By Jeremy Wale, JD

Nearly every hospital in the United States provides some anesthesia services to patients. Most offer surgical services with general anesthesia, providing safe operative care of patients. Such services bring risk exposures, many of which you can proactively mitigate.

General anesthesia demands a patient’s airway be protected and may require a patient to be intubated. As such, related risks include, but are not limited to, dental and airway injuries and respiratory issues. Other potential risks associated with anesthesia delivery include incomplete informed consent discussions, inadequate patient monitoring, and delivery of inadequate or inappropriate medications.

Preventing Dental Injury During Anesthesia

One of the most common general anesthesia injuries is dental injury.¹ Examples include broken or chipped teeth, broken bridges, or dislodged implants. Oftentimes the anesthesiologist may not realize dental damage has occurred. It is not uncommon for cracked teeth or chipped veneers to go unnoticed until the patient detects and communicates the issue.

The patient’s dentition, emergencies, poor intubation or extubation technique, or tools used by the anesthesiologist can factor in dental injuries. Injuries most often occur “during intubation with a laryngoscope in patients where there is limited visibility to the hypopharynx.”² In fact, “50-75% of dental injuries occur during tracheal intubation.”³

Two types of patients are highest risk for dental injury: difficult patients to intubate and those with poor dentition. Difficult patients to intubate have a 20 times greater risk of dental injury.⁴ Patients with poor pre-existing dental status present a five-times greater risk of dental trauma than patients with good pre-existing dental status.

How can anesthesiologists help mitigate dental injury risk? Ensure familiarity with the patient’s general dental condition, which can help identify potential issues before they occur. This effort also may help in the event of an emergency.

Ensure the patient removes all removable appliances from his or her mouth prior to any procedure. This helps prevent damage to the patient’s appliance(s) or teeth.

A well-documented pre-anesthesia assessment of each patient’s dental condition provides an optimal start. This gives the anesthesiologist an opportunity to identify potential problems before he or she begins administering anesthesia—and to discuss those and formulate a plan to mitigate dental injury risk. Additionally, a thorough, documented informed consent discussion identifying potential issues with the patient’s dentition can be invaluable if dental injury occurs.

Likewise, a detailed pre-anesthesia assessment to evaluate the patient for difficulty of intubation will assist the anesthesiologist in avoiding dental injuries.⁵ Knowing areas of concern ahead of time aids preparedness to overcome challenges without damaging a patient’s dentition. Such an assessment is part of a comprehensive informed-consent patient discussion.

Some anesthesiologists add a dental exam to the pre-anesthesia form. That form may include a diagram of the teeth with space for anesthesiologist notations regarding potential areas for concern. This not only serves as strong documentation, but provides a good reminder to complete dental exams for each patient.

Several devices are available to minimize dental injury risk of dental injuries during general anesthesia.⁶ These devices typically are placed on or around the teeth to protect against damage. One institution, the University of Iowa Department of Otolaryngology, “has incorporated dental guards into a protocol for reducing dental injury during laryngoscopy.”⁷

Overseeing Anesthesia for Multiple Patients

In hospitals and surgery centers, it is not uncommon to have one anesthesiologist responsible for multiple patients simultaneously—supervising or consulting for multiple procedures at the same time. This typically occurs when there is a Certified Registered Nurse Anesthetist (CRNA) with each patient, and the physician anesthesiologist is responsible for supervising CRNA care.

Issues can potentially arise when the patient and/or family members are not informed of this team approach. While CRNAs generally are well qualified with specialty training and certification to administer anesthesia, patient knowledge is key. Most patients expect the anesthesiologist will be in the room for the entire procedure unless told otherwise.

If your facility uses the team-care anesthesiology approach, a thorough informed consent discussion explaining the care plan and anesthesiologist availability is advised. This discussion informs the patient and/or family members of the care to be provided and allows questions and concerns to be addressed.

Anesthesiologists Treating Chronic-Pain Patients

An emerging area of risk for anesthesiologists involves treating chronic-pain patients.

Some anesthesiologists sub-specialize in pain management, in addition or instead of traditional anesthesia services. Some patients prefer facilities that provide chronic-pain management.

Pain management presents unique risks requiring proactive assessment, direction, and mitigation. Allegations against physicians in this area can include, but are not limited to, failure to treat, accidental overdose, causing addiction, or death.

Start by assessing whether your facility has anesthesiologists and/or other physicians managing chronic-pain patients. If so, consider several important issues.

Do you have a designated area or clinic for treating chronic-pain patients?

A centralized location for treating these patients helps your facility:

1. track patients and providers; and
2. establish facility-wide policies and procedures for handling this unique medical population.

Another consideration when providing care for chronic–pain patients is whether the physician’s qualifications for appropriately treating these patients. Pain management is a growing healthcare subspecialty, due in part to a reported 100 million Americans suffering from pain.⁸ According to the American Board of Medical Specialties, pain medicine is a subspecialty of anesthesiology, emergency medicine, and family medicine.

Consider employing board-certified pain medicine specialists in your clinic to treat chronic-pain patients. These specialists’ additional education and training will help ensure your chronic-pain patients are being treated by qualified physicians.

Your facility can implement policies and procedures to help lessen potential risks of treating patients who require pain management.

A strong risk-reduction strategy may require each patient to enter into a pain management contract with the treating physician. This contract clearly and concisely outlines the physician’s expectations of the patient and may include:

• The patient agrees not to accept narcotics prescriptions from other providers.
• The patient will not give or sell narcotics to others.
• The patient agrees to refrain from using drugs not specifically authorized by the physician.
• The patient is responsible for managing his or her medication to ensure he or she doesn’t run out before scheduled visits/refills.
• The patient agrees to random drug testing.

This is not a comprehensive list for a pain management contract. Consult with your physicians and legal counsel to create a document that best fits your institution’s needs.

Consider having a policy for ending your pain-management program’s relationship with patients. While best handled on a case-by-case basis, a policy aids consistency. Situations such as illicit narcotics use, persistent missed appointments, or suspected drug diversion are more common instances that typically require action.

Also consider what to do when a chronic-pain patient enters your facility’s ED. When these patients become addicted to opioid medications, they often run out of prescriptions early, and then try to secure narcotics by visiting the ED. An integrated EHR may help notify ED physicians these patients are being treated by a pain specialist; it may further aid understanding that the patient may not receive narcotic pain medications without consulting the pain-management physician.

Lastly, depending on your state, physicians may be able to monitor chronic-pain patients’ prescription history via an electronic prescription monitoring program. Several states have implemented such programs to help fight prescription drug abuse and diversion. Depending on the state, physicians may review a patient’s prescription history or access. Be sure to review your state’s rules to understand what you may access.

It is important for patient care and hospital liability that you take steps to proactively manage the risk around your facility’s provision of anesthesia and care of chronic-pain patients. Establishing sufficient protocol and frequently checking in with staff to ensure their understanding are essential steps in effective anesthesia management.

1 Darawade D, Dubey A, Gondhalekar R, Dahapute S, et al. Assessment of the risk factors for oro-dental injuries to occur during general anesthesia and measures taken by anesthesiologist to prevent them. J Int Oral Health. 2015;7(7):77-79.

2 Darawade D, Dubey A, Gondhalekar R, Dahapute S, et al. Assessment of the risk factors for oro-dental injuries to occur during general anesthesia and measures taken by anesthesiologist to prevent them. J Int Oral Health. 2015;7(7):77-79.

3 Yasny J. Perioperative dental considerations for the Anesthesiologist. Anesth Analg. 2009;108(5):1564-1573.

4 Ribero de Sousa J, Barros Mourao J. Tooth injury in anesthesiology. Rev Bras Anestesiol. 2015;65(6):511-518.

5 Ribero de Sousa J, Barros Mourao J. Tooth injury in anesthesiology. Rev Bras Anestesiol. 2015;65(6):511-518.

6 Board Certified Otolaryngologist. American Medical Forensic Specialists Web site. http://www.amfs.com/news/articlesfrom-our-experts/dental-injuries-during-surgery/. Accessed June 3, 2016.

7 Board Certified Otolaryngologist. American Medical Forensic Specialists Web site. http://www.amfs.com/news/articlesfrom-our-experts/dental-injuries-during-surgery/. Accessed June 3, 2016.

8 IOM report. Relieving Pain in America. National Academies Press Web site. https://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research/Pain%20Research%202011%20Report%20Brief.pdf. June, 2011. Accessed June 6, 2016.

-Jeremy Wale, JD is a ProAssurance Risk Resource Advisor.