WHAT'S IN YOUR CART? Audit to ensure the many drugs in your formulary are being used. If they're being ordered and regularly expiring, it's time to rethink.

The biggest challenge when it comes to controlling anesthesia costs isn't specific to anesthesia at all — it's surgical scheduling, which directly determines anesthesia costs. Optimizing the surgical schedule means using as few rooms as possible to accommodate as many cases as safely possible. Easily said, but much more difficult to pull off.

A week in advance, examine the surgical schedule. You should spot holes in the schedule and room under-utilization. The chief of anesthesia should figure out how to move cases so that safety isn't compromised when rooms are consolidated. For example, patients with diabetes or latex allergies still go first thing in the morning and orthopedic cases have enough lead time that waiting for nerve blocks won't cause delays. I call the surgeons myself to ask them to move times and rooms if we want to make changes. They usually cooperate, because they know any requests are in the best interests of the center.

You need to approach anesthesia staffing with the same flexibility. Our anesthesia group has a designated core team that works with the surgery center, but the number of providers actually in the facility varies depending on how many rooms will be running on a given day and if we're able to "float" providers among several facilities in the area.

If you're in a state that allows CRNAs, like we are, I highly recommend the anesthesia care-team model. We have 1 physician anesthesiologist who supervises the CRNAs and anesthesia assistants and acts as a float — preparing patients, performing nerve blocks, administering any pre-operative medications. Aside from being more cost-effective, an anesthesiologist is available at all times in pre-op/PACU/the ORs to handle complications and ensure all patients are ready for on-time starts.

Filter the formulary
It's important to have someone in your facility who's extremely involved with staying on top of medication costs, because they're often changing and can spiral out of control without careful oversight. I work with our facility's pharmacist to regularly review the formulary and drug policies and procedures. Here are 3 ways we saved after performing a recent drugs/medications audit:

• Evaluate the use of expensive brand-name drugs. We looked at relatively expensive brand-name drugs that could be safely replaced by generics. One such topical ointment, commonly used by our ophthalmologists, which was replaced by a generic equivalent should result in several thousand dollars in cost savings this year based on the cost differential and the volume we use. It's important to discuss the drug substitutions with the physicians that use them to obtain their consent and cooperation.

• Update policies and procedures. We established guidelines for using IV ibuprofen and acetaminophen. These drugs are relatively expensive, and you don't want to fall into the trap of overusing them just because they're more convenient. We use them only where we expect moderate to severe pain, and when the patient would benefit from lower doses of narcotics to minimize the associated adverse side effects. These situations include bigger cases like orthopedics or longer general surgery cases — they're more suited to the multimodal approach. Eventually, as these drugs become more widely used, the pricing might drop, but while it's at this level, we want to avoid widespread, indiscriminate use.

• Eliminate expirations. In combing through the data, we realized we were routinely ordering several drugs and letting them expire without ever having been used. They consisted mostly of a wide variety of narcotics that would expire and be automatically reordered. These items represented only a small line item charge each time they were ordered, so they went unnoticed. We've now put a stop to that.

Streamline and scale up
The key with anesthesia equipment in the outpatient setting is to keep it simple and compact. You don't need invasive monitoring capabilities, such as intra-arterial lines or PA catheters, meant for critically ill patients or bigger cases. Buy only what you need. My facility is part of a chain, so we use our purchasing power to get discounts. If one of your anesthesia machines needs upgrading, maybe the others do, too. Con-sider buying more than one, as a long-term investment, to take advantage of volume discounts.

The multimodal shift
By combining the use of non-opioid IV analgesics post-operatively with nerve blocks pre-operatively, we've decreased the time it takes to discharge the patients who would otherwise occupy PACU beds the longest. Our shoulder and ACL reconstruction patients wake up faster because we use less narcotics, and go home with much less pain and side effects. It's always very nebulous to try to quantify whether faster discharges mean economic savings — even if it does seem like common sense. But to maximize the assumed value, take the approach of "working the margins." You're not going to make smaller cases appreciably faster by going to the effort of multimodal anesthesia, but there's a lot of leeway in the bigger cases, as much as a couple hours. Those cases are the ones to target.