Fast Track Ambulatory Surgery and a Model of Success for a Collaborative Anesthesia Practice

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Fast Track Ambulatory Surgery and a Model of
Success for a Collaborative Anesthesia Practice

• CANA Spring 2005
• Thelma Z. Korpman, MD, MBA
• Sandra E. Morris, MSM, CRNA

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OBJECTIVES

•  1) Will be familiar with current concepts of
  Fast Track Anesthesia in an ambulatory surgery
  center.
•  Preemptive Analgesia
• PONV avoidance. 
•  SAFE Anesthesia
• PASS
• 2)  Will recognize different anesthesia
  techniques to assure quick anesthesia recovery.
• Anesthetic/Medication Usage
• MAC, regional, general anesthesia
• Nerve blocks
• Local anesthetic wound infiltration and
  intra-articular analgesics
• Use of LMA

• 3) Will be familiar with the advantages of
  having a coordinated perioperative team.
• Multidisciplinary Collaboration including
  surgical and anesthesia cooperation increases
  patient safety and satisfaction
• Innovation accountability encouraged
• 4) Will identify the necessity for coordinated
  efforts to ensure quick, efficient turnovers.
• EVS role
• Anesthesia Technical Support.
• PYXIS
• All members of team accountable

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ONTARIO VINEYARD AMBULATORY SURGERY CENTER (OVASC)

• A free-standing surgery center in Ontario serving
  members from Fontana Riverside Kaisers
• Collaborative Practice
• Multidisciplinary Team with effective
  communication among all members of the team
• Several unions
• Efficient patient flow capability
• Not hindered in initiating innovations
• Focused on patient safety and quality care
• Flexibility of all team members

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THE DESIGN

• Pre-emptive
• Patient Education
• Pre-operative Medications (Celebrex, Pepcid)
• Intraoperative Medication
• Ketamine, Dolasetron, Dexamethasone
• Post-operative
• PASS
• PONV, PDNV control

• Fast Track Anesthesia Model
• Team Orientated
• Patient Focused
• Consistent
• Addresses post-operative issues
  pre-emptively
• SAFE Anesthesia
• Short surgical times

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OVASC CREATES A NEW CULTURE

• A positive culture leads to pride, positive
  feelings, innovation, recruitment, retention.
• Supports regional values integrity,
  partnership, diversity, accountability,
  flexibility innovation, quality, service,
  results.

• A positive culture should be good for the
  customer employee
• Culture is made up of values (preferred ways of
  being) and norms (ways of behaving).

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WHAT INSPIRES WORKERS?

• To be a part of something great.
• To do something meaningful.
• To learn something new and interesting.
• To be challenged.
• To be empowered with information, responsibility
  and authority to make decisions. And holding
  them accountable for the results. Accountability
  gives responsibility meaning.
• To have ownership in the outcomes

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REWARD POSITIVE BEHAVIOR

• Group-driven motives acceptance,identification,
  belonging bring loyalty.
• Combine extrinsic (prizes) intrinsic
  (recognition) rewards. Make extrinsic rewards
  personal, immediate public.
• Reward the whole team.

• Money, gifts are extrinsic rewards. They are
  motivating at first but can lose effectiveness.
• Recognition, fairness, flexibility, freedom are
  internal factors that have more impact.

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TEAM AWARD9 ENT CASES DONE BY 1500
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OVASC PATIENT FLOW

• Supports fast-tracking from check-in to discharge
• Process-oriented
• Simplifies patient tracking
• Assures continuous quality improvement
• HIPAA Compliant

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APPROPRIATE CANDIDATES

• ASA PS I and II or III if cleared by MDA.
  Children 2 years.
• Optimized before arrival.
• Expect return to normal function within 12 hours.
• No postop electronic monitoring after PACU.
• Responsible adult to assume responsibility.
• MDA makes final determination

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INAPPROPRIATE CANDIDATES

• Unstable ASA Physical Status III needs
  optimization (ASA III Patient with severe
  systemic disease)
• History of malignant hyperthermia (MH)
• Currently on MAOIs
• Morbid obesity/sleep apnea. Morbid obesity BMI
  35 (BMI kg/m2)
• Acute substance abuse
• No available postop home care
• Known or anticipated difficult airway
• Patient does not want to go home

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CHILD CANDIDATE EXCEPTIONS

• Other than ASA PS I and II
• Congenital malformations
• Genetic disorder
• Known or anticipated difficult airway
• Bleeding diathesis
• Family history of MH

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WHAT TESTS ARE INDICATED?

• EKG over 50 and all other tests per H P.
• Lytes if on diuretic , digoxin or steroids, or
  patient has DM or renal disease.
• Glucose if physiologic age 75, DM, CNS disease
  or on steroids.
• Preg. test if indicated.
• CXR if indicated.

• Appropriate coagulation tests if on
  anticoagulants or has hepatic disease.
• Creatinine if renal disease, DM, on diuretic or
  digoxin.
• Hgb if physiologic age 75, cancer, renal disease
  or on anticoagulant.
• WBC if indicated.

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WHAT IS FAST-TRACKING?

• For a surgery center to run successfully,
  appropriate timely discharge (in 45 minutes)
  must occur after anesthesia sedation.
• Fast-track patients are transferred directly from
  OR table to step-down unit (Phase 2) bypassing
  PACU.
• Determined if candidate for fast-tracking by
  Procedure Anesthesia Scoring System (PASS)

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THE FAST-TRACK MODEL

• 1. Emphasis on health, not disease.
• 2. Patients do not remove clothes.
• 3. Patients arrive just before surgery and
  receive little or no premedication.
• 4. On-time starts essential.
• 5. Post-operative issues are addressed
  preemptively.
• 6. Intraoperative medications are standardized.
• 7. Immediate and consistent feed-back regarding
  patient outcome.
• 8. Population management is possible.

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TRIPLE PREINCISIONAL PREEMPTIVE ANALGESIC THERAPY

• Celebrex 200 mg. po thirty minutes before
  surgery.
• Ketamine 0.15 mg/kg IV five minutes before
  incision. (NMDA inhibitor)
• Local anesthetic field block by surgeon.
  (bupivicaine) and/or nerve block by MDA
  (interscalene, femoral nerve block).

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WHY USE PREEMPTIVE ANALGESIA?

• Central sensitization is dependent on painful
  stimuli acting on N-methyl-D-Aspartate (NMDA)
  receptors within the central neuraxis.
• Apply antinociceptive treatment before surgical
  trauma. Prevents stimulation of NMDA receptors
  central sensitization. Inhibits transmission of
  noxious stimuli.
• Combination may be more effective than any single
  modality.

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PACU BYPASS CRITERIA (PASS)

• Combine modified Aldrete scale with evaluation of
  PONV and postop pain control.
• To bypass PACU, patient must have a postop score
  of 12 points (maximum 14) without a zero in any
  category. These categories (scale 0 to 2)
  include

• Consciousness
• Activity
• Circulation
• Respiration
• O2 sat
• Pain
• Emetic

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PHASE II RECOVERY

• PASS Scores
• Consistent Staff
• Family Interaction
• Comfort measures
• Cataract patients in recliners
• Patients wearing own clothes
• Oral pain medications

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SAFE ANESTHESIA

• Titration of short-acting drugs (propofol,
  sevoflurane, fentanyl, alfentanil, midazolam).
• Patients completely and quickly metabolize the
  drugs and wake up clear headed. Less drug and
  faster emergence.
• BIS-EEG monitors may allow better titration.
• Drinking not prerequisite for discharge.
• Voiding not usually prerequisite but depends on
  type of surgery anesthetic.

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BETTER EQUIPMENT

• Laryngeal mask airways (LMA) tolerated at lighter
  levels of anesthesia
• Flexible LMAs
• LMAs reduce need for muscle relaxants or reversal
  agents.
• BIS monitors.

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LOCAL ANESTHETICS AND NERVE BLOCKS

• Local anesthetic wound infiltration and
  intra-articular analgesics by surgeon most
  important.
• Nerve blocks reduce use of opioids.
• Nerve blocks reduce incidence of PONV.

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SPINAL ANESTHESIA?

• 5 mg of bupivacaine with 20 mcg fentanyl ensures
  rapid recovery

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POST-OP PAIN MANAGEMENT

• Transitional analgesia is initiated in the OR.
• Aggressive pain management.
• NSAIDS (keterolac/COX-2 inhibitors) popular to
  avoid PONV respiratory depression of opioids.
• Ketamine 0.15 mg/kg.
• Local anesthetic wound infiltration,
  intra-articular analgesics and nerve blocks.

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ANESTHESIA TECHNIQUES TO AVOID PONV PDNV

• Propofol
• Hydration
• Minimal opioids
• Minimizing N-M blocking agent reversal doses

• Dexamethasone with or without another antiemetic
• Cox-2 inhibitors rather than narcotics

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PONV

• LAP CHOLE 11
• HERNIAS 1.7
• HEAD NECK 2

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FAST-TRACKING
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5 MINUTES AFTER TONSILLECTOMY
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LESSONS LEARNED

• Teambuilding allows a change of culture and it
  must be maintained. There are continuous
  attempts to go back to what feels comfortable.
• Giving incentives to only one member of a team is
  demoralizing to the others.
• In a surgery center productivity is the measure
  of success, not utilization.
• Add-ons are not appropriate for a surgery center.
  If the staff members see the end in sight, they
  will work fast.

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REASONS FOR CANCELLATIONS

• Patient with suspected difficult intubation with
  very loose lower front teeth for sinus surgery.
• Child with temperature of 101.6 for T A.
• Patient with EKG suspicious for acute MI for
  cataract surgery.
• Didnt follow NPO instructions.
• No responsible adult to accompany patient.
• Child with chromosomal disorder.

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MORE REASONS FOR CANCELLATION

• Diabetes mellitus out of control (300).
• Chart could not be found.
• Morbid obesity with difficult airway

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TRANSFERS TO MEDICAL CENTER

• Recently started on Ace-inhibitor - became
  hypotensive intraop and stayed that way post op.
• Chest pain postop.
• Surgeon worried about postop bleeding
  post-tonsillectomy.
• Persistent nausea after breast surgery.
• Could not void after incontinence procedure

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SECRET TO SUCCESS ACCORDING TO EARLENE FREEMAN

• Fast turnovers and good outcomes require
  teamwork.
• The surgery center will be successful because we
  will work together as a team.
• Improving teamwork and a safe climate results in
  improved clinical outcomes.

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OVASC - CREATION OF A SUCCESSFUL CULTURE

• Collaborative Practice
• Multidisciplinary Team
• Fontana and Riverside Medical Centers
• Several Unions
• Focused on Patient Safety and Quality Care

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MODEL OF A SUCCESSFUL COLLABORATIVE ANESTHESIA
PRACTICE

• HIGH PATIENT SATISFACTION
• HIGH EMPLOYEE SATISFACTION
• FAST-TRACK ANESTHESIA
• LOW PONV AND PAIN SCORES
• LOW MORBIDITY
• FEW ADMITS TO HOSPITAL RELATED TO ANESTHESIA
• LOW CANCELLATION RATES

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ELEMENTS TO SUPPORT COLLABORATION

• Pre-planning Stages
• Collaboration between Fontana and Riverside
  Medical Centers
• Education
• Human Factors
• SBAR
• Implementation
• Maintenance

• KP Vision/Mission Inspired
• KP Goal Driven
• Team-oriented
• ACT-LMP
• Patients Thrive

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ANESTHESIA CARE TEAM

• Cooperative Anesthetic Planning of MDA/CRNAs
• Anesthesia briefing process
• Operating room briefings
• Keep the anesthesia practice uniform
• Clear expectations
• Defined roles
• Leadership endorsed
• Employees empowered to carry out mission

• Work as a unified team within the
  multidisciplinary perioperative team

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ANESTHESIA CARE TEAM - LABOR MANAGEMENT
PARTNERSHIP (ACT-LMP)MISSION CREATE A HIGHLY
RESPECTED DEPARTMENT THAT EXHIBITS AN ENVIRONMENT
OF PROFESSIONALISM, MUTUAL RESPECT AND TRUST

• VISION THE FONTANA ACT IS SEEN AS THE MODEL
  FOR KAISER PERMANENTE

• ALLIES WITH LMP-TAG TEAM
• QI
• LIAISON COMMITTEE

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ACT-LMP GOALS

• Timely and effective issue resolution
• Effective Communication
• Enhance CRNA-MDA relationship
• Engage CRNAs in planning, decision-making
  problem solving

• Reduce impact of external factors

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OVASC ANESTHESIA CARE TEAM

• Cooperation between two medical centers
• Assesses and evaluates anesthesia practice
  mutually
• Common professional respect
• Patient introduced to team members and their roles

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ASSESSMENT OF OVASC

• Patient Satisfaction is Very High (96)
• Surgeons Enjoy Operating here
• State of the Art
• On-time and rapid
• Staff satisfied
• UNAC chapter
• Low turnover rates
• Lower call-off rates

• Leadership Team Focused on Patient Safety and
  Staff Quality of Life
• Close parking
• Short Stay Flow Process
• Recognition
• Celebrations

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QI PROCESS

• MEASUREMENT INCLUDES
• PONV/PDNV
• Pain
• Total time in OVASC
• Service
• Turnover Times
• Staff Turnover Rates
• Patient satisfaction Scores

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SUMMARY

• Safe Collaborative Anesthesia Practice
• Highly productive
• Innovative
• Uses Best Anesthesia Practices
• Promotes pioneering practices
• Innovative and safe use of LMA
• Collaboration between MDA CRNA to determine
  protocols for best anesthesia practices
• Pyxis usage medication management system
• Safe environment for learning new techniques