Looking to improve the efficiency of your arthroscopy service? Focus on the little things that can better your numbers and times, such as smarter scheduling and staffing, equipment preparation, anesthesia choices and fluid management.

1. Know your rights (and lefts)
Schedule arthroscopies by laterality in order to minimize the need to move the table, pumps, video towers and other equipment from side to side. Mounting the video equipment on a boom's articulating arm can help to simplify these moves.

"We group all the rights together and then all the lefts, depending on patient health or allergies, such as latex or if the patient is diabetic," says Elizabeth Diehl, RN, BSN, director of the Roy A. Himmelfarb Surgery Center in Chambersburg, Pa.

Alternatively, if the surgeon has an anatomically mixed lineup of cases, organizing cases primarily by surgical site, then by side, can lend itself to a smoother schedule. If your surgeon is working out of only 1 OR, "do shoulders first, so you can set up the room the night before, and the anesthesiologist has time in the a.m. to do the blocks," says Nancy Logan, CNOR, BSN, MSN, the OR coordinator for Atlantic Health in Morristown, N.J. Schedule "the most labor-intensive case first to allow more time to set up," says Marcia McKay, RN, CPNC, clinical nurse leader at Victoria General Hospital in Victoria, Canada.

2. Book flip rooms
If you've got more than 1 OR available, why not let your surgeon flip between rooms for successive cases? "Operating with 2 rooms is the most efficient way for a quick surgeon to get his cases done," says Peter Bentivegna, MD, FACS, medical director of Cape Cod Surgery Center in Mashpee, Mass. The 2-room approach lets you sidestep the burden of re-arranging equipment for a series of arthroscopies. "If you can book flip rooms, have shoulders in 1 room and knees in the other room," says Ms. Logan. "Do lefts in the first room and rights in the second."

This approach can also shorten the time between cases, as there's no waiting for positioning, prepping or anesthesia induction. "If the doctor has an assistant to close, we flip our surgeons, letting them leave 1 room and walk into their next room. Surgeons love it," says Deb McDougall, RN, BSN, assistant director of surgical services at St. Joseph's Hospital in Chippewa Falls, Wis.

One caveat with the flipping-2-rooms approach: Be sure that the surgeon marks the on-deck patient before he enters the currently active OR, says Melissa Becker, RN, BSN, CNOR, the OR clinical coordinator at Buffalo Surgery Center in Amherst, N.Y. The solution: "We have patients arrive here earlier to ensure that there is enough time to mark them prior to the surgeon going into the OR," she says.

Efficient scheduling isn't limited solely to a slate of arthroscopy cases, though. Depending on the complexity of the case and the speed of your surgeon's technique, single cases might be ideally scheduled in a second OR during a room turnover between 2 larger cases. Says John D. Kelly IV, MD, an orthopedic surgeon from Philadelphia, "While you're doing a big case, set up a small one: It'll be ready before you are."

3. Standardize equipment and supplies
If none of your orthopedic surgeons do arthroscopies the same way, consider standardizing the equipment, instrument trays and supplies they use to simplify case set-up and supply pulling. Custom-made procedure packs are a huge advantage in pulling and opening supplies for a case. Mary Anne O'Brien, RN, BS, director of the Atlanta (Ga.) Sports Medicine Surgery Center, calls them "our best time-saver. They provide everything we need except the shaver blade, which we hold until the surgeon specifies the type." On the case-costing front, remember to wait for that preference to be stated. "We do not open suture or shavers until the surgeons ask for them," says Annemarie Enthoven, RN, director of nursing at Summit Surgery Center in Santa Barbara, Calif.

Of course you've also purchased enough instrument sets for your physicians to perform a reprocessing cycle's worth of arthroscopies. "Having enough equipment in order not to have to sterilize a tray between cases is essential to moving the cases along," says Pat Turner, RN, BSN, MPA, of Community Health Systems in Franklin, Tenn.

How much is enough? That depends on your case volume and the swiftness of your central sterile team and process. Will 3 sets per room let reprocessors stay ahead of the game, or should you keep enough trays on hand to handle 6 cases, which would let the first trays be done in time for the seventh case? Or should you invest in one more set than the number of arthroscopy cases you normally see scheduled in a block?

Smoothly running cases begin with routine pre-operative equipment tests. "Always check the cord and scope before hooking up to prevent delays," says Diane Slocumb, RN, MSA, CNOR, director of surgical services for Cleveland Regional Medical Center in Shelby, N.C. "Check your monitors in the morning to ensure proper connections and that you're able to take pictures," adds Lesley Szilagy, RN, BSN, education coordinator for Orthopaedic and Spine Specialists in York, Pa.

4. Get the most out of your staff
Can your OR staff double as your A.V. squad? "It's very important that the staff understand all of the video equipment in order to troubleshoot the equipment if there is a problem," says Cindy Yashko, RN, BSN, the OR educator at Logan Regional Hospital in Hyrum, Utah.

If the availability of instruments is a concern at your facility, you might consider training your team for jobs outside of the OR, too. "Make sure all OR staff are trained for the wrap room, so they can help the reprocessing staff turn over sets during downtime," says Ms. Szilagy.

Irene Stranz, RN, CNOR, ONC, of Buffalo Surgery Center, notes that stretcher-tables, which can carry a patient from pre-op through surgery to PACU, can shave a substantial amount of time off the process by eliminating the need for patient transfers. Stretchers that accommodate such positioning attachments as armboards, leg holders and shoulder supports can be as versatile as OR tables.

Anesthesia providers can also join in patient management efficiency efforts. "Our anesthesia department is attempting to review all the surgical charts prior to the day of surgery, and contacting patients that may be at higher risk of airway or other complications," says Kristine Lemley, RN, BSN, CPAN, CAPA, clinical manager for same-day surgery and post-anesthesia care at Wheaton Franciscan Healthcare-All Saints in Racine, Wis. "This leaves more time pre-operatively for the same-day RN to begin discharge instructions."

5. Go regional
When it comes to efficient anesthesia for arthroscopy, many say there's only one way to go: regional. "Do a block. This helps to ameliorate post-op pain and assists in a smoother recovery period," says Rebecca Anne Vitillo, RN, BSN, LNC, MSJ, administrator and director of nursing at the Meadows Surgery Center in Rutherford, N.J. "Making sure the patients have nerve blocks is critical to patient throughput and efficiency," adds Shonda Huggins, RN, BSN, nurse manager at Cooley Dickinson Hospital in Northampton, Mass.

Be sure to build time for regional into your surgical schedule. Bring patients back a few minutes earlier so anesthesia providers can get the job done without holding up start times. "Designate a pre-op block room and put in all blocks before the patient arrives in the OR," says Todd Anderson, MD, chief of anesthesiology at Schoolcraft Memorial Hospital in Manistique, Mich.

6. Invest in automated fluid disposal
Given that arthroscopic visualization depends on a steady inflow of irrigation into the joint space, effective fluid waste management is another essential consideration for case-to-case efficiency, since decreasing cleaning time speeds room turnover time. Readers agree that automated fluid disposal options, either portable closed collector units or direct-to-drain systems, make the job easiest, since they can start the cleanup while the case is going on and don't require the transport and emptying of suction canisters by hand.

"If a surgeon only uses 2 3,000ml bags of lactated Ringer's, we can get through 3 knee arthroscopies without having to empty the unit," says Gayle Leggett, administrator of Oasis Surgery Center in Canton, Ohio. She notes, however, that "we always like having a freshly emptied unit to perform a shoulder arthroscopy or ACL repair."

It's always possible that some fluid will escape the suction's action and end up on the floor. Don't neglect the safety of your staff by leaving them to navigate a slick surface, says Sherry Lewis, RN, BSN, CNOR, circulator and OR educator at WellStar Douglas Hospital in Douglasville, Ga. "To keep the room from flooding, we use wick mats on the floor. These are more comfortable to stand on than suction mats, and they absorb fluids very well."