Q How do you determine man hours per case and what is an ideal range?

A Add the hours worked including overtime during a specified time and divide by the number of cases performed during that same period. If you add sick, vacation and other non-productive hours for the same period and divide by total number of cases, you'll get total hours expensed per case. Most facilities use this for the final calculation. It's best to review these calculations as an average over a longer period of time (perhaps a quarter) versus one pay period, recognizing many variables can affect man hours per case, some more manageable than others. Factors to consider include facility hours of operation, physician punctuality, overall volumes, case mix by acuity, staff skill levels and case mix by specialty.

Using industry benchmarks, minimal requirements are rarely below nine man hours per case in a high-volume, single-specialty, low-acuity facility. The maximum need doesn't usually exceed 12 man hours per case in a high-acuity facility performing more complex cases; 11.5 man hours/case ( /- 0.5) is an acceptable standard in a multi-specialty facility.

Sedating endoscopy patients

Q My endoscopy unit will be going to a new anesthesia care setup shortly. Some patients will receive TIVA or MAC by the anesthesiologist, while others will receive conscious sedation by trained RNs. This has raised many questions for our RNs. AORN standards require a circulating nurse in all rooms, but this might not be the case for endoscopy. SGNA has a policy on RNs doing conscious sedation, but not staffing procedure rooms for endoscopy. What are your thoughts?

A By conscious sedation, I'm assuming we're talking about midazolam (Versed), meperidine (Demerol) or fentanyl (Sublimaze) and not propofol (Diprivan). Working under that assumption, from a safety standpoint I'd recommend that a technician assist the endoscopist while the trained RN administers the sedation and monitors the patient. My problem with the endoscopist's administering conscious sedation has always been that his attention is and should be directed at the procedure he is performing and not on the sedation. I feel the same way about RNs giving these potent drugs to patients who have a whole host of concomitant disease processes going on. Whether it's an anesthesia provider or not, whoever is administering these drugs needs to be focused on the patient and monitors, not on the endoscopy procedure.

Staffing an OR

Q What are the guidelines for staffing a room in an ambulatory setting?

A Staffing an OR is the same for an ASC as for an inpatient facility: one RN and one surgical tech per case. For more complicated cases, you may have someone assisting, but in an ASC, the MD usually brings his assistant. In ophthalmology, for example, many doctors might bring a certified ophthalmology tech from their offices. These techs must be credentialed if they're employees of your facility. When this is the case, there is still an RN assigned to circulate, and the tech now functions in the role of instrument person and sets up for the next case. When cases are done with MAC anesthesia, two RNs should be assigned to the room. One circulates and the other only monitors the patient. This should never be compromised.

Allegations of sexual harassment

Q An employee has complained about activities by a physician that sound to me like sexual harassment. What should I do?

A Here are some guidelines to prevent and minimize risk:

• Take action regardless of whether the accused physician is an employee.
• Give the subject of a complaint specific and detailed notice of the complaint and give the person time to respond to the complaint before you take any further action.
• Be sure your medical staff bylaws, policies and procedures provide direction for handling such allegations.
• Be sure employees and physicians know the steps you'll take if someone alleges harassment. Post notices, educate and have employees and physicians sign acknowledgement of receiving a copy of the handbook or policies that contain procedures for dealing with harassment allegations.
• Investigate allegations confidentially. Take notes. Ask the person to put the allegations in writing. Don't try to catch the person in action with a camcorder or tape recorder.
• Document all actions. If the person refuses to put allegations in writing, you should document all actions you took to investigate. Include notes on communications and steps taken to encourage the person to put the allegation in writing.
• Communicate your actions to the parties involved, but don't publicize or distribute a written report of the results of your investigation or disciplinary action.
• Remember that sexual harassment can be a two-way street. Just as an employee may complain about a physician, there is the chance that a physician will complain about an employee.