Tame the wild beast: Staffing same-day surgery

(Editor’s note: One of the most common questions we receive at Same-Day Surgery concerns staffing formulas. This month, we explore the staffing formula from the American Society of PeriAnesthesia Nurses in Thorofare, NJ. In last month’s issue, we featured a formula from the Association of Operating Room Nurses in Denver.)

Same-day surgery is a different animal when it comes to staffing. "In ambulatory surgery, you may have eight to 10 cases in one room, with turnover faster than one hour," says Myrna Mamaril, MS, RN, CPAN, CAPA, nurse manager of preadmission testing, ambulatory surgery, and inpatient post-anesthesia care unit (PACU) at St. Joseph Medical Center in Towson, MD. "You’ll have many more patients in PACU" than inpatient staff would have, Mamaril says. "The flip side is that in pre-op, you also can be required to get patients ready faster," she says.

To determine staffing for such a hectic schedule, consider these essential elements, she says:

• patient classification/acuity (if many of your patients are ASA Class 3, increase your staff levels) and nurse/patient ratio (see box, at right);

• time studies, which also should factor in the number of operating rooms, lengths of OR procedures, availability of staff to prepare patients, and time it takes to prepare patients.

To assist readers who face the challenges of staffing a same-day surgery program, Mamaril offers a detailed explanation of how she conducts time studies on a quarterly basis for her ambulatory surgery program:

Use a large graphic to record information about your program. Every 15 minutes your program operates, determine how many patients are pre-op, peri-op, and post-op. Use color coding to designate your pediatric patients and the type of procedures your patients are having. "You can see when patients are falling out and how you need to add additional staff to match volumes and match the types and acuity of patients," Mamaril says. For example, a nursing home patient with poor hearing may need extra time in pre-op and post-op.

In its most recent time study, St. Joseph Medical Center tracked 2,000 surgical outpatients and AM admissions from the time they came into the facility until the time they left. The staff found that it took an average of 15 minutes to conduct a complete nursing assessment of a patient, start an IV and antibiotics, and administer any eye drops for an outpatient. That time lengthened by about seven minutes for ambulatory surgery patients requiring compression stockings, IVs or antibiotics. The average time for an AM admission was 30 minutes due to the acuity of the patient.

When you obtain these results for pre-op, peri-op, and post-op, multiply those averages by the number of patients per day. This figure then can be matched up with staffing, Mamaril advises. Take that number and match it with nursing care minutes. Also, don’t forget these important points:

• Build in relief for lunch.

• Build in a relief person or a floater who can assist children in postanesthesia. "Pediatric patients are sometimes unpredictable when they’re waking up," Mamaril says. This position can be handled by technical or support staff, she says.

• Consider your history of cases and adjust the timing of your staff if necessary. "For some months, we may do away with the later shift and put in an earlier shift, depending on historical data," she says. In summer, some physicians are on vacation, so you may not need a nurse in the evening; however, you may need more help earlier in the day if cases are shorter due to a greater number of pediatric patients.