Q Our facility was in the direct path of Hurricane Isabel. This is not something we experience often, and I don't think anyone took it seriously. Do you have any suggestions?

A As a Hurricane Andrew survivor, I speak from experience when I say that you should take hurricane or other natural disaster warnings seriously. Construct policies and procedures and in-service employees on these precautions. Personalize these policies to your center via roundtable discussions that include key management personnel and decision-makers, as well as a good representation of staff members. Make certain your board supports your policies in advance. You need a mechanism to determine when you will close the center, cancel cases and reopen the center. Don't wait until your center is in the path of the storm to make these decisions. Employee education is an important part of hurricane preparedness. Do at least an annual hurricane drill, making sure that all employees know their responsibilities.

Q Our freestanding surgery center is across the street from our in-hospital OR. Staff are not required to wear cover gowns within the hospital or surgery center. But staff that go back and forth through the outdoor parking lot are required to wear a cover gown. Your thoughts?

A This truly is a sacred cow associated with times when we had far less control over our environment in and out of the OR. Originally, strikethrough and fluid contamination of scrubs was a common experience associated with cloth gowns, leading to concerns that surgery staff could unintentionally expose others to surgical contaminants if exposure was not detected. Today, standard gowns are far more resistant to penetration and are designed for increased protection. You can buy even more resistant gowns if you anticipate longer cases with greater risk for fluid exposure. From the perspective of picking up contaminants outside the OR and exposing your next patient, logically, the risk of cross-contamination is much greater in the corridors of a hospital than those associated with crossing a street in fresh outdoor air. Surveys have shown that the number of ORs requiring cover gowns in both the hospital and the ASC setting has decreased.

Q I work at a freestanding surgery center in Tennessee. Are fluoro-guided epidural steroid injection procedures reimbursable?

A Yes, fluoro-guided epidural steroid injections (62311; Grouper 1 - $340) are reimbursed in the freestanding ASC setting. The fluoroscopic guidance technical component (76005) can also be reimbursed depending on the contract. However, Medicare, Medicaid, Blue Cross Blue Shield and TNCare do not reimburse the fluoroscopic guidance. Cigna Medicare for Tennessee has local medical review policies that further explain 62311 and 76005, their billing guidelines and when they meet medical necessity.

Q I have only one set of instruments for cataracts, a procedure we perform only once a week with the same surgeon. At times, he may perform as many as four of those procedures in the same day, requiring flash sterilization on all but the first case. Is this OK?

A Flash sterilization was a hot topic in the late 1990s when JCAHO cited some for noncompliance. Some facilities bought 12 sets of eye instruments or 25 arthroscopes. JCAHO does not advise flashing instruments to save resources (personnel or instrument costs). AORN advocates flash autoclaving only when "there is insufficient time to sterilize routinely." Frequency is critical. If you're flashing a tray more than you're routinely sterilizing it, consider buying a minimum number of the same tray to allow processing between cases.