Case Study: Revamped Pre-Anesthesia Procedures Drive Improved Surgical Efficiency

Southeastern Ohio Regional Medical Center, a 95-bed hospital in Cambridge, Ohio, had a clear objective: Perform more surgeries and do so more efficiently.

In 2011, the hospital—better known as Southeastern Med—decided to do something about it. It hired NorthStar Anesthesia — an anesthesia-services management company with 180 locations in 20 states and a proven track record of revamping underperforming anesthesia services. In the five years since, NorthStar has worked in close partnership with Southeastern Med’s surgery department to increase surgical volumes by increasing on-time starts for each day’s first surgeries and decreasing same-day cancellations of surgical procedures.

Improving the efficiency of anesthesia services and surgical procedures is important as Southeastern Med—located between Columbus, Ohio, and Wheeling, W. Va.—adapts to new value-based reimbursement models that pay for services based on quality and efficiency outcomes rather than on the volume of those services.

Challenges

Anesthesia services at Southeastern Med were a long way from being in shape for the transition to value-based patient care when NorthStar took over their management in 2011.

The hospital’s five operating rooms were underutilized, and the staffing of anesthesia services was not deployed efficiently. Three anesthesiologists and two certified registered nurse anesthetists (one full-time and one part-time) provided anesthesia services in three operating rooms five days per week and a fourth room two days per week, leaving one or two operating rooms unused on any given day. Underlying causes of the underutilization included same-day cancellations and delays in beginning the first surgeries each day.

Same-day cancellations often happened when patients arrived for surgery with uncontrolled levels of blood sugar, high blood pressure or other medical issues. Although the hospital ran a pre-anesthesia testing department, patients’ medical issues were not always addressed proactively before the day of surgery.

“Part of the problem was that the anesthesiologists were in the operating rooms all day long,” explains Mark DiLuciano, M.D., regional medical director at NorthStar Ane sthesia of Ohio.

Part of the problem was that the anesthesiologists were in the operating rooms all day long.

Mark DiLuciano, M.D., Regional Medical Director, NorthStar Anesthesia

The anesthesiologists would review the charts with questions from pre-anesthesia testing in the evening, making notes in the chart about how to address patients’ medical issues before surgery, such as through an appointment with a primary care provider to adjust medications.

“Then you had to try to get a hold of the family, and sometimes those things didn’t get taken care of. For example, a diabetic would show up and their blood sugar was way out of control, so you couldn’t do the surgery,” Dr. DiLuciano says.

Solution

NorthStar implemented a multipronged approach to improve the efficiency of anesthesia services, beginning with a change in the staffing model. NorthStar installed a care delivery model in which CRNAs provided anesthesia services under supervision from surgeons but without direction from anesthesiologists.

Over time, NorthStar transitioned to a care delivery model predominately staffed by CRNAs. Dr. DiLuciano—who is the hospital’s chief of anesthesiology and a member of the medical executive committee—is the only anesthesiologist on a staff that also includes five, full-time CRNAs.

Five of those six staff members provide anesthesia services in the operating rooms while the sixth person floats, and all six take call duty. The floater answers questions from pre-anesthesia testing, provides anesthesiology services to the obstetrics department, oversees the post-anesthesia care unit, or PACU, and performs regional nerve blocks on surgical patients.

Because the float staffer is available to answer questions during the day, nurses in pre-anesthesia testing assist patients with follow up steps ordered by anesthesia—such as scheduling doctor’s appointments—before patients leave the hospital campus. NorthStar also worked with the staff in pre-anesthesia testing to develop protocols for what tests should be done based on each patient’s medical history. That ensured that surgeons, anesthesiologists and CRNAs had a comprehensive picture of patients’ health issues and medication regimens.

NorthStar and the surgery department also worked together on an initiative in 2013 to increase the percentage of each day’s first surgeries that began on time. They re-organized most of the pre-surgery processes. For example, surgeons now arrive 25 minutes before a scheduled surgery, giving them ample time to see their patients and sign evaluation and consent forms for regional nerve blocks and for anesthesia services to perform the blocks, which are usually done before a surgery begins, DiLuciano says.

We are not just there to provide anesthesia services. We are there to help the hospital in any way that we can.

Mark DiLuciano, M.D., Regional Medical Director, NorthStar Anesthesia

As process improvement is a continual endeavor, NorthStar and Southeastern Med currently are working on a project to safely speed the rate of operating room turnover between cases. The idea is to streamline coordination, so that operating rooms are cleaned and supplies restocked at the same time as NorthStar staff members bring patients into the PACU.

Results

Southeastern Med’s surgical efficiency has improved dramatically since its partnership with NorthStar began in 2011. The annual volume of surgeries has increased 30 percent to 4,254 last year from 3,251 cases in 2010. The percentage of first case on-time starts improved to 95 percent last year from 60 percent in 2013—a dramatic improvement that began soon after the new processes were introduced. Same-day cancellations now are less than 1 percent, usually hovering around 0.3 percent and 0.5 percent.