Archive for the ‘Risk Management’ Category

Is Your Surgery Center Safe?

January 15, 2013 Leave a comment

safetyfirstThe patient is in the pre-operative area lying comfortably on the stretcher bed when the physician approaches him to do the H&P update.  After greeting one another, the patient reaches into the top sheet and pulls out a gun.  “You better do a good job, Doc,” says he.  The doctor reaches down and takes the gun away from the patient without incident telling him that weapons are not allowed in the center.

A similar incident occurs at another center when the patient, a police officer, does the same thing.  That surgeon reaches for the gun and tells the patient, “John, you are not a police officer at this time, but a patient.  Give me the gun.” They laugh about it, but later the staff share their alarm with the OR Supervisor and Administrator.

In another occurrence the patient, who has become quite argumentative and irascible, is being escorted to his car.  Upon being told, again, that he cannot drive, he opens the driver’s side door and reaches under the seat.  He retrieves a gun which he carries around to the passenger side and puts the gun in the glove compartment.  In this instance, the OR Supervisor drove this patient home!

In one other center a former employee is found dead outside of town in a desolate spot.  The victim of multiple complaints of domestic violence involving her former husband during her time at work, this person is dead and the former husband is still free.

Most adults spend more of their waking hours in their work place during the week than they do in their homes.   This familiarity breeds a feeling of comfort and safety.  This is their “home away from home.”  Their guard is as down as it is at home—maybe more so based upon the “safety in numbers” thought processes most humans have had in the past. We can no longer afford to think along those lines, but must, rather, consider not only our safety at work, but that of our patients, visitors and other staff members.

The safety of your work environment from a security aspect has to be evaluated.  Gather the staff and work with your Safety and Security officer to conduct an intensive security assessment.  Begin in the parking lot.

parking-lotIs your parking lot well lit?  Is it close to the building?  Are there large bins/dumpsters and shrubs behind which someone could hide?  Do staff members arrive at nearly the same time thus forming a “buddy” system for leaving their cars and crossing the lot to enter the building?  Would such a system be possible for all those entering (or leaving), especially during those times when it is dark?

Is the staff entry door well lit or is it an alcove that enhances the darkness and isolation? Is the door easy to enter such as a keyless system, or does it require a key that can be dropped or fumbled thus increasing entry time?  Is the staff entry door kept locked?

Is there a back or side delivery door for supplies?  Is this door kept locked or is it propped open for vendors or visitors—especially those bringing food?  Do external doors include windows, a side window panel, or, at the very least, a peep hole? Even though staff can see the person ringing that bell, is identity confirmed before they can gain entry?

Vendors should always check in at the front desk prior to going to the back or side door to deliver supplies.  At the very least, a known vendor should call the center to advise them that he is about to deliver supplies, etc.  A doorbell should be installed at the delivery door.  Human beings have a Pavlovian response to someone knocking on a door or ringing a doorbell; i.e., the response is to automatically open the door.  But…is this the safest action to take?  With a pre-arranged phone call, once the doorbell rings, the staff member can look through the window or peep hole and verify the delivery person.  However, if this person is not familiar to the staff, some form of identification needs to be presented, before that person gains entry.  Have them show picture ID as well as a company ID.  Vendors going to the front desk would have already presented identification and had it verified.

peepingLeaving back doors propped open or unlocked is a common practice not only for vendor access, but for smokers who want to just pop out for a quick smoke.  This is not a safe practice and should be stopped in your center immediately.

Another issue with the service, staff or emergency doors is that they are frequently all glass in a metal frame.  While this may be more attractive from the outside, and certainly lets in light, consideration should be given to replacing these doors with the solid core variety.  One rule of thumb in any hostile situation is to reduce the visualization of staff, patients and visitors.  A glass door lacks the safety of invisibility.

In one very active OR, a gun wielding man came flying through the double doors of the operating room suite waving the gun in the air and making wild threats.  The man was clearly not of “sound mind,” but his gun was definitely based in reality.  Following that incident, the administration had a lock system installed to separate the patient care areas from the reception/waiting room.

Conduct a complete safety assessment of the waiting/reception/admitting area.  Who unlocks the front door?  When?  Who else is in the building when this happens?  Is it usually dark outside when the doors are unlocked?  If the center is located in an office building, are other offices open already or is the center the only “sitting duck”? Several centers have reported vagrants sleeping either on the benches outside the entrance or in the entry alcove.  Other centers have reported vagrants sleeping in rooms such as that containing the vacuum pump that were left unlocked.  Two centers reported that vagrants had been sleeping IN THE CENTER overnight.  Access was gained by the vagrant slipping into a lobby bathroom while the reception desk was unattended and after the waiting room was empty.  They merely, in both instances, had to wait until everyone left.  With no motion detectors as part of the security system, they were free to raid the refrigerators, shower in the locker rooms, don clean scrubs, and watch television until bedtime.

In two other instances, recovery nurses walked in on strangers in their recovery rooms on “no surgery” days.  Both strangers took off running when the nurses entered.  Only one was caught.  He had been looking for drugs and money.  In both cases, the vagrants were able to enter past the unattended reception desk after the waiting room emptied—as clearly visible, by the way, through the floor to ceiling windows and glass doors in the lobby and waiting room.  While nothing except stark terror occurred in these instances, it could have been otherwise.  When the last person leaves that waiting room, the door needs to be locked regardless of the inconvenience.  Either a thumb lock or crash bar system is acceptable.  A word of caution about the thumb lock is warranted.  If this lock is visible through a glass window, it is worthless…and we are back to the problems with glass doors or doors with large windows!

As mentioned before, all the areas off the waiting/reception area need to have keyless entry locks i.e., into the patient care areas and administration.  There was a time this seemed like overkill in the ambulatory surgery world. Those days are long past.  These locks help prevent, or at least will slow down, easy access to these vulnerable places.

There needs to be a panic button that is knee or foot controlled at the front desk.  This panic alarm should be silent and should go straight to the Central Service/police as recommended by your local authorities.  A good idea would be to have it light up in administration and at the nurses’ stations alerting all in those areas of a violent situation at hand.  The administrator would follow up the silent alarm with a 911 call.

panic buttonCheck this alarm on a regular basis.  Shortly after the Joint Commission introduced its patient safety goals concerning alarms, many centers reported theirs were present but either non-working, or, in one instance, had never been connected to the alarm system. Make sure all staff know where it is, when it is to be used, how it is to be used and their jobs should it be used.

Develop a policy for Aggressor in the Workplace.  Inservice the staff thoroughly and conduct an annual drill.  We have learned much, unfortunately, regarding aggressors from the Columbine, Chardon, Sandy Hook events.  Secure your area.  Shut doors, blinds and curtains.  Lock as many doors as possible.  Stay out of restrooms.  Get as far away from doors as possible.  Evacuate only if safe to do so.  Stay quiet and, if unable to evacuate to a safe place, wait for the authorities.

What would you do if an aggressive attack happened during surgery?  In one center, a patient’s husband in the waiting room, jumped up and screamed that he had a bomb attached to him.  Imagine the terror!  This center had no means to control the bomber’s access to any areas.  He was free to roam while keeping staff, patients and visitors as hostages until the police arrived!  This could have happened in the Pre-op or PACU areas just as easily…and in those centers with the “open” floor plan this is just a door away from the room where surgery is being performed!

In one ambulatory center a staff member’s husband arrived at the front desk and asked for her.  The receptionist called her to the front, where the husband pulled a gun and shot her dead right there in the waiting room.  It can happen anywhere…a hairdresser’s salon, a McDonald’s…a surgery center.  Later it was discovered that this staff person had asked her husband for a divorce the night before.  Urge your staff to communicate problems/issues with you as a leader.  As a leader, you should look for and watch for signs of abuse in your staff members…physical and emotional.  Be alert.  Talk to that person.  Ask them if they believe the safety of the surgery center is at risk.

gunmanRecently, a national poll advised that Americans no longer feel safe.  This is an unfortunate state of affairs, but has us join our sister nations in this aspect.  You need to stay alert. Be observant. Review your policies. Conduct your drills.  Include the physicians in your Safety Plan and Drills. Take your Safety and Environmental Hazard Assessments really seriously. Implement sound safety practices, and most of all, be safe!

Should ASC’s Consider Valium A Safe “Take-At-Home” Pre-Operative Drug?

July 27, 2012 Leave a comment

I recently received an inquiry from one of our Clients regarding a practice the physicians wanted to initiate at their ASC.  The physicians believed that patients would be best served if given 0.5mg of Valium taken post-operatively at home the morning of surgery.  This would enable them to be nice and relaxed when they got to the pre-op area.

Consideradtion #1 Patient Age and Side Effects 

There are several issues going on here.  When considering what drugs to use with any patient, one has to consider the age of the patient and all possible side effects inherent to the age.  Obviously, the elderly and the very young have special considerations regarding their age whenever choosing a drug, but what is in consideration here is adult and geriatric patients.

Valium is a benzodiazeprine and is used widely to reduce tension and anxiety and, in surgery or certain medical treatments, to induce amnesia.  It is also used for seizures, restless leg syndrome, as a muscle relaxant, and for its sedative effects.

Adverse effects include anterograde amnesia.  Cognitive deficits can persist for up to 6 months or longer. Produces sedfation.  Paradoxicaol effects include excitement, rage, worsening of seizures in epileptic patients.  In patients suffering from, or prone to depression these symptoms can worsen.

The sedative effect of Valium may last longer in older patients.  There is also an increased incident of falls and accidents following the administration of Valium in the older patients.  It can lead to catastrophic side effects if mixed with alcohol. (Remember Karen Ann Quinlan?).  Valium is very addictive.  One physician discourages it use under any condition due to its degree of impairment in some patients.

Valium is detectable in the blood for up to 3 days.

If patients are given a sedative at home, doesn’t this increase their chances of falling at home?

Consideration #2 Falls Prevention Strategies at Home 

Falls in the elderly are a serious concern.  Within our ASCs, we initiate a “Falls Prevention Program.”  We inservice our staff in this area and measure their competency.  We track and trend falls and make changes in our Centers to decrease the possibility of falls.  We paint parking guards in the  parking lots and curbs.  We escort patients to their car.  We don’t leave patients alone to dress following surgery, but insist on staying with them to assist.  We identify patients at a high risk to fall with colored socks or wristbands.  We hold their arm when ambulating.  We recognize that the patient has received sedation, and are, thus, at a higher risk to fall.

BUT if these same patients are given a sedative at home doesn’t this increase their chances of falling at home?  I think of some of our elderly patients especially with their walkers, canes, and underlying health conditions that pre-dispose them to falling.  I know, too, how many times patients with underlying conditions get their feet “tangled up” and fall, and know that this risk has to increase when sedated.

Consideration #3 Alcohol Use by Patients

Valium can be lethal if taken with alcohol.  While alcohol use in the elderly is far below that of the 20 something age group, it is not uncommon.  Alcohol use in the elderly may, in fact, be under-reported.  Many retirees believe they can now sit back and do whatever they want.  Many believe they have earned the right to drink whenever and whatever they choose.  Many life-long habitual users may have increased their alcohol intake with all the golf games, card games, bingo matches, etc. to the extent that a “little nip” at breakfast is not uncommon.  This under reporting includes admitting to their physicians the extent of their use.  Valium and Alcohol do NOT mix…even that little nip can be dangerous.  It should be a concern that our patients fully understand this, discuss their use honestly with their physicians, and comply with instructions.

Consideration #4 Patient Depression and Dependence

Depression is increasingly common among our older population.  Their lives have changed, and are continuing to change, on an ongoing basis, in almost every aspect.  They retire from careers of 20-30 years that have demanded a large part of their lives and have helped to define them as individuals.  They become “stay at home” residents of the community.  This is where they might discover they have no hobbies, or they find that the hobbies they had before aren’t available to them now due to heath problems.  Their physical condition has changed.  They don’t have the stamina they once had.  They may be experiencing some underlying health conditions such as high blood pressure, cardio-vascular disease, coronary disease, diabetes.  Their mortality may be smacking them square in the face.   Husbands and wives are thrust together all day long, another adjustment.  Valium can increase this depression…but, the sedative properties may also provide an escape from all their problems and lead to dependence.

Consideration #5 Choosing Alternative Drugs 

The advantages of Valium under a controlled situation cannot be argued.  However, I would argue that there are other equally advantageous drugs that may be used to provide sedation and insomnia.  Cost may be a factor, as some of the alternative drugs are certainly more costly than Valium.

Consideration #6 Patient/Care Person’s Education 

Patients being given Valium should be reminded to not drive, make important decisions, or sign legal documents for up to 24 hours after taking the drug.

At the very least, the patient’s care person needs to be thoroughly educated about the drug during the pre-operative phone call, so as to be able to take the necessary precautions.

Consider #7 Risk Management and an Alternative Strategies

I am not pointing fingers at this drug and saying, “No! No! No!”  Valium is a staple in any health clinic’s inventory as recommended by WHO.  I am merely pointing out that it is not to be considered lightly, and we, as ambulatory surgery healthcare specialists, need to look at it seriously when prescribing it as a “take at home” med prior to surgery.

I recommend, as a licensed risk manager, that we not give the patients this drug at home prior to their admission to the center, but that we expedite the admission process such that their dosage could be given as soon as possible once they are admitted to the pre-op area.

We should always take great consideration in selecting any drug we prescribe to the patient to be taken at home with no medical supervision.

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.


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”.


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.
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