Stressful situations as a CA-1

[BostonBrunette]

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My first 2 weeks as a CA-1 have been a stressful experience. As in multiple programs, my program has me working 1-on-1 with an attending for a few weeks and the cases have been low key (though many) with relatively healthy patients (for the most part), so the stress hasn't been so much the intraop "sh-- hitting the fan". Instead, it's been the following:

--time pressure. The cases deemed "suitable" for someone at my level tend to be short, meaning that 3-4 cases are scheduled for my room, with little down time intraop to set up for the next case. turnover time is supposed to be 30min but often, my attending has been bringing in patients much sooner than that, even if the room is not ready (meaning airway equipment/circuitry has not been changed, emergency meds are not ready, etc). It's gross (and scary) to even think about. I just cant see how that would be safe for the patient. But I keep wondering whether I should have done something differently to avoid such situations. Any suggestions?

--unhelpful techs, unhelpful attending (nice, but very resident-dependent meaning that he doesn't know about any resident-type work such as paperwork details or testing the machine, and is a bit rusty on his anesthesia theory)

--being vigilant about controlled substances assigned to my case (and therefore to my name since I took them out of the Pyxis). It seems to me that being lax about this has the potential of putting one's career on the line (it's common sense, in addition to us being told this MULTIPLE times during orientation). Thus, I feel the need for being obsessive about documenting and returning unused meds as per rules. However, I can start to see how sometimes difficult situations may present themselves, e.g. what if a vial slips, falls, and breaks before you get a chance to draw it up? what if a syringe gets accidentally thrown away during a busy case? what if a syringe disappears during one's break? I have brought up such issues to a few older residents at my program, and they didn't seem too concerned, in fact often their suggestions involve being lax about following the rules for documenting unused meds. Am I being too worried about this? How does this process usually work at your institutions?

How do the pros (the attendings and residents) here deal with these issues at work? Do other CA-1 here face similar situations?

 

[leaverus]

Yeah, all your concerns are valid. As for turnover, you just gotta establish your own routine. Emergency drugs should not have to be drawn up in between cases if you've drawn them in the AM (unless you use them of course, but in that case, i try to draw up a new stick immediately so that i have it for ensuing cases) - and of course, you'll get to the point that for most patients, if you do your anesthsia right, you won't need any ephedrine/neo. If you know that you are going to have several quick cases (4 hysteroscopies for example) you can come in a little earlier in the morning and just crack open that many new circuits and throw in the rest of the stuff (suction, ekg pads, etc.) in each bag. It'll come in time - i know it's easy to say but don't sweat the small stuff and just try to learn as much anesthesia as you can.
As for the narcs/controlled substances, no one should be lax about that; it does need to be strictly documented. Yes, of course, there is the rare dropped vial, but in that case, all you can do is write eg, "Fentanyl 250mcg accidentally dropped" - then sign it and have an attending co-sign it (just don't tell them if you draw the waste up off the floor and slip it into your personal stash 😛 )

 

[sdn1977]

I can address your drug issues only, but the others I'll leave for the physicians here.

For the emergency drugs, I agree, draw up a reasonable quantity of what you need in the AM, but - LABEL, LABEL, LABEL!!! Many M&M occurrences in the or are from drugs which have gotten mixed up in the changing of pts & therefore placement of drugs or the confusion of a situation. If you don't use these drugs in the course of your day - discard them in the syringe waste unit - they don't have to be documented. If you leave them on the cart - we discard them (some used to get angry, but they've gotten over that). The only ones we don't mess with are the trays the guy who is working overnight will be using - but those are very clear to us. For the most part - these drugs aren't too expensive & with time, you'll get to know more what you need to have predrawn.

During your case, don't worry about the narcs - just worry about documenting their administration in whatever units - mcg, mg, etc.. then waste after each case. In my situation an RN can cosign the wastage. If the syringe is drawn up & used with a needle - its wasted in the syringe waste unit. If it has a luer lock cap, its bagged & put back in pyxis in a red contaminated bag. If its still in the vial, its bagged & put back in pyxis - both are in the return bin which is emptied multiple times a day, depending on the number of ORs & volume. We check the mg/mcg units used & wasted against the mg/mcg removed from pyxis. If its reasonable, all is good - you won't hear from us. If its not, you will...within 24-48 hours. We bill (not the pt - actually deduct from the drg....) from the actual amount used in the case.

If something accidentally breaks or gets tossed in the confusion - document & have a licensed person cosign - one of the nurses is ok. It even happens to us when we dispense the drugs - its human & not as unusual as you might think. If you've forgotten, the case is over, the room cleaned & your gone - we still have the paperwork & we reconcile it with the pyxis reports. If they don't match - we find you & then you fill out an after the fact report. No one is going to march you "downtown" for an accidental breakage, altho I appreciate your concern.

Good luck! If you are worried, stop by the OR pharmacy & chat. We'll try to make your life easier.

 

[tussionex]

another pharmacist weighing in here.

- i second all of sdn's recommendations [we really DO drop stuff and break it, too...it happens; we co-sign just like you do. as long as there is a paper trail, you'll be fine]
- at my hospital, we batch what we call "stat packs"....phenylephrine, atropine, sux, and epi at the request of our anes. group. that way, they have they emerg. drugs they want when they may need them, and they are always labeled. perhaps you can talk to your pharmacy about something like that.

 

[UTSouthwestern]

You're facing the normal pressures of the first month of residency. The important thing is to remain focused and not to be afraid of asking the attending for tips, help, etc. when necessary.

Documentation of unused medications for myself means, documenting unused hypnotics or narcotics. I could give a rat's ass if some pencil pusher is wondering what happened to the remaining 60 mg of Sux that I didn't use.

Keep track of your narcs and hypnotics but if you are having trouble with that or the case is long and involved, document that you gave everything and just waste any remaining med you have left (literally shoot it out of the syringe, do not just put a container or vial into the sharps basket: people have actually gone into those things to retrieve vials of fentanyl or morphine that appear to have fluid in it). Now don't do this if you used only 1 mg out of 10 mg of morphine, or 25 mcg out of 250 mcg of fentanyl, etc. If however, you have only 10 mcg of fentanyl or one mg of morphine left, chart it, shoot it into the sharps container, and save everyone the headache of extra signatures and paperwork. In residency, this will vary with attending so you will have to develop a feel for who will allow what. Varying institutions now include ephedrine on the controlled substances list so that may also be another source of paperwork.

Create a system for your charting that you can repeat over and over again from case to case.

Example: For the narrative I follow a pretty standard format I used in residency. With tweaking for prone cases, cranis, hearts, etc.

0645-0651: 18 ga PIV placed. Pt preTx. (BP 122/56, O2 97%RA, PR 88)
0715: To OR 32. PreOx X > 5 min. Mon on VSS.
RSI, eyes taped. DLX1 with Miller 3. Grade 1 view
LTA X 1. 7.5 ETT (down arrow drawn here)
Atraumatic. 4 cc's to cuff. =BBS (+), EtCO2 (+)
Secured @ 22 cm.
0723: L 20 ga radial A line placed with sterile prep and drape
BPPP (Bilateral pressure points padded).
OGT/NGT/ET (Esophageal thermometer) placed.
Bair hugger on.
0728: Ready for prep.
0740: Case start
0750: Begin controlled hypotension. MAP at >=65 at all times
0847: Case end
VSS. TO4 4/4 no fade, (+) 5 sec sustained tetany
(+) Sp. vent. Extubated with purposeful movement.
To PACU w/ O2 FM.

Document your times correctly on your billing sheet. This is one of the biggest problems that causes lost revenue to academic programs. If you have discontinuous time (Placed an IV 30 minutes before you rolled back to the OR), note that time on both your record and billing sheet and document a set of vital signs for that time period (sat, bp, PR are enough). You don't have to put it on the anesthesia record grid, you can just document it on the narrative as I did above. That five to 8 minutes of time adds up over the length of your residency and private practice career to hundreds of thousands of dollars of lost billing.

When you chart your vital signs, be reasonable. I had attendings who insisted that you chart every mean pressure, peak inspiratory pressure, etc. The reality is that you are wasting a lot of time looking at those numbers and recording them when you should be paying attention to the patient and what the surgeons (i.e. rookie, novice early in the year) are doing. I don't record a mean, simply because if they need it later, then they can calculate it with a calculator later. If the peak pressures are staying within a nominal range, then just record your best estimate. I hated seeing young residents scrolling back through the OR vital sign records as the surgeon was putting a trocar through the IVC or aorta, etc.

If you know what cases you are going to be doing the next day and can take blank OR records home with you, pre-write some of the work before the case so that pressure is alleviated somewhat and you have a written record of what you plan to do the next day. Just leave the times blank. Again, some attendings will be OK with it, some will not. Don't waste the records you get on the day of the surgery, keep them for the next day and put stickers in the appropriate places to reflect the correct patient.

One pet peeve I have: The SHARP'S container is for SHARPS. Disconnect the needles from your syringes and put the needles into the sharps container and put everything else into the trash. We don't put coca cola bottles into sharps containers, so why do we put empty bottles of succinylcholine, propofol, etc. into the sharps container. Do your part to prevent filling our landfills with underfilled sharps containers.

If a vial accidentally breaks before you can draw it up, you should have a nurse or your attending immediately witness it, request more narcotic, and record the waste on your narrative and narc sheet (0746: 2 cc vial of fentanyl wasted after vial fell to floor. Witnessed by ___ ).

When you are on break, ideally, the person giving you a break should record any narc usage. If you suspect that the person may have a "habit", draw up a little blood into your narc syringe to give it a beautiful pink-red tint. That will highly discourage anyone from "losing" narcs on break. Also keep track of and anonymously report anyone you suspect of having a "problem."

Unhelpful techs are the norm for academic centers. You can try to force them to do what is necessary, but the majority of these people have been there since the Pleistocene Era and will be highly resistant to change. I encountered this at Parkland but used it as an opportunity to learn every detail of the setup and preparation. It has served me well in private practice, where I have been able to trouble shoot problems that leave my techs scratching their heads. I can also start all of my hearts in 20 minutes or less with all of the line placements, TEE, etc., without a tech, 15 minutes or less with a GOOD tech, so it makes me a more desired candidate for the surgeons and increases my value to the group.

You are still early in training. Develop your routines as you see others use theirs and adopt what you think would fit into your routine. Everyone at your stage, will tell you that their way is the best way and the safest way. You will need to stay open to all suggestions and methods and formulate the one that will work best for your patient and yourself.

Everything will start to slow down for you after a couple of months. You can make it easier on yourself by being there a little earlier at this point in your residency experience. As you develop your routine, little things like knowing exactly how many 20 cc, 10 cc, and 5 cc syringes you will want to open for each case type and each attending will become second hand to you.

Keep little notes on the preferences of each attending. Which one likes sux, which ones refuse sux no matter what, which like morphine and fentanyl, which like sufentanil only, two IV's only, etc. This type of knowledge will make your life a lot easier during the rest of the residency. Leave out overly personal judgements, but know who is temperamental, who is going to leave you out to dry no matter what happens, etc. Those people are easily pacified/mollified by the resident who is knowledgeable, confident (not arrogant), and flexible with different styles/techniques. Ask good questions, not incessant questions on things that you already know or ask to try to look good. Attendings will pick up on that. Ask questions on things that truly concern or confuse you. If someone is unwilling to spend time teaching you, at least you know that up front and don't have to waste time later trying to dig out pearls of wisdom.

Above all else, no matter how tired you are, you MUST read at least one hour a day, preferably two. That is the minimum amount of time you need to spend to both maintain and enlarge your knowledge base. This is residency, and this is the only time you can practice medicine under someone else's license. Use the opportunity to explore all techniques and avenues and it will make you a dynamic and desirable candidate after residency.

Don't hesitate to ask questions here. We've all been through or are going through the training period. Good to share your misery and your triumphs.

 

[sdn1977]

UT went into much more detail & physician oriented which is what you needed.

I agree with him - we don't care how much sux, propofol, cefazolin - whatever you use. We look at that annually to help the hospital calculate the drg reimbursement rate they need to negotiate. The small amount you use there goes into the bigger picture of how much money is spent on medications during the whole hospital stay for any particular diagnosis. Whether you draw this stuff up & waste the whole thing - no problem....its really not much money (unless you are using epogen, procrit, etc...). Our annual budget is in the millions of dollars, so the small amount you waste is not significant.

You never heard it from me😳 - but we really don't follow the hypnotics that closely. Its primarily the narcotics (& since you folks don't use the CII amphetamine type stuff too much .... perhaps cocaine, thats not an issue).

There are three reasons for us "pencil pushers" (altho I hate this part of my job) to follow this stuff - reimbursement (like I said - an annual thing), our required documentation MONTHLY to the DEA (down to the mcg, mg, whatever unit its in) - your good charting & wasting helps this & finally, following & documenting those rare circumstances of diversion.

In my experience - diversion occurs, but follows a pattern....so it gets picked up pretty easy. You'll notice if pharmacy is following diversion because you'll see the pharmacy "suits" with us - not just the routine pharmacists.

But - all paperwork & documentation aside - in the OR, ICU, ER - none of it matters & can all be done after the fact in an immediate crisis - pt care will always come before paperwork. So - again - if we come to you a day or two later & ask you to document something you might have forgotten to write down in the heat of a busy case.....its only for the paper trail, nothing more. We will never ask you to document someone else's work. And - we won't ask you to alter your record. We'll ask you to fill out an addendum form to the permanent record which records wastage due to unknown reasons & we'll be the cosigner. No blame assigned, just documentation. No one incident is an issue - its a pattern of incidents.

 

[Planktonmd]

All the advice above is valuable but you must learn to chill out a little or you will drive yourself nuts.
"Emergency Drugs" if there is such a thing, can be drawn during a case for next case, although I can't see why you need to draw anything if you know where they are on the cart and where to find a syringe!
the rest of your MMAIDS setup checklist should take about 5 minutes then you have the rest of the 30 minutes turnover time to smoke a cigarette or check your E mail.
This business can be as stressful as you want it to be, so learn how to relax.

 

[VentdependenT]

Thanks UT for the informative post. I concur about the charting thing.

During hearts I usually don't chart till the pt goes on bypass. Only thing I'll write down is the starting PA pressures, CVP, & CO.

 

[UTSouthwestern]

UT went into much more detail & physician oriented which is what you needed.

I agree with him - we don't care how much sux, propofol, cefazolin - whatever you use. We look at that annually to help the hospital calculate the drg reimbursement rate they need to negotiate. The small amount you use there goes into the bigger picture of how much money is spent on medications during the whole hospital stay for any particular diagnosis. Whether you draw this stuff up & waste the whole thing - no problem....its really not much money (unless you are using epogen, procrit, etc...). Our annual budget is in the millions of dollars, so the small amount you waste is not significant.

You never heard it from me😳 - but we really don't follow the hypnotics that closely. Its primarily the narcotics (& since you folks don't use the CII amphetamine type stuff too much .... perhaps cocaine, thats not an issue).

There are three reasons for us "pencil pushers" (altho I hate this part of my job) to follow this stuff - reimbursement (like I said - an annual thing), our required documentation MONTHLY to the DEA (down to the mcg, mg, whatever unit its in) - your good charting & wasting helps this & finally, following & documenting those rare circumstances of diversion.

In my experience - diversion occurs, but follows a pattern....so it gets picked up pretty easy. You'll notice if pharmacy is following diversion because you'll see the pharmacy "suits" with us - not just the routine pharmacists.

But - all paperwork & documentation aside - in the OR, ICU, ER - none of it matters & can all be done after the fact in an immediate crisis - pt care will always come before paperwork. So - again - if we come to you a day or two later & ask you to document something you might have forgotten to write down in the heat of a busy case.....its only for the paper trail, nothing more. We will never ask you to document someone else's work. And - we won't ask you to alter your record. We'll ask you to fill out an addendum form to the permanent record which records wastage due to unknown reasons & we'll be the cosigner. No blame assigned, just documentation. No one incident is an issue - its a pattern of incidents.

You know what bothers me is non health care professionals flagging records. There are three facilities in Dallas at which the medical records department, MR DEPARTMENT, flags physicians for not documenting where that last 10 mg of sux, or 20 mg of propofol went. I was put on suspension at one center without notification by the medical records department for not documenting that I wasted 10 mg of sux, yet they allowed me to document that I gave a total of 150 mcg of neosynephrine, and didn't waste 9.85 mg of neosynephrine. WTF? Raised hell about it and they no longer flag anesthetic records for non-controlled substances, but it took 5 months for them to make the change.

 

[UTSouthwestern]

Thanks UT for the informative post. I concur about the charting thing.

During hearts I usually don't chart till the pt goes on bypass. Only thing I'll write down is the starting PA pressures, CVP, & CO.

In private practice, hearts can be done in 2.5 hours skin to skin, and you have 20-30 minutes to get the patient lined up and ready to go. I write down my basic framework of planned drugs to give, and pre-case start routine with space for time to be filled in. It allows me to focus on the patient in that critical pre-CPB period (or pre-grafting period if we are off pump), without falling too far behind on the paperwork and delaying the start of the next heart.

Venty, and everyone doing hearts now in residency, be sure to put "Diagnostic TEE placed atraumatically", instead of just "TEE placed atraumatically". In some states, this clear designation of TEE as a diagnostic, not just a monitoring device means an extra $50-110.

 

[tussionex]

You know what bothers me is non health care professionals flagging records. There are three facilities in Dallas at which the medical records department, MR DEPARTMENT, flags physicians for not documenting where that last 10 mg of sux, or 20 mg of propofol went. I was put on suspension at one center without notification by the medical records department for not documenting that I wasted 10 mg of sux, yet they allowed me to document that I gave a total of 150 mcg of neosynephrine, and didn't waste 9.85 mg of neosynephrine. WTF? Raised hell about it and they no longer flag anesthetic records for non-controlled substances, but it took 5 months for them to make the change.

really? wow....good thing they don't audit pharmacy records. if there is a question of sterility, or i'm not comfortable with how my tech made something...it goes out!
obviously, the patient isn't repeatedly charged for our QA....your example is yet another of the absurd amount of over-documentation that is causing the healthcare system to spiral further downward!

 

[urgewrx]

In private practice, hearts can be done in 2.5 hours skin to skin...

How many hearts you do in one day?

 

[UTSouthwestern]

really? wow....good thing they don't audit pharmacy records. if there is a question of sterility, or i'm not comfortable with how my tech made something...it goes out!
obviously, the patient isn't repeatedly charged for our QA....your example is yet another of the absurd amount of over-documentation that is causing the healthcare system to spiral further downward!

I told them that this was an astronomical waste of time and resources and likely something being done just to justify an exhorbitant MR budget. Like you said, one of the many wastes of resources that could be directed toward more patient care. The system isn't broken, it's abused.

 

[UTSouthwestern]

How many hearts you do in one day?

Varies with the schedule and who's on vacation. Most I've done is 5 in a 24 hour period, flip flopping between two rooms. I'd estimate my group does between 2200-2800 a year.

 

[deleted87051]

My list yesterday:

7:30-13:00
1. TEE/Cardioversion
2. Prone anal condyloma
3. same
4. same
5. hemorrhoidectomy (also prone)
6. lap chole
7. lap chole
8. inguinal hernia
9. inguinal hernia

13:00-14:00 had a break. Actually got to eat some real food in the cafeteria and complete some billing tickets.

14:00-18:00
10. Massive butt/thigh abscess on homeless, hemiplegic, alcoholic guy.
11. IM rod tibia.

18:00 home

Keys to safety AND efficiency:
1. Be neat, make it a habit. Keep your work area organized and as mentioned above, label EVERYTHING.
2. Be prepared. I call all my patients the night before so I can do a cursory "Hi, I'm Dr. X, got any last minute questions?" preop before the actual case.
3. Anticipate. This gets easier after you learn your specific surgeons and procedures.

 

[Mman]

--time pressure. The cases deemed "suitable" for someone at my level tend to be short, meaning that 3-4 cases are scheduled for my room, with little down time intraop to set up for the next case. turnover time is supposed to be 30min but often, my attending has been bringing in patients much sooner than that, even if the room is not ready (meaning airway equipment/circuitry has not been changed, emergency meds are not ready, etc). It's gross (and scary) to even think about. I just cant see how that would be safe for the patient. But I keep wondering whether I should have done something differently to avoid such situations. Any suggestions?

I find that any case > 1 hour probably has at least a 5 minute window when I can at minimum pop open some new syringes and slap lables and needles on them and set them aside for drawing up drugs later. If I have another spare 5 minutes, I can draw up everything except the controlled substances for the next case. Between cases, I'll drop off my patient (5 minutes), return excess narcs from the case and pick up new ones for the next (5 minutes), and go turn over the room by getting a new circuit and suction setup and drawing up the narcs (5 minutes). That leaves me 15 minutes to talk with the next patient and get any extra setup stuff (transducers and ultrasound or whatever else) I might need and still make a 30 minute turnaround.

The biggest wastes of time I tend to encounter are PACU nurses that aren't ready to take report when I drop the patient off or don't have all their monitors ready to roll. If everything runs smooth including the tech helping turn the room over, I could pull a 20 minute turnover most of the time except the nurses in the OR can't or won't turn it over that fast anyways.

It took me about 2-3 months to really get the hang of turning the room over quickly. I'm sure I'll continue to make minor improvements here and there.

 

[BostonBrunette]

I find that any case > 1 hour probably has at least a 5 minute window when I can at minimum pop open some new syringes and slap lables and needles on them and set them aside for drawing up drugs later. If I have another spare 5 minutes, I can draw up everything except the controlled substances for the next case. Between cases, I'll drop off my patient (5 minutes), return excess narcs from the case and pick up new ones for the next (5 minutes), and go turn over the room by getting a new circuit and suction setup and drawing up the narcs (5 minutes). That leaves me 15 minutes to talk with the next patient and get any extra setup stuff (transducers and ultrasound or whatever else) I might need and still make a 30 minute turnaround.

The biggest wastes of time I tend to encounter are PACU nurses that aren't ready to take report when I drop the patient off or don't have all their monitors ready to roll. If everything runs smooth including the tech helping turn the room over, I could pull a 20 minute turnover most of the time except the nurses in the OR can't or won't turn it over that fast anyways.

It took me about 2-3 months to really get the hang of turning the room over quickly. I'm sure I'll continue to make minor improvements here and there.

Yeah, I can make do with a 30min turnover, but at one point my attending was bringing in patients sooner than that (like 15 min after the prior one)!!

 

[Mman]

If your attending is bringing the patient in 15 minutes after you just left the room, I hope they won't mind if you are still changing the circuit and drawing up drugs while they help the patient on to the OR table and hook up monitors.

 

[johankriek]

0645-0651: 18 ga PIV placed. Pt preTx. (BP 122/56, O2 97%RA, PR 88)
0715: To OR 32. PreOx X > 5 min. Mon on VSS.
RSI, eyes taped. DLX1 with Miller 3. Grade 1 view
LTA X 1. 7.5 ETT (down arrow drawn here)
Atraumatic. 4 cc's to cuff. =BBS (+), EtCO2 (+)
Secured @ 22 cm.
0723: L 20 ga radial A line placed with sterile prep and drape
BPPP (Bilateral pressure points padded).
OGT/NGT/ET (Esophageal thermometer) placed.
Bair hugger on.
0728: Ready for prep.
0740: Case start
0750: Begin controlled hypotension. MAP at >=65 at all times
0847: Case end
VSS. TO4 4/4 no fade, (+) 5 sec sustained tetany
(+) Sp. vent. Extubated with purposeful movement.
To PACU w/ O2 FM.

.

holy moly if i wrote this much i would have writers cramp by the end of the day... stick to the highlights.. nothing more..

 

[sdn1977]

You know what bothers me is non health care professionals flagging records. There are three facilities in Dallas at which the medical records department, MR DEPARTMENT, flags physicians for not documenting where that last 10 mg of sux, or 20 mg of propofol went. I was put on suspension at one center without notification by the medical records department for not documenting that I wasted 10 mg of sux, yet they allowed me to document that I gave a total of 150 mcg of neosynephrine, and didn't waste 9.85 mg of neosynephrine. WTF? Raised hell about it and they no longer flag anesthetic records for non-controlled substances, but it took 5 months for them to make the change.

I will apologize for the medical records dept for any "flagging" of the charts which occur - its not my dept, but it got you worked up, so I'm always good at making folks try to feel better about what they have no control, or little control over. I'm not sure they were "flagging" you about the wastage...just the usage - sometimes a certain mg above a set level changes the drg. But, only you know, so I'll assume they were just out to get you & those who give neo, sux or propofol & didn't document wastage - could happen! After all - they changed their practice.

As a pharmacist, I have little contact with medical records & their need nor necessity to "flag" your chart. As far as I know, it has to do with the acuity of the pt & how they can code different drgs & how it integrates into the drg. They will sometimes come to us to find out what is actually happening when some drug is being given or when a drug goes above a certain mg/mcg amount - was the acuity changing, for example. Likewise, they are the folks who have to ensure we are alll complying with hospital policy of signing orders, wasting drugs, etc... As Tussionex pointed out, in the pharmacy we waste drugs daily - in fact, we waste "expensive" drugs - like tpns & tpas if they weren't compounded properly - and often, without question. In our judgement, it wasn't done correctly so it gets redone.

The point here is to separate what each dept is looking for - pharmacy looks to document narcotic use & wastage - why???? Because we transmit that information monthly (on some drugs daily) to the DEA. They really are not the horrible agency some make them seem to be - they just want a paper trail (or electronic given the site).

Medical records is looking to document acuity to increase drg reimbursement & to comply with the various agencies they deal with - JCAHO, HCFA, etc...Their purpose right now is to increase reimbursement so the hospital can stay afloat.

The medical record is a legal document - like our compounding documents & distribution documents. We all occasionally have to go back & justify what we did & why - for controlled substances - for legal reasons, for pharmacists - "expensive" drugs - for budget reasons & for you folks - some drugs may change the acuity & thus, the drg - a reimbursement reason. I don't know for sure because I'm not an MR person - I just know when I've been asked by an MR person what is the significance of adding one drug or another or what might an increased dose mean.

We look at different things. You're correct though - if you don't sign an order or an anesthesia record - yeah - you'll get flagged. You gotta sign everything - but then so do we all! If it wasn't written down, it didn't happen - but, the rules allow you to write it down after the fact if it did indeed happen & there was "reasonable" reason to document after the fact - particularly our narcotic records which are not a part of the legal chart.

I disagree with you though - MR FINDS billing - lots & lots of billing which is not written down. They've become pretty good at deciphering what is going on with a particular pt & being able to put that into a billing perspective - which is what makes the hospital go 'round. Its a difficult job - particularly for those who are not "saavy" about healthcare - but if you've ever done a chart review - its mind numbing!!!!

 

[UTSouthwestern]

holy moly if i wrote this much i would have writers cramp by the end of the day... stick to the highlights.. nothing more..

You've got to be kidding me. These are the highlights. Take out the stuff in parentheses that are explaining some shorthand and you have a very short narrative. If you didn't write something covering tube placement, pressure points, eye care, etc., then you didn't do it in a court of law.

 

[UTSouthwestern]

10 mg of sux and 20 mg of propofol in a 140 kg 5V CABG patient does not alter the coding status of the case or the hospital admission in any way. It wouldn't alter the coding status of a 17 year old ASA 1 patient undergoing a tonsillectomy either.

This was purely an exercise in unnecessary paperwork and one that caused enough consternation in all of the physicians at MCM such that a committee had to be formed to review all of MR's policies. Five months later . . . .

Narcotics documentation is one thing, but cheap commonly used, non-narcotic anesthetic meds . . . .

 

[tussionex]

in the pharmacy we waste drugs daily - in fact, we waste "expensive" drugs - like tpns & tpas if they weren't compounded properly - and often, without question. In our judgement, it wasn't done correctly so it gets redone.
!!!!

hey sdn - how's about wasting 20 epidural syringes [when the tech wasn't sure how much fent she added]? that was a bit of a paperwork, but i don't really care; fent's cheap and i'm not putting patients at risk. yes, we MAKE epidurals [our volume is heavy but not enough to justify the cost of contracting out]

about what drugs are you transmitting daily info to the DEA? that paperwork does not fall under my purview, but i know nothing we use gets reported daily.

 

[tussionex]

10 mg of sux and 20 mg of propofol in a 140 kg 5V CABG patient does not alter the coding status of the case or the hospital admission in any way. It wouldn't alter the coding status of a 17 year old ASA 1 patient undergoing a tonsillectomy either.

This was purely an exercise in unnecessary paperwork and one that caused enough consternation in all of the physicians at MCM such that a committee had to be formed to review all of MR's policies. Five months later . . . .

Narcotics documentation is one thing, but cheap commonly used, non-narcotic anesthetic meds . . . .

10mg of sux? 1 vial? cheap, cheap, cheap....unless there's a shortage🙂

i agree with both you and sdn; careful record keeping is a necessity for many reasons, but torturing the physicians [and everyone else] with more paperwork benefits no one!

 

[Planktonmd]

holy moly if i wrote this much i would have writers cramp by the end of the day... stick to the highlights.. nothing more..

😀
I agree!

 

[urgewrx]

0750: Begin controlled hypotension. MAP at >=65 at all times

Your controlled hypotension is MAP>=65? Where is the hypotension?

 

[UTSouthwestern]

Your controlled hypotension is MAP>=65? Where is the hypotension?

Ahhhh, it's keeping the systolic around 85-90, while maintaining the MAP at 65 or higher (actually 60 or higher, but I try to keep it consistently over 65). Since most of my patients are hypertensive with high means, it still qualifies as controlled hypotension.

 

[Planktonmd]

Ahhhh, it's keeping the systolic around 85-90, while maintaining the MAP at 65 or higher (actually 60 or higher, but I try to keep it consistently over 65).

Let's see: 85 sys and mean of 65 this requires BP = 85/55 that is tough to maintain!

 

[urgewrx]

Ahhhh, it's keeping the systolic around 85-90, while maintaining the MAP at 65 or higher (actually 60 or higher, but I try to keep it consistently over 65). Since most of my patients are hypertensive with high means, it still qualifies as controlled hypotension.

Do you do "hypotension" on all your cases?

I call that low normal BP, in case you are wondering.

 

[invitro]

Hey just want to chime in too...

I thought the first two weeks was pretty stressful, but I think after doing it so many times (I had a least 3-4 cases/day) you get really used to it. I just have to start reading....2 hours a night it is!

 

[VentdependenT]

Do you do "hypotension" on all your cases?

I call that low normal BP, in case you are wondering.

Why? If the patient has baseline hypertension with autoregulation shifted to the right then I'd call that hypotension.

 

[urgewrx]

Why? If the patient has baseline hypertension with autoregulation shifted to the right then I'd call that hypotension.

I agree with you. I start a lot of my pts with BP of 210/100. Run them most of the time at 120/80. Would you consider this controlled hypotension? I don't. In fact I'm on a neo drip most of the case.

Do we know how much hypotension is necessary to call it controlled hypotension? Is it 20% below baseline? What is baseline? Can you define it from one measurement 1 hr before the case(when pt's are the most anxious)? Most of us will agree on a MAP of 50-55mmHg (end point for most studies on controlled hypotension), unless the pt started like that.

Some of you might be asking who cares? But, this is very relevant. We charge 5 units for "controlled hypotension". Basically doubling the price of a short ENT case where it might be required, or 75 more minutes of anesthesia (4 units per hour). Why do we charge so much for it? Because it carries additional risk.

I think most people willl agree that in the above given example a MAP of 65 is not "controlled hypotension" in a pt with a starting BP of 122/56. That is normal perfusion pressure in a normotensive pt. Where are you exposing yourself so much that you merit an extra 5 units? Yet it was documented like so for the billing department. We have to have some clear end points, otherwise we can easily be accused of fraud.

This is why I had to point this out. Be very careful with your billing. You don't want to commit fraud inadvertently.

 

[jwk]

My list yesterday:

7:30-13:00
1. TEE/Cardioversion
2. Prone anal condyloma
3. same
4. same
5. hemorrhoidectomy (also prone)
6. lap chole
7. lap chole
8. inguinal hernia
9. inguinal hernia

13:00-14:00 had a break. Actually got to eat some real food in the cafeteria and complete some billing tickets.

14:00-18:00
10. Massive butt/thigh abscess on homeless, hemiplegic, alcoholic guy.
11. IM rod tibia.

18:00 home

Keys to safety AND efficiency:
1. Be neat, make it a habit. Keep your work area organized and as mentioned above, label EVERYTHING.
2. Be prepared. I call all my patients the night before so I can do a cursory "Hi, I'm Dr. X, got any last minute questions?" preop before the actual case.
3. Anticipate. This gets easier after you learn your specific surgeons and procedures.

Holy crap Batman - that's a bunch of cases in 4 1/2 hours!

 

[bubalus]

A few of my many eccentricities/habits:

I have the room turned over before I leave. I usually have a few minutes sometime during the case when I can pull out the new suction, ekg pads, etc as well as draw up my next induction drugs as well as any emergency drugs I may have used. By having everything ready, I extubate, spend 30-60 seconds plugging everything in while watching the patient closely, then leave the room. The next time I come back to the room, it's with the next patient.

All clean medications stay on the anesthesia cart. All medications currently in use stay on the anesthesia machine. If I only give 4 cc of fentanyl when I've drawn up 5, I cap the syringe with a rubber cap and write "dirty" and the patient's name on the label. It goes into a ziplock in my narc box to keep it separate from the rest of the drugs. We waste our drugs with the pharmacy tech at the end of the day. I only use the rubber caps for the dirty drugs, so that's another indication it's been used. Putting the patient's name on the syringe can help me track down that missing 1 or 2 ccs at the end of the day.

 

[sdn1977]

hey sdn - how's about wasting 20 epidural syringes [when the tech wasn't sure how much fent she added]? that was a bit of a paperwork, but i don't really care; fent's cheap and i'm not putting patients at risk. yes, we MAKE epidurals [our volume is heavy but not enough to justify the cost of contracting out]

about what drugs are you transmitting daily info to the DEA? that paperwork does not fall under my purview, but i know nothing we use gets reported daily.

Our CII Ns are transmitted in "real time" to DEA - part of the software. The time is the time they are removed from pyxis (since pyxis is still part of pharmacy). That allows us 24 hours (we stretch to 48-72 hrs) to reconcile discrepancies - a 106 form gets filled out.

The software bills at the time the drug is removed as well, so when the software goes down - all h*ll breaks loose paperwork wise!

CIII-V gets transmitted monthly.

We have much fewer restrictions on paperwork in the pharmacy - compounding rules are easier than administration rules - but, there are fewer players as well.

 

[UTSouthwestern]

Do you do "hypotension" on all your cases?

I call that low normal BP, in case you are wondering.

Definitely not. Just some of the ENT cases and the spine cases.

Keeping the BP in a very specific range that allows for a low systolic pressure with a mean of 60-65 requires a lot of micromanagement, judicious use of fluids, and a vicious minidrip of neosynephrine. It's worth it on the spines, but the ENT's want it all the time, even on your healthy 18 year old for FESS/septoplasty, etc. Fine by me - extra billing points.

 

[UTSouthwestern]

I agree with you. I start a lot of my pts with BP of 210/100. Run them most of the time at 120/80. Would you consider this controlled hypotension? I don't. In fact I'm on a neo drip most of the case.

Do we know how much hypotension is necessary to call it controlled hypotension? Is it 20% below baseline? What is baseline? Can you define it from one measurement 1 hr before the case(when pt's are the most anxious)? Most of us will agree on a MAP of 50-55mmHg (end point for most studies on controlled hypotension), unless the pt started like that.

Some of you might be asking who cares? But, this is very relevant. We charge 5 units for "controlled hypotension". Basically doubling the price of a short ENT case where it might be required, or 75 more minutes of anesthesia (4 units per hour). Why do we charge so much for it? Because it carries additional risk.

I think most people willl agree that in the above given example a MAP of 65 is not "controlled hypotension" in a pt with a starting BP of 122/56. That is normal perfusion pressure in a normotensive pt. Where are you exposing yourself so much that you merit an extra 5 units? Yet it was documented like so for the billing department. We have to have some clear end points, otherwise we can easily be accused of fraud.

This is why I had to point this out. Be very careful with your billing. You don't want to commit fraud inadvertently.

All very true points. It is important to clarify in your preop assessment, what the pt's baseline BP is during his/her clinic visits, home readings (if applicable), and preoperatively (I record a range of xxx-xxx/yy-yy). I then clearly state that my plan will include a drop in BP by 20-40% for minimization of blood loss. Some carriers do not consider this controlled hypotension and simply do not pay or consider it part of the anesthetic package and bundle it in with the base points (i.e., no matter what you do/record, they won't pay). For others, this is enough documentation. Since I can micromanage the pressure to a low SBP with mean around 60-65, I keep it there and document it appropriately. I could drop them to means of 45-50 with SBP's 75-80, but with my patient population, that typically is a drop of 40-50% and not worth the risk of compromising organ perfusion pressures, mostly in the long spinal reconstructions (older scoliosis patients, 360 fusions, etc.).

 

[jwk]

All very true points. It is important to clarify in your preop assessment, what the pt's baseline BP is during his/her clinic visits, home readings (if applicable), and preoperatively (I record a range of xxx-xxx/yy-yy). I then clearly state that my plan will include a drop in BP by 20-40% for minimization of blood loss. Some carriers do not consider this controlled hypotension and simply do not pay or consider it part of the anesthetic package and bundle it in with the base points (i.e., no matter what you do/record, they won't pay). For others, this is enough documentation. Since I can micromanage the pressure to a low SBP with mean around 60-65, I keep it there and document it appropriately. I could drop them to means of 45-50 with SBP's 75-80, but with my patient population, that typically is a drop of 40-50% and not worth the risk of compromising organ perfusion pressures, mostly in the long spinal reconstructions (older scoliosis patients, 360 fusions, etc.).

We've pretty much stopped doing "controlled hypotension" altogether, particularly those that want the means <60. We definitely don't do any controlled hypotension on spine cases any more.

 

[deleted87051]

Holy crap Batman - that's a bunch of cases in 4 1/2 hours!

One of our fastest and also excellent surgeons. Butt cases are 5-10 min (15-20min anes time), lap chole 20-25 min(about 35 min anes time.) One of the hernias actually took longer than average. The most challenging part of the cases are getting my notes/charting/orders done. Wish I had a stamper plate.