Care of the Morbidly Obese in the Surgery Center

 

As America’s waist band expands more and more, we are seeing patients who qualify for the classification of the morbidly obese being admitted to the surgery centers for their procedures.  This practice will, most probably, NOT go away, but will become even more popular.  The question emerges as to whether or not the average surgery center is prepared to take care of such patients.  From what this author has seen, unless the center performs bariatric surgery neither the available equipment nor the staff/staffing are adequate to provide safe care of the patient.

 

In the past leaders in the surgery centers designated a pound limit for admission to the center; e.g, patients over 350 pounds would not be admitted for procedures.  This figure was primarily selected based upon the poundage limit of stretchers and OR tables.  There was not, on the whole, a conversation about other equipment (exception being a lift) needed in order to care for this type of patient.  There was an assumption that any patient weighing 350 pounds was obese; however, just asAmerica’s waist band has expanded, so has our height.  We are seeing many more patients in the ambulatory surgery centers who are 6’6” tall and taller.  Those patients may not, in fact, be classified as obese.  This distinction has forced us to begin evaluating a patient’s level of obesity based on his body mass index (BMI).    Today the designation of obesity can only be made by performing a BMI.

 

In many centers neither the patient’s weight nor BMI is made known until the day before the procedure when the schedule is sent to the ORS.  This practice does not allow adequate preparatory time to plan for a safe environment for these patients.  Rather, this information must be collected at the time the patient is scheduled.  Collect the patient’s height and weight as a matter of course during the scheduling process, then calculate the BMI. Calculation of the BMI is accomplished by taking the weight in kilograms divided by height in milometers squared (kg/m2).  The following classifications should be followed:

 

< 18.5  Underweight

18.5-24.9  Normal

25.0-29.9  Overweight

30.0-39.9  Obese

>40.0  Morbidly Obese

 

Instruct the scheduling secretary to notify the ORS of any BMI greater than 35 immediately so that proper preparatory actions and processes can be put in place.

 

Preoperative Care:

•  The Scheduling Secretary calculates the BMI and alerts the ORS if BMI is >35
• The BMI is posted on the surgery schedule if  >35.
• The preoperative RN completes the nursing assessment following the nursing care plan for patients who are morbidly obese and the assessment tool for patients who are morbidly obese.
• The preoperative nurse place the inflatable patient transfer pad on the pre-op bed and collects the appropriate sized blood pressure cuff, patient gown bed linens and extra large sequential compression devices for each leg.
• The anesthesia providers assess the patient in the preoperative area to include the lungs, oral airway and history of OSA.  The anesthesia provider determines the presence of all required specialty equipment to meet the special needs of the morbidly obese to include intubation equipment and CPAP or BIPAP, as appropriate, head cradle and elevation wedge.
• The preoperative RN assesses lung sounds, vital signs, oxygen saturation, presence of edema, and information regarding sleep habits such as snoring, daytime sleepiness and other symptoms of OSA,
• The preoperative RN performs postoperative teaching in the preop area teaching the patient regarding deep breathing, leg exercises, incentive spirometry, CPAP or BIPAP (bileval positive airway pressure).

Notes:  The preoperative RN should interview the patient regarding reflux/GERD and should alert anesthesia where the patient admits to this condition.  Determine with the patient to what degree he is able to lay flat.  Advise anesthesia of this response.

 

Intra-operative Care:

• The anesthesia provider pre-oxygenates the patient.  Provide two anesthesia providers where a difficult airway is anticipated.
• The anesthesia provider positions the patient’s head using a head cradle and an elevation wedge being especially aware of the patient’s needs regarding the presence of GERD/reflux while awake and the impact of this condition on the patient’s comfort as well as the hazard it imposes regarding the possibility of aspiration.  The need for the elevation wedge is evident.
• The circulator procures extra drapes to adequately create the sterile field while protecting the patient from the possibility of “pooling” of prep and/or irrigation solutions especially in skin folds.
• The circulator gathers extra large equipment as needed such as bariatric instrumentation for retractors, etc.
• Extra large step stools are provided for additional staff to prevent leaning across or onto the patient.
• Provide pads, positioning and protective devices to prevent pressure points and assess these areas frequently.
• Position hands such that maximum protection is allowed.
• If patient is to be in the lithotomy position, check prior to the day of surgery with the surgeon to determine the acceptability of available stirrups; i.e., candy cane vs. boot, etc.
• The patient in lithotomy position will require special attention to fluid volume shifts and ventilation changes presenting in this position.
• Select anesthesia based on procedure to be performed utilizing regional or local whenever possible.  Ketorolac is recommended.
• Deflate the inflatable patient transfer device once the patient is on the table.
• Prior to draping, check again for pooling making sure crevices are dry.
• If intubated, following the procedure the anesthesia provider should delay extubation as long as possible.
• Reinflate the patient transfer device for transferring the patient from the OR table to the stretcher bed.
• Advise the PACU that the patient is about to be transported from the OR.
• The anesthesia provider and circulating RN transport the patient to the PACU with oxygen.
• If possible due to the procedure performed, transport the patient with the head of the bed elevated to  30-45 degrees in order to relieve the intra-abdominal pressure on the lungs.
• If extubated, transport the patient with a nasal or oral airway in place.

 

Postoperative Care:

• Maintenance of the airway is a special challenge in the post-anesthetic morbidly obese patient and should be monitored closely.
• Have CPAP or BIPAP ready for immediate use in the PACU.
• Maintain the elevation of the head of the recovery bed.
• Make sure emergency airway equipment is immediately available.
• Limit narcotic and sedative use and use ketorolac when possible.
• Use nebulized breathing treatments as needed.
• Observe patient for conditions and complications associated with severe obesity after surgery to include

1. >congestive heart failure
2. >deep vein thrombosis
3. >myocardial infarction
4. >pulmonary embolism
5. >respiratory depression
6. >rhabdomyolysis (deep muscle damage)
7. >skin breakdown

• Initiate standard postoperative care

 

Care of the morbidly obese in the PACU and discharge area requires a one-on-one staffing ratio until the patient is ready for discharge.  It is crucial that this patient be rigorously monitored.  Deep breathing/breathing treatments and leg exercises are crucial.

Getting the patient up and out of the recovery bed to a chair as quickly as his condition allows is vital to his successful recovery.  Repetitive education regarding breathing and leg exercises at home is critical.  Provide demonstrations and demand the patient return the demonstration.  Make sure he applies his CPAP device properly.  Solicit the patient’s return explanation regarding the prevention of DVT (and the care person’s explanation, too).  Remember that this patient’s size in itself is an obstacle in his moving his body to the extent needed.  The nurse providing postoperative instructions must ensure the patient’s level of understanding is such that he will “move the mountain” in order to best provide the best outcome possible for his care.  The need to limit pain medication may further inhibit his activity and limit his compliance.  Be firm.  Explain possible complications and the degree that inadequate ventilation and exercise contribute to these even to the point of pneumonia and blood clots that could, potentially, be fatal.

 

In providing the best possible patient education, the nurse caring for these patients must be aware of the underlying emotional needs as well as the obvious physical that are present.  The patient may be defensive about his weight.  He may, even, be in denial of the extent of the problem.  He may be embarrassed, but, certainly sensitive about the issue.  Protect his privacy.  Provide as much privacy during the assessment and teaching phases of his care as the physical plant restrictions allow.  Plan this out prior to the patient’s admission.  Is there space anywhere that can be commandeered to provide these special needs?  This patient needs staff support.

 

How do you provide staff support of the morbidly obese patient when literature and studies abound regarding the stigma and bigotry that exists regarding such patients?  Start now with providing staff education.  Have round table discussions on the subject.  Contact local eating disorder clinics or bariatric centers for expert guest speakers.  Given the staffing constraints that exist in most surgery centers, nevertheless, select and assign staff members carefully when planning the patient’s care.  Just as there are considerations in making other staffing assignments due to religious beliefs, etc., so these may exist among your staff members regarding weight and the morbidly obese.  Staff members should be assessed as to whether such pre-conceived convictions can be set aside to provide the degree of support these patients need.

 

Care of the staff person must also be planned and implemented when caring for the morbidly obese.  Injury is a very real hazard whether a back injury from moving the patient or an injury sustained trying to prevent a patient from falling or working with lifting devices, etc.  Determine how best to mitigate such circumstances.

 

And…finally… calculate the costs of providing care to the morbidly obese patient in the ambulatory surgery center.  If your center does not routinely provide care to bariatric patients, what are all the direct and indirect costs you will be incurring compared to the reimbursement you will be receiving.

 

Ambulatory Surgery Centers by their very nature were first developed to care for ASA I and II patients.  Are we over-stepping our very admission criteria by admitting the morbidly obese patient?  Perhaps we should consider carefully that these patients might be best served in a hospital environment.

Renewing Patient Centered Care in ASCs

While preparing for a talk I gave recently at the Wyoming State ASC meeting, I happened upon an article where the authors discussed Medicare’s commitment to “patient centered care” the new “buzz” words.  I was somewhat astounded at this assertion having been involved in the ASC industry since 1979…this is not a new initiative…

PART 1 – THEN: THE INFANCY OF ASC PATIENT CENTER CARE

During the beginning days of ASC business, it was all about creating “high tech, high touch, patient centered care in a warm, home-like environment.”  The largest impetus physicians’ cited when asked why they were building their own surgery center was not about making money, rather it was about “returning the control of the patient back to their physician” …and then curbing the outlandish hospital bills their patients were presenting to them for simple procedures.

I am reminded of one physician telling me of a patient of his who needed a culposcopy, so he scheduled it at the hospital. He did not have the equipment to do this procedure in his office and believed the anxiety the patient was exhibiting warranted the services of an anesthesia provider.  A few weeks after the procedure was performed the patient brought him a copy of her bill from the hospital for $7,500 for a procedure that took minutes to do.  He bought the equipment, got an anesthesia provider to agree to come to his office to do conscious sedation and charged his patients $1,200 which not only covered his expenses but paid the anesthesiologist.

Concept #1: Reduce High Deductibles and Charges

Hospitals were being reimbursed $5,000 and more for a cataract procedure that physicians were getting a pittance for performing in their tiny “surgery centers.”  Patients were complaining of the high deductibles to their physicians who were embarrassed for having taken the patient to the hospital, where he experienced “financial rape.”  Patients were being charged not only for the rent of the OR, but equipment fees and fees for every sponge and widget used AND the charges for these were not small!

Concept #2 Eliminate Excessive Testing

Physicians also were disgruntled that patients whom they scheduled for surgery at the hospital were forced to undergo a battery of tests.  A full panel of lab work was required, a chest x-ray, an EKG, a UA.  This required an additional visit, if not more than one, to the hospital to have these tests performed.  Many of the patients were elderly, had transportation difficulties or worked, thus these extra visits posed a hardship on the patients.  In addition, of course, the costs of these tests were passed on to the patient, at least in part, thus adding to his financial burden.  Surgeons, endoscopists, and anesthesia providers loudly proclaimed and argued that these tests were excessive for the vast majority of their patients and that the preoperative lab requirements needed to be customized/individualized to the patient, the procedure and the type of anesthesia to be delivered.  Hospitals replied that these were their requirements and that was just what was so!  The physicians were left thwarted in their efforts to reduce the inconvenience and cost to their patients.

Concept #3: Improve Patient’s Health Esteem 

Physicians and their staffs committed to providing the best outpatient surgery care possible to recognized that a huge part of this process had to deal with promoting the patient’s image of himself as an otherwise healthy human being.  Studies conducted at that time showed that patients going to the hospital, even for outpatient labs, assumed a sick role.  Everyone knew someone who had gone to the hospital, and even if not VERY sick when they were admitted, got infected and died, or just went to the hospital and died.  Hospitals were strange, mysterious places where patients were “done unto” with little input into their care.  Once they were in the system they were just a number shuttled from one area, from one department to another following the proper colored tape on the floor (in place of a conveyor belt) to the proper department!  This process most certainly did not promote the patients image of himself as “otherwise healthy.”  In addition, many hospitals used the emergency room entrance as the intake entrance for their outpatients.

Concept #4: Eliminate Long Waits and Improve Patient/Physician Communication

Physicians and their patients were also disgruntled that on the day of the surgical procedure patients were told to come to the hospital hours before their surgical appointment time resulting in very long preoperative wait times.  In addition, rather than building a “surgery center” or even remodeling a space inside the hospital to incorporate the visual concepts of an ambulatory surgery environment, hospitals were just taking a deserted wing and putting a sign up that said “Day Surgery.”  The inpatient ORs were used with the outpatients scheduled in amongst the inpatients resulting in long delays, and the outpatient frequently being “bumped” for an emergency.

In one instance a young woman was admitted for a cervical conization.  She was told to be at the hospital at 6:30 am even though her procedure was not scheduled until 10:30 am.  When she questioned the lengthy time, she was told there was lots of paper work to get done and other preparations.  (In fact, this particular hospital scheduled all their outpatients for surgery that day to arrive at the same time.)  This young woman arrived at the admitting desk as instructed and sat in the lobby with other obviously sick patients waiting for her name to be called out loudly to come to the desk.  Now understand, this young lady was already highly anxious about her procedure and how it would impact her future child bearing.  Finally, after waiting for an hour, she was admitted and sent to the second floor of the hospital.  On her arrival she was given a patient gown and told to “get into bed”.  Someone would be with her shortly.  She waited another hour for one of the nurses to arrive, take her vital signs and review her history.  That being done, the nurse left the room and shut the door.  This person was left there, with her caretaker alone.  No one came near.  10:30 came and went.  The caretaker went to the door several times and peered out looking for someone, anyone!   When noon came, the caretaker walked down the corridor and found the staff sitting at the nurse’s station eating pizza.  She asked about the delay and was told by a “not too pleased” staff person she would call the OR to check.  Soon after the door to the woman’s room swung open and an orderly pushed in a rickety old gurney telling the patient to get on there while the nurse came running with her “pre-op” shot.  Upon return to her room following the procedure the nurse gave the young woman another shot.  This time it was 50 mg. of Demerol which left her sound asleep in the hospital bed until nearly 7:30 pm that night—-13 hours after she first appeared for her appointment at the admitting desk for a 30 minute procedure.  The average stay in an ambulatory surgery center would not have exceeded 3 hours at the most!

Concept #5: Give Patients a Voice

Physicians believed, rightfully so, that they had very little control over the care of their patients once they were admitted into the system.  They knew that their patients were becoming more sophisticated.  They were watching medical shows on television.  The news media was full of medical information.  The patients were making demands and were questioning.  They were no longer willing to be that person who was “done unto”.  Rather, they wanted to have a say in their care—to be a part of the healthcare team.

Concept #6:  Reduce Infection Risk

Physicians further believed that the safest place for their patients to undergo their procedures would be in their surgery center, where they would not be mixed in with sick hospitalized patients who were potentially infectious.

Concept #7: Hire Competent Staffing and Create Effective, Efficient Staffing Patterns

Physicians were very much aware that they could individually select their staff—their experienced staff—and provide any additional training these staff persons needed thus ensuring the most experienced, most qualified staff in the preoperative, OR, Procedure and recovery areas as well as the sterile processing.  They knew that in the hospital, even though there were nurses who were assigned, say, to the orthopedic or gynecologic operating room and who were in charge of taking care of the equipment and instrumentation for those areas, these nurses were not always available.  There were call ins, vacations, staffing shortages, etc., all of which impacted the availability of these “specialty trained” nurses and technicians for the surgeon,  This left the physician, not infrequently, performing surgery with staff who, sometimes, were minimally trained in the physician’s particular procedures.  This delayed cases and resulted in a high degree of frustration for the physician.  We knew in the industry that we could cross train our staff and provide this physician with the trained staff he needed to care for his patient throughout the patient’s stay.

Concept #8: Develop Efficient Surgery Scheduling

Physicians were also frustrated for both themselves and their patients at the delays in the surgery schedule that left their patients either waiting in their hospital beds, in the Surgery Suite corridors or in the preoperative area where they were, once again, mixed in with hospital inpatients.  This left physicians sitting in the doctors’ lounge waiting for a room to do their procedure.  Another contributing issue was that room turnover times in the hospital surgery suites were running any where from 45 minutes to an hour.  In an ambulatory surgery center at that time they were running 7-10 minutes.  These delays caused the physicians’ office schedules to back up and resulted in the lengthy disruption of the patient’s lives.

Concept #9: Identify Opportunities to Deliver Personable Care

We in the early infancy of ambulatory surgery recognized that this was as much a specialty as surgery, radiology, emergency, intensive care, etc.  We recognized that the patient presenting for ambulatory surgery had special needs just as those presenting for in-patient surgery, radiographic studies, cardiac caths or were admitted to an emergency department or intensive care.  We recognized that this person coming to our surgery center had a CHOICE in where to have his procedure performed.  We recognized he was our “guest”.  His concept of himself as an otherwise healthy person needed to be promoted, for we were going to return him to his normal environment with as little disruption and in as short a time as  possible.  We recognized that his care person was a critical member of his team and that he was the center of this team.  We recognized that our “barking” his name out in the waiting room didn’t support his dignity.

Concept #10: Maintain High Touch, High Tech Patient Centered Care

In some surgery centers, the pre-op nurse actually came into the waiting room and went  directly to the patient, touching his shoulder and saying, “Mr. Jones, we are ready for you.”  These centers kept a seating chart much like restaurants at the reception desk, so when the receptionist called pre-op to advise them that their patient had arrived (one hour before their scheduled procedure, or thirty minutes if a local),  she told the nurse where the patient was seated and any identifying information.  This set the tone for the patient for how he could expect to be treated throughout his stay.   “High Touch, High Tech, Patient Centered Care” became the mantra in ambulatory surgery.  The tone was efficient, warm and friendly.  The staff were highly trained and all CPR trained with most ACLS and where pediatrics were performed PALS trained.

Concept #11: Develop a Staffing and Patient Family

There was a team environment of patient, physician and staff.  We built one staff lounge where, for sometimes for the first time, the staff mingled with the physicians.  The high volume surgeon of the month got a t-shirt embossed with “I’m # 1”.  Cakes were baked for birthdays.  Pot-luck dinners once a month were the norm.  QI studies were done when room turnovers exceeded the allowable time.

Patients walked into the ORs whenever possible. Parents occasionally came in with the little children until they were asleep.  Morning reports before surgery involved a discussion of each patient’s special needs.  Surgery centers were staffed “skinny” but with highly skilled, experienced nurses who were flocking to work there.  None were hired who didn’t say in their interviews that they “wanted more patient contact”.

PART 2 – NOW: ASC PATIENT CENTERED CARE OF TODAY

Somehow these concepts have become eroded as the years have gone by.  Something has shifted in the ambulatory surgery industry.

Eighty percent of all surgery is being performed outpatient.  There are over 5,000 surgery centers in theUSwith more being built every day.  We are doing sicker patients than ever before—more acute.  Our infection rate is up.  Our complications are up!  CMS asserts physicians are hiring unqualified and inexperienced staff to work in their centers and that this is a contributing factor. One could argue that infections and complications are up because we are doing more surgery in the surgery centers than ever before…except that CMS says they are up, too, because not only are physicians hiring unqualified and inexperienced staff, but they are not being rigorous in adhering to patient admitting qualifications to include ASA status.  I am afraid in many instances that this is so.

CMS is surveying surgery centers all across the country and closing them down for failure to adhere to regulations.  H&Ps are older than 30 days and aren’t updated on the day of surgery.  Physicians are arguing that a history and physical performed a year ago is valid. At times this argument includes patients over the age of 80!  Physicians don’t want to update the H&P on the day of surgery or to assess the patient at the bedside in pre-op stating it will slow him down!  Surgeons and endoscopists are arguing they shouldn’t have to assess their patient in post-op for the same reason stating, too, that anesthesia can do it!  They are complaining about having to sign, date and time their orders, the H&P and the consent.  They are complaining about having to have an interim OP report on the patient’s chart prior to their leaving the center.

One patient complained recently in my hearing that she was being wheeled into the OR but hadn’t seen her physician!  In another instance a 44 year old woman died at a surgery center following an 11 ½ hour surgery for a brow lift, upper and lower blephs, cheek implants, a rhytidectomy and chin liposuction.  She was delivered to the recovery at 7:30 pm on a Friday night.  The surgeon and anesthesiologist left the building immediately.  Her temperature was 94.6.  Her blood pressure was 94/60 but anesthesia didn’t stick around to get these numbers, nor did her surgeon!  She was dismissed two hours later to home after sitting in a wheelchair for one hour during which no vital signs were taken.  When she stepped out of the car in her driveway after complaining of shortness of breath during the drive, she dropped dead from multi-focal pulmonary emboli!  This organization had not followed any of their procedures from controlling the time limits for acceptable procedures to be performed at the center, warming the patient during surgery, or post-operative care!  A good risk management mantra is “whenever there is a medical error, there is a human error!”

This was also true in the case of the much publicized patient death inFt. Myers,Florida.  It always is.  In the case of the plastic surgery patient mentioned above, errors started immediately with allowing the case to be scheduled.  When queried, the Administrator/ORS admitted she didn’t bring it to the Medical Director’s attention that the physician had scheduled all of this for a 5 hour time slot, when she knew he couldn’t do all that in that amount of time.  Her statement was that she knew cash flow was low and that the CEO and the Medical Director would both approve it…and so, a relatively young woman died.

Is CMS wrong in their presumptions?  Have we gotten so enamored of the monies to be made in ambulatory surgery centers that we have lost site of the patient and their safety?  Have we gotten so arrogant in our belief that ambulatory surgery is safe that we have lost site of what is best for the patient?  CMS is correct.  We need to drop back and rediscover the concept of  “patient centered” and get this back into our surgery centers.

Physicians ARE staffing their centers skinnier than ever before.  They are working staff from 7 in the morning to sometimes 10-11:59 pm.  I got a call recently as to how late this particular surgeon could do surgery.  I advised him that “overnight” meant 12 midnight, so he made sure all his patients were dismissed by 11:59pm.  I got another call from an Administrator who was threatening to fire a nurse for making a medication error.  After gathering the facts I discovered this happened at 10:30 at night after she had come on duty at 7 that morning.  Breaks were a quick bite in the staff lounge between cases.  When I advised this Administrator of the labor laws AND that fatigue contributed hugely to medical and medication errors and that they was accountable for not staffing adequately, the Administrator’s response was concern for overhead in hiring more staff and that if physicians time was cut to the designated surgery center closing time that this physician might not come back.  I ask you, “Would you want to be that physician’s patient undergoing your procedure there with a grossly fatigued staff and patient?”

Physicians and Administrators are hiring OR Supervisors with no previous OR experience.  They are hiring oncology nurses to work pre-op and recovery; nurses with no previous experience in either of these arenas.  Experienced nurses aren’t applying in these physician-owned surgery centers citing no benefits, long work hours, and poor pay…AND this isn’t just occurring in physician-owned centers alone, but in those being run by some well known, large and successful management companies, as well as centers where hospitals have a partial ownership.

Staff are NOT being allowed to attend outside training programs on pertinent issues such as sterilization.  Owners are arguing the cost of even electronic webinars for their staff. Owners and Administrators, ever mindful of the bottom line, are citing the cost of the program and the cost of bringing in as-needed staff to cover for the person out attending the seminar.  In some instances, even the Administrators are not being given approval to attend national ASC meetings.  The cost of joining professional organizations such as the AORN, ASCA or APIC as a line item on the budget is being crossed off.  Physicians, and administrators, are hiring previously inexperienced persons to work in sterile processing and soiled receiving washing, processing and sterilizing equipment.  Oftentimes, these persons have a rudimentary understanding of English and are unable to read instructions regarding cleaning agents, the cleaning of the instruments and equipment, policies and the instructions for the use and maintenance of the sterilization equipment.  The same holds true for the housekeeping staff and/or contractors.  CMS is citing housekeeping practices in their surveys as a failure to comply.  Physician owners/management companies/administrators are screaming “Foul!”  …but is it really?

CMS is telling us that patient safety HAS to come first.  You cannot draw the line anywhere in the surgery centers to define where this shouldn’t be in place, and it starts with owners, managers and staff becoming “patient centered” once again.

Disposing of Drugs

More and more surgery centers (and other healthcare institutions) are faced with the challenge of disposing of their unwanted or expired drugs.  The Controlled Substance Act and DEA regulations dictate the handling of controlled substances to include the disposal of unused drugs.  Pharmacies are mandated NOT to take back unused or expired drugs.  In the past, organizations were advised to return these to reverse drug distribution centers or to the DEA, but now, neither of these will accept unused or expired drugs.  We were, also in the past, advised to flush them down the drain.  This included not only unused drugs or expired drugs, but medication left in syringes and IV solutions and/or other medications in solution.  While expired pharmaceuticals do not represent a serious threat to public health or to the environment, improper disposal may be hazardous if it leads to contamination of water supplies or local sources used by nearby communities or to wildlife.  States such as California and Washington prohibit disposal of virtually any drugs down the sewage system.

In general, wastes that are acceptable for flushing down the sewage system include IV solutions such as saline or glucose, lactated ringers, or solutions containing nutrients or electrolyte salts.  Not acceptable would be IV solutions containing antibiotics, actineoplastic/chemotherapeutic agents, controlled substances or narcotic pain medication.

Drugs Suitable for Flushing per the FDA include:

• Fentanyl citrate
• Daytrana Transdermal Patch
• Duragesic Transdermal System (fentanyl)
• OxyContin Tablets
• Avinza Capsules (morphine sulfate)
• Baraclude Tablets (entecavir)
• Reyataz Capsules (atazanavir sulfate)
• Tequin Tablets (gativloxacin)
• Zerit for Oral Solution (stavudine)
• Meperidine HCL Tablets
• Percocet (oxycodone and acetaminophen)
• Xyrem (sodium Oxybate)
• Fentora (fentanyl buccal tablet)
• Meperedine tablets (demoral)

Understand that this author and other environmental experts disagree with the FDA and these disposal recommendations. Instead it is recommend to crush all solid medication or dissolve medications (solid or liquid) in water and mixing that solution with kitty litter (already in the center as part of the spill kit for hazardous substances) or other unpalatable substance such as coffee grounds for disposal.

The White House Office of National Drug Control Policy (ONDCP) and the EPA, as well as the American Pharmacists Association (APhA) have all published similar recommendations.

Institutions producing large amounts of unused pharmaceuticals such as hospitals or pharmaceutical distribution centers may utilize encapsulation to destroy unused or expired drugs.  Encapsulation involves immobilizing the pharmaceutical in a solid block with a plastic or steel drum.  The container is then filled with cement, a cement-like mixture, plastic foam or sand.  Such disposal methods are not practical for a surgery center; rather, surgery centers should use either the above “crushing and dissolution” method or inertization/immobilization.

Inertization is a variant of encapsulation and involves removing the packaging materials, paper, cardboard and plastic, from the pharmaceuticals.  Pills are removed from the blister packs, ground, mixed with water and some mixture—could be litter or coffee grounds—placed in a bottle such as an empty saline bottle, top taped and then hidden in the trash to go to landfill.

Ampoules can be crushed using protective hand and eye wear and placed in mixtures such as above or diluted with water and disposed of as above.  Sweep up the crushed glass and dispose of in sharps containers practicing safety precautions.

The disposal of controlled substances must always be in the presence of two licensed persons, one of whom should be your pharmacy consultant.  Substances have to be rendered unusable as discussed above, and then can be dispersed among the landfill (or follow the above FDA list for sewage disposal).

Aerosol containers to include inhalers should go to the landfill.

Non-controlled substances may be disposed of by:

• Keep the medication in the original container, but mark out any identifying information.
• If pills, add water to dissolve.  For liquids, add litter or coffee grounds or even dirt/sand.
• Close the lid and secure with duct or packing tape.
• Place the bottles inside an opaque container such as a saline or water/irrigating solution bottle, detergent bottle, etc.
• Capeand tape the container closed.
• Hide the container in the trash.  DO NOT place in your recycling bin

There is HUGE emphasis being placed on controlling the unlawful distribution of drugs today.  We, in the ambulatory surgery industry, can do much to curtail this activity by properly controlling how WE dispose of the unused or expired drugs in our centers.

Please follow our blog for more information to come as this remains a hot topic especially in the realm of controlled substances.

Measuring Patient Satisfaction, Part 3

Conversations with the QI Coordinator in these incidences (in part 2) resulted in significant changes in the entire education of the patients. In all of the centers the decision was made to conduct the postoperative teaching during the preoperative phone call or visit.   The QI Committee met to discuss what additional steps could be taken to enhance patient teaching and in all cases came to the realization that their teaching really had been only to cover the usual basics all patients experience during the first 48 hours postoperatively, but did not include effective discharge planning; i.e., care beyond the basic physical care of the wound, etc.  The next step was to identify the types of procedures where additional education and planning would be warranted.  The groups identified additional information that would be needed.  All of the groups admitted that they always asked if there was a caregiver and stressed that that person, or someone, had to be there to drive the patient home.  However, they never inquired regarding the health of the caretaker or much more beyond the driving the patient home conversation.  “Can your caretaker adequately care for you at home?  Can this person provide your meals?  Change your dressing?  Help you ambulate?”  These questions were added to the preoperative teaching.  Additional questions developed included the home environment; e.g., are there stairs to navigate to the TV?…to the bedroom?  Who will prepare your meals?  Help you bathe?  These questions became very helpful when in the course of interviewing one patient, it was discovered that his “caretaker” would be his wife.  He had planned to take a cab in for his cataract surgery and to return home where his wife would assume his care.  However, it was discovered that his wife was a cardiac patient and was bedridden!

The next step many of the groups made was to contact the various patient care coordinators in some of the physicians’ offices soliciting their help in getting this information from the patient at the time he was scheduled for his surgical appointment.

The pre-op staff in the centers revised their preoperative phone call process to make the call on the average two weeks prior to the scheduled appointment in order to allow adequate time for the patient to make his plans.  One center developed a service of adult care persons to serve as caregivers for their patients.  These persons were all known to the center staff.  Background checks were done on them. CPR certification was a requirement to be placed on the list.  The patients who had no caregivers were given the list and had the option to contract with one of these persons.  The patient paid the caretaker.  These persons were bonded and screened by the center leaders.  This alleviated cancellations at the last minute due to the unavailability of a caretaker, or the confrontation of the patient postoperatively when no caretaker arrived to take him home.  The caretaker brought the patient to the center for his procedure, stayed and participated in the postoperative instructions, drove the patient home, prepared him a meal, stayed the first night and brought him back for his first postoperative visit.  This program has been in place several years at this particular center resulting in high patient satisfaction rates.

Additional centers have begun asking their focus questions through postoperative e-mails to the patients and are reporting very positive results from this process.

Measuring patient satisfaction need not be a hair pulling, frustrating process, but, rather, can result in tremendous satisfaction on the part not only of the patient but of the center leaders and staff.

Measuring Patient Satisfaction, Part 2

The first step is to review and revise your existing questionnaire.  Turn it into a tri-fold brochure and place a stack of them in your waiting room with a sign that says, “Please tell us how we are doing!”

The goal now becomes to transform the measurement of patient satisfaction/perception of care into focus questions.  These are questions that are identified by the QI Committee and the members of the Medical Advisory/Executive Committee and may be asked of the patient over a designated period of time by the staff during the postoperative phone calls.

Meet with the QIC members and the medical staff on the MAC/MEC.  Advise these persons of the intent to ask the patient questions the outcome of which will make a difference in how you practice.  A topic is selected with 2-4 questions regarding that topic.  These are put into a questionnaire or QI study format and are asked during the post-op phone call.  The callers gather the questionnaires and forward these to the QI Coordinator for analysis.  The QI Committee and/or the MAC/MEC determine if the identified topic will be queried for one, two or three months.  Results are submitted to the various committees when completed for further input.  Some of the questions asked include:

• Did you observe the staff washing their hands during your stay at the center? How? When?
• Was your recovery experience what you expected and how could we have improved upon that?

• Was you pain management adequate?  Did the pain medication you were prescribed work, or did you have to contact your physician for another/different prescription?
• Did your caretakers ask your name, the type and site of the procedure you were to undergo in pre-op, prior to starting a treatment such as an IV or prior to giving a medication, and in the OR?
• Did you feel the staff provided you a safe environment?
• Did you experience any infections postoperatively even if not related directly to the procedure you had done?  Were you on postoperative antibiotics?  How long did you take them?  Did you finish your course of medications?

Periodically, physicians may come forth with a comment like, “You know, I have always wondered if patients (fill in the blank) post-operatively.”  You can use these questions for your focus studies.

From questions like those identified above the committee members can identify two or three additional questions on each subject.

Results of these focus studies can be dramatic; e.g., the question about the recovery experience produced several major issues:

• One patient had undergone a knee arthroscopy with a inguinal block. He was a professional football player whose caretaker was his 5’4”, 112 lb wife.  It seems he had to climb a series of steps from his driveway to get into his house.  The TV was in a basement media center and the bedroom was on the second floor.  He fell several times while trying to navigate to reach these various areas.
• Patient # 2 underwent surgery for her bilateral carpal tunnels.   During the postoperative phone call she expressed her upset in that both hands were splinted.  Her husband was the helpless type who couldn’t even” fill the teakettle for a cup of tea”, but she couldn’t help…neither could she perform her own personal, intimate care.  She reported being extremely frustrated and embarrassed.
• Patient #3 had experienced bilateral bunionectomies to include excision of her Taylor bunionettes with no understanding whatsoever of the amount of pain she would experience.  In this instance, she, too, had to climb stairs to her front door and to her second floor  media room  and bedroom.

In all of the above cases, which occurred at different surgery centers, there was inadequate teaching for the postoperative experience. Obviously the level of satisfaction regarding their experience was very low.

Measuring Patient Satisfaction, Part 1 of 3

“There must be a mechanism in place to measure a patient’s satisfaction.  The patient has  the right to express his satisfaction or otherwise.”  

These are the regulations and the standards imposed upon surgery centers by regulatory agencies such as CMS and the different state licensing agencies as well as by the various accreditation organizations.

In the early days of ambulatory surgery we took that to mean that every patient was to be given a copy of our standardized patient satisfaction questionnaire upon his discharge from the center with a request to mail it back at his earliest convenience.  This form was frequently a list of questions put together by the Medical Director, the Administrative Director and the OR Supervisor/QI Coordinator.  We dutifully distributed these forms to our patients and implemented numerous tactics trying to get back more than the usual 20-30%.  We tried giving them a self-addressed, stamped envelope at no small expense.  That helped, and sometimes got us up to a 40% return.  We tried telling our Medicare patients that the form was required to be given to them by Medicare in the hopes they would think that they had to send it in if they wanted Medicare to pay the ASC fees.

These tactics worked to the extent that they worked.  There were centers who reported returns as high as 80-90%.

Research into these reports, however, sometimes uncovered some interesting processes in place to reach those percentages.

In one center that reported nearly a 100% return rate, we found the surgeon was bringing the form into the exam room during the patient’s post-operative visit.  He would ask the patients the questions and duly complete the questionnaire with their responses.  After that, he would have the patients sign and date the form.  He was very proud of his response rate, but one wonders whether his patients felt free to respond openly with any criticisms.

In another center the staff went over the questionnaire with the patients during the post-operative phone call and completed the form.  Again, concerns are raised regarding how free the patients felt in giving their response. Nevertheless the organization was reporting exceptionally high percentage of returns on their surveys.

The passing out of the questionnaires, or the completion of them by the staff, met the absolute requirement that the patient be queried, or be given the opportunity to express his satisfaction or otherwise; however, within three-four months of a center’s opening, it became blaringly obvious that certain questions were problematic.  These questions always resulted in poor ratings; e.g.,

• Waited too long.
• Surgery didn’t start on time.
• The room was too cold.
• The fees weren’t discussed adequately.

The QI Committee reviewed the comments and implemented everything they could to try to increase satisfaction in these areas.  We did time studies and tried to work with the patients to ensure they didn’t arrive too early at the center on the morning of their procedure.  We met with the medical staff, especially those who were chronically late.  We altered our schedules, but still those complaints persisted.  We let patients wear their street clothes where possible.  We got them socks to wear on their feet.  We bought blanket warmers and wrapped them in toasty blankets.  We bought warming units of various kinds.  We met with surgeons and, where possible, increased the OR temperature as much as allowable.  We developed proposed fee schedules to give to the patients identifying the various fees for which they would be billed along with those of the ASC.  But…in spite of all these efforts these areas continued to be the ones with the ongoing complaints. So….we set up critical thresholds and declared that we would not address those issues unless we got a percentage of complaints greater than our threshold.  We continued, though, to get the complaints even though we had done everything we could think of to remedy those issues.  We even altered the survey forms taking off the offending questions, but what we, again, found was that we were not learning anything new from the questionnaires.  They truly were just an exercise to meet the regulations and standards, as we struggled to get an acceptable return rate.

But wait!  What if there was a better way the results of which could impact the way we deliver our care in our surgery center? This would take the entire process out of being a painful exercise and turn it, instead, into a valuable tool.

In part 2, I’ll share how to make this process  simple, impactful and painless…