INDISPENSABLE The anesthesia team must relentlessly proceed with the thought in mind that it can always be improving, says Jay Horowitz, CRNA, of Quality Anesthesia Care Corp. in Sarasota, Fla.

Back in the day, it didn't much matter how long it took to turn over an operating room or administer peripheral nerve blocks. We didn't worry much about how long a patient was in the recovery room, even if they were nauseated and vomiting. Patients were delivered to the anesthesia group without any effort on our part (heaven forbid we help push a stretcher). All we had to do was give an anesthetic and wake up the patient.

My, how times have changed.
Giving a safe anesthetic today is the bare minimum you should expect from the anesthesia team. Your anesthetists should play an active part in the overall effort to increase patient satisfaction, enable efficiency and increase your competitive edge, both in the perioperative area and outside the OR.

ROLL UP YOUR SLEEVES Anesthetists shouldn't hesitate to help turn over a room or push a stretcher. No prima donnas allowed, please.

Value-added services
Before patients ever arrive at the facility, the anesthesia team should help ensure on-time starts, decrease cancellations, and address patient clinical and billing concerns.

For example, patients can fill out pre-anesthesia questionnaires electronically and have them delivered straight to the anesthesia team leader. After reviewing the pre-anesthesia information, the leader can order additional tests, consult with and get clearance from other medical team members, and formulate any additional orders to be completed upon the patient's admission.

Patients should be able to direct-dial the anesthesia team leader with both clinical and billing questions. Sure, you can have an 800-number and a nameless, faceless billing person on the other end, but patients really appreciate speaking with someone personally involved with their care. A note to you anesthesia providers: Don't forget to close the call by telling the patient you will look forward to seeing them on the day of their surgery.

Once the patient has arrived at the facility, the anesthesia team should be able to provide a consistent staffing model to ensure on-time starts. The anesthesia team can improve turnover times by using techniques that produce timely emergence from anesthesia, making sure the next patient is ready (including placing a block for the surgical procedure and/or post-op pain management) and even pushing stretchers if necessary.

The anesthesia team should have an agreed-upon protocol applicable for all patients based on standardized post-operative nausea and vomiting (PONV) risk assessments. They should have a PONV prophylaxis protocol and use PONV-sparing techniques by using more regional anesthesia and emetogenic-avoidance techniques like propofol/ketamine infusions.

Working with the rest of the surgical team to preempt post-op pain by using regional techniques, local anesthetics and parenteral medications, anesthesia providers must make patients relatively comfortable in PACU and ready for a timely discharge.

Additionally, the anesthesia team should ensure timely antibiotic administration and employ evidence-based anti-embolism strategies like TED hose and sequential compression devices.

Constant improvement
As anesthesia departments are reorganized, purchased, merged or just wanting to hold on to their current practice sites, it is the value-added efforts that make the anesthesia team indispensable. And indispensability equals job security. If the anesthesia team is not continually evolving, continuously seeking quality improvement and being an active player in increasing your competitive edge, it may be time to try a different tack.

There are various ways to become indispensable. Many start simply with an attitude that tells you they're committed to the success of the facility and each of its stakeholders. An offer to serve on committees can be invaluable, whether it's peer review, quality assurance, credentialing, pain management, or pharmaceuticals and therapeutics. Simply attending, listening and contributing to committees demonstrates their devotion to success.

Beyond attitude, they can put this into practice by engaging in projects and activities that strengthen the bottom line. Anesthesia team evaluation before capital equipment purchases can save a lot of time and energy as you wade through the myriad choices in quality and cost for these much-used, vital items. Anesthesia team participation in development and review of policies and procedures can ensure that what happens in practice aligns with policy, and that policies ensure safe, cost-effective and efficient practice.

Good PR
The anesthesia team members should be enthusiastic ambassadors for the facility. Since an anesthesia team can make a huge difference in attracting and retaining surgeons, nurses and ancillary personnel, they should be part of recruitment, hiring and retention activities. Prospective surgeon recruits should have a member of the anesthesia team involved in facility tours and Q&A sessions.

Within the community, a member of the anesthesia team should be available for educational or practice seminars that the facility or individual surgical practices use to recruit new patients. This is a terrific opportunity to interact with surgeons, their staff and prospective patients (who'll appreciate a friendly face when they arrive for surgery).

Putting the right providers with the right patients and surgeons at the right time is a critical anesthesia team function. Ambulatory anesthesia is different from other anesthesia sub-specialties, with special techniques and desired outcomes. Not all anesthetists are good at or interested in it. Your team's mindset needs to be "every case, every day."

"COORDINATING THE ENTIRE OR PROCESS"
Life of a Truly Hands-On Anesthesiologist

BUZZING There's not much anesthesiologist Phil Bilello, MD, doesn't do at Paoli (Pa.) Surgery Center.

I do everything at my 4-OR surgery center. Not just clinically. I get involved far beyond that. My role here at the Paoli Surgery Center in suburban Philadelphia is really coordinating the entire OR process, not only on a clinical basis, but also in the behind-the-scenes business aspects and acting as liaison between our corporate partner and the surgeons' staff, and between the anesthesia and nursing teams. It's an all-encompassing role. I try to keep my finger on the pulse on all levels.

•Wine and dine surgeons. I enjoy having dinner with other surgeons' offices. There's no better way to get more cases at your surgery center than to share a meal, either with surgeons you're trying to recruit or with those whose volumes you're trying to increase.

•Credentialing. As president of the medical staff, I review and approve surgeons' credentialing files. We have around 100 physicians, so it's a pretty big job. Between 2 and 5 recredentialing packets land on my desk every week.

•Peer review. Twice a month, I'm involved in peer review. We'll pick a subgroup such as ENT, pediatrics, orthopedics or cataracts, and review their cases. Just the other day, we peer-reviewed 30 cases. Nurses go through charts to make sure we checked all that we should have.

•Quality assurance committee. Once a month, this committee — our head nurse, 2 surgeons and I — meets to go over infection control issues, whether patients received their antibiotics on time, complications and new policies we're considering.

•Medical executive committee. The medical executive committee must approve all amendments to our center's policies. A group of 7 doctors, the administrator, the head nurse and the head OR nurse meets quarterly to discuss certain issues that we'd like to bring to this committee for approval. Examples of issues we've recently tackled: adding or removing drugs from the formulary, tweaking the block schedule or changing the minimum number of cases surgeons must perform at our center to remain on staff.

•Block schedule. I manage and coordinate the entire block. As you know, the block schedule is a very dynamic part of a surgical center. I consider the block schedule to be real estate. Real estate is about location. Everybody's concerned about where his location will be. It's difficult to make everybody happy. You have to tread very lightly because you don't want to hurt feelings. Let's say we need to find space for a new surgeon who wants to come on staff. I'll approach a surgeon who's not filling his block. "Dr. Jones, we've noticed that your volume is down. You have a block every Tuesday from 7:30 a.m. to 12 p.m. We need to cut you back to every other Tuesday." I also work with our scheduling staff, educating them on what kind of cases we want to do first instead of later in the day, and how to set up the rooms.

•Pharmacy inventory. I bet no other provider does this. I handle all the pharmacy inventory and all of the materials inventory (anesthesia circuits, airways, endotracheal tubes, spinal trays, needles and syringes) for our center. Every day I review our pharmacy and anesthesia inventory, making sure we have all the drugs we need, and that drugs don't expire. Every month, I order what we need. I've also streamlined our drugs. We used to have 4 different types of muscle relaxants. Now we use one.

•Staff education. I give nursing staff educational lectures so they can earn CME credits and stay current. I just gave a few on sleep apnea and the obese patient, how smoking affects anesthesia, the latest fasting protocols and treatment of local anesthetic toxicity. We'll hold lectures at day's end, either in the staff lounge or in the pre-op area.

— Philip Bilello, MD

Dr. Bilello ([email protected]) is president of the medical staff at Paoli (Pa.) Surgery Center.

All for one, one for all
This isn't your father's anesthesia services world anymore. The competition has increased, the stresses on the medical system have increased, and reimbursements have decreased and don't appear to be headed in a positive direction. By working together and communicating openly to achieve mutually rewarding goals, you and your anesthesia team can have a very long and prosperous relationship.