Meena Desai, MD, managing partner of Nova Anesthesia Professionals, discusses what to expect from an anesthesia provider in an ambulatory surgery center — and how to evaluate performance on an ongoing basis.
1. ASC experience. First and foremost, ASC anesthesia providers should come to the center with ASC experience, Dr. Desai says. The culture of an ASC is very different from a hospital, and behavior that would be acceptable at a hospital can derail the relationships, finances and clinical quality of a surgery center. "We work in the ASC environment really hard and fast, and we do it with no extra staff or new toys," Dr. Desai says. "Hospital anesthesia people are not used to helping themselves because they've got extra staff to help them." She says anesthesiologists with ASC training are forced to be more resourceful, flexible and confident with their skills because they often work alone.
2. Positive impact on the bottom line. Anesthesiologists can positively impact the bottom line at a center by improving efficiency, Dr. Desai says. "Are they constantly waiting to complete a task before they start another task?" she says. "Are you always waiting for them to do a block during OR time?" She says ASC leaders should talk to staff members and anesthesia providers about where the most time is wasted during the surgical encounter.
For example, a staff member might have to stand around while an anesthesiologist performs a pre-op evaluation and looks at charts for the first time — tasks that should be performed prior to the surgical encounter. If a one-room center is doing an orthopedic day and needs a block for a shoulder case, that case should be scheduled first so the block is placed before OR time starts. Anesthesiologists can participate in this discussion and determine how to streamline these activities so no one is left standing idly.
3. Relatively quick room turnovers. Benchmark your room turnover times and expect anesthesiologists to help stay relatively close to that benchmark, depending on the type of case they are working. Dr. Desai says in a GI suite, turnover times should average about 7-8 minutes; in a multi-specialty ASC, turnover might be as high as 12 minutes. "If you're way over that — and it could be due to many, many factors — anesthesia should help play a role in fixing that," she says. The ASC leaders can also look from practitioner to practitioner to determine whether one anesthesia provider contributes to higher turnover times than the others.
4. Attention to drug and disposable lists. Anesthesiologists should help you streamline the drugs and disposables you use, Dr. Desai says. "We don't usually keep five sizes of endotracheal tubes, and anesthesiologists should help you [narrow that number down]," she says. "You can go with one brand of drug and try generic if you can, unless there's a new proven reason to try the latest thing."
She recommends asking anesthesiologists to sit down with a list of drugs and disposables and determine which providers spend the most money on supplies. In this discussion, anesthesia providers may discover their rationale for using a particular supply is faulty. For example, an anesthesiologist may want to use a more expensive drug that saves a few minutes in the operating room. But unless the ASC is able to schedule another case because of the extra time, the drug may not be worth the additional cost.
5. Playing on the "ASC team." Your anesthesiologists should be on the "ASC team" — not the practice team or the hospital team, Dr. Desai says. "There are many ways their participation can be helpful in the surgery center," she says. "For instance, there are a lot of drug shortages, and you need to know how to accommodate them on short notice. Do the anesthesia providers care about any of the issues that actually affect you, and do they accommodate those issues if possible?"
Anesthesiologists should demonstrate a vested interest in the success of the ASC — an interest that goes beyond working hours, Dr. Desai says. For instance, some surgery centers must now buy end-tidal CO2 monitors to comply with new regulations. "Perhaps the surgery center doesn't need the $5,000-$6,000 monitor and can use the handheld monitor instead," Dr. Desai says. "This lets you comply with regulations while saving money." In this case, your anesthesia providers should be able to tell you whether the more expensive monitors are necessary.
6. Designated group leader. Your surgery center anesthesia group should designate a leader to act as a liaison between the anesthesiologists and the surgery center. This leader should be a "people person," because anesthesiologists interact very differently with surgeons, ASC administrators and staff members. The leader should understand the nuances of each relationship and act as an informational source when someone has a question.
Once the anesthesia leader has been chosen, that leader can assign anesthesiologists within the group to head other projects. For example, one anesthesiologist might have a particular expertise on brand name versus generic drugs, meaning he or she should head a committee to decide drug purchases.
7. Consistency among anesthesiologists. Anesthesiologists should work to reduce variability from one provider to another, Dr. Desai says. This kind of consistency promotes better clinical quality and reduces cost. For example, using the same selection criteria for all patients will ensure the ASC does not treat patients who must be admitted to the hospital. If anesthesia providers agree to use the same equipment and items, the ASC can save money on more expensive supplies and achieve better contracts by buying in bulk. Anesthesiologists should sit down as a group and hash out these issues, and benchmarking data on clinical quality and supply costs should demonstrate this consistency.
8. Proactive attitude toward regulatory and technological changes. Every year, regulatory changes and technological advancements alter the way physicians treat patients. If your ASC anesthesiologists sat down and created a patient criteria list last year, the list may be outdated by now. "Many things have changed between last year and this year, and you need to make sure someone is looking at that and determining that what you're doing is relevant and appropriate today," she says. Anesthesiologists should review ASC anesthesia policies on a yearly basis at minimum and advise ASC leaders on policies, equipment purchases and selection criteria.
9. Commitment to thorough patient selection. Dr. Desai strongly believes that pre-operative patient selection and screening is the only way to avoid undue cancellations at a surgery center. She says this process should start with the surgeon's office, so schedulers do not book the wrong patients in the first place. "We in-service the surgeon's office every six months and go over anything that's changed or anything they're missing," she says. "For instance, who has come through in the last six months who shouldn't have come through?"
She says it's much easier to catch these patients at the scheduling point than to cancel a case because a patient's neck is too thick or their body weight is too high. She says anesthesiologists should go over patient selection criteria and determine which patients are appropriate for surgery at the ASC.
10. Low rate of unplanned hospital admissions. Dr. Desai says surgery center anesthesia providers should be expected to keep the rate of unplanned hospital admissions low. "You want to fall less than the national rate, and that rate is very small for ASCs," she says. "Unplanned admissions can result from any post-operative complication that would require monitoring overnight or hospitalization." She says unplanned admissions can be caused by a variety of factors, including surgical factors — bleeding, perforation or a surgical complication — and anesthesia factors — aspiration, chest pain, shortness of breath or low oxygen saturation.
She says most unplanned admissions can be avoided through thorough patient selection. If your surgery center is seeing more unplanned admissions than usual, dig down and determine the cause. "It might not be because of the anesthesia, but you need to know," she says.
Related Articles on Anesthesia:
Anesthesia Residents Approve of Tablet Devices
Spinal and Local Anesthetics Shorten EVAR Length of Stay
Somnia Anesthesia's CMO Comments on Misconceptions of Propofol
1. ASC experience. First and foremost, ASC anesthesia providers should come to the center with ASC experience, Dr. Desai says. The culture of an ASC is very different from a hospital, and behavior that would be acceptable at a hospital can derail the relationships, finances and clinical quality of a surgery center. "We work in the ASC environment really hard and fast, and we do it with no extra staff or new toys," Dr. Desai says. "Hospital anesthesia people are not used to helping themselves because they've got extra staff to help them." She says anesthesiologists with ASC training are forced to be more resourceful, flexible and confident with their skills because they often work alone.
2. Positive impact on the bottom line. Anesthesiologists can positively impact the bottom line at a center by improving efficiency, Dr. Desai says. "Are they constantly waiting to complete a task before they start another task?" she says. "Are you always waiting for them to do a block during OR time?" She says ASC leaders should talk to staff members and anesthesia providers about where the most time is wasted during the surgical encounter.
For example, a staff member might have to stand around while an anesthesiologist performs a pre-op evaluation and looks at charts for the first time — tasks that should be performed prior to the surgical encounter. If a one-room center is doing an orthopedic day and needs a block for a shoulder case, that case should be scheduled first so the block is placed before OR time starts. Anesthesiologists can participate in this discussion and determine how to streamline these activities so no one is left standing idly.
3. Relatively quick room turnovers. Benchmark your room turnover times and expect anesthesiologists to help stay relatively close to that benchmark, depending on the type of case they are working. Dr. Desai says in a GI suite, turnover times should average about 7-8 minutes; in a multi-specialty ASC, turnover might be as high as 12 minutes. "If you're way over that — and it could be due to many, many factors — anesthesia should help play a role in fixing that," she says. The ASC leaders can also look from practitioner to practitioner to determine whether one anesthesia provider contributes to higher turnover times than the others.
4. Attention to drug and disposable lists. Anesthesiologists should help you streamline the drugs and disposables you use, Dr. Desai says. "We don't usually keep five sizes of endotracheal tubes, and anesthesiologists should help you [narrow that number down]," she says. "You can go with one brand of drug and try generic if you can, unless there's a new proven reason to try the latest thing."
She recommends asking anesthesiologists to sit down with a list of drugs and disposables and determine which providers spend the most money on supplies. In this discussion, anesthesia providers may discover their rationale for using a particular supply is faulty. For example, an anesthesiologist may want to use a more expensive drug that saves a few minutes in the operating room. But unless the ASC is able to schedule another case because of the extra time, the drug may not be worth the additional cost.
5. Playing on the "ASC team." Your anesthesiologists should be on the "ASC team" — not the practice team or the hospital team, Dr. Desai says. "There are many ways their participation can be helpful in the surgery center," she says. "For instance, there are a lot of drug shortages, and you need to know how to accommodate them on short notice. Do the anesthesia providers care about any of the issues that actually affect you, and do they accommodate those issues if possible?"
Anesthesiologists should demonstrate a vested interest in the success of the ASC — an interest that goes beyond working hours, Dr. Desai says. For instance, some surgery centers must now buy end-tidal CO2 monitors to comply with new regulations. "Perhaps the surgery center doesn't need the $5,000-$6,000 monitor and can use the handheld monitor instead," Dr. Desai says. "This lets you comply with regulations while saving money." In this case, your anesthesia providers should be able to tell you whether the more expensive monitors are necessary.
6. Designated group leader. Your surgery center anesthesia group should designate a leader to act as a liaison between the anesthesiologists and the surgery center. This leader should be a "people person," because anesthesiologists interact very differently with surgeons, ASC administrators and staff members. The leader should understand the nuances of each relationship and act as an informational source when someone has a question.
Once the anesthesia leader has been chosen, that leader can assign anesthesiologists within the group to head other projects. For example, one anesthesiologist might have a particular expertise on brand name versus generic drugs, meaning he or she should head a committee to decide drug purchases.
7. Consistency among anesthesiologists. Anesthesiologists should work to reduce variability from one provider to another, Dr. Desai says. This kind of consistency promotes better clinical quality and reduces cost. For example, using the same selection criteria for all patients will ensure the ASC does not treat patients who must be admitted to the hospital. If anesthesia providers agree to use the same equipment and items, the ASC can save money on more expensive supplies and achieve better contracts by buying in bulk. Anesthesiologists should sit down as a group and hash out these issues, and benchmarking data on clinical quality and supply costs should demonstrate this consistency.
8. Proactive attitude toward regulatory and technological changes. Every year, regulatory changes and technological advancements alter the way physicians treat patients. If your ASC anesthesiologists sat down and created a patient criteria list last year, the list may be outdated by now. "Many things have changed between last year and this year, and you need to make sure someone is looking at that and determining that what you're doing is relevant and appropriate today," she says. Anesthesiologists should review ASC anesthesia policies on a yearly basis at minimum and advise ASC leaders on policies, equipment purchases and selection criteria.
9. Commitment to thorough patient selection. Dr. Desai strongly believes that pre-operative patient selection and screening is the only way to avoid undue cancellations at a surgery center. She says this process should start with the surgeon's office, so schedulers do not book the wrong patients in the first place. "We in-service the surgeon's office every six months and go over anything that's changed or anything they're missing," she says. "For instance, who has come through in the last six months who shouldn't have come through?"
She says it's much easier to catch these patients at the scheduling point than to cancel a case because a patient's neck is too thick or their body weight is too high. She says anesthesiologists should go over patient selection criteria and determine which patients are appropriate for surgery at the ASC.
10. Low rate of unplanned hospital admissions. Dr. Desai says surgery center anesthesia providers should be expected to keep the rate of unplanned hospital admissions low. "You want to fall less than the national rate, and that rate is very small for ASCs," she says. "Unplanned admissions can result from any post-operative complication that would require monitoring overnight or hospitalization." She says unplanned admissions can be caused by a variety of factors, including surgical factors — bleeding, perforation or a surgical complication — and anesthesia factors — aspiration, chest pain, shortness of breath or low oxygen saturation.
She says most unplanned admissions can be avoided through thorough patient selection. If your surgery center is seeing more unplanned admissions than usual, dig down and determine the cause. "It might not be because of the anesthesia, but you need to know," she says.
Related Articles on Anesthesia:
Anesthesia Residents Approve of Tablet Devices
Spinal and Local Anesthetics Shorten EVAR Length of Stay
Somnia Anesthesia's CMO Comments on Misconceptions of Propofol