SAFETY IN ASCS

SAFETY IN ASCS
Putting Patients First

By Kathy Dix

For years, patients have been kept particularly safe in ambulatory surgery centers (ASCs). The fact that most patients are relatively healthy, and there voluntarily rather than emergently, makes it easier to release them in the condition they arrived in. However, no system is absolutely perfect, and it is still possible to improve on an already good thing.

Patient safety extends to nearly all areas within the facility, and also to all the steps within their short stay — check-in, pre-op, peri-op, post-op/recovery, and discharge. Patients need to be kept safe from harm and infection from the moment they walk in the door until they are wheeled out to their cars.

Many facilities around the country that had already made patient safety a priority, put an even greater focus on it in 2002, when the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) announced its first National Patient Safety Goals. These goals include specific actions proven to reduce the frequency of medical errors. As part of the JCAHO accreditation process, each healthcare organization is reviewed for compliance with these goals, which were required by JCAHO in 2004, and have been updated each year since.

For 2007, the Joint Commission has made several changes/additions to its 13 goals. As part of goal 8B, not only is a list of all of the patient’s medications given to the next service provider when the patient is referred or transferred, but the medication list must also be given to the patient upon his or her discharge from the facility. And in the new goal 13, patients are encouraged to be actively involved in their own care; goal 13A requires healthcare providers to define and communicate to the patients how they and their families can report concerns about safety, and they are encouraged to do so.

The National Patient Safety Foundation points out that even an element as simple as staffing shortages can have a deleterious effect on patient safety; the foundation encourages healthcare facilities to address the problem with a multi-faceted approach — education; an environment conducive to teamwork and accountability; and fiscal and personal recognition of effort and advancement.

And the Association of periOperative Registered Nurses (AORN) has its own Patient Safety First program, which is part of the organization’s broader patient safety initiative. It was launched in 2002 by the AORN Presidential Commission on Patient Safety for the purpose of developing resources to help clinicians in surgical and procedural settings provide safe patient care while following best practices.

Even the World Health Organization (WHO) has made a statement regarding patient safety — the organization established the World Alliance for Patient Safety in 2004, after a World Health Assembly Resolution urging WHO and member states to pay the closest possible attention to the problem of patient safety. Each year, the alliance delivers a number of programs covering systemic and technical aspects to improve patient safety around the world.

Putting Patient Safety Into Practice

Lynn Saul, RN, administrator of the Ohio Orthopedic Surgery Institute in Columbus, Ohio, finds that the purchase of Stryker Trio beds has dramatically improved multiple facets of the transport process within her facility. “These operative stretchers help us prevent patient transfers from stretcher to OR bed to stretcher,” she explains. “It helps us to be more efficient, it has obviously limited the potential for patient injury and employee injury, and it is a timesaver.”

Although patients are awake when they are transferred to the OR from pre-op, they are generally asleep for the transfer back to the recovery area, so utilizing this all-purpose operative stretcher reduces the number of personnel needed.

Saul’s facility has also focused on improving the home-going process after the patient has been discharged. “As ASCs become more comfortable doing more elaborate or involved cases, home-going instructions are very important as well as the instructions for the other party that will be continuing our care at home,” she observes. “What we’ve done is, on the day prior to surgery, we begin educating the patient and family about what is going to be necessary when they get home. We incorporate the family into the recovery room process and the teaching process, so they’re comfortable [with instructions for the care they need to provide] by the time the patient is released, and they have all their questions answered. We demonstrate wound care, crutch walking, cryotherapy management (ice), medication management, important contacts and phone numbers, and the reasons to get in contact with the physician or physician’s office, or instructions about when, if necessary, to seek a higher level of care.”

Saul says that the difference between the Ohio Orthopedic Surgery Institute and the other local facilities is that they maintain their family-oriented feel. Allowing both patients and family to ask questions of the anesthesia personnel and the physician before the procedure creates a sense of comfort for those who will be at-home caregivers after the patient is discharged.

However, patient transport and discharge instructions are not the only facet of patient safety that is being improved at her facility — the biggest patient safety threat these days is correct site surgery, Saul reports, and, she adds, “We often get caught up in the busyness of managing the schedule and getting the patient’s care done. It’s very important that we stop, take a time out, and communicate to the team that we’re doing the right thing on the right person. That causes everyone to take note that it’s all about this patient getting this particular procedure right now, and nothing else matters. Especially in the specialty of orthopedics, given that we’re working on extremities, determining whether we’re working on the left or right side is critical, compared to other procedures — for example, there’s only one way to do a tonsillectomy! I really value having a tenured, experienced staff delivering the highest level of patient care I can, and that’s something ASCs can tout over hospitals, because we don’t have high turnovers in staff, and our staff members know their equipment, and their physicians and physician preferences very well.”

In another center, the staff has the major patient safety goals well in hand, and is able to bring up “lesser” patient safety issues to management, which simply has to find good solutions.

“Honestly, I’m not sure that we remind the staff about patient safety as much as the staff reminds me about it,” quips Barbara Ramsey, MSN, administrator of the Rush Surgicenter in Chicago. “All of this, obviously, is based a lot on the JCAHO patient safety goals. Sometimes you have to do this extra paperwork, and you moan and groan about it, but the end result is that when the safety goals came out, and even prior to that, the staff will notice things, and it will be a concern for them. Maybe there is a late discharge because a case went a little long, and they’re looking at it in terms of, ‘It’s dark outside — Do we have security in the building?’ We bring the issue to Quality Improvement and talk about it. With a couple of our cases, if the pain level has been greater and we don’t feel it’s safe for the patient to be discharged later, we’ll try to schedule those patients in the beginning of the day. You may not think this is a patient safety issue, but it is.”

The staff, Ramsey says, brings to bear what the patient says, or what they feel is safe, good care, regardless of whether or not it is part of the national patient safety goals. “They usually bring the issue to us, because they’re the ones out there working,” she adds. “That tells me that we did a good job educating them in being observant for patient education and safety. Just like the medication reconciliation now — it’s cumbersome to look at how we’re going to put the process in place to ensure our patients know what they had, what they can take, what they can’t take, and what a reaction might be. The staff is very attuned to that, and may say, ‘This lady drinks ginseng tea, and that has an effect with this medication. For their safety, in order for them to be able to have this preoperatively, what do we need to do?’”

The time of discharge is important for this surgery center, because it is located in a metropolitan setting, and patients often have a long way to travel to home in the suburbs. “We consider transportation and traffic — ‘Is it safe to leave at 4 o’clock in the afternoon, or should we keep the patient an extra hour so they miss rush hour?’ We try to vary our schedule to accommodate patients and physicians at the same time,” she explains.

The center just recently switched to using electronic medical records, and Ramsey recalls that the official time of the time-out was, at first, not very accurate. “We found that if you go by the computer clock, every time should be the same, but not all of the computers were set correctly. Then, the staff started using wall clocks, which are never on time. Room One could have five minutes after the hour, and Room Two could have two minutes after. We noticed part of it was the time-out start time and finish time — it wasn’t correlating to what we had written down and what anesthesia had written down. Everything is now set correctly.”

The time-out procedure has helped avoid medical errors regarding the correct site of surgery, too, she adds. In a couple of incidences, the patient would say, “No, it’s supposed to be the left side,” although the procedure had been scheduled for the right side.

“We never had an incident [of wrong-site surgery], but we have had a case in which the written documentation was transposed, so we have found that the time out patient safety goal works well,” she says.

Simple items in the daily routine can have a dramatic result on patient safety. Every day, Ramsey’s staff ensures that all the carts are in good working condition. If they are not, they are immediately taken out of service. “The staff members check those carts daily, because they notice it the minute they put a patient on there, if the bed isn’t going up correctly, or if the side rails are loose. If you’re doing 400 cases a month, you pretty much know if that bed is or is not working, so it’s immediately reported and called out for repair.”

And when it comes to the actual transport process, because Rush Surgicenter is a teaching institution, anesthesia is always included as part of the transport team. “It’s either a resident and a CRNA, or someone from anesthesia and usually the RN from the OR, or two personnel from anesthesia, so there’s always a professional clinical person doing the transport. The only time we use a transport service that is composed of a non-medical professional is after discharge, wheeling the patient downstairs to their car in a wheelchair,” Ramsey explains.

The surgery center recently made a positive change that will certainly impact patient safety — they created a new full-time position for a clinical educator, filled by a registered nurse. “The primary reason is for recruitment retention, because it is so difficult to find OR nurses anymore. We needed to be able to bring in new graduates or RNs without OR experience and be able to train them. So we established this position, which is a 60/40 split — 60 percent as a staff nurse and 40 percent in the educational role. In fact, we just hired our first new graduate, who is in our orientation program, as our guinea pig. That role as clinical educator can be expanded so much — anything from HIPAA training, to patient safety goals, to clinical practice guidelines. That person will be responsible for coming up with the program to best implement these. The clinical educator is the one who knows those patient safety goals, is the one who knows where the patient safety is, is the one who can address an issue and say that we need to do something about it. Obviously, it’s not fair to have one person come up with all the ways to take care of this, but the fact that we have an educator out there is a huge step in recognizing little things before they become big issues. They work at the facility, they know what goes on, and in the educator role, they are experienced, so they know the right way to do it. When you hire an educator, they’re very stringent about ‘This is the way it should be done; this is the proven way to perform to get the desired outcome.’ With that in mind, they’re going to notice anything that is not as it should be,” she says.

“In our monthly staff meetings, we always cover patient safety,” says Steve Blom, administrator of the Specialty Surgery Center in San Antonio, Texas. Each month, Blom or the staff managers will tackle a different topic relating to patient safety — anesthesia monitoring, keeping side rails up on beds, etc.

Although Blom and his managers come up with the patient safety topics for the monthly meeting, in the interim, staff members will often approach them with an issue they’ve noticed, one that can be rectified right away. “We’re in a new facility that we moved into in October 2005,” Blom says. “You think you’d remember to ask for everything you need (during construction), but after we’d been in the facility for six months, one staff member asked, ‘Why don’t you have mirrors on the corners, so we can see who’s coming around?’ We never thought of it. We were able to go out the next day to Lowe’s, purchase the mirrors, and then pop them up on the walls. In another instance, we had to retrofit some additional automatic doors. We kind of missed it in the construction phase — we had a couple of automatic doors in the original plan, but after we moved in and began to work in the facility, we realized it would be nice to have additional push-button doors for nurses trying to open a door with a patient in a wheelchair.”

Blom encourages his staff to notify him as soon as they realize something is missing or not working quite as well as it could be. “You have to forcefully keep everybody reminded about patient safety, because it’s easy to be laissez faire. We keep it in the forefront of the staff members’ minds,” he affirms. “We have focused on correct site surgery in the past, but we have to revisit it. We do take the time-out, and we do mark the site before the patient is sedated in pre-op.”

They have to be particularly careful about following the timeout and correct site marking with their eye cases, as cataract cases are one of their most frequent procedures. “We stop and verify with the anesthesiologist, the surgeon, and the scrub nurse and scrub tech what we’re doing and what side we have documented,” he adds.

Approximately 65 percent of the Specialty Surgery Center’s cases are ophthalmology, with the remainder as ear-nose-and-throat procedures. “Those eye cases, you would often consider high-risk because nearly every patient is elderly,” Blom points out. He reduces risk to the patient by keeping them on the same stretcher throughout pre-op and the procedure, letting them transfer to a recliner for the last 15 minutes to 30 minutes they are inside the facility. “That’s where our risk area is — stretchers and falling,” he clarifies. Patients who already have impaired vision are naturally at a higher risk, and as the elderly often have slower reflexes, it’s important to reduce their risk of falls as much as possible.

Blom also has to place an especial focus on the safety of patient care for after discharge, because many of them will show up at the surgery center without a competent adult to drive them home and provide adequate post-operative care at home. “We will not do a procedure if they’re not escorted by an adult to take care of them at home,” he states. “It’s a common-sense approach, but it’s amazing how many people come in with nobody with them. That is a safety issue.”

Often, Blom has to institute a change in the timing of discharge instructions. “We will on certain occasions give the discharge instructions to the patient ahead of time, because they’re groggy after the procedure. The patient teaching generally will start with a pre-op phone call with patients. We have a nurse call all the patients before they come into the facility, and go over what the expectations are so they know what will happen when they come in, and what happens after the surgery, what the expectations are, what eye drops to take, etc. This is all reinforced and given to them in writing. The nurse making the pre-op call is more comprehensive, and talks about the whole process, what the patients need to be doing and what happens when they go home, as opposed to just calling and giving pre-op information and being done with it,” he explains.

“For surgery centers, it’s all about the efficiency and the flow, and the more prepared everybody is, the better everything works. The point of this preparation is ensuring that there are no surprises,” he says.