This article is written by Ann O'Neill, director of clinical operations at Regent Surgical Health. This article was originally printed in the Regent Surgical Health newsletter and has been republished here with permission.
Do any of the following scenarios sound familiar? A case is cancelled at the last minute because a patient just announced he was dropped off at the ASC by a friend and has no one at home to support his recovery. Or better yet, the patient drove himself to the center and had planned to drive himself home. How about a same-day case cancellation occurring because the admitting nurse and anesthesia provider first learned when the patient came to the facility that the patient has a BMI of 48 and the ASC does not have beds or lift equipment to accommodate a patient of that size? Same-day surgery cancellations, delays in scheduled surgeries, patient complications and surgeon and patient dissatisfaction are costly by-products of improper pre-operative patient assessments. Timely, accurate patient screening and appropriate referral of at-risk patients will decrease your ASC’s number of cancelled or postponed surgeries and improve physician and patient perception of your facility.
PPAs are essential to providing safe patient care. When looking to improve the PPA process, you must start with understanding the PPA goal and continuum.
The Goal: Patient safety through identification and addressing risks related to anesthesia and surgery as soon as possible before a procedure.
The Process:
• The surgeon’s office calls to schedule a procedure.
• After the surgery is verified by the business office, an RN will make a phone call to the patient or patient’s representative to start the PPA process through an interview, while documenting all the pertinent data on the PPA form. Ideally, the surgeon has pre-ordered any needed tests.
• The case is referred to an anesthesia provider for further evaluation if the patient exhibits risk factors (according to facility protocol).
• The patient is given instructions on how to prepare for and what to expect the day of his procedure.
• On the day of the procedure, the admitting nurse verifies the data that has been collected with the patient and fills in any gaps.
• The anesthesia provider interviews the patient to finalize any decision about anesthesia risk.
• The surgeon assesses the patient to update the history and physical and finalize any decision about surgical risk.
Barriers to effective PPA must be addressed. Multiple factors can play into poor PPA. Examples include: last minute scheduling, staff availability, staff competency to perform assessment, lack of appropriate facilities to use for screening, inadequate assessment/screening tools and patient communication issues. Evaluate the current processes that are in place, identify system breakdowns, and address each one.
Some high level tips for managing the logistics of the PPA process:
• Maintain a close relationship with the surgeon’s office – the patient is a shared responsibility and the surgeon’s office can facilitate gathering the right patient data in a timely manner.
• Designate a private area for interviewing the patient either by phone or in-person.
• Be proactive versus reactive – perform the patient calls ASAP after the case is scheduled; don’t wait until the night before the scheduled procedure.
• Staff to cover the PPA – don’t flex off your last RN on low census days if PPAs are not up to date. Yes, this adds to the cost per case, but it saves on the cost of delayed or cancelled cases.
• Use seasoned RNs to perform your patient interview (whether by phone or in person) — ideally nurses who are strong critical thinkers, have proven head-to-toe patient assessment skills, excellent communication skills and who can adapt well to the communication abilities of the patient.
• Limit the number of nurses who perform the PPA to preserve continuity of the process.
• Create a PPA protocol and script the patient interview process to protect continuity and accuracy from one nurse to the next.
• Modify your PPA form to be a checklist rather than narrative documentation.
• Use a documented, medical executive committee approved, evidenced-based protocol for referring at-risk patients to an anesthesia provider for further evaluation.
• Use evidenced-based parameters to establish a MEC approved protocol for surgeons to use when ordering pre- operative lab or other tests.
• Monitor PPA interviews to look for opportunities to be more efficient.
• Communicate early and often between staff, surgeon and anesthesia provider so that patient needs can be addressed as soon as possible, before the day of the procedure.
AORN suggests that the content of the PPA include:
• A baseline physical assessment
• Allergies and sensitivities
• Signs of abuse or neglect
• Cultural, emotional and socioeconomic assessment
• Pain assessment
• Medication history, including nonprescription medications, illicit drugs, herbal medications and supplements
• Anesthetic history
• Results of radiological examinations and other preoperative testing
• Discharge planning
• Referrals
• Identification of physical alterations that require additional equipment or supplies
• Preoperative teaching, including which medications are to be taken or withheld before surgery, preoperative shower and NPO requirements
• Informed consent and/or knowledge of the procedure
• Development of a care plan
• Documentation and communication of all information per facility policy
Additionally, ASCs should screen for:
• Obstructive Sleep Apnea
• BMI - anesthesia risk and/or facility equipment concerns for safely holding and moving patients
The PPA process and supporting systems are important to the safety and quality of patient care. The success of any changes in the PPA process can be easily measured quantitatively in your cancellation, delay, and patient complication rates and qualitatively in your physician and patient satisfaction scores. Make the changes needed to achieve timely, accurate PPAs and appropriate referrals of at-risk patients to improve the quality of the ASC services.
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