Manipulation under anesthesia (MUA) can be a useful alternative for patients who would otherwise be good candidates for manipulative therapy, especially when difficulties prevent the successful application of manipulation in the office setting. Patient-guarding behavior, abnormal adhesion formation and other factors can cause an early, unsatisfactory plateau. Performing manipulation and special stretching techniques while the patient is sedated offers the opportunity to help the patient achieve increased mobility without the interference of pain and guarding.
MUA is most commonly performed in surgical centers. The hospital is also an appropriate MUA setting, as long as the chiropractor is familiar with the hospital environment. There are facility, regulatory and political aspects that must be considered. Just as with the surgical center, hospitals require that the provider be a member of the staff with privileges in good standing. To remain in good standing, the provider needs to have all patient records up to date. Medical staff dues must be current. The medical staff office needs to maintain proof of licensure, certification and malpractice coverage. Most importantly, the provider must be privileged to perform MUA in the hospital.
The hospital maintains a privilege list, known as a delineation of privileges sheet, for all medical staff. Even though medical physicians have a plenary license that allows the performance of any medical procedure, the hospital restricts the procedures they are permitted to perform. The provider must demonstrate proficiency before the procedure is added to their privileges. Typically, the provider must perform a predetermined number of supervised procedures to demonstrate proficiency.
A chiropractor wishing to perform MUA might have to perform 10 or more MUA procedures before it is added to their delineation of privileges sheet. If MUA is new to the hospital, the chief of orthopedics might be responsible for observing the procedures. The hospital's medical executive committee needs to make bylaws changes to establish the manner in which MUA will be performed in the hospital. If MUA is established in the hospital, the chief of chiropractic is more likely to be responsible for certifying proficiency.
The chiropractor should be aware of the political climate in the hospital. The two most important aspects of politics are territory and ego. The chiropractor will not want to perform MUA on hospital patients when the diagnosis clearly indicates the need for orthopedic, neurological or pain specialty management. For this reason, it is crucial to choose only those patients who are excellent MUA candidates. There is no reason to fuel a competitive specialist's claim that the chiropractor is performing procedures on inappropriate patients. You might even hear some jealousy from a surgeon who does not like the idea of a chiropractor earning a greater fee for performing MUA than the surgeon might earn.
When proposing that MUA be performed in the hospital, the chiropractor should expect scrutiny. The hospital administration will want to know what other hospitals allow chiropractors to perform MUA. They will want to know about training, safety and reimbursement. Do not expect the hospital to be willing to be paid through arbitration. They will want you to perform MUA only for patients with insurance pre-certification. One of the most difficult aspects of making any proposal to a hospital is the possibility of having an antagonist on the medical staff. Even when the majority appears to approve, one naysayer is unfortunately predictive of a denied proposal.
MUA can be performed for the acute patient when requested by the pain specialist. Likewise, the chiropractor may be requested to perform MUA in the emergency room. The ER attending physician can summon an anesthesiologist, who will sedate the patient for the purpose of enabling a more effective manipulation. The chiropractor should obviously only perform this type of MUA if specifically privileged to do so as documented on the delineation of privileges sheet.
MUA is almost exclusively performed as an outpatient procedure. In the hospital, the chiropractor will be competing for space on the operating-room schedule. The chiropractor will obviously take care not to compete for the prime time against "the big hitters." MUA is also easier to schedule in the surgical center because all of their procedures are elective. In the hospital, you run the risk of having an MUA bumped by an emergency surgery.
While MUA is usually easier to perform in the surgical center, there is good reason to perform at least some MUAs in the hospital. In order for MUA to survive scrutiny, it must be performed in an ethical manner. Working in the hospital is like working in a fish bowl: There are no secrets. Everyone can see when a procedure is successful and when it fails. Performing MUA in this highly scrutinized environment will bring additional credibility to the procedure. The chiropractor will also have increased opportunity for interactions with a wider variety of medical specialists and members of the hospital staff. Increased networking obviously leads to greater referrals and deeper integration into the hospital setting
For more information on hospital chiropractic, visit the American Academy of Hospital Chiropractic Web site at www.hospitaldc.com.
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