Surviving the Anesthesia Staffing Crisis

Many ASCs are forced to think creatively to maintain proper, affordable and consistent coverage.

During our latest annual salary survey, we added a question about the ongoing anesthesia staffing and payment crisis at ASCs, and it’s clearly on the minds of many of our respondents. While the majority of surgery centers report zero or minimal impacts, a large minority reported the situation has been difficult at their facilities.

Too much, too little

ASC leaders had a lot to say about the rising costs of anesthesia services and the uncertain availability of providers when they are needed.

Juanita Jones, RN, administrator/director of nursing at Innovative Procedural and Surgical Center, a pain management ASC in Las Vegas, says large anesthesia groups in her center’s region have signed contracts with local hospitals, leaving ASCs like hers in a bind. “They will not commit to ASCs’ needs until the day before if they don’t have full day lineups,” she says. “We have to pay a stipend to our anesthesia provider.” At Surgical Eye Center in Greensboro, N.C., “lots of days we only have one provider where we used to have two,” says Center Director Julie Maiden.

Many ASC leaders are cobbling together their OR schedules based on anesthesia provider availability. “Sometimes we have to cap a room because some of the anesthesia nurses leave at 3. Luckily, we are usually able to work something out,” says Patricia MacMaster, RN, director of nursing at Vantage Surgery Center in Moorestown, N.J., an affiliate of Virtua Health.

Respondents who requested anonymity delivered some brutal assessments of the anesthesia situation at their ASCs. They speak of paying income guarantees to anesthesia providers, considerably bumping up their rates, canceling cases and closing ORs. “We cannot find enough CRNAs, and we have taken a hit on the amount of cases that can be done,” says one. “We have two ORs currently closed due to inadequate anesthesia staffing,” says another.

An additional anonymous comment revealed a similarly dire situation: “We have closed rooms early and for full days due to lack of coverage by our contracted anesthesia providers.”

Others cited high cancelation fees their ASCs must agree to pay anesthesia providers when surgeons don’t or can’t use their allotted block time. Some ASCs are even requiring patients to pay cash for anesthesia services.

Even ASCs that characterize their current anesthesia situations as “fine, with no issues” have the nagging feeling they might be skating on thin ice. “We are OK right now,” says Tiffany Courington, AS, nurse manager at Cataract & Laser Surgery Center of South Georgia in Valdosta. “But I think that will change.”

Cracks in CRNA model

As many ASCs have moved to less expensive CRNA-only models, often out of necessity, some have found them less reliable than they’d prefer.

Christina Kline, RN, clinical nurse manager at Valley View Surgical Center in Lebanon, Pa., says her ophthalmology ASC has contracted a nurse for anesthesia services. “He is very reliable,” she says. “However, in case of an emergency or him being sick, we are not guaranteed a replacement at the last minute.”

Some speak of CRNAs being limited in their ability to place regional blocks or work certain complex surgeries. For example, another eye center, Medical Eye Associates in Macon, Ga., has contracted with CRNAs, but sometimes finds itself limited in procedural scope as a result. “Coverage can be an issue due to level of CRNA comfort with performing anesthesia for certain procedures,” says OR Manager Jo Anna Brett, RN, BSN.

Other facilities are finding anesthesia providers so difficult to secure or pay for that they are forced to use locums to fill gaps in their surgical schedules, which negatively impacts the consistency and cohesion of their OR teams.

As evidenced by the myriad of difficulties surrounding ASC anesthesia staffing, there’s no easy, foolproof solution to the problem. Each center’s situation is unique, as are the solutions and workarounds. Patient safety, of course, always remains the priority.

Inside job

Livonia (Mich.) Outpatient Surgery Center, a single-specialty ophthalmology ASC, made a decision nine years ago that has certainly stood the test of these disruptive times: the establishment of its own anesthesia group of 15 CRNAs. “I have personally and professionally known most of them for 20 years, and they are loyal,” says Executive Director Laura Picano-Wilson, RN, CNOR, CAIP. “Our CRNAs are paid well and rarely work over eight hours. We do our own billing in-house, so the group is able to sustain itself without much oversight or cost to the ASC.”

Many of Livonia’s CRNAs still work at hospitals and put time in with the ASC on the side. “It is great extra money, and the efficiency we practice each day usually gets them out within six to seven hours,” says Ms. Picano-Wilson.

When asked if other ASCs should consider establishing such a model in today’s climate, she doesn’t have a definitive opinion. “I would like to think our model would succeed anywhere, but I may just be lucky to have a group that enjoys quick ophthalmology cases, lives close and is motivated by money,” she says. “I am fortunate to have the present group.”

Livonia’s setup isn’t immune to external market factors, however. “We did increase their daily rate a few years ago, so I imagine that subject will come up again soon,” says Ms. Picano-Wilson.

Sedation only?

Some ASCs are working without anesthesia providers altogether and using RNs to sedate patients instead.

“We do not have anesthesia at our center. RNs provide conscious sedation,” says Lauren Phillips, BSN, administrator at The Cardiac and Vascular Institute Ambulatory Surgery Center in Gainesville, Fla. “We only use nurses/moderate sedation,” says Julie Goza, RN, chief nurse executive at another cardiovascular ASC, Merced (Calif.) Vein & Vascular Center.

Suzanne Green, RN, OR manager and director of nursing at The Eye Surgical Center of Fort Wayne (Ind.), a small ASC that focuses on cataract and glaucoma surgeries, foresees continued success by exclusively employing an oral conscious sedation model it has used for over a decade.

“We use a combination of two types of benzodiazepines, with dosing amounts driven by a couple factors: age and ASA score,” says Ms. Green. “It’s considered RN sedation. However, we hook our patients to a cardiac monitor to record their vitals every five minutes as we would if we were using IV anesthesia. The outcomes are wonderful, and we have next-to-zero recovery time before discharge.”

Ms. Green knows her center is an outlier, even in the ophthalmology space. “I feel we are still in the minority and, unfortunately, one of the reasons could be money,” she says. “Many places may give a Xanax, then place an IV and push 1mg of Versed, and with another doctor or CRNA in the room, the payment is much more then RN sedation.” Ms. Green says many facilities defer to their policies instead of going to the governing board and requesting a change in that policy. “There is also a fear that, ‘What if something goes wrong and you need IV access?’ or ‘You can’t do surgery without an IV,’” she says.

She responds to those concerns by explaining her center’s own approach.

The Eye Surgical Center of Fort Wayne’s nurses numb the eye topically and intraocularly, resulting in very little pain and pressure. Ms. Green says her team is great at calming patients and making them feel comfortable, and that a fully stocked crash cart with IV supplies is available if needed.

“Plus, the medication we give is very minimal,” she says. “As a former ER nurse, I understand the fear and frustration that goes along with IV placement.”

Ear to the ground

Many ASCs are finding that staying fully staffed for anesthesia services requires significant work, creativity, vigilance and, in some cases, an informed serendipity resulting from awareness of changes in their local markets.

Consider The Orthopaedic Surgery Center at Orthopaedic Associates of Wisconsin in Pewaukee. “We have three employed anesthesiologists and started an anesthesia care team (ACT) model this year with two full-time employee CRNAs and a cadre of 1099 CRNAs who fill in as needed,” says Executive Director LoAnn Vande Leest, RN, MBA-H, CNOR(e), CASC.

Local market dynamics worked to her center’s favor. “As the old adage says, timing is everything,” she says. “We were fortunate that there was a split in the anesthesia group at our partner hospital at the same time our center was looking to hire anesthesiologists.

“Two really good guys who liked our surgeon-owners and culture decided to make our ASC their ‘place.’ After a bit of time, a third anesthesiologist from one of the nearby metro hospitals wanted more work-life balance, so he joined as well.”

Last November, when Ms. Vande Leest’s center launched its ACT model, a local hospital system was moving its employed CRNAs to a different model, resulting in some looking elsewhere for employment. “We were fortunate to get a couple from that,” she says. “We also utilize 1099 CRNAs, and those that work with us find the work very rewarding, as opposed to a consistent professional diet of GI cases.

“My best advice is for ASC leadership to keep your ears open to changing dynamics in the hospital industry, where you might find those willing to move into the ASC industry,” says Ms. Vande Leest.” OSM