What monitoring equipment features, such as pulse oximetry, are indispensable to your anesthesia providers and the nurses who care for patients in your surgery center? What features, such as anesthetic agent analysis, are simply matters of preference or convenience? Are there lower-tech (and lower cost) alternatives that work just as well? To uncover the answers to these and other questions, we queried manufacturers and facility managers about vital signs monitors. Plus, as a nurse anesthetist with nearly 20 years experience in ambulatory surgery, I can tell you what features anesthesia providers adore in a vital signs monitor, and what we abhor. And if you don't already know, let me tell you where to find the best monitor ever created on the planet.

The top of the line
As you begin the process of selecting the monitor that just fits your ASC, never ever forget who the best monitor ever constructed is: Your staff. The anesthesia team and your ASC patient care employees are the most significant patient monitors you have in your building. The electronic vital signs monitors you purchase for your OR and PACU are either going to help or hinder them.

Any monitor must be easy for your staff to use, or it may distract these vital people from the very patient they are monitoring. But never buy a vital signs monitor so easy to use that the staff can set it and forget it, because that's when the patient may be forgotten, too. That popular one-touch "Silence Alarms" button certainly makes a monitor more user friendly, but silenced alarms can mean a silent - permanently silent - patient.

Bottom line? The vital signs monitor you select must complement and boost your staff's skills and facilitate assessment of the outpatient's condition, but it is not a substitute for a finger on the pulse and an eye on the patient.

The gold standard
The American Society of Anesthesiologists basic monitoring standard states the anesthesiologist should continually monitor the patient's oxygenation, ventilation, circulation and temperature. Nothing new there. We all know that means we will monitor, at a minimum, the patient's EKG, BP, SaO2, end tidal CO2 and temperature during general anesthesia. Anything less could lead you into litigation. But not all anesthesia vital signs monitors are created equal; not all surgery centers and outpatient surgery procedures are equal. So even while meeting the minimum standard you've got some elbowroom to customize your monitors to facilitate and standardize patient care in your facility. After that, the only issue is how much you're willing to pay for it. Because the effects of anesthesia don't just magically vaporize at the OR door, here we'll be considering both OR and PACU monitors.

Office-based vs. freestanding
Most ASCs are freestanding or tucked into hospitals. But now more surgeons are building their own ORs in their offices. That changes nothing in the standard of care for monitoring, says a leading plastic surgeon who's past president of the American Association for Accreditation of Ambulatory Surgery Facilities.

"Anything that is monitored in a hospital or freestanding center should be monitored in office-based surgery. Monitors make surgery a safer, more positive experience for the patient. Monitors avoid a problem, which is easier than treating a problem," says Robert Singer, MD, who has an office-based surgery center in La Jolla, Calif.

It's sound logic. A procedure that might be done in a hospital but is also performed in a physician's office still involves the same risks and the patient expects the same degree of care, if less of the hassle.

"It's important to not overlook recovery room monitoring. Historically, that is where many of the problems occur," says Dr. Singer. "I also think it's essential that one has backup monitors. If a piece of equipment isn't functioning you don't want to have to cancel surgery, but of course you should not proceed without appropriate monitors. You need enough monitors for each patient in your facility whether they are in the OR or recovery."

"In addition to monitors, you need an appropriately trained anesthesia provider. The days of a surgeon doing surgery without someone else monitoring the patient are passed," adds Dr. Singer.

Evaluate your needs
Before choosing a monitor for your facility:

• Consider your staff's skills and patient care load. A high nurse/patient ratio means your staff will lean more heavily on a monitor's assessment of the patient's condition. They'll need one that is quickly set and then easily booted up for the next patient. When caring for several patients, a busy PACU nurse will find that a lightweight, portable monitor she can place in her line of sight will facilitate patient care.
• Review previous cases to ascertain average patient acuity. That will help you determine the features you'll most often use in a monitor. If your anesthesia team sometimes bring intubated patients to your PACU, you may want to have available at least one PACU monitor that measures end tidal CO2. If you do complex, long cases under conscious sedation, you may want to consider level of consciousness monitors like a Bispectral Index monitor.

Who's got what
"We've recently purchased the Invivo monitor for our operating rooms," says Cathy Gilland, RN, BS, administrator of the East Memphis Surgery Center (EMSC) in Memphis, Tenn. "We've been pleased with them. They're user friendly and the display is easy for us to read."

EMSC is also preparing to replace the 12-year-old monitors in its PACU. Not as user friendly, those monitors required multiple steps before the first vitals appeared on the screen. In general, Gilland expects to keep a monitor in service for about 10 years; EMSC typically budgets $3,500 to $5,000 for a PACU monitor.

"We're hoping to purchase smaller, portable monitors for the PACU. Sometimes you have to be very creative with recovery room space. Our nurses can position a portable monitor where they can see it," says Ms. Gilland.

"That's been our philosophy: To make a product that is full-featured, easy to see and easy to use at an affordable price," says Jeffrey Chiprin, director of sales of Invivo Research. "That's why the Invivo M12 monitors appeal to the ambulatory surgery center market. We package the monitor in a single box with a small footprint that meets the size concerns of an ASC."

Designed specifically for ASC use, Invivo monitors are a popular choice in ASCs. Mr. Chiprin reports that Invivo OR monitors that include anesthetic agent monitoring cost around $11,000. Invivo PACU monitors run around $6,500.

"Our products are created with the OR and ASC in mind," says Mr. Chiprin. "In an ASC environment, you may connect as many as 10-12 patients per day to the monitor and therefore the requirements of the monitor are very different."

Aimee Vonessen, RN, at Outpatient Care Surgery Center in San Diego, Calif., was instrumental in the decision to purchase Welch Allyn monitors for her facility's OR and PACU. Ruling out ICU-type monitors with features like central line monitoring that her ASC doesn't need, her team based it decision primarily on the monitor's price and ease of use.

"We chose the Welch Allyn because it was cheaper and it is very easy to use. Also, you can go back and find past patient data and print it out," says Ms. Vonessen. "The screen size isn't huge and it isn't in color, but it's fine for what we need."

One of the things her team didn't like about some monitors was the standard setup or default screen. "A lot of monitors you set up the way you want it, but after each patient it reverts back to the standard setup," she says. "So then you have to reset it again with the next patient, and that was wasting time."

Monitoring the future
Choosing a monitor is a tougher decision than in the past. There's a lot more to be considered than does it have an EKG and a BP. Hospitals and physician offices are moving, albeit slowly, towards electronic medical records. It's inevitable that in the future your ASC monitors will be required to not only display, but collect, store, and transmit patient data. That means networking. Massive networks will be linked with other providers in order to facilitate transfer of information and to enhance patient care. Collected data will also be used in ASCs to optimize efficiency. So consider future networking capability if you're buying monitors that you hope will last a decade. It's unlikely you'll be able to upgrade a $5,000 monitor in five years if your institution decrees that you be networked in order to share patient data and information.