CRITICAL CARE Anesthesia providers can make or break procedures performed in outpatient facilities.

Are you happy with your anesthesia providers, or have you had it up to here with them not pitching in and helping out? Our survey of 138 facility leaders revealed that only 9% are looking to switch anesthesia services any time soon. While most trust in the clinical abilities of their CRNAs and anesthesiologists, that doesn’t mean some of you don’t wish your providers spent more time outside the staff lounge between cases (see “Readers Sound Off on Anesthesia Providers” on page 64).

Positive reviews
There are many things Brenda Vahle, RN, CAPA, loves about her anesthesiologists, starting with their help in launching the now 3-year old BSM Surgery Center in Corvallis, Ore.

“I had never set up a center before,” says Ms. Vahle. “They picked out every piece of equipment they’d need, every medication in the formulary.”

Today, they help conduct mock codes such as malignant hyperthermia and lidocaine toxicity drills. They come in on their off days to attend staff meetings, answer their cell phones at any hour and will lend you a tractor. Wait, a tractor? “If you need them to,” laughs Ms. Vahle. “This is farm country.”

Her surgery center started with a group of 9 anesthesiologists, some of whom would sedate the same way, no matter which procedure patients were undergoing. Patients would sometimes take longer to wake up than the surgery lasted, which jammed up the recovery room.

In the years since, Ms. Vahle and the center’s physician-owners handpicked a core group of 5 providers who have the mindset to work in ambulatory surgery. “They are proactive in ensuring patients are pain-free and experience no [nausea or vomiting]” she says. “They have a knack to manage anesthesia so patients are alert soon after they arrive in recovery, and are ready to go home in a timely manner.”

Her providers have achieved 99% positive ratings in patient satisfaction surveys over the last 3 years. A Joint Commission surveyor recently said he had never seen a more dedicated group. Their hand hygiene practices are impeccable. They listen closely to breath sounds, focus intently on airway assessments and perform detailed pre-op assessments. Following notoriously painful ACL surgeries, 95% of patients require no additional medication other than the femoral and popliteal blocks the anesthesiologists administer.

You know those providers that you wouldn’t want sedating your family? (Yes, you do.) “There’s not one here like that,” says Ms. Vahle.

ABOVE AND BEYOND Anesthesiologist Ryan Johnson, MD, does more than sedate patients at BSM Surgery Center in Corvallis, Ore.

Patient care or productivity?
Maddie Linder, RN, CASC, is the administrator of the multispecialty Bethesda Outpatient Surgery Center in Boynton Beach, Fla. The facility works with 3 CRNAs and an anesthesiologist from an outside agency. She says the service they provide is “fine,” the 4-letter word of compliments.

“There is no fault whatsoever in their clinical abilities,” says Ms. Linder. “I’d have any of them put me or a family member asleep.”

It’s the rest of their efforts she takes issue with. The providers will go to pre-op with nurses to bring patients back to the OR, but that’s basically it.

“It’d be nice if they pitched in, especially on busy days,” says Ms. Linder. “Or at least change the breathing circuits on their machines between cases.”

The issues she’s facing are not reflective of the agency as a whole. When one of the providers is on vacation, a substitute from the group is willing to go above and beyond his assigned duties. “It’s like night and day, a breath of fresh air,” says Ms. Linder.

She confirms that her facility isn’t a country club, despite the providers’ preference to lounge between cases. “It’s a frustrating situation,” says Ms. Linder. “I’ve expressed my concerns, so it’s nothing new.”

But because she’s not really their boss, Ms. Linder is limited in what she can do and finds it difficult to demand more.

“Every article I read in this magazine is about anesthesia providers needing to be part of the team,” says Ms. Linder. “We don’t have that here. I wish we did.”

Is that a big deal? “On busy days it is,” she says. “If they pitched in during room turnovers or helped with pre-op assessments, that would facilitate everything, speed things along and even help them with their efforts.”

She’s obviously more than a little frustrated with wanting more value-added services from her providers, but she’s also more than happy with the quality care they provide, especially for the numerous pediatric patients brought to the facility by a busy ENT practice.

For now she’s left weighing the pros and cons of asking for 3 new providers. Is the unknown worse than working with what they have now? What’s more important: Taking great care of patients or helping to improve overall efficiencies? “It’s all about the patients, says Ms. Linder. “The other stuff is nice, but patient care is most important.”

But what can be done to manage the daily frustrations? Write out all your expectations in anesthesia agreements or policies and procedures, and not just the ones centered on patient care, suggests Ms. Linder. Do you want them to help turn over rooms or run staff in-services? Mark that down in black and white.

The director of a California surgery center whose providers also practice at the local hospital isn’t happy with their tendencies to employ “acute care” anesthesia instead of sedation suitable for an ASC.

On the condition of anonymity, she laments that the group’s services haven’t evolved in the past 5 years. She’s requested that they designate an anesthesiologist to attend monthly and quarterly meetings to ensure they buy into changes to the anesthesia practices the facility is trying to make.

Ms. Linder agrees that providers need to know they’re an integral part of the team. “They have to help out,” says Ms. Linder. “Demand that they meet your expectations. If they don’t, let it be known that you’ll find someone else.”

SURVEY RESULTS
Readers Sound Off On Anesthesia Providers

We wanted to know what our readers think about the anesthesia providers who care for their patients, so we asked them if their providers ...

Actively participate in committee meetings.
Yes, all the time	42%
Most of the time	19%
Only occasionally	24%
No, never	15%

Constantly work to develop new skills.
Strongly agree	41%
Agree	39%
Disagree	17%
Strongly disagree	3%

Are key to keeping your facility on the cutting edge of care.
Strongly agree	43%
Agree	40%
Disagree	15%
Strongly disagree	2%

Help ensure cases start on time.
Strongly agree	51%
Agree	30%
Disagree	16%
Strongly disagree	2%

Help recruit physicians
Yes	47%
No	53%

Help speed room turnovers.
Strongly agree	37%
Agree	37%
Disagree	20%
Strongly disagree	7%

Work with surgeons to bring challenging cases to the outpatient arena.
Strongly agree	51%
Agree	30%
Disagree	16%
Strongly disagree	2%

Always comply with your facility’s policies and procedures.
Strongly agree	31%
Agree	46%
Disagree	22%
Strongly disagree	1%

Follow proper infection prevention practices.
Strongly agree	37%
Agree	43%
Disagree	17%
Strongly disagree	3%

Source: Outpatient Surgery Magazine, August 2014, n=138

Balancing act
Administrators and surgeons want to fill the ORs with patients. Centers thrive on case volume, but the cases are getting more complex. Everyone’s interested in patient safety, but could there be an underlying internal tug-of-war between volume-driven surgeons and anesthetists who make the ultimate call on which patients can be operated on in an outpatient setting?

“There can be,” admits Ms. Vahle, but she says her providers strike the right balance between patient safety and scheduling pressures, and work closely with surgeons to ensure the right patients enter the ORs. Her nurses flag potential concerns — high body-mass index, untreated sleep apnea, unresolved lung issues — and ask the anesthesiologists to review the charts to see if the patients are suitable for outpatient surgery. Oftentimes, they’ll come to the center to assess high-acuity patients in person, which some providers aren’t always willing to do.

Kari Stewart, CASC, administrator of the Pasadena (Calif.) Plastic Surgery Center, says her providers help avoid case cancellations by screening patients for troublesome comorbidities. “When necessary, they can be counted on to make a good judgment call regarding case selection,” she says.

Ms. Stewart values the flexibility and communication skills of her group and appreciates their light-handed techniques, which limit the number of groggy patients in recovery — a critical component of keeping the surgical schedule on track in her small surgery center with only 3 pre- and post-op beds.

An anesthesia team needs to be the right kind of conservative, says Ms. Linder. “We have very few transfers, and we don’t cancel a lot of cases,” she explains, touting the constant communication her providers have with surgeons, including e-mailed lists of requirements for undergoing surgery in the center.

Ms. Vahle admits that living in a small town where nothing is ever more than a 10-minute drive away improves her providers’ availability, but she’s also grateful for their obvious dedication to the craft.

“I’ve been a nurse for 25 years,” says Ms. Vahle. “Of all the places I’ve worked, I’ve never met a group of anesthesiologists like this.”