s a certified registered nurse anesthetist (CRNA), I provide anesthesia services for plastic and endoscopy procedures in an office-based setting. Office-based practice has unique advantages and efficiencies that are similar to an outpatient surgery center while requiring the same vigilance and standard of care as any other perioperative practice setting. Advantages of officebased practice, when compared to an inpatient or other outpatient setting, include increased patient and provider convenience and satisfaction, scheduling flexibility, staffing consistency, efficiency, patient privacy, increased cost-effectiveness, and decreased risk of infection.1,2 My experience as a member of small clinical teams, providing patient care for both brief and sometimes lengthy procedures, confirms the importance of teamwork, effective communication, and collaboration during all phases of patient care. Office-based team members have multiple responsibilities that they complete collaboratively. These responsibilities include optimizing patient care, improving communication with the patient, and building and promoting a culture of safety. Additional responsibilities that affect the provision of care in the office-based setting include participating in professional advocacy, participating in professional associations and leadership activities,
and contributing to the sustained financial success of the office-based setting. THE OFFICE-BASED TEAM In an office-based environment, the perioperative team is a small cohesive group of clinicians with the common goal of providing safe patient-centered care. To meet this common goal, the team members implement patient selection criteria, work to improve communication with patients, and promote a culture of safety. Optimizing Patient Safety Having established criteria for patient selection and identification of risk factors related to office-based procedures provides the team with guidelines to optimize each patient’s safety and outcomes. Factors used to determine the appropriate care for patients include nurses and other care providers assessing the patient’s health, anesthesia and psychosocial history, complexity of comorbidities, type and duration of procedure, and postoperative care requirements.3 To provide appropriate support for the patient’s care, he or she may be asked to complete a health history questionnaire before admission. Having this information allows the anesthesia professional time to discuss with the team how to optimize the patient’s care before the
The AORN Journal is seeking contributors for the Patient Safety First column. Interested authors can contact Sharon A. McNamara, column coordinator, by sending topic ideas to [email protected] http://dx.doi.org/10.1016/j.aorn.2014.10.005
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PATIENT SAFETY FIRST day of surgery or procedure, begin to formulate an anesthetic plan, and contact the patient to clarify information or alleviate any concerns.4 This type of careful preparation by staff members and patients helps prevent unnecessary cancellations on the day of the procedure.4 Patient-centered care in the officebased setting continues throughout office check-in, preoperative evaluation, procedure, recovery, discharge, and follow-up. Improving Communication Two-way culturally sensitive communication supports shared decision making in treatment and management options.5 An actively engaged patient is better able to partner with facility staff members and can play an important role in his or her care.6 To optimize communication, clinicians at our facility provide patients with advanced information during the preadmission telephone call and provide them with procedure-specific instructional material. Additionally, staff members engage patients during their care through preoperative communication and education that may n n n n n n n
decrease anxiety,7 improve understanding of perioperative processes,7 reduce the need for postoperative pain medication,7 increase self-efficacy,7 assist patients in recognizing and reporting unexpected outcomes after discharge,8 increase patient satisfaction,8 and reduce readmission rates.8
Patient communication continues beyond the preoperative period. Our clinicians continue to inform and educate patients regarding the next steps of their care, what to anticipate during the procedure, information about recovery, and specific instructions on what to expect after discharge. Clinicians discuss possible side effects of the procedure or prescribed postoperative medications. Additionally, we also provide information on management or emergency procedures for complications.
Promoting a Culture of Safety Team cohesiveness, trust, and open communication are key aspects of a culture of safety.9,10 In any procedural setting, each team member must feel safe to stop the procedure and ask the team to discuss and resolve a potential patient safety risk. In my office-based setting, we promote a culture of safety by finding opportunities for shared learning, developing a plan for patient-centered anesthesia care, following practice guidelines and standards, using checklists to improve processes, performing a time out before every procedure, and collecting and reviewing data as a way to continue to improve quality. In a Lean11 office-based practice, each individual plays a major role on the team by contributing his or her professional expertise to advocate for the safety of the patient. Team members find opportunities for this type of shared learning throughout the day, particularly when a patient presents with an unusual health condition (eg, family history of malignant hyperthermia) or we are preparing to do a new procedure. Through our shared learning environment, the nurses alert anesthesia professionals to information that is valuable for developing the patient’s anesthetic plan (eg, patient has a full beard, which may make mask ventilation difficult, or the patient is overweight, which may complicate positioning and oxygenation). In my experience, partnering of anesthesia providers with the perioperative nursing staff has raised our vigilance and awareness for patient-specific considerations, and this partnership supports the CRNA in the delivery of safe anesthesia care. To develop the plan for patient-centered anesthesia care, the anesthesia professional considers the patient’s health status, request for type of anesthesia, and procedure. He or she discusses the risks and benefits of the possible anesthetic choices and answers patient questions to obtain informed consent. The types of anesthesia that may be considered in an office-based surgery setting include topical and local anesthesia, monitored
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anesthesia care, and the administration of regional blocks or general anesthesia, depending on the procedure and plan for postoperative pain management. All health care professionals have practice guidelines and standards. Although office-based practice is not regulated in all states, each facility and clinical team must follow applicable state statutes, regulations, and rules to optimize the patient’s surgical experience.2 The facility must have appropriate personnel, protocols, procedures, equipment, and supplies necessary to provide complete perioperative care.1,12,13 Technology and equipment are integrated into every procedure. For safe and reliable equipment function, staff members should perform preventative maintenance and daily and case-specific safety equipment checks according to manufacturers’ recommendations.1 Additionally, policies for transferring patients to a higher level of care must be readily available.1,12,13 Physiological monitors, medications, supplies for routine and emergent care, and equipment should be available to care for the patient, perform the procedure, and provide emergency care (eg, difficult airway management,14 local anesthetic toxicity,15 malignant hyperthermia crisis,16 surgical fires17). Additionally, telephone numbers for emergency medical services, the Malignant Hyperthermia Hotline, and a nearby hospital should be available and posted.12 Another measure that helps protect patient safety in the office-based setting is the use of checklists. Team-based checklists standardize what, when, how, and by whom interventions are performed and can reduce errors in routine and emergency situations.18 Many processes, such as the preprocedure verification or the transfer of patient care, can be standardized by using a checklist.10 Checklists are designed as stand-alone safety measures, but more typically are part of a broader quality improvement initiative.18 Shapiro et al19 and the Institute for Safety in Office-Based Surgery20,21 have developed a patient safety checklist that is adapted to the needs and concerns of office-based clinicians.
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PATIENT SAFETY FIRST The time out at the start of the procedure is another standardized process for patient safety and serves as a communication and safety check between the anesthesia professional, proceduralist or surgeon, and the nursing team to identify and address possible risks to patient safety before beginning the procedure.22 It is optimal for the time out to occur before anesthesia induction because this allows the patient to participate in the verification process.23 During the time out, team members should suspend all noncritical activities and be actively engaged in the process.23,24 A time out should be conducted as a final assessment and confirmation that the correct procedure is planned and is to be performed at the correct site on the correct patient.23 Our team continuously works to improve patient safety through a review of outcomes to develop education and quality improvement for our practice. Registered nurses and CRNAs work collaboratively to learn from each other and to improve the delivery of patient care. We integrate concepts of team-based learning into our professional development through in-house training and quarterly mock emergency drills and simulation practice (eg, how to handle airway emergencies) that foster competencies such as interpersonal communication and teamwork while providing constructive feedback and refining clinical knowledge and skills.25 This is a part of a continuous quality improvement process to maintain a highly competent and welltrained staff. We also collect data about procedure cancellations on the day of surgery, postoperative nausea and vomiting, prolonged postprocedure stays, transfers to the emergency department, and admissions to the hospital, and we review these data for our quality improvement processes. ADVOCACY Professional advocacy is an important aspect of working in any practice setting. Education and development of valued relationships with legislators, regulators, and payers are key steps in
PATIENT SAFETY FIRST advocating for health care quality, patient access to care, and reduction of the cost of care.4 Locally, we invite legislators to come visit our facility to experience firsthand the high-quality care we provide each day. The importance of networking to develop strong relationships should not be underestimated. Collaborative relationships between professionals, such as clinicians, legislators, regulators, payers, and other health care organizations, support initiatives that improve care delivery through the development of meaningful health care policy, practice guidelines, and standards.26 PROFESSIONALISM Our team continuously seeks information regarding new advancements in patient care, techniques, and technologies. To accomplish this, our facility leaders support and encourage staff members to participate in professional development through membership and leadership in state and national professional associations. Professional associations serve as educational and networking resources on the latest trends in patient care. They develop practice-related education, guidelines, and resources; link clinicians to others in the field; and provide avenues for advocacy for the profession. It is important for office-based professionals to remain engaged with their professional organizations so they can be informed of the most recent standards, guidelines, and evidence-based techniques for practice. The American Association of Nurse Anesthetists (AANA) is the professional organization for nearly 47,000 CRNAs. The AANA’s web site, http:// www.aana.com, contains numerous practice-related resources. In particular, the AANA publishes Standards for Office Based Anesthesia Practice12 and other resources dealing with clinical topics such as practice considerations for regional anesthesia administration, critical incident stress management, latex allergy management, and infection control. Additionally, a broad range of patient educational resources, including brochures, fact
sheets, and a children’s coloring and activity book, can be downloaded at http://www.aana.com/ forpatients. THE BUSINESS OF OFFICE-BASED PRACTICE In addition to focusing on teamwork and the patient experience, promoting professionalism, and advocacy, sustaining the business side of an office-based practice is important to build a contemporary robust practice. Business and administrative staff members at our facility manage the fiscal health of the organization through ongoing periodic and annual budget analyses to forecast revenue and expenses. Vendor partnerships are core to maintaining a facility’s financial health through contracts for supplies, equipment, and medications. Practice managers monitor their periodic automatic replenishment level supplies and maintain the amount of supplies in stock that will meet the demands of upcoming procedures and minimize waste. Monitoring procedure volumes for appropriate staffing models also helps control costs. CONCLUSION Because of the smaller setting and staff size, the interprofessional team structure and workflow in an office-based setting are more closely linked than those in a larger facility. All team members are crucial contributors to the patient’s well-being and safety. The relationships and trust built between the perioperative nurses, CRNAs, other staff members, and surgeons are the foundation of a high-performing, cohesive, and effective team.9 Facility leaders promote a culture of safety through transparent communication, trust, and continued learning among all team members and patients. Vendor, stakeholder, legislator, and professional peer relationships are each valued in a successful office-based practice. Patientcentered teamwork fosters a positive environment, as well as collaborative trusting relationships between coworkers, to deliver high-quality, safe, and patientcentered care.
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References 1. Bogan V. Anesthesia and safety considerations for officebased cosmetic surgery practice. AANA J. 2012;80(4): 299-305. 2. Urman RD, Punwani N, Shapiro FE. Patient safety and office-based anesthesia. Curr Opin Anaesthesiol. 2012; 25(6):648-653. 3. Marley RA. Outpatient anesthesia. In: Nagelhout JJ, Plaus KL, eds. Nurse Anesthesia. 4th ed. St Louis, MO: Saunders Elsevier; 2010:892-920. 4. Ahmad S. Office baseddis my anesthetic care any different? Assessment and management. Anesthesiol Clin. 2010;28(2):369-384. 5. Coulter A. Patient engagementdwhat works? J Ambul Care Manage. 2012;35(2):80-89. 6. Schwappach DL. Review: engaging patients as vigilant partners in safety: a systematic review. Med Care Res Rev. 2010;67(2):119-148. 7. Johansson K, Nuutila L, Virtanen H, Katajisto J, Salanter€a S. Preoperative education for orthopaedic patients: systematic review. J Adv Nurs. 2005;50(2): 212-223. 8. Younis J, Salerno G, Chaudhary A, et al. Reduction in hospital reattendance due to improved preoperative patient education following hemorrhoidectomy. J Healthc Qual. 2013;35(6):24-29. 9. Mitchell EN. Improving communication and building trust. AORN J. 2013;98(3):218-219. 10. Patient-Centered Perianesthesia Communication, Practice Considerations. Park Ridge, IL: American Association of Nurse Anesthetists; 2014. 11. Toussaint JS, Berry LL. The promise of Lean in health care. Mayo Clin Proc. 2013;88(1):74-82. 12. Standards for Office Based Anesthesia Practice. Park Ridge, IL: American Association of Nurse Anesthetists; 2013. 13. Kurrek MM, Twersky RS. Office-based anesthesia: how to start an office-based practice. Anesthesiol Clin. 2010; 28(2):353-367. 14. Apfelbaum JL, Hagberg CA, Caplan RA, et al; American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118(2):251-270. 15. Neal JM, Bernards CM, Butterworth JF IV, et al. ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med. 2010;35(2):152-161. 16. Malignant Hyperthermia Association of the United States (MHAUS). How to be prepared, 2014. http://www.mhaus .org/healthcare-professionals/be-prepared. Accessed September 24, 2014.
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PATIENT SAFETY FIRST 17. US Food and Drug Adminstration. Recommendations for healthcare professionals on preventing surgical fires. Published 2011. http://www.fda.gov/Drugs/DrugSafety/ SafeUseInitiative/PreventingSurgicalFires/ucm270636.htm. Accessed September 24, 2014. 18. Winters BD, Gurses AP, Lehmann H, Sexton JB, Rampersad CJ, Pronovost PJ. Clinical review: checklistsdtranslating evidence into practice. Crit Care. 2009; 13(6):210. 19. Shapiro FE, Punwani N, Urman RD. Checklist implementation for office-based surgery: a team effort. AORN J. 2013;98(3):305-309. 20. Safety Checklist for Office-Based Procedures. The Institute for Safety in Office-Based Surgery (ISOBS). http://isobsurgery.org/wp-content/uploads/2012/03/safety -checklist.jpg. Accessed October 10, 2014. 21. Shapiro FE, Punwani N, Urman RD. Putting the patient into patient safety checklists [Patient Safety First]. AORN J. 2013;98(4):413-418. 22. Michaels RK, Makary MA, Dahab Y, et al. Achieving the National Quality Forum’s “never events”: prevention of wrong site, wrong procedure, and wrong patient operations. Ann Surg. 2007;245(4):526-532. 23. National patient safety goals effective January 1, 2014. Office-Based Surgery Accreditation Program. The Joint Commission. http://www.jointcommission.org/assets/1/6/ OBS_NPSG_Chapter_2014.pdf. Accessed September 24, 2014. 24. Pennsylvania Patient Safety Authority. Time-out! Wrongsite surgery update. Pa Patient Saf Adv. 2011;8(2):80-84. http://patientsafetyauthority.org/ADVISORIES/Advisory Library/2011/jun8(2)/Pages/80.aspx. Accessed September 24, 2014. 25. Parmelee DX, Hudes P. Team-based learning: a relevant strategy in health professionals’ education. Med Teach. 2012;34(5):411-413. 26. Strech S, Wyatt DA. Partnering to lead change: nurses’ role in the redesign of health care. AORN J. 2013;98(3): 260-266.
Sharon Pearce, MSN, CRNA, is a certified registered nurse anesthetist with Carolina Anesthesia and Associates, Hickory, NC, and is President of the American Association of Nurse Anesthetists, Park Ridge, IL. Ms Pearce has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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