Painless IV Starts
Here's a technique that does away with the big "ouch."

Patients let us know how the IV venipuncture feels with a big "ouch." They often tell us that the IV start was one of the worst parts of their surgery, especially with multiple attempts. Allow me to share what we call the painless IV. It starts with a Xylocaine (lidocaine) skin wheel with an insulin syringe and a 28- or 29-gauge needle. Place the needle at a high (70- or 80-degree) angle to the skin. Next, inject adjacent to the vein, only in the very surface layer of the skin and not beneath the skin, .02ml to .03ml (two lines on the U-50 syringe). After a 30-second wait, the patient won't feel the venipuncture. Your first-time patients will say, "Wow, I didn't feel that." Your returning patients will request the "painless IV." One important note: Done incorrectly, the skin wheel can be more painful than the IV needle itself.

Robert R. Jirgl, CRNA
Anesthesia Service of Dowagiac
Dowagiac, Mich.
[email protected]

Have Your Patients Check Themselves In
Are long check-in lines a problem at your facility? You might want to borrow a page from the Countess of Chester Hospital in Chester, England, which developed an electronic system that lets patients check themselves in via touchscreen computer kiosks.

"Patients are becoming used to seeing these systems in airports, cinemas and GP surgeries, and we feel Countess of Chester patients can benefit from this technology also," says Mark Jones of the hospital's information management and technology (IM&T) department. Rather than wait in long lines at the reception desk, patients can now confirm their personal data — gender, date of birth, postal code — on touchscreens located in the outpatient waiting rooms.

Once a patient has verified his information, the machine prints out a ticket that the receptionist scans to access the patient's record and check him in. Mr. Jones says the hospital is working with the touchscreen vendor to remove this last step so patients can check themselves directly into the hospital's computer system.

Project manager Robin Drummond-Hay says the system has cut patient check-in times in half and thinned lines at the outpatient reception desks. He says it also helps protect patient privacy. "Patients can check their personal details on the screens without having to repeat information to the receptionist in an open environment," says Mr. Drummond-Hay.

The check-in system follows on the heels of the hospital's RemindMe e-mail and text messaging service, which was launched last September as a way to reduce missed appointments. The hospital recently announced that more than 10,000 patients had signed up to receive electronic reminders of their appointments.

— Irene Tsikitas

4 Little Coding and Billing Errors That Can Cost You Big
Modifiers. One little modifier can make a big difference if you don't use it or if you use it incorrectly. Take colonoscopies, for example. The physician does several lesion removals or biopsies on several sites within the colon. The surgeon removes a polyp via snare in the cecum (45385 primary procedure), takes a cold biopsy in the rectum (45380-59) and removes another in the sigmoid by hot forceps (45384-59). If your coder/biller doesn't bill them separately or bills them without a modifier ??"59, you lose big bucks.

Another modifier that can have a negative effect if used incorrectly is the bilateral services modifier -50. Research the rules for your individual insurance contracts for the use of this modifier. Some will require an LT or RT modifier and some want the modifier -50. You don't want to bill something with or without a modifier -50 to Medicare if that isn't the way they want it. For example, if a CPT code for a Medicare patient has a bilateral indicator of 3 and you don't bill it with two units, you missed out on the 100-percent payment for both procedures. For help in California, go to www.medicarenhic.com/ providers/articles/bilateralservices_1106.pdf. For other states, find more info at www.cms.hhs.gov/apps/pfslookup/step0.asp.

Not billing for supplies. Be sure to dissect the operative report to find the supplies that you can bill out. Not billing for intraocular lenses, mesh, screws or implants can cost you hundreds of dollars.

Typos. Transposed insurance ID numbers are one of the most frequent errors that can cost you. By the time the insurance sends your claim back, you might have lost 30 days in your revenue cycle. Consider software that checks eligibility for you and will flag your claim before it gets out the door. Always have your staff review for errors while updating this valuable information.

Not following up on claims quickly. Some insurance plans only give you 30 to 60 days to submit a claim. After that, well, you get nothing. You just lost the revenue for the entire case. Know each of your payors' time limits.

Kimberly Orwig, CPC, CPC-H
President
Physician Claims Solutions
[email protected]

"Walk a Mile in My Shoes Day" Shows Your Staff Others' Responsibilities
We've recently begun arranging for each of our pre-op and PACU nurses to spend a day walking around with and job-shadowing our OR nurses in an effort to help them better understand what's involved in staffing the OR. We call it "Walk a Mile in My Shoes Day."

Every surgery center cross-trains. But while cross-training is teaching someone else how to do your job, "Walk a Mile in My Shoes" is showing them why you do your job the way you do. What your responsibilities, roles and needs are. Why you might not be able to do things the way other staffers think you should. A pre-op or PACU nurse might actually be surprised at what they learn from an OR nurse's day.

We're planning to have OR nurses follow their pre-op and PACU counterparts as well, and perhaps even get the front desk and business office staff, the clinical and materials managers involved. The more staffers who know how the process works, the more smoothly we can work as a team.

Gina Espenschied, RN, BSN, CNOR
Administrator
Surgery Center at Brinton Lake
Glen Mills, Pa.
[email protected]

Give Post-op Instructions Before Pre-op
Patients aren't at their best when they're recovering from anesthesia. They're often groggy and tired, and their caregivers are often too concerned to listen carefully as a staff member gives post-operative instructions. Because of these factors, we wondered how much they actually heard and remembered when they got home.

So instead of waiting until after the procedure, we began telling patients and their caregivers what they had to know to optimize their recovery in private rooms before going into the pre-operative area. We found that they were more attentive at this phase and were more willing to ask questions. The caregivers would also have time to think about the instructions while the patient was in surgery, and sometimes they would approach us with additional questions as the patients recovered.

While we haven't done a test or a survey, we're certain that the patients remember more when they don't have to deal with post-anesthesia haziness. That makes them much more likely to follow our instructions.

Kathleen Royles
Administrator
Reading Surgery Center
Reading, Pa.
[email protected]

Writing the Price Makes Surgeons Think Twice
The surgeons at our facility like using a particular suture with a metal anchor that costs $108. To get them to consider using a less expensive alternative, I took a magic marker and wrote "$108" on each suture's package. Often this reminder is enough to make them stop and consider whether they really need the anchored sutures or if they can use something else.

Lynda D. Simon, RN
OR Manager
St John's Clinic: Head & Neck Surgery
Springfield, Mo.
[email protected]

We Cut Our Cataract Turnover Times By Forming a Specialized Team
I wasn't happy with our facility's turnover times for cataract cases, which ranged from 21 to 24 minutes. I also heard surgeons complain that some of the personnel didn't know the procedure well enough to offer the right instrument or do the right thing at the right time.

Instead of working with rotating staff members for these cases, we created a specialized cataract team. I designated some staff members to receive special training from the main ophthalmology societies and academies so they'd know every part of the procedure from pre-op to the last steps in the OR. While all the training and testing was expensive, I figured that the staff would stay with our facility longer if they saw themselves as respected experts, so it would cost less in the long run than bringing in new hires and getting them up to speed.

The training paid off. Our turnover time for cataract cases is down to five to seven minutes and the surgeons are very happy with the quality of service our staff provides. Best of all, the staff members take pride in their work.

Carol Martin, RN, MBA
Director of Perioperative Services
Carondelet Health Network
St. Joseph's Hospital
Tucson, Ariz.
[email protected]