Your anesthesia service is the oil that makes your facility's engine purr. Without providers who are committed to being efficient, your surgical schedule will stall and sputter. Here are 10 small and not-so-small things anesthesia providers can do before, during and after a case to keep your facility humming.

Pre-op

1 Start IVs in pre-op.
Nothing irritates a nervous patient or a busy surgeon more than having to wait in the OR while the intravenous line is placed, says La Mesa, Calif., anesthesiologist Adam Dorin, MD, MBA. The simple solution to improving patient flow: Train nurses to place IVs in the pre-operative holding area. Exceptions to this rule include patients with a known history of difficult IV placement or physical status suggestive of a probable difficult IV.

"The placement of a needle-less heparin lock - which can be adapted in pre-op or the O.R. with an IV bag and tubing where necessary - saves time, lets patients receive medication when necessary and lets the surgery begin that much sooner upon entering the operating room," says Dr. Dorin.

Dr. Dorin paints the ideal scenario. Pre-op nurses ready the IV supplies early in the morning as the first patients are being admitted. They then place the heparin lock once the paperwork is completed, and the patient has changed and is waiting to be interviewed by the anesthesia provider.

2 Use an internist.
Here's a question for those of you in hospital settings: Ever consider using an internist to perform pre-op evaluations? "An internist trained to do pre-op evals slanted toward anesthesia care is hugely valuable," says James Mayfield, MD, medical director of perioperative services and vice chairman of anesthesiology at the Medical College of Georgia in Augusta. "[Internists] know what we're looking for, and patients get a real thorough evaluation."

Internists can check blood pressure, heart rate and can recognize cardiac and blood sugar level issues, while freeing anesthesiologists for increased time with patients in the OR, says Dr. Mayfield. But the biggest advantage, he says, is cost. "Internists make about $130,000 a year, as compared to about $240,000 for an anesthesiologist."

3 ID patient liaisons.
Identify two or three dedicated pre-op nurses to act as liaisons among patients, anesthesia providers and surgeons, bridging the communication gap between these groups in addition to performing their routine duties, says Dr. Dorin. "I've worked in several facilities where this role was routinely performed by the nurse administrator, and numerous cases were saved from cancellation," he says.

Liaisons would ensure that all the necessary lab tests and H&P information is available early in the pre-op process. In the event of last-minute problems, the nursing liaison can make quick fixes to get the patient back on track or added to the schedule later in the day.

4 Pick up the phone.
Several experts we talked to stressed the importance of the pre-op phone call. Talking with patients the day before surgery is a simple practice that takes just a few minutes, but can be a huge time and money saver.

"Spend a few minutes on the phone to answer questions that arise," says John Dombrowski, MD, PC, anesthesiologist and pain management specialist at Georgetown University Hospital in Washington, D.C. "Reminding patients about not eating before a case, the correct time to show up and what medications they can and cannot take will dramatically reduce the number of cases you need to cancel."

Dr. Dombrowski recommends placing calls around 2 p.m. the day before surgery - late enough to remind patients about pre-op instructions, but early enough to reach surgeons' offices if you need to cancel a case or change the start time.

In Dr. Dorin's experience, the most common problems stem from diabetics (on a complex regimen of insulin and oral hypoglycemics, or with an insulin pump) or patients with a whole host of cardiac medications who aren't sure what medications to take and what medications not to take during the 12 hours or so before surgery.

5 Organize the meds.
Creating drug kits, comprised of basic medications anesthesiologists need during procedures, will dramatically increase case efficiency, says Dr. Mayfield. He recommends using a compartmentalized tray - like the top of a fishing tackle box - to divide induction agents, muscle relaxants, beta-blockers, blood pressure medications and boxes of atropine, epinephrine and benadryl for patient emergencies.

"Your anesthesia group can determine the specific contents," says Dr. Mayfield. "The point is that anesthesiologists only need to go to the pharmacy twice a day - at the beginning and end of each day - instead of running there between cases." He notes that the anesthesia manager prepares the kits at his facility the night before cases; one kit per room per day is sufficient, he says.

Intra-op

6 Prevent PONV.
The single biggest concern in ambulatory anesthesia is controlling post-op pain and nausea and vomiting, says Dennis Pellecchia, MD, medical director of the Reading Hospital Surgicenter at Spring Ridge in Wyomissing, Pa. "A truly cost-effective practice is choosing the best drug for the right situation," he says.

Dr. Dorin agrees. To control PONV, he prefers to give weight-appropriate doses of Decadron (dexamethasone), when not contraindicated, and Reglan (metoclopramide), plus or minus Zofran (ondansetron) or Anzemet (dolasetron) to every patient - preferably at the beginning of short cases. "Patients who are pain-free and have no nausea are happier customers and move through the surgery center with more efficiency," says Dr. Dorin.

Others have different approaches. "The use of nausea drugs is very expensive," says Dr. Dombrowski, "and they're not always needed." For that reason, he says, patient selection is critical. Dr. Dombrowski recommends you only give anti-emetic drugs to high-risk patients - those with a history of nausea or motion sickness. If a patient is high-risk, Dr. Dombrowski notes that older drugs are less expensive and just as effective as newer options. He considers Decadron an excellent, cost-effective option for controlling PONV.

7 Go regional.
Maximizing the use of regional anesthesia is the ideal way to curb costs and improve patient outcomes. "Regional anesthesia wherever and whenever possible facilitates throughput, especially in the PACU and discharge phase, because patients arrive awake and comfortable," says Eugene Viscusi, MD, director of the department of anesthesia at Thomas Jefferson Medical College in Philadelphia. He adds that regional anesthesia provides great pain control and reduces the incidence of nausea and vomiting.

"In an ideal setting, you could allocate a regional block room to perform these procedures under a monitored setting before entering the operating room," says Dr. Dorin. But since staffing levels and facility space are often far from ideal, make regional anesthesia supplies readily accessible, he adds.

In addition to greater speed and patient comfort, using a regional technique could add dollars to your bottom line. "You can bill for the management of the patient's post-op pain," says Dr. Dombrowski. He notes that the follow-up phone call and the placement of a pain pump's catheter are billable expenses.

8 Embrace technology.
Here are three tools that can improve an anesthesia provider's efficiency.

• LMAs. A laryngeal mask airway, which sits over the vocal cord and lets patients spontaneously breathe during the procedure, eliminates the need for expensive muscle relaxants and reversal agents. "Using atropine along with a reversal agent has been implicated with PONV," says Dr. Pellecchia. "By using LMAs, we're able to avoid giving other drugs."
• Consciousness monitor. An awareness monitor lets you titrate medication levels so the patient receives just the amount needed, says Dr. Mayfield. "Patients come out of sedation quicker because less drugs are used. Recovery times are therefore improved," he says. See "Mind Reader?" on page 57.
• Patient warming. Maintaining normothermia speeds recovery times by preventing development of adverse outcomes, says Chris Mahoney, RN, MS, PhD, professor of business administration at Winona State University in Winona, Minn.

Post-op

9 Measure the doses.
Analyze your PACU patient management techniques to make sure that opiates aren't being used in amounts or frequencies that preclude the appropriate and efficient throughput of patients, says Dr. Dorin.

Often without realizing it, PACU staff will use more medication than is really necessary - medicating patients more as a means to keep them manageable while attending to other patients than as a remedy for pain. "Monitor narcotic use in the PACU and trend recovery times by patient and staff member," says Dr. Dorin. "This can be a valuable educational and research tool."

10 Fast-track patients.
Any patient who has received a local sedation or a regional pain block may be a good candidate to bypass the first stage recovery and proceed directly to the Stage II area for quicker preparation for discharge.

"Each manager needs to analyze the types of procedures at her facility and seek input from the anesthesia provider to determine what works best for her patients," says Dr. Dorin. In his experience - barring an unusual patient condition or surgeon request - all local sedation cases (breast surgeries, simple hemorrhoidectomies, podiatric cases, hernias and cataracts, for example) can go straight to Stage II recovery. There, patients receive instructions, have IVs removed, change and prepare to leave. "Moving appropriate cases directly to Stage II cuts about one hour off the usual recovery room stay," says Dr. Dorin.

Quality over quantity
Ensuring quality outcomes is probably the most cost-effective approach to your anesthesia practice, says Dr. Pellecchia, who warns that adverse outcomes will negate any savings you may encounter through cost-cutting measures that jeopardize patient safety (see "Just How Safe Is Anesthesia (Really)?" on page 76).

"Remember, quality in an ambulatory surgery setting is an all-encompassing concept, involving both good patient outcomes and efficiency," says Dr. Dorin. "One without the other just won't cut it."