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Is it Time to Refine Your Anesthesia Regimen? |
An internal analysis may help you cut costs and improve patient satisfaction. |
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Dianne Taylor, Contributing Editor |
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In the fast-paced surgical environment, what was good enough yesterday may not be appropriate today. Nowhere is this truer than in the realm of anesthesia. The choice of anesthetic agents, monitoring technology, and duration of surgery have all changed dramatically.
Given these many variables, the best way to ensure a cost-effective anesthesia approach may be an internal analysis of your current practices. Recently, two surgical centers did so. Although conclusions will vary from facility to facility depending on the anesthesia professionals on staff and the types of procedures, these facilities' experiences show how this exercise can reduce anesthesia costs and even improve patient care.
Case #1:
The St. George Surgical Center
Recently, the management team at St. George Surgical Center in St. George, Utah, noticed that some patients seemed to experience prolonged recovery and require more post-op airway management than others. To verify this anecdotal observation and uncover the cause, the team undertook a performance improvement study that ultimately paid off.
The team members first created a data collection worksheet. Besides patient and procedure information, the team recorded anesthetic agents used, airway management techniques (chin lift, endotracheal intubation, oral, LMA), PACU time, postop airway management time, time until secondary recovery (transfer to a recliner with the patient in an alert state), and incidence of nausea on the worksheet. Within 10 weeks, the team gathered data on 151 similar cases that, when categorized by anesthesia practitioner, revealed telling trends:- The incidence of post-op nausea varied dramatically from one practitioner to another (from 0 to 36 percent of patients). Several of the facility's nine practitioners had no or few patients with nausea, while four had a significant share of patients who developed postop nausea (from 17 to 36 percent).
- Time needed to manage the airway postoperatively (e.g., chin lift) varied between practitioners. Average per-patient postop airway assistance time was 1.5 minutes per case, ranging from 0 to over 3 minutes depending on the practitioner.
- Average time to second recovery was over 71 minutes per patient, ranging from 47 to 90 minutes per anesthesia practitioner.
Although each of the nine practitioners used different regimens, a close look at their practices revealed two potential causes. First, the practitioners with the highest postop nausea rates and airway management times seemed to rely more heavily on volatile, as opposed to IV, anesthesia. One practitioner's regimen, which included a Diprivan induction followed by high-flow volatile maintenance regimen, almost certainly contributed to the airway management and nausea problems, says Ken Summerhays, RN, CNOR, the facility's director of nursing. Second, those with the highest recovery times tended to wait until the patient was in PACU before ordering or performing an IM injection for postop pain control.
After the study, the anesthesiologists with the highest rates of postop nausea and airway management needs were eager to improve their records. Thus, a type of mentoring program began, in which the anesthesiology team met and discussed alternate approaches. As a result, they implemented two changes:- Although each practitioner's regimen varies, they began relying more on IV and less on volatile anesthesia. "Some may induce with a volatile anesthesia and transition to IV, while others induce with IV and stay with IV," notes Mr. Summerhays. Gaylen Gurr, MD, the center's Chief of Anesthesia, commonly uses a remifentanyl/propofol induction, followed by a remifentanyl/propofol/60% NO2 maintenance regimen that also includes a muscle relaxant. "This new approach gets patients out as quickly and comfortably as possible because there are virtually no residual effects," notes Dr. Gurr. "I can probably get through the day using two vials of remifentanyl and four to five vials of propofol."
- The practitioners began routinely injecting an IM dose of Demerol approximately 35 minutes before the end of the procedure to maintain the analgesic effect of the short-acting remifentanyl without interruption.
 In all, a follow-up study of 61 cases at the center showed that the changes led to clinical improvements (Table 1). Among most practitioners who altered their regimen, nausea rates declined. The practitioner who switched from the high-flow volatile anesthesia regimen showed the most significant reduction in the incidence of nausea-from 35.6 percent to 14.3 percent among his patients.
From an economic perspective, the study was a clear-cut success; the changes shaved off $100 to $150 per knee arthroscopy. These savings resulted from a $50 reduction in anesthetic costs, a near $30 reduction in antiemetics, and from 30 to 45 fewer minutes of total recovery time per case, which includes a 15-minute average reduction in the time to second recovery. "We have moved away from prophylactic antiemetics unless the patient history indicates they are needed," notes Mr. Summerhays, "We don't see the hangover effects that we used to, and it makes intuitive sense to keep the procedure as safe as possible."
Case #2:
The Melbourne Same-Day Surgery Center
When physicians purchased the majority share of the Melbourne, Florida-based Melbourne Same-Day Surgery Center from a local hospital in 1999, medical director and anesthesiologist Jet Webb, MD, decided to take a close look at the center's efficiencies. He and his team of 16 CRNAs and 22 anesthesiologists decided to trial some new anesthesia approaches and scrutinize the PACU protocol. The result, says administrative director Lynne Stoldt, RN, is an improved approach to anesthesia and a more efficient PACU protocol that saves the facility $6 per case in anesthesia costs and an average of nearly 25 patient-care minutes per case, with no reduction in patient satisfaction. With a caseload of 800 per month, this adds up to an anesthesia cost savings of $4,800 and a time savings of approximately 330 patient care hours per month.
The changes implemented at the center include:- A change in volatile agents. Although desflurane can be more difficult to use, according to Dr. Webb, many of the center's practitioners switched from sevoflurane to desflurane for maintenance during routine general anesthesia cases because of its short-acting properties. "Our patients now awaken just three minutes after the flow is turned off," he says. The practitioners still use sevoflurane for pediatric cases, and some also still prefer sevoflurane when using the LMA.
- Use of a BIS monitor. Although Dr. Webb initially trialed the BIS monitor to assure a lack of awareness during surgery, the machine has helped some of the facility's practitioners decrease volatile agent consumption. However, the BIS monitor has been somewhat of a mixed blessing. According to Dr. Webb, the biggest problem has been increased patient movements, and he now uses substantially more IV narcotics than before. Ms. Stoldt also says the benefit of the BIS monitor depends heavily on the skill and experience of the practitioner. "Those who use it consistently and understand it gain a lot of benefit, whereas those who use it occasionally do not," she notes. The facility received the machine free of charge and has developed a system for reducing the cost of the disposable electrodes.
- Use of generic propofol. Although the facility stocks Diprivan for patients who may have a sulfite allergy, the center now commonly uses generic propofol. Generic propofol now typically sells at a 15 percent discount to the branded Diprivan, according to Denis McNicholl with Priority Healthcare Inc., and the generic price can fall as much as 40 percent below that of Diprivan under GPO contracts. Although a clear money-saver, Dr. Webb notes that the generic formulation may perform a little differently. "In my experience, it does not appear to be as potent as the branded product," he says, "and we have also noted some tonoclonic movements and muscle rigidity."
- Increased use of blocks. For major orthopedic cases, the staff now uses local blocks routinely to maintain pain control.
- New PACU protocol. After the joint venture, the center quickly got rid of its rigid policy to always perform four sets of vital sign assessments in 15-minute intervals and keep all patients who received fentanyl for a minimum of one hour before release. Instead, the team adopted a more flexible policy. "We don't think anymore in terms of how long to keep patients," explains Ms. Stoldt. "Instead, we focus on how they're doing."
Thanks to the new anesthesia approaches, she says, patients often arrive in recovery meeting their preoperative PAR scores immediately, including normal oxygen saturation in room air. "The most difficult challenge was getting the nurses to move patients through, and we're still working on this," notes Ms. Stoldt.
Overall, these changes have not altered the Melbourne center's patient satisfaction ratings. Ms. Stoldt and her team conduct follow-up phone calls on the first postoperative day and one month after surgery, and the resultant patient satisfaction rating has remained steady at 93 percent.
Given the variability of anesthesia practices, refining your anesthesia regimen can be a challenging and time-consuming task. Yet, as these two case examples demonstrate, an internal analysis can be an effective and worthwhile way to achieve greater cost-effectiveness and better patient care. "We learned that anesthesia is everything," concludes Ms. Stoldt.
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