How to supervise 3-4 ORs

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How do anesthesiologists prioritize when supervising 4 operating rooms? How to manage the flow? Are we supposed to just do prep, post ops and be readily available for critical portions of the case?. Imagine running 4 ors with quick cases and short turnover times.
what happens if there are problems in 2 operating rooms at the same time? What is legality in that situation? Will I be able to get help from anesthesia desk?
Thanks
 
And that’s the problem with covering 4 rooms. Legally especially general cases and Medicare medical direction. It is hard to meet all 7 elements of direction. Most places will bill has qZ modifiers
 
My day:

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when we run 4 rooms, we try to balance it out. 1 long robot room (less turnover), a longer A-fib ablation room, 2 flip total joint room. That sort of thing. 4 busy general OR rooms with LMA's and ETT's is a tough day and we try very hard not to do things like that.
 
GA8314 said:
when we run 4 rooms, we try to balance it out. 1 long robot room (less turnover), a longer A-fib ablation room, 2 flip total joint room. That sort of thing. 4 busy general OR rooms with LMA's and ETT's is a tough day and we try very hard not to do things like that.
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do they all start at different times? cant imagine how you start 4 rooms all at 7am and not have delays
 
anbuitachi said:
do they all start at different times? cant imagine how you start 4 rooms all at 7am and not have delays
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As mentioned earlier, it’s SUPER important to know who to trust & who not to trust, which is even harder when starting out somewhere. We routinely do 3-4 rooms, but majority is routine cases. On call CRNA gives breaks/lunches so I’m free for blocks/epidurals/inductions . . . .The only days that get hairy are when there’s only one anesthesiologist there & not our normal 2 (this happened a lot while volumes were down during April -July).
 
Its honestly not that bad. I cover 4/1 probably 90% of the time. Schedule makers are aware of that, its not like youre going to cover a Vats, liver resection, crani, and big vascular case all at once. Ill often have an ortho flip room, so one 730 and the other is an 830 start. then maybe a gyn and gen surg room. worst case usually 3 730 starts. you learn to prioritize based on CRNA strength and patient asa status. if i have a good crna inducing an asa 2 for a chole im probably not showing up for induction if im busy.

if its really busy, which is super rare, our doc of the day that carries the phone is usually not covering rooms, so ill call them to help in my rooms. The other day i was scrubbed for a central line while a CRNA was having an issues in another room, told her to call him and he was able to troubleshoot until i arrived.

our group is very flexible and everyone is always happy to help each other.
 
buccsmf1 said:
Schedule makers are aware of that, its not like youre going to cover a Vats, liver resection, crani, and big vascular case all at once.
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lol I know some guys who work for an AMC that cover crap like that except it's 5 rooms!😵
 
In smaller sparsely populated areas, I have done call every 5 night with 4 other CRNA providers covering other nights and I am available during day time. However things got ugly when I had to sign all the charts for all the providers, and was putting my malpractice in jeopardy. quit that job.
That practice has a constant turnover of anesthesiologists.
 
inquisitiveanes said:
In smaller sparsely populated areas, I have done call every 5 night with 4 other CRNA providers covering other nights and I am available during day time. However things got ugly when I had to sign all the charts for all the providers, and was putting my malpractice in jeopardy. quit that job.
That practice has a constant turnover of anesthesiologists.
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I have seen those jobs listed and it says they are independent. Why are u signing the charts?
 
inquisitiveanes said:
In smaller sparsely populated areas, I have done call every 5 night with 4 other CRNA providers covering other nights and I am available during day time. However things got ugly when I had to sign all the charts for all the providers, and was putting my malpractice in jeopardy. quit that job.
That practice has a constant turnover of anesthesiologists.
Click to expand...

You were signing charts for cases you never even saw? When you werent even on shift?? You arent even there to put out fires. You were their liability sponge.
 
buccsmf1 said:
Its honestly not that bad. I cover 4/1 probably 90% of the time. Schedule makers are aware of that, its not like youre going to cover a Vats, liver resection, crani, and big vascular case all at once. Ill often have an ortho flip room, so one 730 and the other is an 830 start. then maybe a gyn and gen surg room. worst case usually 3 730 starts. you learn to prioritize based on CRNA strength and patient asa status. if i have a good crna inducing an asa 2 for a chole im probably not showing up for induction if im busy.

if its really busy, which is super rare, our doc of the day that carries the phone is usually not covering rooms, so ill call them to help in my rooms. The other day i was scrubbed for a central line while a CRNA was having an issues in another room, told her to call him and he was able to troubleshoot until i arrived.

our group is very flexible and everyone is always happy to help each other.
Click to expand...
With all due respect, you say it's not bad because you're not supervising 4 rooms in reality. Not showing up for induction means exactly that. It's direction not supervision despite what you bill.
 
buccsmf1 said:
Its honestly not that bad. I cover 4/1 probably 90% of the time. Schedule makers are aware of that, its not like youre going to cover a Vats, liver resection, crani, and big vascular case all at once. Ill often have an ortho flip room, so one 730 and the other is an 830 start. then maybe a gyn and gen surg room. worst case usually 3 730 starts. you learn to prioritize based on CRNA strength and patient asa status. if i have a good crna inducing an asa 2 for a chole im probably not showing up for induction if im busy.

if its really busy, which is super rare, our doc of the day that carries the phone is usually not covering rooms, so ill call them to help in my rooms. The other day i was scrubbed for a central line while a CRNA was having an issues in another room, told her to call him and he was able to troubleshoot until i arrived.

our group is very flexible and everyone is always happy to help each other.
Click to expand...
Our group is anywhere from 2:1 to 4:1 depending on what cases are in progress and time of day. We are a busy high-volume practice, but strict medical direction. The charge doc for the day makes the doc assignments. Our flip total joint rooms has one doc doing spinals in pre-op with an anesthetist and two anesthetists in the OR, so technically they're 3:1. If a doc is covering a big case (AAA, crani, etc.) then they're likely only covering a couple less complicated rooms.

Regardless - for all GA cases, a doc is present for induction on every case. Period. I'm not sure why some of you get so worried about the theoretical 3-4 rooms starting at the same time. They don't - unless you magically have surgeons appear exactly on time all at once, which has never been my experience in 40 years of practice. One will start a little early, one or two may start a little late. So what? If two rooms are ready to go at the same time, one of them will have to wait a couple minutes. It's not like "induction" takes 20 minutes. For most cases that's a 2-3 minute event. We NEVER induce without the doc. All our cases are billed as medical direction and we adhere to the TEFRA requirements and document accordingly.
 
Agree with above. Busy days can really, really suck. But the vast majority of the time I’m 4:1, the OR is the easy part. And I’m at a pretty high volume ortho/vascular/neuro/thoracic practice.

Putting in post op orders, preop calls, PACU sign out, trauma/stroke pager is the real killer and mental drag.
 
Shimmy8 said:
Agree with above. Busy days can really, really suck. But the vast majority of the time I’m 4:1, the OR is the easy part. And I’m at a pretty high volume ortho/vascular/neuro/thoracic practice.

Putting in post op orders, preop calls, PACU sign out, trauma/stroke pager is the real killer and mental drag.
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You forgot OB.
 
MoMoGesiologist said:
I don’t think this is good. You r ok with this?
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There are times when I am 1:1 or 1:2 and CRNA starts case on their own for an easy MAC case or something because I'm doing a block because room is ready earlier than anticipated. I try to not to do that but it does happen on occasion where things sometimes don't align. But I'm at a place where leadership will throw anesthesia under the bus if we do literally anything to "delay" a room, even when surgeon is late they try to make it an anesthesia delay so I don't want to be the one to put the brakes.
 
2Fast2Des said:
There are times when I am 1:1 or 1:2 and CRNA starts case on their own for an easy MAC case or something because I'm doing a block because room is ready earlier than anticipated. I try to not to do that but it does happen on occasion where things sometimes don't align. But I'm at a place where leadership will throw anesthesia under the bus if we do literally anything to "delay" a room, even when surgeon is late they try to make it an anesthesia delay so I don't want to be the one to put the brakes.
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I wonder who they’ll throw under the bus if something goes awry during induction. 🤔
 
2Fast2Des said:
There are times when I am 1:1 or 1:2 and CRNA starts case on their own for an easy MAC case or something because I'm doing a block because room is ready earlier than anticipated. I try to not to do that but it does happen on occasion where things sometimes don't align. But I'm at a place where leadership will throw anesthesia under the bus if we do literally anything to "delay" a room, even when surgeon is late they try to make it an anesthesia delay so I don't want to be the one to put the brakes.
Click to expand...

Are you suggesting they start an easy MAC without you having had the chance to see the patient in preop? Or just that they brought the patient back (whom you've already seen in preop) and started a prop gtt without you present? If the former, you have no business doing supervision if you can't handle that 1:1 or 1:2 (or even up to 1:4). If the latter, I don't think many people supervising care if a CRNA starts a prop gtt for a MAC when they aren't in the room.
 
This morning while running the board:
- open aortobifem with CVL, art line, epidural
- neuro trauma flip room
- outpatient gen surg room
- IR cases

Everyone seen, all procedures done, and all inductions made. Get there early, chug coffee, plan 10 steps ahead and enjoy the 8:30 break.
 
Shimmy8 said:
This morning while running the board:
- open aortobifem with CVL, art line, epidural
- neuro trauma flip room
- outpatient gen surg room
- IR cases

Everyone seen, all procedures done, and all inductions made. Get there early, chug coffee, plan 10 steps ahead and enjoy the 8:30 break.
Click to expand...

You mean the 5minute break before you see the next wave of preops?
 
Great time management skills and clinical judgment are important no matter how many rooms covered. That can also be said if working alone in a room with multiple cases. When running the schedule we put the colleague who can't get out of their own way in a room with the longest and fewest cases to minimize their impact on the workflow and the number of complaints that filter back.
 
DrZzZz said:
Are you suggesting they start an easy MAC without you having had the chance to see the patient in preop? Or just that they brought the patient back (whom you've already seen in preop) and started a prop gtt without you present? If the former, you have no business doing supervision if you can't handle that 1:1 or 1:2 (or even up to 1:4). If the latter, I don't think many people supervising care if a CRNA starts a prop gtt for a MAC when they aren't in the room.
Click to expand...

That's why I chose a job I do my own cases. We only supervise on days where we are first call, 1 to 2 CRNAs since we run the board and do blocks. That being said I am there for induction and emergence all the time unless situations arise where timing can go awry and I'm unable to be there for either but I'm able to ask a colleague if free to be there. That being said our CRNAs are good so I'm not terrified I have to bail something out routinely so there's that
 
2Fast2Des said:
But I'm at a place where leadership will throw anesthesia under the bus if we do literally anything to "delay" a room, even when surgeon is late they try to make it an anesthesia delay so I don't want to be the one to put the brakes.
Click to expand...

Sounds like a toxic workplace. Hope u get paid well to deal with that BS
 
Shimmy8 said:
This morning while running the board:
- open aortobifem with CVL, art line, epidural
- neuro trauma flip room
- outpatient gen surg room
- IR cases

Everyone seen, all procedures done, and all inductions made. Get there early, chug coffee, plan 10 steps ahead and enjoy the 8:30 break.
Click to expand...

This seems...unsafe.
 
Shimmy8 said:
This morning while running the board:
- open aortobifem with CVL, art line, epidural
- neuro trauma flip room
- outpatient gen surg room
- IR cases

Everyone seen, all procedures done, and all inductions made. Get there early, chug coffee, plan 10 steps ahead and enjoy the 8:30 break.
Click to expand...


Does the first case go back early so you can launch it before you need to induce the other rooms? Does IR start later than the OR?
 
Shimmy8 said:
This morning while running the board:
- open aortobifem with CVL, art line, epidural
- neuro trauma flip room
- outpatient gen surg room
- IR cases

Everyone seen, all procedures done, and all inductions made. Get there early, chug coffee, plan 10 steps ahead and enjoy the 8:30 break.
Click to expand...

Hope they are all staggered and procedures performed by you or deferred to the CRNA?
 
3 7:30/8 starts. Flip room not til 9. First patient for bifem got here early for lines. Saw the other two In between art line/central line/epidural. Inductions are quick and always a little staggered.

It looks bad on paper but once you’re used to it...
 
Shimmy8 said:
3 7:30/8 starts. Flip room not til 9. First patient for bifem got here early for lines. Saw the other two In between art line/central line/epidural. Inductions are quick and always a little staggered.
Click to expand...

Why do you have to see patients in between? Son't you do all the procedures at one time?
 
Don’t *have* to...but as soon as art line was done I ran to see one of my preops in the next bay over while nurse was getting all my central line supplies out/ultrasound rolled over. See preop patient #2.

Turn back to my first patient for central line. Finish that, while they’re getting patient set up in position for epidural I ran down the hall to see preop patient 3. By time I was back patient #1 was just getting sat up for epidural.

Not the usual steps, but it got the job done today. And to be fair, this morning was a little more chaotic than usual. Didn’t want a case to be held up from rolling back if I struggled with one of the procedures.

I could always ask my partners to see one or snag an induction but I prefer to take care of myself if I can.
 
Shimmy8 said:
Don’t *have* to...but as soon as art line was done I ran to see one of my preops in the next bay over while nurse was getting all my central line supplies out/ultrasound rolled over. See preop patient #2.

Turn back to my first patient for central line. Finish that, while they’re getting patient set up in position for epidural I ran down the hall to see preop patient 3. By time I was back patient #1 was just getting sat up for epidural.

Not the usual steps, but it got the job done today. And to be fair, this morning was a little more chaotic than usual. Didn’t want a case to be held up from rolling back if I struggled with one of the procedures.

I could always ask my partners to see one or snag an induction but I prefer to take care of myself if I can.
Click to expand...

Getting kicked in the nuts repeatedly with a steel-toed boot sounds more fun than what you just described.
 
Shimmy8 said:
Don’t *have* to...but as soon as art line was done I ran to see one of my preops in the next bay over while nurse was getting all my central line supplies out/ultrasound rolled over. See preop patient #2.

Turn back to my first patient for central line. Finish that, while they’re getting patient set up in position for epidural I ran down the hall to see preop patient 3. By time I was back patient #1 was just getting sat up for epidural.

Not the usual steps, but it got the job done today. And to be fair, this morning was a little more chaotic than usual. Didn’t want a case to be held up from rolling back if I struggled with one of the procedures.

I could always ask my partners to see one or snag an induction but I prefer to take care of myself if I can.
Click to expand...

I hope this is not your every day routine. Sounds stressful as ****
 
inquisitiveanes said:
In smaller sparsely populated areas, I have done call every 5 night with 4 other CRNA providers covering other nights and I am available during day time. However things got ugly when I had to sign all the charts for all the providers, and was putting my malpractice in jeopardy. quit that job.
That practice has a constant turnover of anesthesiologists.
Click to expand...
Please stop using the word Provider. It’s simply CRNAs or Physicians or Anesthesiologists. Provider is a murky term used to try to put us all on the same level. The more we continue to use it the more we are “equal”.
 
chocomorsel said:
Please stop using the word Provider. It’s simply CRNAs or Physicians or Anesthesiologists. Provider is a murky term used to try to put us all on the same level. The more we continue to use it the more we are “equal”.
Click to expand...



Very murky indeed.


Urban Dictionary: provider

provider: a euphemism for [prostitute], one who performs [sexual acts] in exchange for monetary [compensation].
www.urbandictionary.com www.urbandictionary.com
 
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