia is given)
    • Medications to treat anesthetic toxicity
    • Medications to treat hypertension and arrhythmias
    • Medications to treat anaphylactic reactions
    • Reversal agents, including naloxone hydrochloride and flumazenil
    • Oxygen, suction, Ambu bag, appropriately sized airway masks, oral or nasal airways, and tongue blades
    • EKG oscilloscope
    • Defibrillator/monitor or automated external defibrillator
    • Glucometer
    • Blood draw equipment
    • Stethoscope, sphygmomanometer
    • Pulse oximeter
    • Emergency power source

    These additional resources may be useful:

    Take a Fearless Inventory

    The selection of emergency supplies should be a reflection of an ASC’s patient population and all the contingencies detailed in the emergency plan. “At a minimum, every ASC should have a well-stocked crash cart, a monitor/ defibrillator or automated external defibrillator, positive pressure ventilation available (bag valve mask), oxygen and suction. If an ASC is using general anesthesia, dantrolene should also be kept on hand to counter malignant hyperthermia,” said Mr. Simonson. Like Dr. Shepard, he recommends that the facility conduct periodic drills. “The person designated to administer the dantrolene, for example, should know what it looks like, where to find it and how to draw it up.”

    Stock outside the box. One item that is not ordinarily part of the advanced cardiac life support protocol, but which Dr. Shepard strongly encourages an ASC to keep on hand, is a glucometer. “Considering that one of the most commonly occurring crises is hypoglycemia, it is intuitive to have a glucometer. When a patient is still conscious, a glass of orange juice will quickly bring them out of their emergency. The glucometer will confirm that the patient has a blood sugar count below 60 and, indeed, the symptoms are due to hypoglycemia,” said Dr. Shepard.

    Expired crash cart is a bad crash cart. ASCs should also have policies in place for maintaining emergency equipment and supplies.

    Outdated medication should be disposed of monthly and crash carts should be checked weekly, and always after use in an emergency. “To prevent confusion, one person should be responsible for maintaining the crash cart and emergency equipment,” said Dr. Shepard.

    Most important, staff members who will be using the supplies and equipment should be kept current on how to use them properly. “You don’t want someone who was last trained 20 years ago when they were a resident or intern to perform emergency procedures. Misusing equipment or administering medication that you are not familiar with can be a tremendous mistake and can potentially make an already serious situation worse,” said Mr. Simonson.

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    1 Etziono, D. A. et al. Ann Surg 2003;238(2):107.