Surgeon being 2 roomed?

[neuroride]

We have days where a surgeon, maybe ortho and possibly a general surgeon that have 2 ORs booked to flip back and forth. Some days we have 2 CRNA's for them, usually just one. Does anyone else have this going on at their institution?

We are running into surgeons and administrators complaining about not having enough OR's running each day when one surgeon may have 2 OR's for themselves. Seems like the thing to do would be to only have 1 OR per surgeon and have another one OR open for add-ons/more cases.

Welcome any thoughts or how people run themselves

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[urge]

I would give 2 rooms to a surgeon that brings consistent business. The surgeons with sporadic cases can wait.

 

[Twiggidy]

I would give 2 rooms to a surgeon that brings consistent business. The surgeons with sporadic cases can wait.

That's the only answer needed. Money talks

 

[Planktonmd]

This is a very common situation and as my friend Urge said you need to make sure that the money makers get what they want whatever it is!

 

[norwood]

We have days where a surgeon, maybe ortho and possibly a general surgeon that have 2 ORs booked to flip back and forth. Some days we have 2 CRNA's for them, usually just one. Does anyone else have this going on at their institution?

Yep, works well to let the circulator and scrub turn over the room without delaying the surgeon.

 

[Noyac]

We do it on occasion. We require a certain number of cases, ie: 5or > total joints for the ortho dude. He must leave the previous case while the PA closes and he goes to the next room for positioning. Or he needs 2 PA's. The surgeon can not be allowed to wander in on their own time. If they do, then they get one anesthesia person. We also do this when the room is available for bigger spine cases since the setup can take up to 45 min.

All in all, this can be beneficial for all involved when done correctly. When done poorly it is a nightmare. The ideal case is under 2hrs with significant setup time. Total joints for example. I don't see how a gen surg can really fit this situation. Unless maybe they have a first assist or PA but still not seeing it.

We also do this with our hand surgeon at the ASC since we do many blocks on cases that are usually less than an hour. Works well in this situation. We can get 10-15 cases done in a reasonable amount of time. ENT could fit this

Another down side to all of this is the surgeon to surgeon resentment. I have seen this get out of hand. It can be absurd.

 

[chocomorsel]

We do this all the time. I work mostly with neurosurgeons doing spine work. While the PA closes the last case, he starts the next in the other room. Works great on those days cuz we get a break in between for a few minutes. Usually 30min or less. The crappy part is when he gets two rooms and just one anesthesiologist. That blows. No downtime whatsoever. Very long, tiring day. It does speed things up as there's no turnover time to clean the room. Just waiting on me.

 

[ambiturner]

We do this for pedi ENT (tonsils and ear tubes) and quick gen surg cases (hernias, choles). Patients usually healthy so the pre-ops are quick and anesthesia is straightforward. Usually done with the fast surgeons who have 10-15 cases between the two rooms that day and tend to have very predictable operating times. Always have CRNA/resident in each room with one covering attending.

 

[aneftp]

We do it on occasion. We require a certain number of cases, ie: 5or > total joints for the ortho dude. He must leave the previous case while the PA closes and he goes to the next room for positioning. Or he needs 2 PA's. The surgeon can not be allowed to wander in on their own time. If they do, then they get one anesthesia person. We also do this when the room is available for bigger spine cases since the setup can take up to 45 min.

All in all, this can be beneficial for all involved when done correctly. When done poorly it is a nightmare. The ideal case is under 2hrs with significant setup time. Total joints for example. I don't see how a gen surg can really fit this situation. Unless maybe they have a first assist or PA but still not seeing it.

We also do this with our hand surgeon at the ASC since we do many blocks on cases that are usually less than an hour. Works well in this situation. We can get 10-15 cases done in a reasonable amount of time. ENT could fit this

Another down side to all of this is the surgeon to surgeon resentment. I have seen this get out of hand. It can be absurd.

This is exactly what we do. Surgeon must have more than 4 cases and help close with PA or other assistant.

Same with letting spine doc has another room even with less than 4 cases. Again it's because of the setup and flip and stuff with spine cases.

However there are some days no flip room is available. Even when anesthesia is available. Because some surgeons don't want smaller room. Or 3 cardiac rooms all used up (well there must always need to be available cardiac room free). But a lot of days 2 cardiac rooms are being used so free room isn't really free to use

 

[IlDestriero]

We do this for pedi ENT (tonsils and ear tubes) and quick gen surg cases (hernias, choles). Patients usually healthy so the pre-ops are quick and anesthesia is straightforward. Usually done with the fast surgeons who have 10-15 cases between the two rooms that day and tend to have very predictable operating times. Always have CRNA/resident in each room with one covering attending.

My peak was 32 healthy ENT cases in 2 rooms with 2 anesthesiologists and 1 surgeon, many BMTs. Done by 3.
Those days are gone as EPIC slows everyone down. Now it's maybe 25 at best.

 

[mostwanted]

We usually have a jump room for one of our fast heart surgeons, not unusual to be on the 4th case by 2-3pm. An attending supervises both with fellows/residents.

 

[urge]

My peak was 32 healthy ENT cases in 2 rooms with 2 anesthesiologists and 1 surgeon, many BMTs. Done by 3.
Those days are gone as EPIC slows everyone down. Now it's maybe 25 at best.

Did they clean the instruments between cases?

 

[Mman]

Did they clean the instruments between cases?

Why? At our outpatient facility we do 4 BMTs per hour including turnover time in a single room. If that's all you did, we could do 32 in 1 room and be done by 3.

 

[Noyac]

Pedi ENT is the bomb, not to mention it is also a cash cow.

 

[leaverus]

heck i know a place where an ortho surgeon gets 3 rooms. he brings the money so they accommodate.

 

[IlDestriero]

The non research Peds ENT work horses make almost $1m.

 

[sleepallday]

We do it pretty often too for our large volume surgeons. Usually an anesthesiologists for each room. Or sometimes just one- this can be a fast paced day especially when i have blocks to do for both rooms. But i honestly prefer it this way, then having to wait in between each case for the surgeon. (not to mention its also a great productivity day)

The key to make this work, especially if I'm the only anesthesiologist between two rooms, is to have good techs that have my room set up for me. And nurses that have the patient ready for the block, with drugs and equipment out, patient on the monitor, and consent ready.

 

[IlDestriero]

Many of our surgeons get 2 rooms, or flip cases into the add on room or a room that ends early. It's a common practice. Some surgeons, for several reasons, never get 2 rooms. We always staff them with 2 different anesthesiologists or extenders.

 

[pgg]

Place I used to work, the orthopods would get 2 rooms for their total joint days. They'd bring 2 surgical PAs and they'd flip between rooms doing the major bits of carpentry, while the PAs opened and closed. Talk about a cash cow choking on cash and drowning in cash, with cash smothered on top ... the hospital and anesthesia group bent over backwards to keep a drill and hammer in the surgeon's hand.

 

[Mman]

The non research Peds ENT work horses make almost $1m.

almost? They should make more than that if they are busy and have an even moderate payor mix. I think ours take home about $1.5M and that's with less than 50% insured.

 

[Ezekiel2517]

Only for the heavy hitters. And you can just tell how much they love it when they see they got 2 rooms with 2 separate teams. They'll be walking around like they own the joint. Subtly bragging about it to the lowly 1-roomed folk. But it sets a dangerous precedent b/c they'll expect it every time. If they don't get it next time they operate, they'll throw a hissy fit and complain nonstop.

 

[IlDestriero]

Only for the heavy hitters. And you can just tell how much they love it when they see they got 2 rooms with 2 separate teams. They'll be walking around like they own the joint. Subtly bragging about it to the lowly 1-roomed folk. But it sets a dangerous precedent b/c they'll expect it every time. If they don't get it next time they operate, they'll throw a hissy fit and complain nonstop.

This sounds familiar...
I like it when I run the board, as I just don't listen to them. Others take it personally, "try to work something out" and move cases, etc. I say sorry and leave the OR office. They can whine to the nurses and admin support people. And God forbid I actually do work something out for them and they can't do it because their lying ass is stuck in another room. I'm like an elephant, I'll never forget, or forgive. There are a couple of dudes that need to have real emergencies for me to start early, open a second room, etc.

 

[urge]

Only for the heavy hitters. And you can just tell how much they love it when they see they got 2 rooms with 2 separate teams. They'll be walking around like they own the joint. Subtly bragging about it to the lowly 1-roomed folk. But it sets a dangerous precedent b/c they'll expect it every time. If they don't get it next time they operate, they'll throw a hissy fit and complain nonstop.

That's not the way to do it.

You review their past volume and assign them 2 rooms ahead of time, block time, so they can schedule even more cases those days. If they don't deliver then you drop them back to 1 room, letting them know they are not worth it. They might prefer having 2 rooms 2 days a week than 1 room 4 days a week.

 

[neuroride]

Thanks all, I understand the ortho flip rooms but we end up giving 2 rooms to a general surgeon that has to take 1.5 hrs for a GB, not kidding.

On another topic, who at there has an anes doc run OR? We have a group of 3 OR nurse supervisors and secretary that run things. By days end, I want to usually pull my hair out.

 

[pgg]

Thanks all, I understand the ortho flip rooms but we end up giving 2 rooms to a general surgeon that has to take 1.5 hrs for a GB, not kidding.

That doesn't make any sense. But he probably truly believes he takes 20 minutes to do the surgery and the other hour+ is anesthesia time and prep.

On another topic, who at there has an anes doc run OR? We have a group of 3 OR nurse supervisors and secretary that run things. By days end, I want to usually pull my hair out.

We have one periop who runs the OR with one anesthesiologist. Every time the surgeons want to add a case or change a scheduled case, they have to call the OR RN and the anesthesiologist. We talk directly and decide if we have staff and space, and how soon. It works very well, usually.

 

[Carbocation1]

Isn't this how crnas started gaining practice rights? Soon there will be certified nurse operators who will perform minor parts of the surgery, and it will gain traction from there. And it's easier now since there is a precedent with crnas with anesthesia.

 

[IlDestriero]

On another topic, who at there has an anes doc run OR? We have a group of 3 OR nurse supervisors and secretary that run things. By days end, I want to usually pull my hair out.

Our Children's Hospital uses an Anesthesiologist and a Nurse Manager every day. The guy running the (electronic) board responds to emergencies and makes the schedule for the next day. Occasionally they take an easy room as well to keep things moving. It is a good system. The biggest problem is with the OR nurses schedules, having to go down to x rooms by X o'clock, and sometimes we need to keep moving but none/not enough volunteer to stay late. Their overtime system is screwed up, so they could, depending on what shifts they worked, end up staying and working a couple extra hours for no overtime compensation. It's not a big surprise that they would rather go home as scheduled. The dullard nurse management doesn't seem to think that's a problem, yet wonders why they won't volunteer to stay late to help out. They are corporate stooges that are hurting the system. They should be sticking up for their nurses and making more effective policies that improve retention of good nurses, morale, productivity, etc. I suspect it will reach a head in a year or two and raging senior surgeons will take heads, but by then the damage will be done.

 

[Promethean]

On another topic, who at there has an anes doc run OR? We have a group of 3 OR nurse supervisors and secretary that run things. By days end, I want to usually pull my hair out.

When I was an OR nurse, I often ran the schedule in cooperation with the anesthesiologist in charge. We cooperated. I was responsible for the physical plant, the availability of instruments and supplies, and the nursing / surgical tech staffing. The doctor was responsible for managing anesthesia resources and staffing. The collaboration worked quite well.

As for 2 rooms... that was a source of much games-playing and childish status seeking. Some folks would demand a second room just because one of their colleagues had gotten one, even if their case load didn't really justify it. I have seen foot-stomping, name-calling, toddler-esque meltdowns. Some anesthesiologists would give in to that, even though it only rewarded and encouraged further bad behavior the next time. And then there was the guy who always started with 2 maxed out rooms, and wanted a 3rd, or even a 4th... so, he would start adding on cases until he had so many that if he didn't get another room, if we made him stay into the night to finish his add-ons, it would overwhelm our reserves for responding to real emergencies. This happened week after week for years, but he kept getting away with it over the objections of both nursing and anesthesia. Dolla dolla bills, yo.

And then there were the surgeons who wanted the OR staff to play elaborate shell games with the families so that they wouldn't see the surgeon that they thought was working with their loved one having the pre- or post- op convo with someone else. As if I had nothing more urgent to do than help him pretend to be more focused on his patients than he really was. I could try to bounce them from one waiting room to another per his whims, but that actually only increased their anxiety, as they thought they were being pulled aside to get terrible news in private.

 

[Promethean]

Our Children's Hospital uses an Anesthesiologist and a Nurse Manager every day. The guy running the (electronic) board responds to emergencies and makes the schedule for the next day. Occasionally they take an easy room as well to keep things moving. It is a good system. The biggest problem is with the OR nurses schedules, having to go down to x rooms by X o'clock, and sometimes we need to keep moving but none/not enough volunteer to stay late. Their overtime system is screwed up, so they could, depending on what shifts they worked, end up staying and working a couple extra hours for no overtime compensation. It's not a big surprise that they would rather go home as scheduled. The dullard nurse management doesn't seem to think that's a problem, yet wonders why they won't volunteer to stay late to help out. They are corporate stooges that are hurting the system. They should be sticking up for their nurses and making more effective policies that improve retention of good nurses, morale, productivity, etc. I suspect it will reach a head in a year or two and raging senior surgeons will take heads, but by then the damage will be done.

Sounds very familiar. Either we worked together, or this is a recurring theme.

I was always happy to stay, because even without overtime, extra pay is extra pay... and eventually, if you keep staying, you will get into OT territory. But then, I am a workaholic and a team player. If I could stay two hours and keep a room running so that 2-3 more add-ons could get done, that would be 2-3 add-ons that the night shift wasn't trying to fit in around traumas or running up the the PICU to put a baby on ECMO.

 

[deleted171991]

Sounds very familiar. Either we worked together, or this is a recurring theme.

It's a recurring theme. Happens in my workplace, too.

The corporate bean-counters have forgotten that employees are people, so basic human psychology applies. It's ironic that US education puts so much emphasis on social studies, and yet nobody knows crap about people. Or they just don't care.

Employees can feel that these big corporations don't give a damn about them, and respond in kind: No, to going the extra mile. In the end, they are not the ones laughing all the way to the bank. "Team player" is just a synonym for being expected to do more work than one is paid for, while others reap the benefits.

 

[deleted682700]

It's a recurring theme. Happens in my workplace, too.

The corporate bean-counters have forgotten that employees are people, so basic human psychology applies. It's ironic that US education puts so much emphasis on social studies, and yet nobody knows crap about people. Or they just don't care.

Employees can feel that these big corporations don't give a damn about them, and respond in kind: No, to going the extra mile. In the end, they are not the ones laughing all the way to the bank. "Team player" is just a synonym for being expected to do more work than one is paid for, while others reap the benefits.

Creative destruction at its finest is happening in medicine in USA. Administration has short term goals which include the CEO making some short term changes which papers his/her resume and they move up the corp world.
Waxing and waning Medicare medical payments to hospitals meaner cheaper replacements and new hires. Hospitals are becoming giant experiment grounds for new hires to swim or sink at their own peril. Experience is being sacrificed as having no value.

In fact we doctors are our worst enemy. We are eagerly compliant to a fault. We have adapted to EMR and are becoming data entry workers to EMR. One of the venture capitalist, vinod khosla says doctors cannot compete with machines that these vulture corporatists design. In fact questions are being raised about medical judgement, Do we need experience and what is its value. How does medical bussiness value experience?

The end result is that we are slowly becoming a corporate employee. Eventually will be forced to sign up for less as the bargaining power is compromised, leading to complete walmartization of medicine.

 

[Gas]

Bringing up an old thread. I totally understand giving orthopedic surgeons 2 rooms with a PA closing while surgeon drops out and starts the next case. We do this whenever we have extra CRNAs and it works great. However, with surgeons the more you give, the more they want. Does anyone give a surgeon 2 rooms if they don't have a PA with them? Meaning is it okay for a surgeon to be closing in one room while in room number 2 they are inducing, doing a spinal, or doing a nerve block and then they wait for the surgeon to finish closing in room number 1? Is this even legal by CMS rules? Just wondering, any input appreciated.

 

[criticalelement]

It's a recurring theme. Happens in my workplace, too.

The corporate bean-counters have forgotten that employees are people, so basic human psychology applies. It's ironic that US education puts so much emphasis on social studies, and yet nobody knows crap about people. Or they just don't care.

Employees can feel that these big corporations don't give a damn about them, and respond in kind: No, to going the extra mile. In the end, they are not the ones laughing all the way to the bank. "Team player" is just a synonym for being expected to do more work than one is paid for, while others reap the benefits.

spot on post brother. every word.

 

[chocomorsel]

Bringing up an old thread. I totally understand giving orthopedic surgeons 2 rooms with a PA closing while surgeon drops out and starts the next case. We do this whenever we have extra CRNAs and it works great. However, with surgeons the more you give, the more they want. Does anyone give a surgeon 2 rooms if they don't have a PA with them? Meaning is it okay for a surgeon to be closing in one room while in room number 2 they are inducing, doing a spinal, or doing a nerve block and then they wait for the surgeon to finish closing in room number 1? Is this even legal by CMS rules? Just wondering, any input appreciated.

I don't know if it is legal or not. But it happens frequently enough. If the surgeon doesn't keep you waiting, I don't see the problem. Seems efficient to me.

 

[Promethean]

I don't know if it is legal or not. But it happens frequently enough. If the surgeon doesn't keep you waiting, I don't see the problem. Seems efficient to me.

Efficient as long as everything runs according to plan.

It is always a gamble, when you stretch your resources thin in the name of efficiency. It does pay off, the vast majority of the time, by shaving minutes or even hours off the day's schedule. But, if you do it often enough, luck will eventually, inevitably, run out and there will be a complication that might have been avoided if the attending had been there instead of scrubbed into the next case. Or at least that is the position that the lawyers will take.

When surgeons work on a colleague's family member, I notice they don't break scrub early to get the next case going. They finish and take that patient to recovery before moving on to the next. Practicing as if every patient is similarly important may make the day longer, but there is less to apologize for when something does go wrong.

 

[Consigliere]

"Team player" is just a synonym for being expected to do more work than one is paid for, while others reap the benefits.
- FFP

I'm printing this out and putting it above the desk in my office. Brilliant!

 

[Promethean]

"Team player" is just a synonym for being expected to do more work than one is paid for, while others reap the benefits.
- FFP

I'm printing this out and putting it above the desk in my office. Brilliant!

While I appreciate the sentiment that FFP was expressing, he was responding to the phrase itself, totally out of the context in which I'd just used it.

I was certainly not doing more work than I was being paid for, or letting others reap undue benefits from my labor. Recall, I was an hourly employee when I was being a "team player," and staying late to do more cases and clean up the OR schedule... I wasn't only being compensated in warm fuzzies, but in cold hard cash at time and a half.

Now as a desperately broke medical student, I *really* miss those opportunities to be a team player and top up my checking account.

 

[ASnaves]

This is something that is changing at the Cleveland Clinic. I don't know about how it works at the main campus, but for the regional hospitals, surgeons are no longer allowed to make incision on their patient in the next room until the first patient is closed. From my understanding, CCF is not allowing for PAs or residents to do the closure while the attending starts the next case. They are only allowing fellows to do that now. This is apparently going live on April 18, and has caused quite a bit of uproar with the surgeons I work with (a very busy ortho regional hospital). Some of the information about this is at http://www.cleveland.com/healthfit/index.ssf/2016/03/cleveland_clinic_queried_in_us.html Personally, I feel this is a bit excessive.

 

[Ronin786]

This is something that is changing at the Cleveland Clinic. I don't know about how it works at the main campus, but for the regional hospitals, surgeons are no longer allowed to make incision on their patient in the next room until the first patient is closed. From my understanding, CCF is not allowing for PAs or residents to do the closure while the attending starts the next case. They are only allowing fellows to do that now. This is apparently going live on April 18, and has caused quite a bit of uproar with the surgeons I work with (a very busy ortho regional hospital). Some of the information about this is at http://www.cleveland.com/healthfit/index.ssf/2016/03/cleveland_clinic_queried_in_us.html Personally, I feel this is a bit excessive.

It was all fine and dandy until patients and/or lawyers got a wind of it and think that the surgeon not closing skin on everybody is a complication. There was a big hoopla about MGH doing this a few months ago.

https://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/

 

[Random Anesthesiologist]

"Team player" is just a synonym for being expected to do more work than one is paid for, while others reap the benefits.
- FFP

I'm printing this out and putting it above the desk in my office. Brilliant!

Should be on one of those motivational posters.

 

[Brahnold Bloodaxe]

Ironically (since this is the anesthesia forum), do you think it's possible that this practice of surgeons booking multiple rooms will result in midlevel encroachment in surgery like what we've seen in anesthesia? You know, one surgeon doing the "critical" parts of procedures in 4 simultaneous ORs and leaving 90% of everything else to PAs or nurses..

 

[Gas]

Ironically (since this is the anesthesia forum), do you think it's possible that this practice of surgeons booking multiple rooms will result in midlevel encroachment in surgery like what we've seen in anesthesia? You know, one surgeon doing the "critical" parts of procedures in 4 simultaneous ORs and leaving 90% of everything else to PAs or nurses..

I definitely think this is the wave of the future. Starting off with "straightforward" cases, slowly expanding to almost all cases, then developing a sense of overconfidence and reluctance to call the attending when things go south. Sound familiar?

 

[Psai]

Ironically (since this is the anesthesia forum), do you think it's possible that this practice of surgeons booking multiple rooms will result in midlevel encroachment in surgery like what we've seen in anesthesia? You know, one surgeon doing the "critical" parts of procedures in 4 simultaneous ORs and leaving 90% of everything else to PAs or nurses..

Already starting to happen in ortho

 

[Doctor4Life1769]

Agree, it happens all the time in those total joint rooms.