Less anesthesia, careful scheduling boost efficiency
Study offers insights from best performers
In 1996, myringotomy with tympanostomy tube insertion was the most frequently performed procedure on children younger than the age of 15. More than 95% or 490,000 of the 512,000 myringotomies performed that year were performed in an ambulatory surgery setting.1
Twenty-two organizations, with more than 7,500 myringotomies performed during the study period, participated in the study of clinical practices related to myringotomy by the Accreditation Association for Ambulatory Health Care’s Institute for Quality Improvement. Annual volume for outpatient programs participating in the study ranged from 40 to 1,645 myringotomies per year. Results show that while a higher case volume is related in a slight decrease in operating room time needed for the procedure, overall facility time is not affected by case volume.
A good example is Midwest Surgery Centers in Terre Haute, IN. While the facility performs fewer than than 200 myringotomies per year, the center posted the lowest overall facility time of 77 minutes for the time the patient checks in to the facility to when the patient is ready for discharge. Overall facility times for study participants ranged from 77 minutes to 192 minutes, with a median facility time of 109 minutes. (For a list of benchmark results for all categories, see box.)
One of the reasons for Midwest’s short facility time is a quick discharge time of nine minutes, also the lowest time in the discharge category. "We are able to discharge our patients quickly because we use as little sedation as possible," explains Joanne L. Floyd, MD, anesthesiologist and medical director for the surgery center. "We also don’t use any pre-op sedation for children," she adds.
By keeping the children relaxed and making the trip to the operating room fun, the elimination of pre-op sedation greatly speeds the recovery, Floyd points out. "They watch movies in the pre-op area, hold their favorite stuffed animal that they’ve brought from home, and ride to the operating room in a wagon," she says. "If the child doesn’t want to ride in our wagon, the nurse may offer to race the child to the OR, anything to reduce anxiety," she adds. They also allow a parent to accompany the child to the operating room to hold his or her hand until the child is asleep, she says.
Century Surgical Associates in Pittsburg, KS, reported the shortest pre-procedure time, which is defined as the time the patient arrives to the time the patient is in the operating room.
"Our pre-procedure time averaged 36 minutes because we handle all pre-op questions on the telephone three to five days prior to the procedure," explains Paula Gilmore, RN, BSN, director of nursing for the center. "When the patient arrives, we only have to perform the physical assessment and verify some information we obtained in the pre-op call," she says. A thorough pre-op telephone call is especially important in her center because the ENT on her staff operates clinics as far away as 75 miles, so it is impossible for families to come to the surgery center for a pre-op visit, she adds.
Parents are told to arrive 30 minutes prior to the procedure, so there is little time spent in the waiting room, points out Gilmore. "We are fortunate with our scheduling because we have the entire day scheduled for one ENT surgeon," she says. "We do schedule the myringotomies early in the day because the procedures are quick, and because children who have been NPO since midnight will need to be fed as soon as possible." To reduce nausea, they do encourage parents to keep their children NPO for five to six hours, but patients who are bottle-fed are required to be NPO for only four hours, and breast-fed infants are NPO for two hours, she says. The early scheduling of myringotomies also ensures that these procedures are not delayed by more complex, longer ENT procedures, she adds.
Gilmore’s facility also reported the third shortest overall facility time in the study. "One of the ways we keep things moving smoothly is that a different nurse from each area is responsible for greeting and moving the patient from area to area," she says. Rather than tie up one nurse with one patient, using different nurses to escort patients to each area as soon as they are ready keeps everything moving efficiently, she adds.
While outpatient program managers usually don’t want to see that their facility performed poorly in a benchmark study, Fleet McClamrock, MBA, administrator of Palmetto Surgery Center in Columbia, SC, was happy to see that his facility reported the second highest length of time in the pre-procedure time.
"We already knew that our patients were waiting too long because they were arriving too far in advance of their procedures, and surgeons were switching the order of cases on the day of surgery, which resulted in even longer waits for some patients," McClamrock says. "Although we have known that this was a weakness, the ability to point to our results in comparison to other outpatient surgery programs at quality assurance meetings and medical executive committee meetings helped us convince many of our surgeons that we needed to change our scheduling process."
Prior to the benchmark study, the surgeons’ office staffs would schedule patients within the surgeon’s block of time, tell patients to arrive one hour before surgery, then send the schedule to the surgery center. "We always try to schedule the youngest patients first, but sometimes the office staff would add an infant later in the schedule," McClamrock explains. "This would mean that the surgeon would take the infant as soon as the family arrived prior to other patients who had been waiting."
To reduce the amount of time families spend in the waiting room, McClamrock’s staff have taken over the scheduling responsibility for some of the surgeons and the other surgeons have agreed to ask patients to arrive only 30 minutes prior to the procedure. "We’ve also worked with the office staffs to make sure they schedule the youngest patients first, so there is no shuffling of the schedule on the day of surgery," he adds.
Although they still are working with office staffs to change scheduling procedures, efforts are paying off, McClamrock says. "We’ve already seen our wait times cut in half, and we’re hearing fewer complaints from parents on the day of surgery," he reports.
Reference
- Owings MF, Kozak LJ. Ambulatory and inpatient procedures in the United States, 1996. Vital Health Stat 1998; 13:139.
Sources/Resource
For more information about the Institute for Quality Improvement’s Myringotomy with Tympanostomy Tube Insertion Study, contact:
- Joanne L. Floyd, MD, Medical Director, Midwest Surgery Centers, 650 Surgery Center Drive, Terre Haute, IN 47802. Telephone: (812) 232-8325. Fax: (812) 232-1519. E-mail: [email protected].
- Paula Gilmore, RN, BSN, Director of Nursing, Century Surgical Associates, 100 N. Pine Road, Pittsburg, KS 66762. Telephone: (620) 231-9072. Fax: (620) 231-1199. E-mail: [email protected].
- Fleet McClamrock, MBA, Administrator, Palmetto Surgery Center, 109 Blarney Drive, Columbia, SC 29223. Telephone: (803) 865-8200. Fax: (803) 419-7910. E-mail: [email protected].
To order a copy of this study, contact the Accreditation Association for Ambulatory Health Care’s Institute for Quality Improvement by phone at (847) 853-6060 or fax at (847) 853-9028. Copies of the study can also be purchased by going to www.aaahc.org, choosing "education programs and products," then choosing "products." The cost of the study for organizations that did not participate is $85.
In 1996, myringotomy with tympanostomy tube insertion was the most frequently performed procedure on children younger than the age of 15. More than 95% or 490,000 of the 512,000 myringotomies performed that year were performed in an ambulatory surgery setting.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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