Can ASC Procedures Go Longer Than 4 Hours?
True or false? Medicare rules state that a procedure in an ambulatory surgery center can't last more than 4 hours. Not exactly true. To be considered for inclusion on Medicare's ASC list, the procedure wouldn't be expected to last more than 4 hours. Splitting hairs perhaps, but a distinction worth sharing with the next Medicare surveyor that cites you for performing a procedure that lasted more than 4 hours.

Pennsylvania has a 4-hour time limit on operating time and a total of 4 hours of directly supervised recovery. And Medicare's Conditions For Coverage for ASCs says "the expected duration of services would not exceed 24 hours following an admission."

Cosmetic surgeon Richard Greco, DO, MD, of the Georgia Institute for Plastic Surgery in Savannah, Ga., says his facility has imposed a 6-hour case time limit. A committee reviews all cases that last longer than 7 hours "to see why it occurred, and to make changes to avoid it from occurring again." Another facility's policy requires that a planned procedure shouldn't be expected to require more than 4 hours of operating time.

Cases posted for 5 hours would be at the long end of our accepted practice, says an anesthesiologist.
Sarasota, Fla., anesthesiologist Carl Noback, MD, says "the skill and care of the surgeon in conjunction with the anesthesia provider are more important than a time limit." Florida CRNA Jay Horowitz, who works some facial plastic cases longer than 8 hours, says anesthesia techniques like spontaneous ventilation and propofol-ketamine allow for rapid, stable discharge in less than 60 minutes.

Evidence suggests that the number of complications (atelectasis and DVT, for example) increases after 5 hours of surgery, but a 2006 study, "Duration of Anesthesia as an Indicator of Morbidity and Mortality in Office-Based Facial Plastic Surgery," by Neil A. Gordon, MD, and Marc E. Koch, MD, found that anesthesia duration was not an indication of patient morbidity and mortality.

"Consider each patient and procedure individually," says S??o Berkowitz, MBA, CRNA, BSN, of Anesthesia Relief Services in Georgia. "When people become cavalier and abide by a blanket rule, that's when problems occur."

— Dan O'Connor

Keys to Getting Patient Satisfaction Surveys Returned
The feedback noted on patient satisfaction surveys is invaluable. Too bad you can't get them all back, right? Administrator Jay A. Shorr comes close. He says the Advanced Cosmetic Laser Center in Ft. Lauderdale, Fla., sees more than 90% of the surveys they hand out. How? By sharing the importance of surgical safety with patients, and by asking them to help alert his staff to problem areas that need correcting. "Like anything else," he says of increasing your response rate, "it's all in the approach." Try these tips:

• Remind patients several times — while they're in your facility and again during follow-up phone calls — why satisfaction surveys are important, how you'll positively apply the information you gather and the role they play in improving the care your staff provides.
• Include pre-paid envelopes with the surveys you dole out in order to make responding easier.
• Give surveys to patients in recovery and encourage them or their families to fill out the forms before leaving the facility, instead of hoping they are brought back during post-op visits or dropped in the mail.

If all else fails, perhaps you need to look for the silver lining in a sluggish response rate. One reader doesn't mind receiving only about 15% of the surveys she distributes. Any more, she admits, would be overwhelming.

— Daniel Cook

Baby Shampoo As Vaginal Prep?
What should you use as a vaginal prep for patients who are allergic to iodine? "Baby shampoo, believe it or not," says Thomas S. Dardarian, DO, an OB/GYN from suburban Philadelphia. What about skin cleanser Phisohex? "It's for external use only," says Dr. Dardarian. "I would be careful."