The end of the twentieth century was not an easy time for the UCSF Medical Center at Mount Zion. In December 1999, in the wake of a troubled merger with Stanford, the center closed its inpatient service, emergency room and intensive care unit (ICU). “Most surgery was transferred overnight to Moffitt (the UCSF Medical Center at Parnassus),” says Bill Shapiro, MD, the chief of anesthesia at Mount Zion. Four operating rooms remained open, but service was limited to ambulatory surgery and 23-hour stays.
In April 2000, however, the merger with Stanford ended. In July 2001, Mount Zion revived its inpatient service by providing limited low acuity surgery for a strictly defined patient population, mostly patients with breast and thyroid cancer. In the ensuing years, as Mount Zion’s reputation for high quality surgical oncology has grown – it’s the only NIH-funded Comprehensive Cancer Center in northern California, according to the National Cancer Institute – the services at Mount Zion have steadily expanded. (It doesn’t hurt that the facility has also proven to be efficient and profitable.)
In July 2003, with the leadership from our department, Mount Zion reopened its ICU, signaling change to patients of a higher acuity. Since then, many types of surgery have been transferred from Moffitt, including gynecological cancer, urological cancer, and some colorectal, orthopedic, and head and neck cancer. All eight operating rooms are back in service and the facility has grown to 85 inpatient beds, including seven in the ICU. “And there are plans to increase the number of operating rooms, expand the ICU, increase the number of medicine patients, and expand the pain management service,” says Shapiro.
The Department of Anesthesia, which never left Mount Zion, has played an instrumental role in the center’s resurgence. “Working collaboratively with other specialties here, we’ve been intimately involved in the planning and implementation of Mount Zion’s expansion,” says Shapiro.
Providing Service, Leading Units
Today, the Department of Anesthesia and Perioperative Care either leads or is vitally involved in delivering most of the key services at Mount Zion. It provides 24/7 emergency coverage for the entire location – both the hospital and cancer center. It runs the Prepare (pre-operative) Clinic. It staffs the operating rooms with faculty, residents, and certified registered nurse anesthetists (CRNAs). It oversees the ICU and Acute Pain Service. “We take care of patients before, during, after, and long after surgery,” says Pamela Palmer, MD, PhD, director of the UCSF Mount Zion Acute Pain Service, as well as the director of UCSF PainCARE (Center for Advanced Research and Education).
The department also provides anesthesia for in-vitro fertilization at the women’s health center. In addition, until quite recently anesthesiologists were the only physicians on duty overnight at Mount Zion. (In 2006, a hospitalist and a surgical resident began sharing that responsibility.)
Finally, anesthesiologists at Mount Zion are beta testing the electronic anesthesia record – Picis – for the entire UCSF Medical Center. “We’re helping to make the electronic anesthesia record happen,” says Spencer Yost, MD, who became Medical Director of the ICU in 2005. His hope is that as Picis becomes more fully integrated with the hospital database, its use will free anesthesiologists to focus even more attention directly on patient care. Recently, clinical research (i.e. clinical trials) has become increasingly common at Mt. Zion.
Growth Brings Challenges
Despite all the positives in Mount Zion’s resurgence, the growth raises new challenges for the all of the providers there. For example, says Yost, “Even though there is a fair amount of thrombosis associated with cancer, we don't do vascular surgery here.”
From an anesthesiologist’s perspective, “We do a lot of high-level anesthesia and pain management here: peripheral nerve blocks, implant pumps and stimulators, thoracic epidurals,” says Palmer. Such procedures could support a broader range of surgery, she notes, such as neurosurgery, but there are no neurosurgeons at Mount Zion, and the radiology resources are limited.
There are efforts underway to enhance some of those resources – radiology recently added new equipment – but at this point Mount Zion is not designed to be a full-service hospital. Not only is there no emergency room or cardiac cath lab, but as noted above certain surgeries – neurosurgery and thoracic surgery among them – are presently better suited to the resources at the Parnassus campus.
In his seven-bed ICU, Yost sees firsthand the difficulty of reconciling the desire to expand services and the potential challenges it raises. “Our ICU is designed for short-stay-type patients,” he says. The reason is simple: if a majority of the patients had longer term needs, there would be few beds available in the ICU, which in turn could present new challenges for a busy surgery schedule. Though he recognizes the recent return of internal medicine patients to Mount Zion as a step forward, Yost is concerned that they might also present new challenges.
He certainly understands how a high throughput ICU could cause frustrations for some physicians, but at least for now believes it simply speaks to the reality of how Mount Zion has evolved. “We contribute a different subset of the whole UCSF ensemble,” he says. “And I would argue that because we’re small, focused, and efficient we deliver extremely high-quality care.” Yost, who splits his time between Mount Zion and the Parnassus campus, notes that Mount Zion has done a good job of keeping the anesthesia care consistent between the two facilities. “Modes of mechanical ventilation, beta adrenergic blockade, and other clinical protocols are all performed in the same manner,” he says.
“There also might be more continuity of follow-up here,” says Palmer. “For example, when I’m rounding on the acute pain service…if patients live nearby and have longer term cancer pain issues we can follow-up with them in the pain management clinic.” Something like that is not necessarily available in other settings.
The Entire Spectrum of Pain Management
Because the bulk of Mount Zion’s caseload is surgical oncology, pain management is another place where anesthesiologists, with their expertise in invasive pain management, assume the major role. “Cancer pain can change by the day and can feel like a sign to the patient that they’re dying,” says Palmer. “It causes acute suffering and depression. That’s why we have a drop-in policy for cancer patients and why we’re very aggressive in treating their pain.”
Palmer notes that even beyond cancer pain, pain management has grown in importance over the past few years. Pain is now known as the fifth vital sign; in the U.S. alone 25 million people suffer from acute pain, while another 50 million endure chronic pain. “People are dying in pain,” says Palmer. “All physicians should be pain experts.”
Unfortunately, there are many gaps in providers’ understanding of how to manage pain. Palmer offers as an example the fact that while JCAHO has mandated that every facility have a pain resource nurse, many who take these jobs have no formal training in pain management. To respond to this type of need, Palmer and her colleagues have developed two important initiatives.
The first is the ChaMPS (Challenges of Managing Pain Symposium) lecture series, for which participants can earn continuing medical education (CME) credits. Held the first Thursday of every even month at Mount Zion, the series brings in expert speakers to talk about pain management.
The second initiative is UCSF’s first online program in pain management. Beginning in September 2005, Dr. Palmer and colleagues began offering a postgraduate certificate in pain management online to clinicians around the world. Offered in collaboration with the University of Sydney and University of Edinburgh, Dr. Palmer serves as the faculty director for a course that, according to its brochure, “contributes to improved patient outcomes globally by providing clinically relevant postgraduate education in the sciences, concepts, and procedures for pain management within the context of today’s multidisciplinary patient care team.”
Prepare Clinic More Than Doubles Its Patient Numbers
On the front end of the Mount Zion treatment spectrum, the hospital has an outstanding Prepare (i.e. Preoperative) Clinic that has grown right along with the growth of the hospital. In the last few years, a team of nurse practitioners and consulting attending physicians – always an anesthesiologist – has gone from seeing an average of 11 patients per day to between 26 and 28.
Christopher Hatch, MD, is the director of the Prepare Clinic, having taken over from Daniel Swangard, MD, the original director. “At Mount Zion, we see a lot of older cancer patients with multi-organ disease,” says Hatch. “Ideally, we see them a couple of days ahead of time…we want to have a global focus, look at co-morbidities and the various issues and complications that can arise from the stress of surgery.”
Hatch believes that anesthesiologists are the ideal perioperative caregivers. “We’re well-versed in the goings-on of the perioperative period and, aside from surgeons themselves, we’re the most familiar with the surgical environment, so we’re a good go-between among consulting specialties and surgical specialties,” says Hatch.
Expanding a Vibrant Teaching and Clinical Research Program
Even with their clinical demands at Mount Zion, anesthesiologists there also have maintained an active teaching and clinical research program. Shapiro notes that many important studies about patient care have emerged from the clinical research at Mount Zion – and that the program is continuing to build.
For example, Rachel McKay, MD, and Jackie Leung, MD, MPH, have completed research at Mount Zion; Jim Caldwell, MD, Pekka Talke, MD, and Yost are poised to begin studies there. The researchers have studied or will study everything from recovery time for outpatient surgeries to the effect of different anesthetics on cardiac function, post-surgical delirium among older patients, reversing neuromuscular blockades, and using adenosine as a “pre-emptive analgesic” for reducing post-operative pain.
“Our department has also recruited a nationally renowned anesthesiologist and clinical researcher, Christian Apfel (MD, PhD),” says Shapiro. Apfel’s work on post-operative nausea and vomiting has made a significant contribution to improving the effects of anesthesia on patients.
Is the Role of Anesthesia at Mount Zion a Model?
Anesthesia’s nearly ubiquitous presence is, perhaps, unusual in a modern hospital, but it has historical roots in the closing and reopening of key services at Mount Zion. When the emergency room and ICU closed in 1999, the internal medicine staff was all transferred as well. “Without them being here, we were front and center,” says Dr. Yost.
Shapiro points out that Jeffrey Katz, MD, who in 1990 became the first Chief of Anesthesia at Mount Zion in the UCSF era, also has played a significant role. He remained as chief until becoming the Clinical Director of Anesthesia services at Moffitt. Currently, Katz is the Perioperative Director of the Moffitt and Mount Zion operating rooms. “Jeff’s previous experience as Chief of Anesthesia at Mount Zion helps me personally,” says Shapiro. “And I know his prior experience at Mount Zion helps the Medical Center make good decisions regarding Mount Zion's current and future challenges.”
In addition, Palmer believes there are historical roots outside of the facility’s particulars that argue for more frequent use of anesthesiologists to do things like run operating rooms and ICUs. For example, code blue situations make anesthesiologists’ airway and ventilation expertise particularly important. And, she says, “When people are in trauma, in surgery, we’re the experts in regulating levels of consciousness, decreasing pain, keeping them breathing, and keeping their blood circulating.”
In the end, however, Shapiro believes the role anesthesia has played and continues to play at Mount Zion has worked well, in large part because of the collaborative nature of the entire staff. “It’s the communication and shared responsibility of everyone here that’s created such a smooth-running facility,” he says.
This story first appeared in the 2006 V4.1 issue of Anesthesia News.