Charles J. Militana, MD, director of ambulatory surgery centers for North American Partners in Anesthesia and director of anesthesia for Dorothy and Alvin Schwartz Ambulatory Surgical Center, North Shore University Hospital, Manhasset, N.Y., discusses six priorities for anesthesiologists practicing in ambulatory surgery centers.
1. Tools to provide appropriate ambulatory anesthesia care. Dr. Militana says to provide excellent anesthesia care in a surgery center, anesthesiologists must be equipped with the necessary tools. "Taking care of ambulatory patients is quite different than taking care of patients who will have a prolonged recovery room stay or who are expected to stay overnight," he says. "This requires unique skills and unique tools."
For example, ASC anesthesiologists often perform regional techniques using ultrasound guidance for shoulder arthroscopies and anterior cruciate ligament repairs. The ASC would therefore need an ultrasound machine to perform regional blocks to provide the highest standard of care for those patients.
2. Freedom for anesthesiologists to act as 'perioperative providers.' Anesthesiologists can play a crucial role in the perioperative process by leading pre-surgical testing and overseeing post-anesthesia care, Dr. Militana says. For example, anesthesiologists can help identify which patients are at risk for nausea and vomiting or have cardiac or pulmonary issues prior to surgery. They can also improve PACU care by planning for effective pain management after surgery through the use of regional anesthetics and using preemptive analgesia protocols and appropriate analgesics postoperatively.
He says anesthesiologists are important to the perioperative process because they can tailor the surgical experience to each individual patient. "Throughout the whole process, from pre-surgical testing through the intra-op and post-op period patients should be getting individualized patient care," he says. "They should feel like they're the only one you're taking care of on that particular day, even though they know that may not necessarily be the case.”
3. Ability to cancel cases if medically necessary. When asked if anesthesiologists should have the ability to cancel cases when patients are inappropriate candidates for ambulatory surgery, Dr. Militana says, "Without a doubt." He says his surgery center has always given anesthesiologists the authority to cancel surgery if necessary.
"We approach it with the belief that we are the patient's advocate," he says. "Sometimes we have to take heat for it, but it's in the best interest of the patient." ASC administrators should explain to physicians and staff that anesthesiologists have the authority to cancel cases and review case cancellations after the fact to determine whether they could have been prevented.
4. Efficient, effective pre-surgical testing process. Dr. Militana says anesthesiologists should be placed in charge of developing pre-surgical testing policies to ensure an effective, efficient overview of patient conditions. "You want to minimize the same-day cancellation rate," he says. "The last thing you want is a patient to go through the process and have the surgeon and ambulatory staff members there, and then have the case canceled because something fell through the cracks during the pre-surgical testing process." He says same-day cancellations eat into profits and damage patient and provider satisfaction.
Pre-surgical testing processes should identify patients at higher risk for specific conditions such as nausea and vomiting, cardiac or pulmonary complications, as well as those patients that would most benefit from a pre-emptive analgesia protocol. "Pre-emptive analgesia is very important with respect to controlling patient pain post-operatively," Dr. Militana says. "It also increases patient satisfaction." He says staff members should understand how to "zero in" on certain risk factors to keep pre-surgical testing efficient. "You don't want patients spending an inordinate amount of time during the presurgical testing process," he says.
5. Involved anesthesia director. The anesthesia director at a surgery center should be heavily involved in policy decisions and problem-solving, Dr. Militana says. This person should work at the surgery center on a regular basis and take the lead in policy and procedural decisions for the anesthesia department. "The director needs to take an active leadership role in meetings and on a day-to-day basis," he says. "That means providing anesthesia on a daily basis, getting your hands dirty each and every day." He says this consistency will give anesthesia leaders credibility when problems come up at leadership meetings. "You don't want to be at a meeting hearing about the problems," he says. "You want to be able to say, 'I've been there and I've seen them.'"
The anesthesia director should also take charge of disciplinary issues involving anesthesia providers. "The leader needs to hold his staff responsible for their actions with respect to, [for example], not showing up on time," he says. "There have to be some consequences for these actions." He says the anesthesia director should be able to approach every member of the anesthesia team and address problems without causing ill feelings among staff members.
6. Respect among surgeons, nurses and anesthesia providers. Dr. Militana says most importantly, anesthesiologists need to feel appreciated by the surgery center and respected by their colleagues. "Once the department of anesthesiology is appreciated for what they do, that will make things run more smoothly," he says.
However, he cautions anesthesia providers that it may take time to build respect in a new surgery center. "If you're hired by a surgery center where there's a different attitude than you'd hoped for, you can't come in like a bull in a china shop," he says. "Stick to your principles and apply the high quality standard of care that you are there to provide, and, over time, attitudes will begin to change."
Read more about North American Partners in Anesthesia.
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1. Tools to provide appropriate ambulatory anesthesia care. Dr. Militana says to provide excellent anesthesia care in a surgery center, anesthesiologists must be equipped with the necessary tools. "Taking care of ambulatory patients is quite different than taking care of patients who will have a prolonged recovery room stay or who are expected to stay overnight," he says. "This requires unique skills and unique tools."
For example, ASC anesthesiologists often perform regional techniques using ultrasound guidance for shoulder arthroscopies and anterior cruciate ligament repairs. The ASC would therefore need an ultrasound machine to perform regional blocks to provide the highest standard of care for those patients.
2. Freedom for anesthesiologists to act as 'perioperative providers.' Anesthesiologists can play a crucial role in the perioperative process by leading pre-surgical testing and overseeing post-anesthesia care, Dr. Militana says. For example, anesthesiologists can help identify which patients are at risk for nausea and vomiting or have cardiac or pulmonary issues prior to surgery. They can also improve PACU care by planning for effective pain management after surgery through the use of regional anesthetics and using preemptive analgesia protocols and appropriate analgesics postoperatively.
He says anesthesiologists are important to the perioperative process because they can tailor the surgical experience to each individual patient. "Throughout the whole process, from pre-surgical testing through the intra-op and post-op period patients should be getting individualized patient care," he says. "They should feel like they're the only one you're taking care of on that particular day, even though they know that may not necessarily be the case.”
3. Ability to cancel cases if medically necessary. When asked if anesthesiologists should have the ability to cancel cases when patients are inappropriate candidates for ambulatory surgery, Dr. Militana says, "Without a doubt." He says his surgery center has always given anesthesiologists the authority to cancel surgery if necessary.
"We approach it with the belief that we are the patient's advocate," he says. "Sometimes we have to take heat for it, but it's in the best interest of the patient." ASC administrators should explain to physicians and staff that anesthesiologists have the authority to cancel cases and review case cancellations after the fact to determine whether they could have been prevented.
4. Efficient, effective pre-surgical testing process. Dr. Militana says anesthesiologists should be placed in charge of developing pre-surgical testing policies to ensure an effective, efficient overview of patient conditions. "You want to minimize the same-day cancellation rate," he says. "The last thing you want is a patient to go through the process and have the surgeon and ambulatory staff members there, and then have the case canceled because something fell through the cracks during the pre-surgical testing process." He says same-day cancellations eat into profits and damage patient and provider satisfaction.
Pre-surgical testing processes should identify patients at higher risk for specific conditions such as nausea and vomiting, cardiac or pulmonary complications, as well as those patients that would most benefit from a pre-emptive analgesia protocol. "Pre-emptive analgesia is very important with respect to controlling patient pain post-operatively," Dr. Militana says. "It also increases patient satisfaction." He says staff members should understand how to "zero in" on certain risk factors to keep pre-surgical testing efficient. "You don't want patients spending an inordinate amount of time during the presurgical testing process," he says.
5. Involved anesthesia director. The anesthesia director at a surgery center should be heavily involved in policy decisions and problem-solving, Dr. Militana says. This person should work at the surgery center on a regular basis and take the lead in policy and procedural decisions for the anesthesia department. "The director needs to take an active leadership role in meetings and on a day-to-day basis," he says. "That means providing anesthesia on a daily basis, getting your hands dirty each and every day." He says this consistency will give anesthesia leaders credibility when problems come up at leadership meetings. "You don't want to be at a meeting hearing about the problems," he says. "You want to be able to say, 'I've been there and I've seen them.'"
The anesthesia director should also take charge of disciplinary issues involving anesthesia providers. "The leader needs to hold his staff responsible for their actions with respect to, [for example], not showing up on time," he says. "There have to be some consequences for these actions." He says the anesthesia director should be able to approach every member of the anesthesia team and address problems without causing ill feelings among staff members.
6. Respect among surgeons, nurses and anesthesia providers. Dr. Militana says most importantly, anesthesiologists need to feel appreciated by the surgery center and respected by their colleagues. "Once the department of anesthesiology is appreciated for what they do, that will make things run more smoothly," he says.
However, he cautions anesthesia providers that it may take time to build respect in a new surgery center. "If you're hired by a surgery center where there's a different attitude than you'd hoped for, you can't come in like a bull in a china shop," he says. "Stick to your principles and apply the high quality standard of care that you are there to provide, and, over time, attitudes will begin to change."
Read more about North American Partners in Anesthesia.
Related Articles on Anesthesia:
Point of Care Electronic Prompts Improve Physician Compliance With SCIP Measures
American Society of Anesthesiologists Receives Highest Accreditation Status for CME Providers
Pentobarbital Manufacturer Says Drug Is Not Safe for Lethal Injections