orm_february-2024 - 30

OR Business
" You need to have a
solid reason to do a procedure
as an inpatient, "
says Karen Curley,
nursing director of procedural
services. " You
may have someone who
is 87 years old, but they
are very healthy, fullfunctioning,
and can go
home the same day. A
Karen Curley,
MSN, BSN,
RN, CNOR,
NEA-BC
younger person may have comorbidities
and no one at home to help them. "
Site of service selection is difficult
to manage because there are many
clinical factors and variables that can
impact the patient's surgical risk.
" Insurance companies will look at a
procedure like joint replacements and
hysterectomies and ask if it could have
been outpatient, " says Smith. " You better
have your documentation on the
spot and ready to go, proving why they
needed to be inpatient. Otherwise, you
won't get paid. If we're denied, that is a
significant loss of revenue. "
Many variables can contribute to
whether or not a procedure becomes
inpatient or outpatient.
It
is always a
challenge for each surgical facility to
determine the patient's specific needs
in preparation for surgery.
Fourth handoff: Preadmissions
testing
Preoperative and preadmission testing
is an integral part of the care coordination
process, as it ensures patients are
adequately prepped for surgery. There
are challenges in gathering all the necessary
clinical documentation because
multiple sources and stakeholders are
involved. While every patient needs a
consent form and H&P within 30 days
of surgery, specific procedures dictate
the need for any additional testing.
" For instance, a patient may need a
cardiac clearance. Or if they have a certain
medical condition, a medical clearance, "
says Viadero.
Viadero's facility has a preadmis30
OR
Manager | February 2024
sions testing (PAT) department comprising
three nurses and two coordinators.
The patient will hear from central scheduling
at the hospital and then have an
interview with a PAT nurse. During that
interview, a nurse may discover that
additional clearances are required. PAT
is responsible for keeping everyone updated
on the latest information regarding
patient status. The fallout is broad if
a patient slips through the cracks.
" If a cardiac work-up is missing or
a patient fails to stop their blood thinners
at the right time, surgery gets canceled.
You have patient and surgeon
dissatisfaction. Supplies that have been
opened need to be thrown away, " says
Viadero. " Let's say that was a four-hour
case. Now you're calling patients at
home to move them up. They're not
happy, and anxiety increases as they try
to hurry up and get to the hospital. It's
a big snowball. "
Curley says that one of the leading
causes of cancellations in her experience
is physicians ordering cardiology
consults for a patient who may not need
one. " Instead of going by the guidelines,
it seems easier just to have them
get one. But it takes time to get a cardiology
appointment, which may not happen
before surgery, " says Curley.
Fifth handoff: Vendor, supply
chain management
An incorrect implant selection is another
aspect of joint cases that can result
in cancellations. Suppose a patient
has a nickel allergy, and the vendor representative
is not alerted. In that case,
they might bring an implant with nickel
for the procedure, causing a patient
safety risk, case delay, or cancellation.
" We have to make sure the implants
we provide for this patient do not contain
something that will cause an adverse
reaction, " says Ast. " This should
come to the staff's attention much
earlier than the day of surgery if we're
using a scheduling or reservation technology
that highlights that. "
Facilities still follow manual processes
to select and alert implant/product
selection for patient procedures.
Schedulers spend multiple hours per
week calling vendors to alert them to an
implant/product need. They spend additional
hours verifying that the implant/
product will be delivered with enough
time to prep for the case. However,
this leg of the process starts with the
surgeon.
" We have items here on the shelf
we've purchased, and we obviously prefer
the surgeon to utilize those, but ultimately
they have the best idea of what
is best for the patient, " says Ast. " We
may need an item we don't have in our
inventory, so the surgeon is usually responsible
for contacting those reps and
letting them know that their support will
be needed for an upcoming procedure. "
For instance, Ast says his facility
does not own any sets for total joints.
In this scenario, the surgeon would give
the rep details about the schedule (proactive
reps will call the hospital and ask
about the schedule for the following
week). The rep will arrive the day before
surgery with the appropriate instrumentation
and biologicals so there is time
to process and sterilize them. But the
unexpected often happens.
" We had a physician today who has
a preferred vendor for a trauma procedure,
and he has a case he wants
to put on tomorrow's schedule. That
vendor could not provide support, so he
contacted me and asked what options
we had for him. Now at this point, the
onus falls on the facility to reach out to
vendors. I was able to touch base with
a vendor that could come out and support
the procedure, " says Ast.
While it is common for vendor reps
to assist the surgeon in technical support
before and during surgery, some
try to make the most of this facetime
by upselling more expensive products.
Ever conscious of the bottom line, most
facilities have contractual protections
against this.
www.ormanager.com
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orm_february-2024

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