Here are three ambulatory anesthesia experts on how surgery centers can work with anesthesia providers for more cost-effective services.
1. Implement standardized pre-op assessment criteria for all anesthesia providers. To maximize ease and convenience of patient preoperative evaluation, with a goal of eliminating same-day cancellations and the elimination or reduction of redundant preoperative laboratory requirements, specific pre-op guidelines are set and disseminated to surgeons & facility staff. "When all anesthesia providers follow these same protocols, everyone is on the same page, eliminating confusion and case cancellations," said Susan Kizirian, RN, chief operating officer for ASCOA. "Any variance to the protocol allows immediate evaluation for patient appropriateness and subsequent testing and evaluation as necessary."
2. Have anesthesia providers talk directly to surgeons for ineligible cases. Since the surgeon scheduled the case, it is the surgeon who cancels the case. The primary relationship is between the surgeon and the patient. When the anesthesia provider takes a moment to contact the surgeon to discuss the criteria they are evaluating with the surgeon, frequently the exchange results in the case not being cancelled. "It is also a learning opportunity for the facility staff and the surgeon to dialog over anesthesia concerns and evaluate and improve services," Ms. Kizirian said.
3. Move cases through quickly. Patients must be prepped, treated and discharged efficiently to get the maximum number of cases through the surgery center and maximum revenue. The speed of discharge often depends on how quickly an anesthesiologist works.
Anesthesiologists must be accustomed to working in ASCs because the process is different than in inpatient settings, said Neil Kirschen, MD, is the chief of pain management in the department of anesthesiology at South Nassau Communities Hospital in Oceanside, N.Y., and the medical director for the Pain Management Center of Long Island in New York.
ASC patients require different techniques for faster discharge, such as more local anesthesia injections and nerve blocks. Short-acting sedatives should also be timed for the length of the procedure.
"As soon as a procedure is over, a patient should be waking up and ready to have a conversation," he said. "Proper pain killers allow a patient to ambulate sooner and be discharged and more street ready than in a hospital."
He stresses the importance of moving cases through quickly. "You can't bring another patient into the recovery room if all the beds are filled. Timing needs to be such when cases are going in, patients are being discharged," Dr. Kirschen said.
4. Rely on several core anesthesiologists to streamline OR processes. To save money on intra-operative processes, ASCs must focus on recruiting anesthesiologists who are willing to perfect their technique and make the OR more efficient, said Thomas Wherry, MD, principal of Total Anesthesia Solutions and consulting medical director for Health Inventures.
"The skill level of a provider can really impact the flow of the room, and if they're doing eight or nine cases in a day and the anesthesia provider is really slow, that could add an hour to the day easily," he said. "A provider that can get the patient prepared and under anesthesia more efficiently can be a huge cost-savings."
In order to make the OR more efficient, anesthesiologists must build relationships with nursing staff and help them address inefficiencies. This can only be accomplished if an anesthesiologist spends a good amount of time at the center, Dr. Wherry said.
"A lot of centers will insist that out of a group of 20 anesthesiologists, they use a few core providers and one provider that's there on a regular basis," he said. "Without that consistency, you don't get any traction on some of these initiatives." He says the facility should take responsibility for encouraging the core anesthesiologists to identify problems and work with nursing staff and surgeons to fix them.
5. Prevent anesthesia side effects. Patients experiencing side effects to anesthesia can be a major driving force behind anesthesia costs in ASCs, Dr. Kirschen said. When patients experience side effects, such as nausea and vomiting, they require additional care and cannot be discharged as quickly.
"You need to treat them and visit them more frequently in the post-anesthesia recovery room," he said. "You also need to use different medications that can be rather expensive to counteract the nausea."
Anesthesiologists in ASCs should work to prevent side effects in order to reduce time in the PACU and move cases along more quickly. Dr. Kirschen recommends using minimal amounts of opioid narcotics for pain relief and opting instead for sedative hypnotics and prophylactic antiemetics.
"Preempting is the best way to hand those situations," he said. "Certain surgeries are notorious for causing nausea, such as gynecology and cosmetic procedures. Treat those patients properly and avoid side effects later on."
6. Watch the flow of inhalation agents. According to Dr. Wherry, one of the biggest supply costs for anesthesia is inhalation agents, which can be wasted when flows are kept high and distributed into the atmosphere. "You should be working with the group and making sure that high flow isn't just being wasted by going into the atmosphere," he said. He says inhalation agents can be used up very quickly if groups don't keep an eye on oxygen flows — not to mention the harmful effects of pollution when agents are consistently released into the air.
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1. Implement standardized pre-op assessment criteria for all anesthesia providers. To maximize ease and convenience of patient preoperative evaluation, with a goal of eliminating same-day cancellations and the elimination or reduction of redundant preoperative laboratory requirements, specific pre-op guidelines are set and disseminated to surgeons & facility staff. "When all anesthesia providers follow these same protocols, everyone is on the same page, eliminating confusion and case cancellations," said Susan Kizirian, RN, chief operating officer for ASCOA. "Any variance to the protocol allows immediate evaluation for patient appropriateness and subsequent testing and evaluation as necessary."
2. Have anesthesia providers talk directly to surgeons for ineligible cases. Since the surgeon scheduled the case, it is the surgeon who cancels the case. The primary relationship is between the surgeon and the patient. When the anesthesia provider takes a moment to contact the surgeon to discuss the criteria they are evaluating with the surgeon, frequently the exchange results in the case not being cancelled. "It is also a learning opportunity for the facility staff and the surgeon to dialog over anesthesia concerns and evaluate and improve services," Ms. Kizirian said.
3. Move cases through quickly. Patients must be prepped, treated and discharged efficiently to get the maximum number of cases through the surgery center and maximum revenue. The speed of discharge often depends on how quickly an anesthesiologist works.Anesthesiologists must be accustomed to working in ASCs because the process is different than in inpatient settings, said Neil Kirschen, MD, is the chief of pain management in the department of anesthesiology at South Nassau Communities Hospital in Oceanside, N.Y., and the medical director for the Pain Management Center of Long Island in New York.
ASC patients require different techniques for faster discharge, such as more local anesthesia injections and nerve blocks. Short-acting sedatives should also be timed for the length of the procedure.
"As soon as a procedure is over, a patient should be waking up and ready to have a conversation," he said. "Proper pain killers allow a patient to ambulate sooner and be discharged and more street ready than in a hospital."
He stresses the importance of moving cases through quickly. "You can't bring another patient into the recovery room if all the beds are filled. Timing needs to be such when cases are going in, patients are being discharged," Dr. Kirschen said.
4. Rely on several core anesthesiologists to streamline OR processes. To save money on intra-operative processes, ASCs must focus on recruiting anesthesiologists who are willing to perfect their technique and make the OR more efficient, said Thomas Wherry, MD, principal of Total Anesthesia Solutions and consulting medical director for Health Inventures."The skill level of a provider can really impact the flow of the room, and if they're doing eight or nine cases in a day and the anesthesia provider is really slow, that could add an hour to the day easily," he said. "A provider that can get the patient prepared and under anesthesia more efficiently can be a huge cost-savings."
In order to make the OR more efficient, anesthesiologists must build relationships with nursing staff and help them address inefficiencies. This can only be accomplished if an anesthesiologist spends a good amount of time at the center, Dr. Wherry said.
"A lot of centers will insist that out of a group of 20 anesthesiologists, they use a few core providers and one provider that's there on a regular basis," he said. "Without that consistency, you don't get any traction on some of these initiatives." He says the facility should take responsibility for encouraging the core anesthesiologists to identify problems and work with nursing staff and surgeons to fix them.
5. Prevent anesthesia side effects. Patients experiencing side effects to anesthesia can be a major driving force behind anesthesia costs in ASCs, Dr. Kirschen said. When patients experience side effects, such as nausea and vomiting, they require additional care and cannot be discharged as quickly.
"You need to treat them and visit them more frequently in the post-anesthesia recovery room," he said. "You also need to use different medications that can be rather expensive to counteract the nausea."
Anesthesiologists in ASCs should work to prevent side effects in order to reduce time in the PACU and move cases along more quickly. Dr. Kirschen recommends using minimal amounts of opioid narcotics for pain relief and opting instead for sedative hypnotics and prophylactic antiemetics.
"Preempting is the best way to hand those situations," he said. "Certain surgeries are notorious for causing nausea, such as gynecology and cosmetic procedures. Treat those patients properly and avoid side effects later on."
6. Watch the flow of inhalation agents. According to Dr. Wherry, one of the biggest supply costs for anesthesia is inhalation agents, which can be wasted when flows are kept high and distributed into the atmosphere. "You should be working with the group and making sure that high flow isn't just being wasted by going into the atmosphere," he said. He says inhalation agents can be used up very quickly if groups don't keep an eye on oxygen flows — not to mention the harmful effects of pollution when agents are consistently released into the air.
More Articles on Anesthesia:
NAPA: Use STOP-BANG Assessment for Sleep Apnea Screening
Lippincott Williams & Wilkins Releases Mobile, Interactive 'Clinical Anesthesia'
ASA President Dr. John Zerwas Discusses Anesthesia Awareness in Atlantic Letter