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Fast Track Ambulatory Surgery and a Model of Success for a Collaborative Anesthesia Practice

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Sandra E. Morris, MSM, CRNA. OBJECTIVES ... MODEL OF A SUCCESSFUL COLLABORATIVE ANESTHESIA PRACTICE. HIGH PATIENT SATISFACTION ... – PowerPoint PPT presentation

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Title: Fast Track Ambulatory Surgery and a Model of Success for a Collaborative Anesthesia Practice


1
Fast Track Ambulatory Surgery and a Model of
Success for a Collaborative Anesthesia Practice
  • CANA Spring 2005
  • Thelma Z. Korpman, MD, MBA
  • Sandra E. Morris, MSM, CRNA

2
OBJECTIVES
  •  1) Will be familiar with current concepts of
    Fast Track Anesthesia in an ambulatory surgery
    center.
  •  Preemptive Analgesia
  • PONV avoidance. 
  •  SAFE Anesthesia
  • PASS
  • 2)  Will recognize different anesthesia
    techniques to assure quick anesthesia recovery.
  • Anesthetic/Medication Usage
  • MAC, regional, general anesthesia
  • Nerve blocks
  • Local anesthetic wound infiltration and
    intra-articular analgesics
  • Use of LMA
  • 3) Will be familiar with the advantages of
    having a coordinated perioperative team.
  • Multidisciplinary Collaboration including
    surgical and anesthesia cooperation increases
    patient safety and satisfaction
  • Innovation accountability encouraged
  • 4) Will identify the necessity for coordinated
    efforts to ensure quick, efficient turnovers.
  • EVS role
  • Anesthesia Technical Support.
  • PYXIS
  • All members of team accountable

3
ONTARIO VINEYARD AMBULATORY SURGERY CENTER (OVASC)
  • A free-standing surgery center in Ontario serving
    members from Fontana Riverside Kaisers
  • Collaborative Practice
  • Multidisciplinary Team with effective
    communication among all members of the team
  • Several unions
  • Efficient patient flow capability
  • Not hindered in initiating innovations
  • Focused on patient safety and quality care
  • Flexibility of all team members

4
THE DESIGN
  • Pre-emptive
  • Patient Education
  • Pre-operative Medications (Celebrex, Pepcid)
  • Intraoperative Medication
  • Ketamine, Dolasetron, Dexamethasone
  • Post-operative
  • PASS
  • PONV, PDNV control
  • Fast Track Anesthesia Model
  • Team Orientated
  • Patient Focused
  • Consistent
  • Addresses post-operative issues
    pre-emptively
  • SAFE Anesthesia
  • Short surgical times

5
OVASC CREATES A NEW CULTURE
  • A positive culture leads to pride, positive
    feelings, innovation, recruitment, retention.
  • Supports regional values integrity,
    partnership, diversity, accountability,
    flexibility innovation, quality, service,
    results.
  • A positive culture should be good for the
    customer employee
  • Culture is made up of values (preferred ways of
    being) and norms (ways of behaving).

6
WHAT INSPIRES WORKERS?
  • To be a part of something great.
  • To do something meaningful.
  • To learn something new and interesting.
  • To be challenged.
  • To be empowered with information, responsibility
    and authority to make decisions. And holding
    them accountable for the results. Accountability
    gives responsibility meaning.
  • To have ownership in the outcomes

7
REWARD POSITIVE BEHAVIOR
  • Group-driven motives acceptance,identification,
    belonging bring loyalty.
  • Combine extrinsic (prizes) intrinsic
    (recognition) rewards. Make extrinsic rewards
    personal, immediate public.
  • Reward the whole team.
  • Money, gifts are extrinsic rewards. They are
    motivating at first but can lose effectiveness.
  • Recognition, fairness, flexibility, freedom are
    internal factors that have more impact.

8
TEAM AWARD9 ENT CASES DONE BY 1500
9
OVASC PATIENT FLOW
  • Supports fast-tracking from check-in to discharge
  • Process-oriented
  • Simplifies patient tracking
  • Assures continuous quality improvement
  • HIPAA Compliant

10
APPROPRIATE CANDIDATES
  • ASA PS I and II or III if cleared by MDA.
    Children 2 years.
  • Optimized before arrival.
  • Expect return to normal function within 12 hours.
  • No postop electronic monitoring after PACU.
  • Responsible adult to assume responsibility.
  • MDA makes final determination

11
INAPPROPRIATE CANDIDATES
  • Unstable ASA Physical Status III needs
    optimization (ASA III Patient with severe
    systemic disease)
  • History of malignant hyperthermia (MH)
  • Currently on MAOIs
  • Morbid obesity/sleep apnea. Morbid obesity BMI
    35 (BMI kg/m2)
  • Acute substance abuse
  • No available postop home care
  • Known or anticipated difficult airway
  • Patient does not want to go home

12
CHILD CANDIDATE EXCEPTIONS
  • Other than ASA PS I and II
  • Congenital malformations
  • Genetic disorder
  • Known or anticipated difficult airway
  • Bleeding diathesis
  • Family history of MH

13
WHAT TESTS ARE INDICATED?
  • EKG over 50 and all other tests per H P.
  • Lytes if on diuretic , digoxin or steroids, or
    patient has DM or renal disease.
  • Glucose if physiologic age 75, DM, CNS disease
    or on steroids.
  • Preg. test if indicated.
  • CXR if indicated.
  • Appropriate coagulation tests if on
    anticoagulants or has hepatic disease.
  • Creatinine if renal disease, DM, on diuretic or
    digoxin.
  • Hgb if physiologic age 75, cancer, renal disease
    or on anticoagulant.
  • WBC if indicated.

14
WHAT IS FAST-TRACKING?
  • For a surgery center to run successfully,
    appropriate timely discharge (in 45 minutes)
    must occur after anesthesia sedation.
  • Fast-track patients are transferred directly from
    OR table to step-down unit (Phase 2) bypassing
    PACU.
  • Determined if candidate for fast-tracking by
    Procedure Anesthesia Scoring System (PASS)

15
THE FAST-TRACK MODEL
  • 1. Emphasis on health, not disease.
  • 2. Patients do not remove clothes.
  • 3. Patients arrive just before surgery and
    receive little or no premedication.
  • 4. On-time starts essential.
  • 5. Post-operative issues are addressed
    preemptively.
  • 6. Intraoperative medications are standardized.
  • 7. Immediate and consistent feed-back regarding
    patient outcome.
  • 8. Population management is possible.

16
TRIPLE PREINCISIONAL PREEMPTIVE ANALGESIC THERAPY
  • Celebrex 200 mg. po thirty minutes before
    surgery.
  • Ketamine 0.15 mg/kg IV five minutes before
    incision. (NMDA inhibitor)
  • Local anesthetic field block by surgeon.
    (bupivicaine) and/or nerve block by MDA
    (interscalene, femoral nerve block).

17
WHY USE PREEMPTIVE ANALGESIA?
  • Central sensitization is dependent on painful
    stimuli acting on N-methyl-D-Aspartate (NMDA)
    receptors within the central neuraxis.
  • Apply antinociceptive treatment before surgical
    trauma. Prevents stimulation of NMDA receptors
    central sensitization. Inhibits transmission of
    noxious stimuli.
  • Combination may be more effective than any single
    modality.

18
PACU BYPASS CRITERIA (PASS)
  • Combine modified Aldrete scale with evaluation of
    PONV and postop pain control.
  • To bypass PACU, patient must have a postop score
    of 12 points (maximum 14) without a zero in any
    category. These categories (scale 0 to 2)
    include
  • Consciousness
  • Activity
  • Circulation
  • Respiration
  • O2 sat
  • Pain
  • Emetic

19
PHASE II RECOVERY
  • PASS Scores
  • Consistent Staff
  • Family Interaction
  • Comfort measures
  • Cataract patients in recliners
  • Patients wearing own clothes
  • Oral pain medications

20
SAFE ANESTHESIA
  • Titration of short-acting drugs (propofol,
    sevoflurane, fentanyl, alfentanil, midazolam).
  • Patients completely and quickly metabolize the
    drugs and wake up clear headed. Less drug and
    faster emergence.
  • BIS-EEG monitors may allow better titration.
  • Drinking not prerequisite for discharge.
  • Voiding not usually prerequisite but depends on
    type of surgery anesthetic.

21
BETTER EQUIPMENT
  • Laryngeal mask airways (LMA) tolerated at lighter
    levels of anesthesia
  • Flexible LMAs
  • LMAs reduce need for muscle relaxants or reversal
    agents.
  • BIS monitors.

22
LOCAL ANESTHETICS AND NERVE BLOCKS
  • Local anesthetic wound infiltration and
    intra-articular analgesics by surgeon most
    important.
  • Nerve blocks reduce use of opioids.
  • Nerve blocks reduce incidence of PONV.

23
SPINAL ANESTHESIA?
  • 5 mg of bupivacaine with 20 mcg fentanyl ensures
    rapid recovery

24
POST-OP PAIN MANAGEMENT
  • Transitional analgesia is initiated in the OR.
  • Aggressive pain management.
  • NSAIDS (keterolac/COX-2 inhibitors) popular to
    avoid PONV respiratory depression of opioids.
  • Ketamine 0.15 mg/kg.
  • Local anesthetic wound infiltration,
    intra-articular analgesics and nerve blocks.

25
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27
ANESTHESIA TECHNIQUES TO AVOID PONV PDNV
  • Propofol
  • Hydration
  • Minimal opioids
  • Minimizing N-M blocking agent reversal doses
  • Dexamethasone with or without another antiemetic
  • Cox-2 inhibitors rather than narcotics

28
PONV
  • LAP CHOLE 11
  • HERNIAS 1.7
  • HEAD NECK 2

29
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30
FAST-TRACKING
31
5 MINUTES AFTER TONSILLECTOMY
32
LESSONS LEARNED
  • Teambuilding allows a change of culture and it
    must be maintained. There are continuous
    attempts to go back to what feels comfortable.
  • Giving incentives to only one member of a team is
    demoralizing to the others.
  • In a surgery center productivity is the measure
    of success, not utilization.
  • Add-ons are not appropriate for a surgery center.
    If the staff members see the end in sight, they
    will work fast.

33
REASONS FOR CANCELLATIONS
  • Patient with suspected difficult intubation with
    very loose lower front teeth for sinus surgery.
  • Child with temperature of 101.6 for T A.
  • Patient with EKG suspicious for acute MI for
    cataract surgery.
  • Didnt follow NPO instructions.
  • No responsible adult to accompany patient.
  • Child with chromosomal disorder.

34
MORE REASONS FOR CANCELLATION
  • Diabetes mellitus out of control (300).
  • Chart could not be found.
  • Morbid obesity with difficult airway

35
TRANSFERS TO MEDICAL CENTER
  • Recently started on Ace-inhibitor - became
    hypotensive intraop and stayed that way post op.
  • Chest pain postop.
  • Surgeon worried about postop bleeding
    post-tonsillectomy.
  • Persistent nausea after breast surgery.
  • Could not void after incontinence procedure

36
SECRET TO SUCCESS ACCORDING TO EARLENE FREEMAN
  • Fast turnovers and good outcomes require
    teamwork.
  • The surgery center will be successful because we
    will work together as a team.
  • Improving teamwork and a safe climate results in
    improved clinical outcomes.

37
OVASC - CREATION OF A SUCCESSFUL CULTURE
  • Collaborative Practice
  • Multidisciplinary Team
  • Fontana and Riverside Medical Centers
  • Several Unions
  • Focused on Patient Safety and Quality Care

38
MODEL OF A SUCCESSFUL COLLABORATIVE ANESTHESIA
PRACTICE
  • HIGH PATIENT SATISFACTION
  • HIGH EMPLOYEE SATISFACTION
  • FAST-TRACK ANESTHESIA
  • LOW PONV AND PAIN SCORES
  • LOW MORBIDITY
  • FEW ADMITS TO HOSPITAL RELATED TO ANESTHESIA
  • LOW CANCELLATION RATES

39
ELEMENTS TO SUPPORT COLLABORATION
  • Pre-planning Stages
  • Collaboration between Fontana and Riverside
    Medical Centers
  • Education
  • Human Factors
  • SBAR
  • Implementation
  • Maintenance
  • KP Vision/Mission Inspired
  • KP Goal Driven
  • Team-oriented
  • ACT-LMP
  • Patients Thrive

40
ANESTHESIA CARE TEAM
  • Cooperative Anesthetic Planning of MDA/CRNAs
  • Anesthesia briefing process
  • Operating room briefings
  • Keep the anesthesia practice uniform
  • Clear expectations
  • Defined roles
  • Leadership endorsed
  • Employees empowered to carry out mission
  • Work as a unified team within the
    multidisciplinary perioperative team

41
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43
ANESTHESIA CARE TEAM - LABOR MANAGEMENT
PARTNERSHIP (ACT-LMP)MISSION CREATE A HIGHLY
RESPECTED DEPARTMENT THAT EXHIBITS AN ENVIRONMENT
OF PROFESSIONALISM, MUTUAL RESPECT AND TRUST
  • VISION THE FONTANA ACT IS SEEN AS THE MODEL
    FOR KAISER PERMANENTE
  • ALLIES WITH LMP-TAG TEAM
  • QI
  • LIAISON COMMITTEE

44
ACT-LMP GOALS
  • Timely and effective issue resolution
  • Effective Communication
  • Enhance CRNA-MDA relationship
  • Engage CRNAs in planning, decision-making
    problem solving
  • Reduce impact of external factors

45
OVASC ANESTHESIA CARE TEAM
  • Cooperation between two medical centers
  • Assesses and evaluates anesthesia practice
    mutually
  • Common professional respect
  • Patient introduced to team members and their roles

46
ASSESSMENT OF OVASC
  • Patient Satisfaction is Very High (96)
  • Surgeons Enjoy Operating here
  • State of the Art
  • On-time and rapid
  • Staff satisfied
  • UNAC chapter
  • Low turnover rates
  • Lower call-off rates
  • Leadership Team Focused on Patient Safety and
    Staff Quality of Life
  • Close parking
  • Short Stay Flow Process
  • Recognition
  • Celebrations

47
QI PROCESS
  • MEASUREMENT INCLUDES
  • PONV/PDNV
  • Pain
  • Total time in OVASC
  • Service
  • Turnover Times
  • Staff Turnover Rates
  • Patient satisfaction Scores

48
SUMMARY
  • Safe Collaborative Anesthesia Practice
  • Highly productive
  • Innovative
  • Uses Best Anesthesia Practices
  • Promotes pioneering practices
  • Innovative and safe use of LMA
  • Collaboration between MDA CRNA to determine
    protocols for best anesthesia practices
  • Pyxis usage medication management system
  • Safe environment for learning new techniques
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