Stay for a while? Not in this SDS unit

Have something else to drink before you go home. You can just relax for a while.

There’s no rush.

Before long, these comments will be as extinct in the same-day surgery program as dodo birds are today.

To survive the crush of capitation, same-day surgery programs are going to have to cut their costs by improving efficiencies and reducing lengths of stay. To assist readers in this effort, we've talked to one program that has reduced overall length of stay in its ambulatory surgery program from 5.5 to 3.6 hours. Here are the tips from the managers of that program:

Develop a general ambulatory surgery care map that includes preoperative care and discharge planning. (See care maps inserted in this issue.)

"Rather than looking at each individual procedure, we looked at all events that need to occur to get a person from the point that they need to have surgery to being discharged to home and managed appropriately post-procedure," says Lyn Ames, MS, RN, CNOR, CNAA, director of perioperative services at St. Luke's Hospital, the New Bedford, MA, site of Southcoast Hospitals Group. Ames spoke recently at the Same-Day Surgery Conference, sponsored by Same-Day Surgery, held in Washington, DC.

Working with alternative sites

This step involved everything from appropriate screening of patients to working with alternative sites outside the hospital. The same-day surgery program wanted to be able to place some patients in skilled nursing facilities or rehabilitation facilities or arrange for them to receive visits from home health nurses.

Use criteria to make sure the patient is appropriate for surgery.

Using criteria to determine appropriateness of care was a first step toward St. Luke's reducing its surgery cancellations from 21% to 2%.

"In a number of places, you find that surgeons do unnecessary surgery," Ames says. "In a managed care environment, you can’t do that."

St. Luke’s uses Sims criteria from Medical Systems Management in Redding, MA. The criteria are available as an on-line package. (See source box, p. 9.)

"The criteria help you weed out all of those unnecessary surgeries," Ames says. "When someone is coming in, the Sims Criteria lists several presenting signs and symptoms for pre-op diagnosis," she says. "If the patient meets the criteria, then it’s good that you scheduled surgery."

Telling people what costs are

Publicize the costs of drugs.

The hospital performed costs analysis of pharmaceutical charges over an 18-month period to determine how much was being spent in four categories: induction agents, narcotics, muscle relaxants, and inhalation agents.

"It turned out, for the most part, people didn’t have any idea what anything cost," says Cheryl Leporacci, manager of anesthesia services. "They would choose the drugs they were most familiar with if they weren’t contraindicated in patients."

The costs of the drugs were published and distributed at department meetings.

"People became much more judicious of what they were doing and when," Leporacci says, referring to methods of induction. "That cut the bill quite a bit."

Due to this process, the use of one expensive narcotic was eliminated, and the use of another narcotic was greatly reduced.

Also, to shorten the wake-up times, the anesthesiologists began to use new drugs including Sevoflurane, an inhalation agent, and propofol. (For more on propofol, see Same-Day Surgery, November 1995, p. 134.)

Persuade physicians to put their histories and physicals (H&Ps) on the chart before the day of surgery.

Before the same-day surgery program attacked the problem, 100 patients a month were arriving at the doors of the OR without an H&P. To address this problem, the necessity of having an H&P was written into the care map as one of the basic interventions.

Physicians were given several options: Dictate the H&P into the hospital’s transcription service, fill out a paper H&P form if they didn’t have access to a computer, fax the H&P to the hospital, or, for those with computer access, have their H&P released into the patient information system.

"Now there are no patients who go to the OR without the H&P," Ames says.

Establish rapid-turnover rooms.

Rapid-turnover rooms were established, and turnover time was reduced from about 25 minutes to 10 minutes, Leporacci says.

The rooms, which initially were used for ENT procedures, had consistent anesthesia teams every day. "We didn’t have variation of personnel that was going to try to do differently or throw another poker in the fire," Leporacci says.

The work was divided up so that everyone had a specific job.

Hurry up and wait

Previously, staff would look at the next patient, get coffee, set up for the next case, and wait for the nursing assistant to bring the next patient.

Under the new system, the teams’ first task of the day was to set up for multiple cases.

"We had the nursing assistants to help us take the dirty things out of the room for us, and we had enough clean equipment for the next case," Leporacci says. "The nurse anesthetist would go directly from PACU or recovery room when they released the first patient — they would release the patient to the PACU nurse and finish charting — and go immediately to pick up the next patient themselves and bring the patient to the room. They could chart on the way to the room if they needed to."