Patient Selection for OHPs

Appropriate selection critical to help ensure patients can receive safe care

The College has developeda new standard to help physicians use their professional judgment in determining a patient’s suitability for procedures performed in Out-of-Hospital Premises (OHPs).

The process of determining a patient’s suitability to undergo a procedure in an OHP involves the complex interplay of several factors, and there can be a significant difference in the way physicians classify patients and determine which patients they consider appropriate to treat in an OHP, says Dr. Catherine Smyth, an Ottawa anesthesiologist. She sat on the working group that developed 10 standards as part of the recent modernization of the Out-of-Hospital Premises Inspection Program (OHPIP). Other standards address expectations about infection prevention and control measures, and drugs and equipment.

The Patient Selection Standard states physicians must only perform a procedure on a patient where they are satisfied the procedure can be safely and effectively performed in the OHP, and it is in the patient’s best interest to do so, taking into account:

1. The patient’s existing health status (e.g., any comorbidities, frailty, stability of any existing conditions), their specific health-care needs and the specific circumstances;
2. The potential complications that could arise from that specific procedure, including potential complications in surgical management, if more than one procedure is to be performed at a time;
3. Anesthetic or sedation factors that may place the patient at a higher risk;
4. The resources that may be required to perform a procedure on that particular patient;
5. The duration of the procedure and the potential for a prolonged recovery period; and
6. The location of the OHP and its proximity to emergency services or hospitals should complications arise from the procedure.

Dr. Smyth said the new standard is an important step forward in patient safety for OHPIP, noting the program has historically seen a number of adverse events that have resulted from inappropriate patient selection.

The Patient Selection Standard requires physicians classify patients prior to a procedure where general or regional anesthesia or sedation will be used, using the American Society of Anesthesiologists’ Physical Status Classification System, and only perform procedures on patients who are classified as ASA I, ASA II or, in some circumstances, ASA III.

Historically, the most ambiguity about appropriateness for OHP procedures has involved patients classified as ASA III — patients with severe systemic disease.

The standard states physicians must only perform procedures on patients classified as ASA III if:

1. the patient’s comorbid condition is unlikely to add significant risk to the anesthetic, sedation or procedure; and
2. the comorbid condition could not reasonably be expected to be adversely affected by the anesthetic, sedation, or procedure.

Several comorbid conditions have been demonstrated to have an effect on patient outcomes after procedures in an OHP type setting. They, therefore, need to be carefully considered in patient selection. Independent factors identified by a majority of studies include:

• Advanced age
• Morbid obesity
• Obstructive sleep apnea
• Cardiac disease
• Chronic obstructive pulmonary disease
• Diabetes mellitus
• End-stage renal disease
• Transient ischemic attack/stroke,
• Chronic opioid use or opioid use disorder, and
• Malignant hyperthermia.

While any one comorbid condition on its own may not make a patient unsuitable for care in an OHP, physicians will need to carefully consider how any of these comorbidities could put a patient at higher risk of a poor outcome in an OHP, says Dr. Smyth.

Generally, patients would be unsuitable for a procedure in an OHP if they:

• have unstable or poorly managed chronic illnesses;
• have unmanaged alcohol or substance use disorders; or
• are undergoing active immunosuppressant cancer treatment.

The Patient Selection Standard does allow room for professional judgment when it comes to determining which ASA III patients may be appropriate to have a procedure in an OHP.

It is important, however, that professional judgment in these circumstances be exercised in a considered way, said Dr. Smyth. The standard requires discussions take place between the physician who will be performing the procedure and the physician administering the anesthesia or sedation in advance. This will help to ensure both physicians have thought through the potential complicating factors of performing a procedure on the patient in the OHP setting, and both agree that it is appropriate to do so in the circumstances.

The requirement to hold such conversations in advance is intended to help physicians manage patient expectations and avoid any pressure to perform a scheduled procedure that might not be appropriate, said Dr. Smyth.