Increasingly, outpatient surgeons, and the surgery centers and hospitals where they work, are adding surgical first assistants (SFAs) as a tool to shorten their procedure times and add more cases.
“Any time you have consistency of personnel as first assistants, it certainly lowers costs by improving efficiency, turnover, time during case, all those things, and accuracy and safety of cases,” says Todd Albert, MD, surgeon-in-chief at the Hospital for Special Surgery, New York, NY. The hospital uses physician assistants (PAs) to operate as SFAs, as well as fellows, residents, nurses, and OR techs. SFAs are one tool that allows the Hospital for Special Surgery to operate at full capacity of about 30,000 cases annually, with three new ORs being built, Albert says. Using consistent first assistants allows a surgeon to speed the surgery, he says. “So it lowers infection rate, lowers cost, increases efficiency, and leads to better outcomes,” Albert says.
Rockford (IL) Ambulatory Surgery Center uses SFAs primarily to assist its cosmetic surgeons, says Steven A. Gunderson, DO, CEO/medical director. “They are exceptionally qualified, do reduce surgery time, in most cases, and best of all, the surgeon is responsible for reimbursement whether it is out of the fee he/she charges the patient or a direct bill to the patient,” Gunderson says. When a general surgeon uses an SFA, which happens less frequently, the first assistant bills the insurance company for the fee.
In terms of reducing surgery time, SFAs have been reported to reduce surgery time by more than 14 minutes to almost 23 minutes per case, which translates to approximately 10-16% reduced surgery time.1 Intralign in Scottsdale, AZ, which employs SFAs to work in hospitals and surgery centers, has found that customers save 15-28% surgical time, reports Miki Patterson, PhD, RNFA, ONP, senior director of orthopedics.
Healthcare facilities have reported that the time and staff savings have translated to cost savings ranging from $100,000 to more than $1 million, Patterson says.
First assistant tasks include handing over instruments and supplies, using suction, using retractors to hold the operating site open, or assisting with the actual surgery, she says. “They complement whatever the surgeon needs,” Patterson says. “They are able to set up prep and drape, if they have worked with that surgeon prior to that and know their preferences, and they are able to suture wounds closed — this can take 10-30 minutes depending on the incisions — while the surgeon sees the next patient and/or dictates,” she says. “An SFA is a licensed clinician, who knows about surgery and anatomy, who works to anticipate what you’re going to do. It frees up the surgeon to do other things.”
Intralign bills the use of the SFA to the insurance company, as long as the case is considered complex enough to require a first assistant. The American College of Surgeons (ACS) has devised an index of what surgeries need a first assistant. (That index is available at the web site of the ACS, which offers a disclaimer that the 2013 file might not be up to date. To access that list, go to http://bit.ly/1Pf8I3O.) Patterson’s experience has been that insurance companies will pay for a first assistant on most cases, as long as they are not simple cases such as procedures on the eyes that don’t require an extra set of hands.
Who works as an SFA varies. In some practice settings, one surgeon will ask another surgeon to operate as the first assistant. Many facilities hire a PA or nurse practitioner (NP) to work for the practice. Other facilities hire freelance SFAs to work specific cases. Intralign hires mostly MDs and PAs to work as SFAs, along with a few NPs and registered nurse first assistants (RNFAs).
The ACS has recommendations on who is qualified to serve as a first assistant in a Statements on Principles document.2 While acknowledging that the qualifications of an SFA can vary depending on the operations, surgical specialty, and facility, the ACS says that ideally, the SFA “should be a qualified surgeon or a resident in an approved surgical education program.”2 However, the ACS says that it might be necessary to use nonphysicians, such as surgeon’s assistants or PAs with additional surgical training who meet national standards and are credentialed.
The Association of periOperative Registered Nurses (AORN) has a statement on the advanced practice RN (APRN) serving as an SFA.3 As of Jan. 1, 2016, APRNs who haven’t previously worked as a FA are required to do the following: “to acquire the knowledge and skills needed to provide safe, competent, surgical first assistant services by completing a program that covers the content of the AORN Standards for RN First Assistant Education Program, which may be a stand-alone program or may be a portion of a graduate or post-graduate program (e.g., additional coursework included in a graduate APRN program).”
Based on a Q&A published in the December 2015 AORN Journal, AORN acknowledges that flexibility might be needed to adopt different interpretations or more stringent education requirements/qualifications. The AORN Position Statement on RN First Assistants says that effective Jan. 1, 2020, persons entering an RNFA program must have a baccalaureate degree.4 However, RNFAs who were practic-ing as SFAs before that date should be permitted to continue working as RNFAs, the organization says.4 All PAs, MDs, NPs, and RNFAs working as SFAs are licensed by the state in which they work, and they are credentialed by the facilities.
Ensure that you are using a person with the right qualities, Albert emphasizes: “mostly willingness to learn and curiosity, so they’ll stay interested.”
The most important step to take before hiring or using SFAs? Ensure you need them, Albert says. Ask: Do you have the volume to support it? Are you lacking the assistant’s help?
“If a doctor is operating alone, it’s not nearly as good a situation as having a qualified FA in there too,” he says.
REFERENCES
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Bohm ER, Dunbar M, David Pitman D. Experience with physician assistants in a Canadian arthroplasty program. Canadian J Surgery 2010; 53(2):103-108.
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American College of Surgeons. Statement on Principles. Sept. 18, 2008. Accessed at http://bit.ly/1NQZEo1.
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Association of periOperative Registered Nurses. AORN Position Statement on Advanced Practice Registered Nurses in the Perioperative Environment. 2014. Denver. Accessed at http://bit.ly/1NVF0AT.
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Association of periOperative Registered Nurses. AORN Position Statement on RN First Assistants. Denver. 2013. Accessed at http://bit.ly/1IDOaFs.
