PROTECTING PATIENTS FROM START TO FINISH:

By Kris Ellis

Foremost among the objectives of ambulatory surgery centers (ASCs) is the delivery of excellent patient safety and quality of care. Nowhere is this effort more critical than in the pre-and perioperative settings in which patients prepare for, receive, and recover from surgical procedures. In order for ASCs to protect their patients and decrease the risk of adverse events, a number of issues must be successfully evaluated and managed.

Determining whether or not a patient is a viable candidate to receive treatment in an ASC is the first order of business in the screening process. Oftentimes, this is done over the phone. “Our first assessment of the patient is a phone assessment, and we do that the day before surgery,” says Theresa Puchalsky, RN, CNOR, nurse manager at Mechanicsburg, Pa.-based West Shore Surgery Center. Puchalsky notes that this initial assessment is crucial in identifying any concerns or disease processes that could potentially cause a problem post-operatively or inter-operatively.

“I think the most important thing in the pre-op screening process is to make sure that you’re picking a good candidate to do surgery in the outpatient setting,” says Brenda Kathman, RN, surgical services manager at Watertown, S.D.-based Mallard Pointe Surgical Center.

Kathman’s facility also performs the initial screening process over the phone. “We don’t make the patient go out of the way and actually show up at the center to do a pre-screening,” she says. “We’re screening to make sure they’re healthy, appropriate candidates for the outpatient setting.” Patients’ current medication list can be reviewed over the phone as well, and appropriate instructions given. “We tell them what day and time their surgery is, and if there are any medicines that need to be discontinued for a couple days before surgery. We also let them know what medicines they should not skip because there are some we do want them to continue taking, even though we don’t want them to eat or drink.”

The screening process, including the types of questions asked, should be modified as it becomes necessary or practical to do so, according to Puchalsky. “Actually, we just looked at something recently that we’re going to change on our pre-op assessment sheet,” she says. “We’re going to ask an additional question about family history of any neuromuscular diseases, because sometimes that can preempt a patient with MH (malignant hyperthermia).”

“We have changed our assessment sheet several times to reflect our practice,” Puchalsky continues. “We had a patient who had some breathing problems post-op, so we changed how we asked questions about what medicines patients are on.” She explains that patients who use an inhaler or nebulizer are encouraged to bring the device with them on the day of surgery. “We’re limited in the medications and treatments that we have here; that way if the patient were to have a problem, what they’re normally used to using is with them.”

“I can’t stress enough the importance of good, thorough pre-screening to avoid adverse outcomes,” says Susan Manor, RN, BA, CGRN, clinical manager at Monroe, Mich.-based Mercy Memorial Outpatient Surgery Center. “Here, this begins with the surgeon’s offices. They are all fully aware of who is and is not an appropriate candidate to come here. We, like most ASCs, do only ASA (American Society of Anesthesiologists) class I, II, and stable III patients. Each of our patients is called two to three days prior to their scheduled surgery and a thorough assessment is conducted over the phone. In looking at the chart, if our assessment nurse sees a need for the patient to come in and have a face-to-face interview with the anesthesiologist, then that is arranged.”

Missed or forgotten information during the initial phone conversation may be picked up by further discussion and evaluation. “If patients forget to tell you anything over the phone, on the day of surgery when they come in, we have an anesthesiologist talk with them and check them over,” says Kathman. “They go through the medical history that was obtained and listen to the heart and lungs, and things can be picked up there, so while they’re reviewing on the day of surgery, things can get caught at that point.”

Puchalsky points out that patient anxiety must be taken into consideration when obtaining relevant information. “Patients are nervous; they’re having surgery,” she says. “You’re speaking to them for a short amount of time, trying to do an assessment, to get to know what their medical and health history is and yes, sometimes they forget to tell you some of the most important things, and I think that’s why it’s important that as they go through their care, every caregiver who comes into contact with them does ask them the same questions over and over. Some people get irritated with that, but that really is a reason for it — because they’re nervous and they forget. You might be the third person to ask them if they have any allergies, and they say, ‘Oh yeah, I forgot to tell them.’ We see that quite frequently.”

Thorough and repetitive questioning and assessment can be well worth the effort if it uncovers a potentially complicating condition. “Missed information can result in, minimally, cancellation of the case, and the extreme, of course, is a life-threatening response to surgery,” says Manor. “Specifically, we watch for things like cardiac and respiratory issues, sleep apnea with use of C-Pap, history of TB, HIV, hepatitis C, CHF, high BMI (body mass index), dialysis patients, unstable diabetes and hypertension.”

Patient transportation is another issue that can be addressed during the screening process. “We specifically ask who their driver is going to be,” says Puchalsky. “We need a name because sometimes patients take that lightly and think they can drive themselves home. It has to be a responsible adult companion; we have patients who have tried to bring a 16-year-old with a learner’s permit to drive them home, so we require that it’s someone who’s 18 or older.”

Traditionally, ASCs have remained relatively unhindered by problems with infectious outbreaks and events. Maintaining this success does require the vigilance and dedication of each facility’s staff, however.

“In pre-op certainly I think the biggest risk is probably the IV start, and we follow sterility procedures for that,” says Puchalsky. She also points out that patients undergoing procedures in ASCs are often of good health and thus are at low risk for infectious complications. “Our patients are generally healthy, so we’re not usually seeing patients who are compromised prior to their surgeries, so usually post-operatively it’s not a problem.”

Manor attributes her center’s nine years of being free from infection issues to adherence to recognized standards. “We adhere to AORN (Association of periOperative Registered Nurses), SGNA (Society of Gastroenterology Nurses and Associates), JCAHO (Joint Commission on Accreditation of Healthcare Organizations), OSHA (Occupational Safety and Health Administration), and AAMI (Association for the Advancement of Medical Instrumentation) standards for sterilization/ high level disinfection processes in our facility,” she says. “Our entire perioperative staff takes ownership of this issue. We ask the surgeons to report any infections immediately, and send out a print-out of their cases monthly to help remind them. If an infection is reported, we get all pertinent documentation, including culture report, and go back in our log, check our documentation, and pull any items from those sterilizer loads and reprocess. Our instrument techs/scrub nurses are very well trained and follow all the guidelines for proper cleaning and sterilization. We rarely have an infection.”

“One thing that we do is we track all of our surgery class I procedures,” says Kathman. Her facility tracks these procedures for occurrence of infection. “What we do is send out a list of surgeries we performed for the month and then we send out a page that goes to the surgeons who performed them. They just mark if there were any complications or infections and then it comes back to us and if there was, then we have an infection control nurse who does a little digging into some of the history, what went on with that case, what went on with their post-op environment, and their treatment and all of that.”

Precautionary measures such as tracking cases that may involve equipment malfunction can also be important, as Puchalsky explains. “The loads are labeled, so if we process something for a particular patient, we identify the load with a patient sticker, and then if there’s any kind of malfunction that wasn’t picked up ahead of time, we’ll track it for infection control purposes,” she says.

“We have an infection control committee that sends out letters to physicians monthly asking for any post-op complications,” Puchalsky continues. “We will track particular patients if we know of any event that has occurred that may compromise the sterility during the procedure. Even if we don’t think it’s an issue, we still follow it just as a double check to be sure. We do that frequently.”

Puchalsky also stresses the importance of the very basics. “Certainly good hand washing is of utmost importance,” she says. “We do have the alcohol-based hand rub at each patient’s bedside, where we have a sharps container. So before and after caring for a patient you can grab a shot of that. Our infection control rate has always been well below national averages.”

Numerous studies and analyses have warned of the many serious threats that sharps injuries can pose, both to healthcare workers (HCWs) and a facility’s budget. While safer instruments and equipment can offer excellent protection in many cases, HCWs must still exercise caution when handling sharps. The National Institute for Occupational Safety and Health (NIOSH) recommends several ways to prevent needle-stick injuries:

1. Avoid the use of needles where safe and effective alternatives are available.

2. Help your employer select and evaluate devices with safety features.

3. Use devices with safety features provided by your employer.

4. Avoid recapping needles.

5. Plan safe handling and disposal before beginning any procedure using needles.

6. Dispose of used needle devices promptly in appropriate sharps disposal containers.

7. Report all needlestick and other sharps-related injuries promptly to ensure that you receive appropriate follow-up care.

8. Tell your employer about hazards from needles that you observe in your work environment.

9. Participate in bloodborne pathogen training and follow recommended infection prevention practices, including hepatitis B vaccination.¹

Kathman explains that her facility has promoted sharps safety in several different ways, including the use of safer equipment whenever possible. “We also have a binder with permitted safety exception sheets where if maybe there’s something that we use that is sharp that does not have a suitable alternative for safety, we have a sheet that we fill out that says what we’re using, what we’ve tried, how it didn’t meet the performance standards, and why we are not using a safety piece of equipment,” she continues. “For the most part we’ve got a safety alternative at a minimum — all of our scalpels are safety scalpes, all of our needles except one or two are safety needles, just because they don’t make some of them in safety needles.”

Manor’s center also emphasizes using the safest equipment possible, such as safety IV catheters, safety needles, and needleless IV tubing as well as needleless vial access devices. “We also use a neutral zone policy for the sterile field and are looking into safety scalpel use,” she says.

“You can’t re-cap anything,” says Puchalsky. “We have all needleless IV tubing now, so any meds administered through the IV are done through a needleless system. We’ve had a couple of needlestick injuries in the operating room, but I think they were more related to employee safety practices.”

From arrival to discharge, a vital component of ensuring patient safety involves keeping close tabs on each patient’s health status. As patients move through a center, different indicators are considered and assessed.

“Once patients are admitted, they get a baseline set of vital signs,” Kathman explains. “Once they’re taken back to the operating room, they are hooked up to a monitor where they monitor pulse oximetry, EKG, blood pressure, respirations, and then of course all of the anesthesia monitors. Then once they go to the recovery room, they are again put on the EKG, pulse ox, and blood pressure for monitoring. Once they go to the step-down unit or the special care unit, they are not on a monitor unless, for some reason, the nurse feels like they want to monitor them a little more closely. For the most part once they get to special care they’re off the monitor, but they do get another set of vital signs before they’re discharged.”

“We have CRNAs and an MDA for our general, spinal and regional block cases,” Manor says. “We also do MAC (monitored anesthesia care) or LWA (local with anesthesia) for most of our surgical cases. Most of our colonoscopies and EGDs (esophagogastroduodenoscopies) are done with moderate (conscious) sedation by our trained RNs. For conscious sedation cases, the patient’s blood pressure, pulse, respiration, oxygen saturation, and cardiac rate/ rhythm are monitored. They also have nasal O2 on. The same monitoring occurs for MAC/LWA cases. We are looking into anesthesia awareness monitors for our general cases.”

Puchalsky notes that different types of sedation may require different methods of monitoring. “Depending on what level of anesthesia they have, everyone is checked at each area they move to — like from pre-op to OR to PACU (post-anesthesia care unit) — at least once, and of course if it’s a general anesthesia patient they’re monitored the whole time they’re in the OR and the same in PACU when they’re first emerging from anesthesia. If it’s a MAC patient, they’re continuously monitored in the OR and we get at least two sets of vitals on them post-op.”

HIDA Reports Surgery Center Sales Up 24.3 Percent Over Two Years

ALEXANDRIA, Va. — The Health Industry Distributors Association (HIDA) released the 2004 Ambulatory Surgery Center (ASC) Market Report, which revealed that the ASC market is the fastest growing customer market for distributors over the past two years. The top 10 distributed product categories account for 65 percent of the total market.

Additional findings include:

• Distributor product sales to ASCs reached $575.2 million in 2003, an increase of 24 percent since 2001.
• Total patient expenditures at ASCs are estimated at $10 billion in 2003; Medicare reimbursements accounted for $2.9 billion.
• Kits, packs, and custom trays were the No. 1 product category sold through distribution to ASCs in 2001, 2002 and 2003.
• The top five public chains account for 12.8 percent of total ASC facilities, but earn 20 percent of total ASC revenues.

According to the HIDA report, the ASC market is the fastest-growing customer market for distributors, increasing 24.3 percent from 2001 to 2003. By comparison, the long-term care market grew by 10.2 percent, the acute-care market grew by 11 percent, and the physician market grew by 20.2 percent. Expenditures in ASCs were $10 billion in 2003, which is 0.6 percent of total healthcare expenditures. There were 3,865 Medicare-certified ASCs in operation in 2003. The number of ASCs has grown rapidly since 1990, recording positive growth rates every year and a compound annual growth rate of 6.5 percent.

The HIDA report found that the most efficient ASCs generate $528.91 per procedure in net income. The median, however, indicates net income per procedure is $194.77. The most efficient ASCs also report having five operating rooms, and generate $1.263 million per operating room.

The 2004 Ambulatory Surgery Center Market Report aggregates a variety of data to present a unique view of the surgery center market. The report identifies key trends and opportunities for the distribution channel. The report was developed in part with data and information provided by HPIS, a Neoforma company, the American Association of Ambulatory Surgery Centers (AAASC), and the Federated Ambulatory Surgery Association (FASA). The Health Industry Distributors Association (HIDA) is the national trade association representing medical products distributors. HIDA members serve the nation’s hospital, imaging, long term care and physician/alternate care markets.

HIDA provides products and services to enhance the business performance of member companies. Products and services include industry advocacy and representation to Congress and federal agencies, business tools and resources, and educational programs.