Outpatient Endovascular Suites: Are They Good for the Patient or the Doctor?
Physicians administering or supervising moderate sedation/analgesia, deep sedation/analgesia, or general anesthesia should have appropriate education and training. Since hospitalization may sometimes be necessary, a protocol for transfer of the patient to the nearest hospital should also be in place.
Transfer mechanisms should include the ability to offer advanced life support. A written agreement with the receiving hospital should be mandatory. If anesthesia services are provided arrangements regarding the role of these ancillary personnel should be contracted.
High quality X-ray imaging is a prerequisite for evaluation of vascular anatomy and the safe placement of catheters, stents and other intravascular devices. The goal should be to provide the best quality device with the least radiation exposure to staff and patients. Fixed overhead units are considered to offer better images, expedited procedures and potentially less radiation but newer portable units do provide acceptable images for most applications.
However, the choice of image intensifier (fixed overhead or portable) will often be based on space as well as cost considerations. No matter which device is chosen, standard radiation safety precautions should be followed (radiation badges, monthly dosimetry reports, lead lined rooms, etc).Every attempt should be made to assure that the quality and safety of the suite is equal, or superior ,to the in-hospital facility where the surgeon would otherwise be performing these procedures.
Disposable equipment (catheters, contrast agents, angioplasty balloons etc.) should all be present in sufficient quantity and quality to allow the procedure to be performed completely and safely. Strict inventory review must be done on a scheduled basis. There should be sufficient room to perform procedures from the neck, brachial, femoral or distal leg positions. Monitoring equipment including blood pressure, oxygenation, EKG etc should be present.
A regular maintenance program for all equipment must be in place. Satisfactory post-procedural areas should be available and staffed with protocols in place to reach the treating surgeon should an emergency occur. The treating surgeon must be available for a rapid response to unexpected complications that may be life or limb-threatening.
Standard precautions to protect patient confidentiality must be followed and all city, state or federal regulations governing these suites should be observed. Compliance with federal statutes such as the Anti-Kickback law and Stark law as well as individual State requirements must be in place
Physicians who own or lease these endovascular suites must assume an active role in managing the facility. This can result in increased productivity, quality and efficiency but can also result in real or perceived conflict of interest due to increased utilization and compensation.
However, the simplistic implication that physician ownership leads to increased utilization ignores the complexities involved in decision making that include multiple regulatory policies and clinical, non-financial, incentives. Irrespective, the vascular surgeon who receives remuneration for managing or owning the suite should fully disclose this arrangement to the patient or involved parties. Such relationships should be fully transparent to all stakeholders and comply with Federal and State statutes. Ultimately, the patient should be given the opportunity to decide on the location where they are to have the planned procedure.
In summary, then, we believe that many endovascular procedures can be safely performed in outpatient endovascular suites and that this can result in benefits for patient and surgeon. The author's support SVS members' use of these suites, regardless of ownership, as long as potential conflicts of interest are fully disclosed to the patient and provided that high quality care is provided safely and cost effectively.
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