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Talking to some colleagues at other places around the country, it sounds like docs/groups/hospitals have some wildly varying opinions about what is and is not kosher to cover/do at one time, either from a patient care standpoint or more commonly from a CMS/JCAHO perspective. Here are a few examples of things that my group won't do, but I hear many other people do on a regular basis. Feel free to weigh in with how your group handles this stuff.
-covering cases in main OR and c-section in OB. In my hospital, L&D is 4 floors and probably 5 minutes away from the main OR. If we have a case going in the main OR at night and C/S is called we: 1-leave CRNA in the OR and run up to OB to get it started while calling in backup from home (if it's truly "stat"), 2- ask the OB to bring the C/S to the main OR or wait 30 minutes for backup from home (if not "stat"). even if we have 2 CRNAs there (for some reason), we won't supervise upstairs and downstairs because we feel it violates the "immediately available" rule for medical direction. we also apply this to the cath lab or anywhere else not in our main OR suite (GI, radiology, ECT, etc).
-blocks for post-op pain control. these are supposed to be treated as a room (by CMS rules), so we won't do 'em if we have four rooms running. we will have a partner with <4 rooms do it or sign in to one of our rooms while we do it. note that blocks for primary anesthesia (i.e. UE blocks) don't factor in to this, so we will block the next hand case with four rooms going.
-doing things where we are the primary proceduralist (i.e. lines in the ICU, blood patches, etc). we don't do any of these things while signed into any rooms at all, even if the patient is in preop or PACU. we will sign out of everything else, again to avoid not being "immediately available".
-rounding. we won't leave the OR suite to round on catheters/epidurals/etc while we're signed in to rooms. or rather, we won't write the computerized, time stamped notes documenting these rounds while signed in to anything.
NOTE: we can apparently technically get away with almost any of the above if we write "emergency of short duration" on the chart. whether you'll be exonerated in court for your patient dying in the OR while you were doing an "emergency blood patch" is probably not a slam dunk, but it is what it is. Also, labor epidurals don't count against you in any of this, no matter how far away OB is. Sensible, eh?
It's probably obvious, but I practice in an ACT practice with CRNAs under medical direction. None of this probably matters to you if you do MD only or medical supervision. Anyway, how's your group think about this stuff? Any other complicance bugaboos out there? All input is appreciated.
-covering cases in main OR and c-section in OB. In my hospital, L&D is 4 floors and probably 5 minutes away from the main OR. If we have a case going in the main OR at night and C/S is called we: 1-leave CRNA in the OR and run up to OB to get it started while calling in backup from home (if it's truly "stat"), 2- ask the OB to bring the C/S to the main OR or wait 30 minutes for backup from home (if not "stat"). even if we have 2 CRNAs there (for some reason), we won't supervise upstairs and downstairs because we feel it violates the "immediately available" rule for medical direction. we also apply this to the cath lab or anywhere else not in our main OR suite (GI, radiology, ECT, etc).
-blocks for post-op pain control. these are supposed to be treated as a room (by CMS rules), so we won't do 'em if we have four rooms running. we will have a partner with <4 rooms do it or sign in to one of our rooms while we do it. note that blocks for primary anesthesia (i.e. UE blocks) don't factor in to this, so we will block the next hand case with four rooms going.
-doing things where we are the primary proceduralist (i.e. lines in the ICU, blood patches, etc). we don't do any of these things while signed into any rooms at all, even if the patient is in preop or PACU. we will sign out of everything else, again to avoid not being "immediately available".
-rounding. we won't leave the OR suite to round on catheters/epidurals/etc while we're signed in to rooms. or rather, we won't write the computerized, time stamped notes documenting these rounds while signed in to anything.
NOTE: we can apparently technically get away with almost any of the above if we write "emergency of short duration" on the chart. whether you'll be exonerated in court for your patient dying in the OR while you were doing an "emergency blood patch" is probably not a slam dunk, but it is what it is. Also, labor epidurals don't count against you in any of this, no matter how far away OB is. Sensible, eh?
It's probably obvious, but I practice in an ACT practice with CRNAs under medical direction. None of this probably matters to you if you do MD only or medical supervision. Anyway, how's your group think about this stuff? Any other complicance bugaboos out there? All input is appreciated.
