Management Pearls for an Ambulatory Surgery Center

1. Management Pearls for an Ambulatory Surgery Center Eric R. Briggs, M.D. Vanderbilt University Medical Center February, 2018

2. What is an ASC? • Freestanding medical facilities where same day or outpatient surgeries are performed • What Medicare says it’s not: • ASCs are not permitted to share space, even when temporally separated, with a hospital or Critical Access Hospital outpatient surgery department, or with a Medicare-participating Independent Diagnostic Testing Facility (IDTF)

3. What is an ASC? • Freestanding medical facilities where same day or outpatient surgeries are performed • What Medicare says it’s not: • ASCs are not permitted to share space, even when temporally separated, with a hospital or Critical Access Hospital outpatient surgery department, or with a Medicare-participating Independent Diagnostic Testing Facility (IDTF) • Duration of care not to exceed 24 hrs

4. ASC’s • Higher patient, surgeon, staff satisfaction • Lower Cost • More Convenient • Better Efficiency • Lower Infection Rates • Smaller scale but complex and fluid requiring constant attention and adjustments

5. Timeline • 1966-67 – looking for more affordable and accessible outpatient alternatives, hospitals in California and Washington D.C. develop Ambulatory Surgical Care facilities in conjunction with hospitals

6. Timeline • 1970 – “Surgicenter” opens in Phoenix, AZ • Wally Reed • John Ford • First Ambulatory Surgery Center

7. Timeline • Currently – (2015) 5,400 ASC’s; 23 million surgeries/yr • Today ~30% of those receiving care in ASC’s are Medicare beneficiaries • over 3,500 procedures approved

8. Experience • 4 separate ambulatory centers over the last 8 years • MultiSpecialty with GI endoscopies, ophthalmologic, pain procedures, plastics, ENT with peds, gynecologic, urologic, orthopedic/podiatric; 5 OR’s; 2 endo suites; 10 PreOp bays; 9 PACU phase 1; 4 PACU phase 2

9. Experience • Orthopedic Center 30 min away from Vanderbilt Main Campus; 4 OR’s (typically use 2 surgeon model with each getting a “flip” room); 6 preop bays; 6 PACU phase 1 and 4 PACU phase 2 bays • Orthopedic Center on Vanderbilt Main Campus; 3 OR’s (typically use 2 surgeon model with “flip” room competition); 4 preop bays; 4 PACU bays (no phase 2)

11. PreOp • PreOp Assessment • RN typically but may not have to be • Determine unacceptable criteria

13. PreOp • PreOp Assessment • RN typically but may not have to be • Determine unacceptable criteria • Many patients will fall into gray area and should be presented to anesthesiologist prior to being placed on schedule • Criteria may vary depending on the type of surgery

14. PreOp • Arranging OR Schedule • Who does it? (surgeon’s office vs. ASC) • Ensure those that contact patients give explicit and clear instructions • Short/simple case as first start to facilitate starting day on time • Avoid perineural catheters, pts with history of difficult IV sticks, etc. as 1st start cases

15. PreOp • Adequate space • 1 preop bay for each OR • 2 preop bays for rapid turn over procedures (cataracts and colons) • Adequate Staff • More needed in AM

16. PreOp • Paper Charts should be preorganized • Preop evaluation (prefilled), consents, labs/tests, surgeon H&P, billing sheets • EMR should be customized for flow through phases of care • Templates can be built to prefill required fields (normal exam)

17. PreOp • Patient care • Set up realistic expectations for pts • Regional Anesthesia • No Pain = No Opioids = No PONV • Faster out of OR; Faster out of PACU • Multimodal Analgesics • What’s your cocktail? • PONV prevention/plan

18. IntraOp • Continue the effort • Continue multimodal analgesic strategy and be sparing with opioids • Desflurane for long cases (12 hr plastics) • PONV strategy • Careful titration at end of case • Work harder to bring patient out of OR awake

19. PostOp • Management can depend somewhat on how much space is available • PACU bay to OR ratio • Phase 2 bays can help clear out Phase 1 • Ensure adequate staffing • Can fluctuate, so flexibility of Periop RN’s can be key

20. PostOp • Expected Duration of Recovery • Painful surgery vs non • Regional block vs no block • Length of case • Surgeon dependent factors • PACU RN factors • Take this out of the equation

21. PostOp • Get PO started as soon as possible • Snack and beverage • Pain expected to be/described as significant • Start PO analgesics early in PACU course • Titrate IV opioids as indicated • Revisit regional if suitable

22. PostOp • Parallel processing • Discharge instructions to family/friend while another gets pt dressed and ready for discharge • Be present • Offer encouragement

23. OR Management • Competent manager • Good relationship with all personnel required • All will be asked to help out from time to time • Calm demeanor is very helpful • Surgeons/Anesthesiologist/Manager • Work together daily to adjust schedule

24. OR Management • Very Challenging/frustrating • Flexibility is key • Goal is to be as efficient as possible • Get cases done as soon as possible • Get personnel out/off the clock • Time spent up front usually pays off • Case length can be unpredictable, throwing everything off

25. OR Management • Shifting OR’s or staff • Can a Flip Room be opened? • Surgeon in OR is running later and will bump another surgeon • Running ahead of schedule? • Call in pts early

26. Flip or Flop • Surgeons get a flip room? • One surgeon gets 2 OR’s • “Calls out” when closing for next pt to roll back to OR • While one case is closing, the other pt is being induced/prepped/draped • “Reward” for productive surgeons

27. Flip or Flop • Huge time saver for the surgeon • Are we missing out on # of surgeries? • Surgeon must participate to fully utilize this option • See/Mark/Consent next patient before scrubbing into current case • Less utilization of OR though

28. ASC’s • Higher patient, surgeon, staff satisfaction • Lower cost • More convenient • Better Efficiency • Smaller scale but complex and fluid requiring constant attention and adjustments