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Language Barriers

October 4, 2012 Leave a comment

Staff

The question arises over and over as to whether people who are doing the housekeeping and who are cleaning instruments and scopes have to be able to read and speak English in order to be able to read instruction manuals for the use of equipment and for cleaning equipment and scopes, and for mixing solutions, reading instrument cleaning agent labels, and reading MSDS no say nothing of emergency instructions and signs.

According to OSHA, it is not necessary for those persons to be able to read English if the information is also available to them in their language, or if there is a translator who has trained them and/or is available to translate.  

Hmm..so….you best get your applicable MSDS also in that language and you had best get the instructions on the labels on bottles for mixing, etc. in that language, too.  

Can you GUARANTEE that there will always be a translator available when needed?  

What about during the night when housekeeping is there?  Think about it.

 

 

 

 

Patients

How are you all handling your patients’ health literacy?  Health literacy includes much more than reading proficiency.  It is a person’s ability to obtain, use and understand the information given to them.  It includes English proficiency and cultural beliefs.  We, as health care professionals, need to include these in our teaching even though we are feeling rushed in our busy ambulatory surgery/endoscopy centers.  Incorporating these learning styles, cultural beliefs and language abilities will result in the patient having a more positive surgical experience as well as outcomes.

It may be that many of us complete our cultural competencies as a chore, and not incorporate the distinctions we learn into practice in taking care of our patients.  What cultural competency means is that you are open to recognizing that people’s beliefs may be different from our own and some of these beliefs may influence how patients understand their health.

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The Pre-Operative Patient Assessment in an Ambulatory Surgery Center

July 4, 2012 Leave a comment

According to The ADA Group Center policies “all patients deemed appropriate for procedures performed at the Center are to be interviewed in order to collect a comprehensive patient history, to include medications, and to identify inherently dangerous patient conditions. Patients are to be counseled and assessed paying particular attention to special needs inherent to the patient’s age, prior historical events and underlying health conditions as they impact the proposed surgical and anesthetic event.  Vigilance will occur especially in regards to the recognition of risks inherent to surgical procedures relating to potential adverse drug reactions and interactions, potential or anticipated critical events and to the potential for surgical site infections.

During the pre-operative interview, whether conducted on-site or through a telephone call,  the peri-operative staff assess the patient’s ASA status, anxiety level, food and drug allergies, skin issues and integrity,  any potential airway issues such as those identified due to a history of sleep apnea, previous anesthesia issues/susceptibility to malignant hyperthermia, pending lab/radiographic studies and results, pre-operative disease status and those special needs inherent to the patient’s age.

Patient education during this pre-operative interview is crucial.  The time constraints in the ambulatory surgery setting make the collection of comprehensive information and patient education challenging at best.  These time constraints do not, however, serve to provide an excuse to erase the performance of the pre-operative assessment and education process from the organization’s routine activities.

And yet, this seems to be a growing trend, as more and more surgery centers are reporting that staffing constraints have, in fact, negated this activity.

Patient education is one of the primary roles of the peri-operative nurse working in ambulatory surgery.  Research has proven that patient education plays a huge part in successful and positive patient outcomes and in patient outcomes and satisfaction.

Patient education should start with pre-operative brochures either sent to the patient when scheduled, procured by the patient through the organization’s website, or provided to the patient during their pre-operative physician or ASC interview/visit.  This process would be enhanced through on-site tours, group educational meetings, phone calls and education reinforcement conducted on the day of the procedure.

Recently, a licensed risk manager did a trend analysis of patient cancellations in just one of her surgery centers to determine the number of patients being cancelled in the pre-op area on the morning of their scheduled surgical/endoscopic appointment.  Of these, many had either eaten or drank something.  Several had not taken required medication or followed their plastic surgeons pre-operative antibiotic regime.  At least two to three per month had inadequate preps with the same number presenting with incomplete lab work.  Three to four patients each month presented with atrial fibrillation or pulmonary issues.  Top this with a minimum of two to three patients a month presenting with no care person and you have a large number of cancellations occurring after the patients were admitted, and, frequently, had IVs started.  While this number was excessive in this one center, a review of some other centers uncovered similar problems—though not so extensive.  In virtually all of the instances identified, none of the patient’s had received a pre-operative phone call from the center, though all had been sent written instructions.  In all centers staff were queried regarding the breakdown in the performance of pre-operative phone calls/interviews.  New staff members were appalled. Faced with the tight staffing they experienced in the ASC, they could not believe that such a thing would be required of them.  They had no understanding, moreover, of the impact these cancellations had on the organization.  Older staff members often recalled a time when pre-op phone calls and/or interviews were done, and that, oftentimes, there was even a pre-operative coordinator who performed this duty.  None believed there was adequate time allowed in the schedule for this activity to occur.  And yet, this licensed risk manager saw part-time nurses rushing to get out of the center at the end of the schedule, or sitting at the nurses’ station or in the lounge for 20-30 minutes chatting.  This same licensed risk manager witnessed staff gossiping and chatting with one another in different parts of the center throughout the day.  All of this activity added up to a rejection of the staff’s assertion that “there is no time to make these calls”.

Further investigation of center’s performing as many as 7,000 cases a year found that those centers were being successful in completing 85-90% of their calls/interviews. A 100% goal was rejected due to late “add ons” and failure of patient response/inability to connect with the patient preoperatively.  These patients were educated and assessed the morning of their procedure.

CASE STUDY

Adequate preparation makes a huge difference in the patient’s response to his entire procedure.  A four year old was scheduled for bilateral PE tubes.  The grandmother, an OR trained registered nurse living with the family eagerly awaited the child’s phone call scheduling a time for the child to come in for her tour and to get her sample anesthesia and/or surgical mask and to play with the stuffed animal surgical patient.  No call came, so the grandmother awaited the pre-operative phone call to educate the child on what to expect and to gather information in order to best prepare for the care of the child.  No call came.  The grandmother put all her experience in place and did the teaching for the child.  A trip to the hardware store got a mask and hair cover.  The child was told what to expect on arrival, in the pre-operative area…what the OR would look and sound like…it would be cold…everyone would be dressed the same…the equipment, the noises, the table/bed…the anesthesia mask.  On the day of the procedure, the little girl hopped off the pre-op stretcher taking the OR nurses’ hand and walked right down the OR corridor and into the room.  The ASC staff did make a post operative phone call to the family during which she bragged on how brave the child had been and that they had never had a child do that before “without even a whimper”.

CASE STUDY

In another case, a 69 year old patient was scheduled for a colonoscopy.  During her pre-operative visit her physician provided her the packet of information from the surgery center.  This particular patient happened to be an ASC registered nurse of nearly 30 years experience.  A week prior to the surgical appointment, the nurse opened the packet and discovered that the first piece of literature advised her that the procedure would be performed at one of two centers, but not which one. She waited a day or two for her pre-operative call to clarify the issue.  None came, so she called her physician the Friday before the surgical appointment to find out where she should go.

A comprehensive pre-operative phone call or interview is crucial to patient safety and satisfaction.  Needless to say, neither the grandmother in the first example or the RN in the second will frequent those two centers again…and…rest assured their dissatisfaction has been loudly shared with family and friends who will also, most assuredly, shy away from those two centers.

Conducting a comprehensive pre-operative patient assessment and teaching interview, whether on site or over the phone, need not erode into staff overtime pay.  How is it possible to get this very important activity done in the face of “staffing skinny”?

Pre-operative assessments can be conducted as near the time the patient is scheduled as possible.  Consider setting up a system identifying those patients who are awaiting surgery/awaiting the pre-operative assessment and education interview.  All pre-operative staff should be trained to conduct these interviews and to recognize Red Flags reported during the interview for referral.  The “Awaiting” files are checked daily.  The goal would be to do the assessment as soon as possible—some may be two weeks out from their surgery date.  Staying ahead is a bonus allowing time to get those patients scheduled closer to the date of their procedure interviewed.

Once the history is collected, cultural diversities identified, special learning needs addressed and general educational

information imparted, the pre-operative nurse monitors the receipt of lab, EKG or radiographic reports, the physician’s H&P and consents which are all added to the patient’s file whether paper or electronic.  Anything missing is identified well in advance of the surgery date and collected at that time.  Continual monitoring identifies “missings” well ahead of the surgical date thus decreasing those nasty surprises that happen on that date when the H&P, lab work, consents, etc. are missing resulting in case cancellations and/or delays to say nothing of the irate patient and physician.

ASCs pride themselves on patient satisfaction.  Cancellations and delays impact patient AND physician satisfaction tremendously to say nothing of the cost incurred by the organization for supplies used in pre-op, staff hours and salaries, supplies opened in the OR and those corresponding staff costs.  Add this to the negative experience by both the patient and physician, and the cost is even higher.  It could be argued that the organization cannot afford to NOT do the pre-operative interview and assessment.

The Joint Commission and CMS urge ASCs to embrace a culture of patient safety.  How could this even remotely be possible without a pre-operative assessment and educational interview conducted by the ASC?

Losing A Patient

April 10, 2012 Leave a comment

As healthcare workers, we always know that there is a possibility that one of our patients will die on us. 

I began my nursing career in surgical intensive care in a very large teaching trauma center in San Antonio, Texas following a critical care internship.  The patients we got in the SICU were major traumas—a woman thrown under a train by a jealous boyfriend or tied to the tracks by an irate pimp—or arms cut off by a husband; a 14 year old boy who dove into a “too shallow” pool to retrieve his baseball hat while horsing around with his cronies and now faces a lifetime as a quadriplegic and so on. One day I came into the unit, looked around and marched straight out and to the DON’s office where I put my application in to work charge nurse recovery.  Those patients were asleep and as soon as they woke up, they were off to their rooms. Minimum exposure to sadness, to trauma (all intensive care patients left the OR and went straight to the SICU). From there I went to the Operating Room.  Those patients were ASLEEP the whole time I took care of them. So after being a trauma junkie I entered the world of wellness nursing in the guise of same day surgery.  And I fell in love with it.

 

Oh, I have faced death in my beloved world of otherwise healthy patients.  There was the patient we lost—a 46 year old healthy woman who came in for a vein stripping and died because the esophagus was intubated rather than the trachea.  There was the 45 year old woman who came into another center for multiple plastic procedures and after 11 and ½ hours of surgery died upon exiting her car in her driveway of multiple pulmonary emboli. We had the 86 year old who was oxygen dependent, and who wasn’t given oxygen during his stay in the center; consequently exiting the operating room with no vital signs.  Nothing prepares you for such a loss.  You are never fully prepared.  We live in a world of wellness where our patients are, even with all their underlying health issues, truly Class I & II ASAs who consider themselves otherwise healthy.  We see them that way.  We admit them, take their histories, their vital signs, listen to their stories, meet their care persons, laugh with them, get frustrated, give them instructions, put them in the car and wave at them as they leave.  “There we go, another one bites the dust!”, I used to say jokingly as I marked their name off the schedule, did a little jig of happiness and sang a little.  We had returned another patient to his family, to his social world better than when he came in…another success.  We become conditioned that this is the way it IS!  This is the way it SHOULD BE…and it is.  We become, gradually, complacent that it will ALWAYS be that way.  We let down our guard.  We start going on automatic pilot.  We become drones addicted to the routine of everyday life in our busy surgery centers. AND THEN….it happens…and it is catastrophic…a child dies on our table….we work frantically…we do everything we know to do…everything we have learned…everything we have been taught to save this child…to bring him back so we can deliver him safely to his family….but it doesn’t work.  We are left with the horrific impact….the horror of facing the family…the family with…now…empty arms.

 

I remember once when working recovery having a 3 year old little girl brought to me from the OR wrapped in a pink blanket.  Her long black lashes lay silent on her cold, still body.  A little child with major heart defects whose only chance of living was to try to correct them…but she couldn’t hang on…I believe God wanted her too much.  As I carried her in my arms to the morgue down the back steps I was faced with her parents coming up the stairs from the cafeteria.  I just sat down with them right there and handed them their baby.  We held one another and cried.  There is nothing else that can be done.

 

Stephanie broke down in tears when she heard of the loss at one of our surgery centers.  I tossed and turned all night.  We had them bring in a grief counselor for the staff.  Stephanie reminded me that every time a patient comes into our centers, holds out their wrists and we affix a wristband, that patient is now “at risk”.  We must never forget that and must stay alert and ever ready.  Go in peace, Little One.

Transferring Patients in an ASC

March 17, 2012 Leave a comment

One of the Quality Measures CMS has identified that ASCs will have to start tracking, collecting data and reporting on is in the transferring of patients from the ASC to an institution of higher care.  Surgery centers have maintained documentation regarding such transfers from their initial Medicare and accreditation surveys.

The Transfer Log, Incident Report Log and an incident report, itself, are completed for all transfers.  Furthermore, through the Incident Report and Log, the Quality Improvement Coordinator and Risk Manager Designee track any trends.  Such trends are reported to the QI, the MAC and the Board.  Where trending with a particular physician is noted, peer review is conducted.  This all sounds like we, in the industry, are doing everything we should be doing.  Right?  This may be in question.

In the late fall of 2011, The ADA Group conducted a benchmark study amongst 36 clients collecting data identified in the Quality Measures CMS wants tracked.  Out of 36 centers there were 113 reported transfers; however, this is not a pure report, as this included 24 hour admits.  We decided to have them do this, as CMS is looking at hospital re-admissions, and, while, these patients, on the whole, are not being re-admitted to the centers, and while CMS is not requiring ASCs to track such data, The ADA Group believes it bears tracking.  In a future article, we will separate this data to report transfers vs. hospital admissions within 24 hours post discharge from the ASC.  Not all centers reported their volumes; however, with those reporting their caseload ytd for 2011 we tallied a total volume of 55, 357 with a percentage of transfers/24 hour admits of .002 percent.

CMS believes ASCs may not be enforcing their admission criteria, thus inflating the number of hospital transfers that are occurring.

Greater issue is the process that is taking place in the ASCs transferring patients.

As a group of 3 licensed risk managers, we have cause to review incident reports beyond just reviewing logs for trending.  What we are finding is alarming.  As recent as 2010 most charts of patients who were transferred to the hospital had no physicians’ orders advising the staff  TO  arrange for a hospital transfer.  In addition,  many incident reports where patients were discharged from the ASC and sent to the hospital with their care person driving them.

We researched regulations.  It is true that there are no regulations requiring patients be transferred in an ambulance or medical transport service van.  However, in discussing the issue with the State of Florida Agency for HealthCare Administration, Department of Risk Management, we got total support for our stand that ANY patient being transferred to the hospital ER for a HIGHER LEVEL of CARE should be transferred by ambulance.  We are aware that this is an additional cost to the patient, but the risk, the vulnerability of the organization, is just too high to do otherwise.

Recently, we had two occurrences reported to us.  In one, the surgeon came into the recovery with anesthesia following the patient and ordered the staff to send the patient to the hospital once discharged with her care person by private car.  The anesthesia provider argued that he did not want the patient going by private car, but felt an ambulance needed to be called.  Imagine “the day in court”.  The lawyer for the plaintiff asks the nurse manager, CEO or Medical Director, “Did you send the patient by ambulance? No?  …even with the anesthesia provider demanding that mode of transportation?  What WAS your rationale?”

In another instance, the gastroenterologist reports that he believes the patient’s esophagus may have been torn during the EGD when the patient started waking up and coughing.  Consequently, he wanted the staff to advise the patient’s husband that, upon discharge, he needed to take the patient over to the hospital for admission to the ER.  The husband followed these orders, but now things get cloudy.  We have no idea how much time elapsed from the time the patient and her husband left the center and were subsequently admitted to the hospital’s ER.  Did they stop to get the patient (who, after all, had been NPO for hours) a little something to eat or drink on the way?  ….or, maybe, the patient had some sips of the husband’s coffee that was in the car…

When the ORS/QI Coordinator called the hospital the next day for a report from the nurse in charge of the unit to which the patient was admitted, she was advised the patient wasn’t admitted, and, in fact, they did no tests at that particular hospital.  She was advised that they had sent the patient on to a hospital two (2) hours away where there were throat and thoracic surgeons.  When she called that hospital, she was told no report could be given because of  HIPAA (not true as the ASC is part of the patient care continuum). ADAcontacted the hospital’s risk management department and could only learn the patient was to be fed the next day prior to discharge.  The ORS contacted the gastroenterologist who had not been notified by the original hospital OR the final hospital of admission.  Again, this leaves the center so vulnerable, as to be beyond discussion.

The ADA Group’s licensed risk managers discussed this topic of transferring patients with several other licensed risk managers to include the State of Florida.  One risk manager believed that letting the patient go to the ER in a private car was perfectly fine—especially if the hospital is on the same campus.  But, let’s look at this.  The patient belongs to the ASC as long as they are on the ASC property which includes the parking lot.  The hospital parking lot and ASC parking lot are one of the same.  Now, ANYTHING can happen in a parking lot—accidents—and what if the patient had an “episode” enroute?

Always err on the side of patient safety:

  1. Develop a comprehensive policy regarding patient transfers and submit this to the medical staff committee and the Board for approval and revision, clarification, as needed.  In this policy determine the difference between hospital referrals and direct transfers.
  2. Circulate the policy to the medical staff.
  3. Inservice the Center staff.
  4. Document all transfers and referrals on an incident report.
  5. Maintain the incident report log.
  6. Track and report trends.  Note whether or not the patient met the organization’s admission criteria on scheduling.
  7. Follow up all transfers with the nurse in charge at the admitting unit.
  8. Procure a copy of the hospital discharge note.  (You may have to get this from the transferring physician.)
  9. Track and report 24-hour hospital admits to the hospital and re-admits to the ASC.
  10. Report all trending as discussed above.
  11. Inservice staff, monitor and conduct competencies on pre-operative patient instructions that include post-operative instructions.
  12. Conduct QI studies on the effectiveness of post-operative instructions and admission criteria deviations.

Care of the Morbidly Obese in the Surgery Center

January 10, 2012 Leave a comment

 

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.

Categories: Patient Centered Care

Renewing Patient Centered Care in ASCs

December 20, 2011 Leave a comment

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.

Categories: Patient Centered Care
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