Problematic Procedures: Surgery Center Staff Prepare for the Unexpected

Problematic Procedures: Surgery Center Staff Prepare for the Unexpected

By John Roark

When a routine procedure becomes an emergency situation, the ability to respond quickly and effectively is key. Whether it's cardiac or respiratory arrest, difficulty maintaining an airway, excessive blood loss, uncontrollable blood pressure or uncontrolled bleeding when in recovery, any time a patient experiences an unexpected condition, the ambulatory surgery staff must know how to respond.

An Ounce of Prevention

"A simple procedure can turn into an advanced surgery in a heartbeat," says Jane Kusler-Jensen, RN, MBA, CNOR, chair of the Ambulatory Surgery Specialty Assembly of the Association of periOperative Registered Nurses (AORN). "You need to have experienced staff who have seen these types of things before and who can handle them."

Most surgery centers require that all staff is trained in cardiopulmonary resuscitation (CPR), and many nurses are certified in advanced cardiac life support (ACLS), an advanced training beyond basic life support. Denise Augustin, RN, BSN, MBA, executive director of Surgicenter of Greater Milwaukee -- a member of Children's Health System -- requires ACLS certification of all nurses.

"If they come to us and they're not certified, they need to get that training within six months of their hire," Augustin says. "More ambulatory centers are starting to go this route. The nurses know how to respond. They know what medications to administer, under the direction of a surgeon. They're a little more educated, and better able to handle problematic situations."

Thorough patient assessment is a vital step in the offense against details that can spell trouble in the operating room (OR). Pre-admission testing has become much more sophisticated.

"We used to do a lot more tests, but we're doing smarter tests right now," says Carol Imes, RN, MPA, CNOR, director of nursing at Mentor Surgery Center in Mentor, Ohio. "For example, if a person has had chest pain in the last week, we'll do an EKG. But if he or she is a patient who is five years post-op from open-heart surgery and they've had no chest pains, we probably wouldn't do an EKG. We listen to the patient and then decide what tests we're going to do, based on the patient's history and their symptoms."

"We carefully review the patients beforehand," agrees Augustin. "We look very closely at their histories. We have what we call 'notable diagnoses' that would require further tests, information or investigation on behalf of either the surgeon or the anesthesiologist."

A history of stable or unstable angina, sleep apnea or hemophilia will raise a red flag. "We want to make sure that based on their history, the patient can be treated in an ambulatory setting," Augustin adds. "If not, we would tell the surgeon upfront that that they should be treated in a hospital."

For example, a patient's use of herbal medications can create an adverse situation in the OR. "Patients don't tell you about the use of the herbals because they don't think of it as medication," cautions Kusler-Jensen. "Then all of a sudden you've got an uncontrollable blood pressure, and you're not sure what's going on."

"It is now one of the generic questions that we ask every patient before they walk in the door," says Augustin. "We will come right out and ask them, 'Do you take any herbal products?' Depending on what they're on, we'll bring it to the attention of the anesthesiologist and have them make the decision based on what the herbal is, how long they've been on it and when their surgery is scheduled. If it's a week out, then we can have them stop taking the medication. If it's scheduled for tomorrow, then it's up to the anesthesiologist whether it would be appropriate for that patient to be done. The surgery might have to be delayed for a week because of their needing to stop taking the medication for that time period."

Most surgery centers conduct drills to prepare staff for problems that can arise. From medical complications to disaster-type situations, drills are a valuable preparedness tool. Imes conducts at least four disaster drills per year, covering a variety of scenarios.

"We review the things that we need to do, as well as some things that we probably would never face," Imes says. "We don't think a tornado would hit us, but not too long ago a tornado hit a couple of hours away. So that's something that we're going to do this year, just in case."

Malignant hyperthermia, a potentially lethal syndrome experienced by a small number of surgical patients, can be triggered by the administration of certain anesthetic agents. To prepare nurses, Augustin conducts drills twice a year.

"We take our medications that have expired and use them in our drills for the nurses to practice reconstituting the medication from powder into liquid form, so that they have that experience. Malignant hyperthermia doesn't happen that often, but we do the drills so they are prepared for a situation like that."

Anesthesia providers are vital for informing the surgical staff of signs of trouble. "Your anesthesia providers are key to getting you through some of these situations," says Kusler-Jensen. "They've got to be fully competent."

"You're kind of on your own whether the hospital is right across the street or not," says Sharon Tolhurst, RN, CNOR, chief nursing officer for Sarasota Healthcare System in Florida. " We're very lucky because we have good anesthesia. We have a contract with the same anesthesia group that's in the nearby hospital, so there's always anesthesia available."

Tools of Precaution

Most surgery centers have policies, procedures and safeguards in place as a preventive screen against problematic procedures.

"We have a list of patients that we will never do at our center," says Augustin. "Patients with sickle cell disease or a history of malignant hyperthermia, infants with a history of apnea. There are certain procedures we just cannot do. Anything related to cardiac, lung or respiratory items we will not do. Procedures requiring an overnight stay cannot be done in our facility. There are places that have a 23-hour stay and they can do those patients. We do not have that ability, so a hip or knee replacement -- those are common procedures that we cannot do in our facility.

"Most of the procedures we do are less than 2 hours," Augustin continues. "When they get to be a little bit longer, something clicks in the back of your mind and you think, maybe this isn't an appropriate case to be done here."

For all life-threatening emergencies, Imes' staff is instructed to call 911. "That wouldn't be for somebody who has a slow heartbeat -- it has to be a life-threatening situation," she says. "Generally the anesthesiologist on board would alert the staff to call 911 immediately. We try to remember that we're an outpatient surgery center. We can't do the same for the patient that the hospital can."

"All surgery centers should have a facility transfer agreement with an area hospital," says Kusler-Jensen. "The physicians on staff should also be credentialed at that hospital so they can admit that patient. When you do have a problematic procedure, you need to have appropriate emergency setups so that you can handle the problem to get the patient stabilized. You should also have a contract with a local ambulance company."

Surgery centers that are not in close proximity to a hospital pose different challenges.

"Our closest hospital is eight miles away," says Augustin. "We're part of a system that includes a hospital, but we are considered freestanding. In problematic situations, the patient is totally stabilized before they leave our facility, by the nurses and doctors and the anesthesiologist on-site. Because of their advanced training and the medications and equipment we have here, we are able to treat any kind of emergency, including a cardiac arrest. Once they have been stabilized, we call for the paramedics to transfer the patient to the nearest hospital. We have contracts in place with ten local hospitals that allow us to transfer our patients. Most of the time the choice of hospital is dictated by the surgeon, the patient's insurance plan, or their primary MD, but not always the closest one. And because they're stabilized when they leave here, they can go a little farther."

The Surgicenter of Greater Milwaukee has one of the lowest transfer rates for such centers. "Only 0.2 percent of our patients get transferred," says Augustin. "That's very low. The national standard is around 1.6 percent."

Augustin attributes their success to evaluating patients before they even walk in the door. "We really look at all that information and make sure we really understand what kind of patient is coming here. Knowing their history is probably the biggest thing, and knowing what procedures they'll be having done. Plus, if something does happen here, we have the resources to treat a lot of that stuff. Even though a patient might have an 'untoward experience,' we're able to stabilize them and some of them are able to go home -- that attributes to a lower hospitalization rate."

"As more and more patients are hearing about what ambulatory centers can do, once they walk in the door, they say, 'I'll never go to a hospital again.' At first, people were worried about the same things we've talked about -- what if something does happen? You're too far from the hospital. Because our transfer rate is so low, I'm usually able to talk to patients and they feel very comfortable."

ASCs Revel in Low Complication/Transfer Rates

Ambulatory surgery centers (ASCs) are enjoying low complication and transfer rates according to a recent Outcomes Monitoring Project, a quarterly report issued by the Federated Ambulatory Surgery Association (FASA) detailing the performance of ASCs across the country. More than 300 ASCs participate.

According to the report, just 21 percent of ASCs who participated in the monitoring process reported three to seven complications per 1,000 patient encounters. Less than 6 percent had 15 or more complications per 1,000 patient encounters. When it comes to transfers, 50.5 percent of the participating facilities indicated they had a transfer rate of 0.00 per 1,000 patient encounters.

Kathy Bryant, FASA's executive director, believes ASCs excel in the areas of low transfer rates because their focus is on customer service.

"Hospitals basically started without any competitors," she says. "In many ways they started out as a government entity, whereas from day one with ASCs, there was always the choice of going to the hospital rather than the ASC. I think the ASC has had a focus on that patient/customer from the very beginning. I think that focus makes a difference in terms of how you set things up."

"I think ASCs have done a stellar job in terms of preparing the patient before surgery, so they know what they should expect after surgery," she continues. "For example, if you expect to be walking two hours after surgery, there's a lot greater chance that you'll actually get up and walk, than if you think you're going to lie in bed for four hours. They also attempted to educate the patient and what level of pain they could expect. That changes how you respond."

Bryant also believes that preoperative patient screening plays a role. "If you're in a hospital where you've got emergencies and infections, it's going to be harder to control those things, than if you're in a facility where you're better able to control who comes in with the infections. You're not going to screen for everything, so it's very possible that people come to ASCs with infections, but they're not there to get treated for the infections."

Another advantage is a strong ASC team. "One of the things that ASCs do concentrate on is employees," Bryant says. "I think having good employees is very important to an ASC. An average employee doesn't usually last at an ASC. They work very hard to keep the employees that are good, but they have no tolerance for employees that aren't." She adds, "The whole focus in the ASC is developed around what is expected. As a result of that, I think that everyone working at that ASC is committed to the patient and the success, to the extent that if anything problematic does come up, you have everyone right there to deal with it."

That's not to say that people in hospitals don't want to deal with problems. "I'm just saying you have a different atmosphere," she says. "The other thing is that in some cases, the situations that the ASC is dealing with -- they may deal with that same situation more frequently. Or they may deal with that doctor all the time. Certain doctors want to work with a certain nurse. That nurse is always in the OR with that doctor. They really have communication going."

It all adds up to an impressive track record for ASCs and greater patient satisfaction. "It's a whole lot of little things," says Bryant, "but they're all focused on how we make the patient's experience the best, how we make the quality the best it can possibly be. That's everyone's job. There's not a job description that you don't have to care about this because you're only the person that mops the floor. That generally doesn't occur in an ASC."

15 Steps to Saving a Life

Cardiopulmonary resuscitation (CPR) can help prolong life while you wait for additional medical assistance. Here's how to perform CPR on an adult:

1. Tell someone to call 9-1-1.
2. Determine if the injured person is breathing.
3. Position the patient on his or her back, being careful not to move the head, neck or spine.
4. Maintain an open airway while you pinch the patient's nose shut.
5. Give two long, slow breaths, making sure to maintain a seal between your mouth and the patient's.
6. Check for breathing and a pulse
7. Perform rescue breathing if the person has a pulse, but is not breathing
8. Begin CPR if the person is not breathing or does not have a pulse.
9. To position your hands correctly on the patient's chest, find the lower tip of the breastbone, then measure two finger-widths toward the head and place the heel of one hand in this location. Place your other hand on top of the first hand, interlacing the fingers of both hands.
10. Lean forward so that your shoulders are over your hands.
11. Push down on the chest, using the weight of your upper body for strength. Compress 15 times in 10 seconds.
12. Give two more slow breaths after the 15 compressions.
13. Do 15 compressions followed by two slow breaths. Perform this cycle four times.
14. Re-check pulse and breathing.
15. Continue repeating this cycle until the injured person regains a pulse or until additional medical help arrives