When you look at ways to improve the efficiency of your arthroscopy practice, don't stop at what's going on inside the OR. Try these 12 ideas.

1 Consider your unique constraints
You probably schedule same-side shoulders consecutively in the same OR to minimize repositioning equipment between cases, thereby reducing room turnover time and staff fatigue. Also consider other factors that will influence case turnaround: type of anesthesia, number of ORs and equipment availability. Shoulder patients take longer to wake up than knee patients; they typically receive deeper, LMA anesthesia, says Andrea Wappelhorst, RN, director of nursing with the Houston, Texas-based KSF Orthopaedic Surgery Center. When she has two surgeons working her three ORs, she alternates shoulder and knee cases in separate rooms. When the shoulder patient is emerging in OR No. 1, the surgeon can start the knee in OR No. 2.

Lacey Dyer, RN, BSN, clinical manager of Ortho-paedic South Surgical Center in Morrow, Ga., adapts her schedule to instrument reprocessing limitations by alternating cases based on instrument use. In her two-OR center, turnaround time averages seven minutes, in part because she never schedules two instrument-intense cases in a row. "We wash by hand and use an ultrasonic cleaning system, so we have to consider instrument availability," says Ms. Dyer.

2 Educate patients early
Give post-op instructions to patients in pre-op so they can absorb the instructions and develop questions, says Doug Wyatt, director of the LOC Surgery Center in Lincoln, Neb. Mr. Wyatt also educates caregivers by making sure they're present, and repeats instructions in post-op.

3 Streamline protocols
Streamline pre- and post-op protocols into yes-or-no checklists. This helps everyone know what to do while reducing paperwork. Christine Hayes, BSN, CNOR, RNFA, director of Everett Orthopedic Surgery Center in Everett, Wash., says her pre-op protocol sheets not only help ensure patient clearance but also hasten admission.

4 Issue standing orders
At Mr. Wyatt's center, where anesthesiologists perform a lot of pre-op local anesthetic injections and peripheral nerve blocks, RNs prepare standing medication orders in advance. "When the anesthesia provider is available, he can get right to work," he says. At the San Antonio Orthopaedic Surgery Center in Texas, where most arthroscopy patients receive general anesthesia, nurses start PONV medications before surgeons arrive. "The longer these medications are on board, the better the post-op antiemetic effect," says director of surgical services Marsha Smith, RN.

5 Promote flexible staffing
Assign each nurse multiple jobs; you may reduce the risk of nearing day's end with too many jobs undone or experiencing delays when you're short-staffed. "All my nurses do extra jobs during downtime, like drug inventory and laundry," says Ms. Hayes. She uses a float nurse to assist with changeovers and fill in during breaks on days when multiple ORs are running at full steam. She also cross-trains RNs so her nurses can work in both admitting and recovery.

6 Get rid of unnecessary items
When surgeons agree on instrumentation, your staff won't spend time pulling too many preference items. "We have a single custom procedure pack for each of our nine surgeons," says Ms. Dyer, who was able to convince her surgeons that they didn't need non-sterile ACE bandages in their knee scope pack, or both Xeroform and Adaptic dressings, or two ABD pads. "Sit down with your surgeons, price everything out and ask them: Do you need this? Why is it here? Does it really matter to you? You may find they're just used to having things they don't really need," she says.

7 Plan for the worst case
At the Orthopedic Surgery Center of Orange County in Newport Beach, Calif., director Gabrielle White, RN, keeps three sets of cameras and light cords per OR. That's two back-up sets. Her autoclave system, she says, allows her the shelf-life she needs to house these items overnight. "We always plan for the worst-case scenario," she says. Several other managers recommend working only with vendors that can ensure quick turnaround when equipment problems arise.

8 Keep anesthesia light
At the LOC Surgery Center, anesthesia providers perform many arthroscopy procedures under MAC, along with local anesthesia and peripheral nerve blocks, depending on the case. The result, says Mr. Wyatt, is an average total recovery time of just 30 minutes. Mr. Wyatt says 75 percent of his arthroscopy patients opt for MAC because they want to eat and drink early, avoid PONV and go home sooner. "Full general slows the recovery process by at least a half an hour," adds Mr. Wyatt.

9 Perform equipment time-outs
At the San Antonio Orthopaedic Surgery Center, Ms. Smith has reduced the incidence of arthroscopy equipment malfunction by performing equipment time-outs. "Before and after each case, while equipment is running, the scrub tech and circulator check scope function and quality. We log the results and track each scope by serial number through surgery and the processing, maintenance and repair process," she says. Now, her "high repair cost" physicians have become kinder and gentler, equipment malfunctions are fewer and repair costs are down.

10 Manage fluid
Anyone who has mopped up irrigation fluid after a case knows that it can slow turnover time. To minimize the mess, yet keep the fluid flowing, consider low-flow pumps. Ms. Smith uses large suction canisters to prevent the need to change them out intra-operatively. If you use a gravity irrigation system for any of your arthroscopy cases, consider TUR Y-type tubing with two collection bags, with one raised higher than the other. "This obviates the need to stop the case to change out the bags," says Ms. White. The gravity system saves her $55 per case over the specialized tubing that pumps require, "significant when you're getting $600 for a knee scope that costs $1,200 to perform."

11 Move the paper through
Move the patient chart and other paperwork to recovery before the patient leaves the OR. "Our surgeons take the chart and paperwork to recovery as they leave the OR and the case is being closed," says Ms. Dyer. "The recovery nurse then gets the chart and post-op orders five to eight minutes in advance of the patient. She gets the paperwork done and can focus on the patient when he arrives in recovery."

12 Alert recovery
Ms. Hayes knows well what a nurse can do with just a few extra minutes; that's why her circulating nurses always call recovery from the OR with an ETA for each patient. "The recovery nurse then knows if she has the time to do a pre-op call or discharge a patient," says Ms. Hayes.

Eash of these tips, however, depends on the attitude, cooperation and retention of your staff. "You simply can't run an efficient center if you don't have great people standing beside you," says Ms. Smith.