Milton Anesthesia Updates

Staff meeting

March 6th, 2018

Agenda Updates

1. Staffing

2. Volume statistics: 1. Updates on Surgical Services 2. Orthopedics Steering

Committee3. Endoscopy 4. Weekends

3. Pharmacy

4. Techs and Equipment update

5. Intubations after hours

6. Hip fractures

7. Joint commission 1. Charts / Rooms /Drugs

8. Intranet 1. More info

Discussion

• Late shifts ?

• Number of MDs/ CRNAs day

• Electronic record in the ORs ?

3/22/2018 2

Staffing: MDs

Barnett, Sheila

Koropey, Andy

Ma, Haobo

Ngo, Anh (til July 1)

Mollov, Josh (til June )

Levy, Lior

Zimmer, Scott

Akhouri, Vimal

Jankun, Jeff

New – from BIDMC

• Andrey Rakalin (March 2018)

• Tori Dervianko ( July 2018)

• Interviewing others

3/22/2018 3

Staffing: CRNAs

• Greg Sheedy to start week of March 5th : 40 hours

• We are still hiring …• Referral /Retention

bonus

• Per diem candidates welcome

3/22/2018 4

Staffing• OR Staffing

• 3 BIDMC MDs / 8-9 CRNAs per day

• ICU coverage from BIDMC increasing :• 4 weeks per year

• Neves, Bose, Krajewski and possible Pannu.

• Pain coverage • 5 days coverage : Yazdi/ Rana and new Pain NP

• Pain /Spine Program in development

• Handling consults – difficult to track volume / numbers of consults

3/22/2018 5

OR / Volume Updates

• OR #7 : April / May 2018 – will lead to dedicated robotic room • And ? more rooms 3-5 pm – likely 4 until 5pm ultimately

• Endoscopy• Moving to 3 rooms daily .. Possibly 4 and some

Bronchoscopy ( see later )

• New inpatient wing being built• 12 single rooms in mid 2018 (will need DPH approval)

• Several new surgeons being joining

• No more pacemakers / no thoracic • Battery changes okay and loops

3/22/2018 6

FY18 YTD Volume

Excludes minor procedures

Oct Nov Dec Jan FY18 Total

Inpatient 159 141 125 161 586

Budget 140 140 149 145 574

Prior Year 159 125 124 149 557

BTA 19 1 -24 16 12

BTA % 14% 1% -16% 11% 2%

Outpatient 236 207 200 238 881

Budget 267 240 243 266 1016

Prior Year 236 218 228 224 906

BTA -31 -33 -43 -28 -135

BTA % -12% -14% -18% -11% -13%

Inp & OP 395 348 325 399 1467

Budget 407 380 392 411 1590

Prior Year 395 343 352 373 1463

BTA -12 -32 -67 -12 -123

BTA % -3% -8% -17% -3% -8%

Inpatient

Outpatient*

Total

3/22/2018 7

T arget Dec-2017 Jan-2018

Primetime OR Utilization (%) 75% 62% 73%

Cysto Room Utilization (%) 50% 50% 28%

7:30 On Time Starts (Wheels In) (%) 75% 84% 74%

9:00 Late Case On Time Start (Wheels In) (%) 75% 67% 100%

Average Turnaround Time < 28 mins 31 32

Cancellation within 2 days of scheduled surgical case (%)5 <2% 2% 2%

Cancellation within 2 days of scheduled minor proc (%)5 <2% 2% 2%

Add-on Cases (%) <=5% 5% 7%

Block Utilization (%) 85% 75% 75%

SURGICAL SERVICES

BID Hospital Milton Throughput Monthly Metrics

3/22/2018 8

Orthopedic Steering Committee

3/22/2018 9

3/22/2018 10

Robotic Program Volume99 through February 7 (64 prostatectomies, 35 hysterectomies)

3/22/2018 11

4-5 new surgeons for

April • Baretz

• Orthopedic joint replacement• 30%-40% revisions

• Dewire• Given block time - ? Increase volume

pending

• Adra• Director of Bariatric Surgery• Robotic Bariatric Surgery

• Gupta• General Surgery, Bariatric & Colorectal

• Ferrante• General & vascular Surgery

3/22/2018 12

Endoscopy • Updates

• Dr Ukleah ( sp) started & is ramping up – 2-3 days / week procedures

• 3 Endo rooms daily with Dr U • Volume 8-10 per room – approx 25- 30 per day is increasingly

common • Unlikely to get to 4 rooms in near future … but maybe in fall.• 4 rooms will require assessment of flow in unit

• WE ARE GETTING PAID AGAIN ! – change in HPHC policy > ASA 2

• Key points • No general endotracheal anesthesia in Endo – must go to ORs• GI on call coverage is a concern for hospital – possibly will see

more off hours GI consults once this is addressed

3/22/2018 13

Endo – Bronchs

• Bronchoscopy (Dr Czieck) • Likely to increase – but no clear volume strategy yet

(and yes we get paid)

• Need guidelines – volunteers ? (Midaz/ Prop / Fentanyl may be needed or ketamine )

• Minimum do not start without Anesthesia MD aware and present (or immediately available )

3/22/2018 14

WEEKENDs – for MDs • Did overtime analysis

• Called in almost 75% of each Sat and Sun • Average hours 5-6 per day

• East called in 85% for approx. 8 hours …

• But East single day counts for a whole weekend vs Milton is 3 days

• So in short term 1 Milton weekend = 1.5 weekend / quarter (so third weekend carries extra points)

• In September – when new surgeons on board, new ORs etcand new staff will re-evaluate – split weekends or more points …

3/22/2018 15

Pharmacy monthly audits

• Improved reconciliation on no charges • $386 in Jan – down from close to $1000 in past … but

back up in Feb to > $800

• Most common miscounts• Phenylephrine, Propofol, Ondansetron, TXA

• Sodium chloride –asked pharm to reduce # vials … it’s nursing

• Naloxone: • are we using that often ? What is handoff for PACU?

Monitoring / discharge?

3/22/2018 16

Techs and Equipment Update

1. Anesthesia Tech Coverage 6:30 to 5:30pm -Welcome Warren!

2. Carts Ordered for the ORs / Pending date

3. Ultrasound - Need replacement soon – working on capital budget requests ?

4. Other equipment requests ?

3/22/2018 17

Intubations after hours • Worked with the ED and ICU an Hospitalists

• New Policy pending approval

• After 5 pm - Anesthesia is essentially 2nd or 3rd back up • ED (first =in house emergencies )• Intensivist (second at home for impending failure ) • Anesthesia (3rd at home – unless difficult airway called

sooner )

• It is known we are 30-40 minutes out of the hospital.

Will circulate policy …

3/22/2018 18

Hip Fracture ‘Pathway’

• Also pending

• Aim is to get patients to OR in under 48 hours

• Working on automatic notification for Anesthesia to help guide preop so no surprises when OR and surgeon are available …

• Spinal preferred anesthesia ( see this months A&A articles !) We are doing very well.

• Metrics pending

3/22/2018 19

PAT • Erica is back at 0.5 FTE

• Natalie going to move on but 1.0 FTE approved –looking for candidates …

• Need to even out the days to include Friday !

• Anticipate increasing volume as most new surgeons will need PAT for their patients ( Joints, bariatrics etc )

• Rogue CXR preop orders coming through – working to eliminate …

• Very low – almost zero – day of surgery cancelations ..

• PAT great service – especially with 6-7 rooms to start and preop .. .

3/22/2018 20

Joint Commission – Charts and ORs FILL IN EVERYTHING! Diagnosis, ASA, Type of anesthesia, Airway

Preop Vital signs, prior to induction note

3/22/2018 21

Joint Commission and Medications • Lock Pyxis

• Do not leave medications / drugs around

• Narcotic Discrepancy reports by pharmacy • Entered into patient safety reporting system

• Provider notified must reconcile and return to HCQ within 7 days

• Repeat offenders will be questioned

3/22/2018 22

On the Intranet – basic info available about Milton -

3/22/2018 23

Staffing – for discussion OR Nursing

• Nursing currently staffs 2 rooms 3 to 5:30pm, one room until 7:30pm and then call team one room ‘all night’

• Moving to 3-4 rooms from 3 to 5:30 in next 2-4 months

OR Staffing • 3 BIDMC MDs / 8-9 CRNAs per day • If volume continues consider 4 / 10 -11 CRNAs

Anesthesia MDs

Must be ready to relieve 3pm CRNAs in Endo at 3pm if not enough 10 hours for ORs

At 5pm the second MD must be ready to relieve the CRNA if 2 rooms – please do NOT assume the 10 hour CRNAs can stay after 5pm ….

3/22/2018 24

Staffing (cont …) CRNAs

Need minimum of 4 x10 CRNAs hours each day to cover (maybe 5 if Endo going past 3p often)

Consider other creative schedules – 11 hours / 9 hours ?

Other late calls ? Like to 4pm ?

All MDS and CRNAs are expected to work the full day – i.e. until 3pm or 5pm (MDs) – early relief should be viewed as a perk not an expectation….

Exception is the Endo Anesthesia MD who is the equivalent of a ‘first out ‘ downtown … so should be the MD relieved first ( or negotiate with upstairs MDs ) …but again please do not assume you will be out very early …

SUGGESTIONS ? FLEXIBILITY IS KEY – BOTH WAYS

3/22/2018 25

Out and about …

• Welcome to Greg Sheedy our newest Milton CRNA !

• Good luck to our ‘Biggest Losers” and our shrinking department …

• Milton Gala on May 12th - mark your calendars !

• Need to schedule anesthesia lunch – postponed after the food poisoning episode!

• As always THANK YOU ALL !

3/22/2018 26

3/22/2018 27