How to Give Surgeons Great Customer Service
Surgeons perform cases where they feel most comfortable, be it a university medical center, a community hospital or a surgery center. One of the best ways to build your caseload is to make your center a desired location for surgeons. When surgeons don't feel that their needs — or their patients' needs — are being met, they'll go somewhere else. Surgeons are customers with plenty of options. Here are a few customer service issues that transcend every surgical setting.

• Know your surgeons and their procedures. When a surgeon arrives to do a routine case, it should be routine. Getting to know the surgeon's steps and anticipating them will make the case go much smoother. Staff should be cross-trained for several specialties and not be assigned to procedures they don't know. Nothing is more infuriating than asking for an instrument and receiving a blank stare from the scrub nurse. A quick refresher of the instruments for each procedure will alleviate this common complaint.
• Be here now. Leave egos and gossip at the OR door. Focus on the patient and the procedure, not the tiff between the scrub nurse and the circulator. The surgeon doesn't care about this week's nursing schedule or the latest interpersonal drama in the hallways.
• All mod cons. Your facility should be a clean, modern place where surgeons want to bring cases. Remember, you don't get a second chance to make a stellar first impression on surgeons or patients. If you offer surgeons better equipment, they'll bring more technical cases to your center.
• Peak performance. Most surgeons strive for excellence and expect others to do the same. We do not settle for mediocrity, and the surgery center and staff should have the same level of commitment. If you want to attract the best surgeons and best cases, be the best. The majority of surgeons want to become a part of a team and perform high-quality cases in an efficient manner. Paying attention to the details shows a surgeon that the surgery center staff is committed to excellence.

Thomas S. Dardarian, DO
Suburban OB-GYN
Springfield, Pa.

See Dr. Dardarian at OR Excellence
"Give Your Surgeons Great Customer Service"
Saturday, Oct. 3
11:15 a.m. to 12:15 p.m.

Don't Fret Over Expensive Implants and Exotic Insurance Policies
Imagine this: I spend 3 months recruiting one of the busiest orthopedic surgeons in town. For his first case, he schedules a right knee arthro-scopy with a chondroplasty using a $10,000 fresh graft. (Wait! It gets better.) The patient has an exotic insurance plan that we rarely see, and — of course — we don't have a contract. How can I keep from losing a fortune on the case or canceling the surgeon's first procedure with us?

First, we call the insurance company to get the in-network and out-of-network benefits. We also ask the company to agree to pay for the implant. I really don't think this is going to work, but sometimes it does. Then I check to see if I have any historical data on the insurer. With the billing software, I can pull up review procedure and implant reimbursement for various companies. This may give us a picture of how this patient's insurance company might pay. Unfortunately, we don't have any historical data on this particular insurance company.

But I'm not giving up. I contact a third-party billing company that specializes in implants. They have connections across the nation. Using these companies is actually quite easy. I fax them our schedule sheet, all the implant information and the demographic sheet with the patient's insurance information. I make sure they know when the case is scheduled. I prefer to give them a full week to get the implant authorized. In a pinch, they've done it in as little as 3 days.

They get back to us with the authorization. For this case, we insist that the implant company bills the third party directly. To do this, the patient signs an authorization on the day of surgery letting the billing company bill his insurance company. Thankfully, the case is a go. Of course, it took great effort on our part to get the case in the door, but now the surgeon will be able to perform his first case with us and begin a profitable, successful relationship. It was definitely worth it.

Kecia Rardin, RN, CNOR, CASC
Administrator and Director of Nursing
Northwest ASC
Portland, Ore.

See Ms. Rardin at OR Excellence
"Getting Paid for Implants"
Thursday, Oct. 1
3 p.m. to 3:55 p.m.

Communication Is the Key to OR Safety
Surgeons and anesthesia providers are sometimes at odds when it comes to oxygen during cases involving cautery. Anesthesia providers want the oxygen turned up for the patient's sake, while the surgeons want it turned down because of the risk of fire. When using a nasal cannula or face mask, the surgeon needs to tell the anesthesia provider when he plans to begin cautery, so that oxygen can be turned off for at least a minute before the cautery begins. If the patient is intubated, the FiO2 should be below 30%. If the surgeon thinks that the oxygen is turned off when it's on, you may suddenly have a fire.

Communication between all team members and attention to what everyone is doing are the keys to patient safety, especially when it comes to preventing OR fires. Other fire hazards include preps and drapes. The nurse needs to let the surgeon know when the prep is completely dry so that the procedure can begin. Fire-retardant drapes can catch on fire, especially in an oxygen-rich environment. So drapes should be secured tightly around the edges so that there is no oxygen pool near the surgical site.

Medication labeling is another communication issue that can put patients at risk when it's not performed properly. All medication that enters the sterile field should have a label with the following information:

• name of medication (remember, saline is medication, too.);
• concentration;
• date prepared and expiration date; and
• initials of person who prepared the medication.

During surgery is when patients are most vulnerable. They're sedated behind closed doors and away from family and caregivers. Everyone on the surgical team needs to protect the patient, who literally has left his life in your hands. It's a message that needs to be communicated every day, for every case.

Mary Wilson, RN, BSN, CNOR
Clinical Preceptor
West Virginia University Hospitals
Morgantown, W.Va.

See Ms. Wilson at OR Excellence
"You Make the Call: Is This Good Patient Safety?"
Thursday, Oct. 1
2 p.m. to 2:55 p.m.

How to Finesse Induction With Propofol
Anesthesia providers usually give an induction dose of 1.5mg/kg to 2.5mg/kg of propofol, depending upon the age and co-morbidities of the patient. They begin this with a bolus of 200mcg/kg IV over 5 seconds. As predicted, the result is usually apnea and hypotension, which requires mask ventilation or intubation, fluid boluses and vasopressors. To avoid this situation, especially for the frail and elderly, use BIS monitoring and a syringe infusion pump. A propofol loading dose of 2mg/kg can be given at 400mcg/kg/min over 5 minutes, 300mcg/kg/min over 7.5 minutes, or 200mcg/kg/min over 10 minutes while monitoring spontaneous ventilation, airway patency, BIS and blood pressure. Usually when the BIS is about 50 and the loading dose is complete over several minutes, the patient should be ready for deep sedation. The patient still may need intervention, but the responses to the dosage are usually less pronounced.

Daniel K. O'Neill, MD
Assistant Professor of Anesthesiology
New York University School of Medicine
New York, N.Y.

See Dr. O'Neill at OR Excellence
"RNs and Propofol: Who Should Do Conscious Sedation?"
Friday, Oct. 2
4:25 p.m. to 5:15 p.m.

Reprocess Expired Instruments
You probably know about reprocessing used surgical instruments and supplies such as harmonic scalpels, burrs, bits and blades. But you might not know that you can reprocess expired supplies and devices such as procedure packs, sutures and implants.

With reprocessing you can reduce disposal fees and purchase supplies that you'll need for as little as 25 percent of the cost of new products. No matter what you reprocess, it's important to learn as much as you can about the reprocessor. For liability's sake, the reprocessor becomes the "manufacturer" of the device. Talk with or visit some of the reprocessor's clients. Make an appointment to tour the reprocessing facility. It should be clean and seem professional. The right relationship with the right company can save you thousands of dollars each year.

Amanda Llewellyn, MBA, MHA, FACHE, FAHRMM
Assistant Administrator
Clinical Operations and Ambulatory Services
Johns Hopkins Hospital
Baltimore, Md.

See Ms. Llewellyn at OR Excellence
"Secrets to Surgical Supply Savings"
Thursday, Oct. 1
3 p.m. to 3:55 p.m.