Choice of anesthesia affects discharge time

Tips offered for knee arthroscopies

As with all high-volume procedures, same-day surgery managers continuously look for ways to increase efficiency and improve patient care, and there is always room for improvement.

Just ask any of the 25 organizations participating in the third Knee Arthroscopy with Meniscectomy best practices study undertaken by the Accreditation Association for the Ambulatory Health Care’s (AAAHC) Institute for Quality Improvement (IQI) in Wilmette, IL.

All same-day surgery providers can gather tips for efficiency and improved patient care from this study that can be applied to other procedures.

Almost 250,000 knee arthroscopies are performed annually, and almost 96% of them performed in the same-day surgery setting.1

"We performed well in the 2001 study, but we found that we decreased all of our times in the 2002 study," says Pat Armstrong, RN, director of surgical services at Connecticut Orthopedic Specialists Surgery Center in Hamden.

The average facility time, described as the time the patient checks in to the facility to the time the patient is ready for discharge, for Armstrong’s program was less than 150 minutes. The longest facility time among study participants was almost 350 minutes, with the median overall time 218 minutes.

There are several factors that contribute to their success, Armstrong says. "We are a one-specialty surgery center, so we focus on orthopedics and have a seasoned staff who enjoy this specialty," she says. "We also put a lot of effort into improving our efficiency and turnaround times on a continuous basis so that we can predict our times and better schedule our patients."

One way to keep times low is to standardize equipment and supplies used by all surgeons, Armstrong adds. "By having the surgeons agree to use the same video system and same arthroscopy pump, we not only have to move equipment in and out of the OR, but staff members need to learn how to use only one system," she explains.

Another factor that contributes to her facility’s average discharge time is the use of minimal anesthesia. Discharge time is defined as the time from when the patient is out of the operating room to when the patient is ready for discharge from the recovery unit. "We use a block comprised of propofol with small amounts of fentanyl and midazolam so the patient is awake and alert during the procedure," Armstrong says. "This means that our patients are pain-free without the postoperative nausea and vomiting that narcotics and benzodiazepams can cause."

The majority of cases (65%) in the study used general anesthesia, with 18% of the cases using local with intravenous sedation.

Another advantage of having an alert patient is that patient education goes beyond pre-op teaching and continues throughout the procedure, Armstrong states. One finding of the IQI study was that of the 10% of the patients not walking within 72 hours of the procedure, 52% didn’t think that their discharge instructions were clear. This compares to only 9% of the patients who were walking but did not feel their discharge instructions were clear.

"Because our patients are alert throughout the whole procedure, they are able to watch the video as the surgeon operates and ask questions about what is happening," Armstrong points out. "This gives them a chance to understand the surgery and ask about precautions or post-surgical care."

One nurse is responsible for answering the questions if the surgeon doesn’t want to talk during the procedure, she adds.

Delayed cases can affect a same-day surgery program’s schedule for the whole day, so it’s important to take steps to ensure that procedures are started on time, says Peggy LaPole, RN, BSN, continuous quality improvement coordinator for The Orthopedic Surgery Center of Orange County in Newport Beach, CA. Although the study’s median times for setup before and cleanup after each procedure totaled 43 minutes, LaPole’s facility turns over cases much more quickly. There are several reasons for her facility’s turnover time of less than 20 minutes and her facility’s ability to start cases with less than 10 minutes of delay, she says.

"We make sure that we prepare for the day by pulling the cases on the afternoon prior to surgery," she says. "We also use minimal supplies and don’t have specialty packs that include unnecessary items that our surgeons don’t use."

LaPole’s facility also reported an average procedure time of slightly more than 20 minutes when the median procedure time was 30 minutes. "This is due to the experience and teamwork of my staff and the surgeons," she explains.

The median time for pre-procedure was 79 minutes, but Orthopedics Associates’ surgery center in Portland, ME, had an average pre-procedure time of 40 minutes, says Linda Mae Ruterbories, NP, director. Pre-procedure is defined as from the time the patient arrives in the holding area to the time the patient is in the operating room.

"We have our patients arrive no more than 30 minutes ahead of their procedure because we’ve found that when they arrive too early, they have time to sit and wait and become more anxious," she says. "The more anxious a patient becomes, the longer it takes to get things done because we have to spend more time reassuring them." Admitting nurses wear beepers so they can be paged as soon as a patient checks in, Ruterbories adds. "We get their IV started, identify the surgical site, answer questions, and get everything moving," she says. Rather than feeling rushed, patients are more relaxed, she adds.

All pre-op interviews and pre-op teaching is done one day to one month in advance of the procedure, Ruterbories says. "This ensures that the history and physical is in the chart, the patient knows how to use the Cryo/Cuff [Aircast, Summit, NJ], pain medication prescriptions are filled, and we’ve had a chance to answer questions," she says.

Another way to avoid delays is to have the anesthesiologist review the pre-op workups 48 hours prior to the surgery day, says Armstrong. "This gives us time to order labs or X-rays if needed without making the patient wait longer on the day of surgery," she explains. "If the patient doesn’t experience any delays on the day of surgery, it is a positive experience for everyone."

Reference

1. Owings MF, Kozak LJ. Ambulatory and inpatient procedures in the United States, 1996. Vital Health Stat 1998; 13:39.

Sources and Resources

For more information on the results of the Knee Arthroscopy with Meniscectomy best practices study, contact:

  • Pat Armstrong, RN, Director of Surgical Services, Connecticut Orthopedic Specialists Surgery Center, 2200 Whitney Ave., Suite 310, Hamden, CT 06518. Telephone: (203) 407-1500. E-mail: parmstrong@ct-ortho.com.
  • Peggy LaPole, RN, BSN, Continuous Quality Improvement Coordinator, The Orthopedic Surgery Center of Orange County, 351 Hospital Road, Suite 110, Newport Beach, CA 92663. Telephone: (949) 515-0708.
  • Linda Mae Ruterbories, NP, Director of Surgical Center, Orthopedics Associates, 33 Sewell St., Portland, ME 04102. Telephone: (207) 828-2126.

The Knee Arthroscopy with Meniscectomy best practices study is available for $50 plus shipping and handling. To order a copy, go to the Accreditation Association for Ambulatory Health Care Institute for Quality Improvement web site at www.aaahciqi.org and click on "Order" and then click on "Products, Resources," then scroll down to "Knee Arthroscopy with Meniscectomy Study 2002," or call (847) 853-6060.