Balancing peri-operative anaesthesia: Financial efficiency and quality surgical outcomes

Enhancing operating room efficiency by optimising the use of healthcare resources is a crucial role invariably and effectively played by the anaesthesiologists throughout the globe in general and the developing countries in particular. The overall operative cost gets significantly impacted by various peri-operative decisions made by the anaesthesiologists, including pre-operative optimisation, anaesthetic technique, monitoring, airway management, and post-operative analgesia.[1] It places an additional responsibility on the shoulders of the attending anaesthesiologist to ensure cost-effectiveness without compromising the quality of care and overall outcomes and striking a balance between responsible resource utilisation and high-value peri-operative care which extends beyond cost reduction in improving patient outcomes. It necessitates an ethical and evidence-based judicious use of limited healthcare resources, which includes but is not limited to investigations, drugs, disposables, medical gases, monitoring equipment, blood products, and human resources, without compromising the patient safety.[2]

So, what is the right approach and time in achieving peri-operative financial efficiency? The answer to it lies somewhere in between peri-operative financial efficiency planning during the pre-operative period, a thorough pre-operative assessment and patient optimisation which can certainly improve surgical outcomes and reduce peri-operative complications, and thereby the need for intensive care admissions. Ordering pre-operative investigations based on the individual patient’s needs and clinical status rather than routine bulk testing for everyone is a key step in ensuring such results.[3] Pre-operatively, inter-departmental discussion can be decisive if the type of anaesthesia, equipment, drugs, and other consumables anticipated for use are finalised and meticulously planned with all the stakeholders so as to avoid wastage and thereby reduce the costs associated with the anaesthesia management.[4]

However, the real challenge of optimal use of resources lies in the operation theatre arena where even small equipment-related issues sometimes can lead to significant delays and cancellations, eventually reducing the operating room efficiency and increasing the cost to the hospital and the patient.[5] Anaesthesiologists should ensure regular maintenance and quality checks of equipment, delegating responsibilities to technicians and nurses, and overall personal supervision to avoid critical situations as these are the strong attributes associated with the anaesthesia specialty. If avoiding single-use devices can reduce the cost, then procurement of drugs, consumables, monitoring devices, and specialised equipment should also be based on projected surgical workload and shelf life rather than routine overstocking. Nothing can match the meticulous planning and indenting of the precise drugs and equipment as per requirement for each surgical procedure in avoiding the wastage and enhancing optimal use of precious resources.[6]

An individualised, evidence-based approach that takes into account patient physiology, post-operative analgesic requirements, institutional competence, and available resources precisely determines the adoption of the best anaesthesia technique, thereby improving clinical and operational efficiency. Regional anaesthesia has continuously been linked to lower costs because of its additional benefits, such as lower opioid consumption, shorter hospital stays, and faster mobilisation.[7] Availability of a dedicated block room to perform regional techniques can further improve operating room utilisation by avoiding unnecessary delays and increasing case turnover. The debate on the type of anaesthesia, inhalational versus total intravenous anaesthesia (TIVA), is never ending and can be overcome to some extent by adopting a patient-specific, individualised approach with an emphasis on patient safety and quality of recovery. Studies may have shown that TIVA is associated with increased initial costs of consumables such as syringes and pumps, but it is also linked to less post-operative vomiting, improved recovery, and shorter hospital stays which ultimately offset the initial costs.[8]

Intra-operative strategies like low-flow/minimal-flow anaesthesia not only reduce costs but also reduce environmental pollution. Low-flow anaesthesia is a very effective, proven method to reduce anaesthesia gas expenses, especially in prolonged surgeries, with the added benefit of a positive impact on the environment.[9,10] In one of the research articles published in the current issue of the Indian Journal of Anaesthesia, the authors have concluded that using minimal-flow anaesthesia significantly reduced the total anaesthetic consumption without altering the patient recovery characteristics. This approach effectively lowered the carbon footprint of the surgical procedure and offered the added advantage of reduced overall cost.[11]

Traditionally, we believe in prior preparation of drugs in the operating room as an essential measure for patient safety, but choosing patient-specific approaches can significantly avoid indiscriminate preparation and thereby reduce wastage of resources. Overall, in many of the tertiary care centres, some degree of drug wastage is inevitable to ensure patient safety and preparedness for unforeseen intra-operative events. However, implementing strategies focussing on patient-specific drug preparation protocols, using multi-dose vials, and considering sterile trays for the reuse of unopened drugs can significantly avoid wastage.[12] The success of these policies depends upon the proper utilisation of anaesthesia and surgical department services in the meticulous documentation of peri-operative resource consumption, including drugs, disposables, and equipment, both pre- and post-operatively. Where institutional policy permits, unopened and unused drugs or consumables should be returned to the pharmacy, with appropriate documentation, to minimise costs and preserve valuable healthcare resources. Nowadays, various medical insurance schemes, both public and private, including Ayushman, launched by the Government of India, also necessitate, directly or indirectly, the judicious use of available resources so as to maintain the operational and financial adequacy.

In the post-operative period, mandatory rounds by the anaesthesiologists and proper instructions to nursing staff can avoid unnecessary indenting of drugs and consumables, especially in the first 24 hours besides ensuring the patient safety and quality of recovery.[13] For proper implementation, the surgical team should also be informed and taken into confidence of the specific post-operative orders from the anaesthesia side to ensure adherence. Maintenance of records in the wards to ensure proper handover and transfer of drugs by the operative staff to the ward nurse is a definite measure in avoiding wastage of resources.

Providing cost-effective peri-operative care requires continuous efforts to improve quality through regular audits every 3 to 6 months by a team led by an anaesthesiologist to ensure strict maintenance of record keeping and documentation and accountability with an emphasis on operating room utilisation, drug wastage, equipment performance, and healthcare costs.[14]

Enhanced Recovery After Surgery (ERAS) programmes have emerged as one of the most cost-effective peri-operative strategies. Effective coordinated multi-disciplinary implementation of these programmes can possibly result in reduced post-operative morbidity, shorter hospital stays, improved patient satisfaction, and significant cost savings to both the patient and the hospital.[15,16] The principles related to personalised anaesthetic care and precision anaesthesia with emphasis on patient-specific factors, including genetics, overall health, physiological status, and individual drug responses when combined with advanced monitoring and predictive tools, definitely help in optimising anaesthesia, maintenance of stable haemodynamic parameters, improving pain management, and supporting a faster recovery. Also, the advent and penetration of artificial intelligence, machine learning, wearable monitoring devices, and digital peri-operative platforms in the medical field have greatly helped in identifying high-risk patients, monitoring of physiological changes in real time, improving operating room scheduling, optimising inventory management, foreseeing maintenance of anaesthesia workstations, and predicting post-operative complications.[17,18] Having said this, the financial constraints in low- and middle-income countries definitely create a barrier in achieving financial efficiency and maintenance of high-quality peri-operative care. Thus, education in healthcare economics and biomedical equipment management helps anaesthesiologists become effective peri-operative physicians who balance high-quality patient care with responsible use of resources. Training in the efficient management of resources should be incorporated into the teaching curriculum for trainees so that these skills are inculcated at a very early stage in their careers.[19]

Financial efficiency is achieved not by simply cutting costs but by providing the best possible care through the responsible use of resources and appropriate, environmentally sustainable technology. Easier said than done, but it is challenging to execute at the ground level due to multiple barriers including institutional protocols and culture, subjectivity in clinician behaviour, procurement policies, or even lack of awareness. It cannot be achieved rapidly, but with regular adherence to customised individual patient care protocols as well as daily vigilance for the first few weeks, we can definitely achieve financial efficiency in anaesthesia practice. Moreover, the commitment to improve financial efficiency and quality peri-operative care rests not only with anaesthesiologists but also with everyone in the team, including surgeons, nurses, and technicians. Thus, anaesthesiologists are in a unique position to spearhead this shift towards sustainable, value-based healthcare, and financial stewardship should be regarded as a quality indicator of peri-operative care.

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