MILTON ANESTHESIA UPDATES

STAFF MEETING

JUNE 19TH 2018

AGENDA

1. Surgical Volume

2. Staffing

3. Pharmacy / Cardioversions

4. Equipment update

5. Shareable Ink

6. Meditech

7. Joint commission

6/21/2018 2

SURGICAL AND ENDOSCOPY VOLUME

Key part of the Milton Hospital Strategic Plan

Resources allocated for additional OR RNs, Surgical Techs and PACU, Holding

Area RNs (some posted some will be in near future)

Additional Orderly ( in addition to replacing Warren)

PAT adding per diem RNs to keep up with telephone volume (extra 0. 5 NP FTE

already added earlier – total 1.5 NP in PAT )

Major renovations in CPD and additional staff

Endoscopy* – leadership reorganization – Dottie now local Charge RN. Other

changes imminent

*Recognition that for 4 rooms need better throughput

6/21/2018 3

NEW SURGEONS / SERVICES

Orthopedics

Baratz ( TJ and revisions)

Dewire (Ankles / LE)

Sammy ( Hand / wrist )

General

Adra (Robotics / Bariatrics / Gen

Surg)

Gupta ( Bariatrics / Gen Surg) arrived

– operating soon

Ferrante (Vascular too)

Robotics Now daily blocks

Urology – Chang, Lin

Gyn – Li, Garrett , Lefevre

General – Cataldo, Adra, Bresnick

BTW - South Shore Urology – low

volume (one of the explanations behind

budget.)

6/21/2018 4

OR / VOLUME UPDATES

OR #8: May 2018 – dedicated robotic room (opened up block time for

robots every day )

Currently 2 rooms always staffed 3-5:30 pm - increasing to 4 rooms 3-5:30 in

September (and as needed now )

Endoscopy ( includes Bronchoscopy)

3 rooms daily ( except vacation & some Tuesdays)

4 rooms on 1st, 2nd, and 3rd Wed -starting July

New inpatient wing opening this summer

12 single rooms ( will decompress PACU)

Throughput Project with PWC Consultants just launched –

to look at patient progression for inpatients – may recommend changes to admitting

process (possible impact on PACU and floor discharges) 6/21/2018

-5

FY18 YTD Volume

Excludes minor procedures

Oct Nov Dec Jan Feb Mar Apr May FY18 Total

Inpatient 159 141 125 161 123 118 117 146 1090

Budget 140 140 149 145 149 156 179 189 1247

Prior Year 159 125 124 149 131 135 132 124 1079

BTA 19 1 -24 16 -26 -38 -62 -43 -157

BTA % 14% 1% -16% 11% -17% -24% -35% -23% -13%

Outpatient 236 207 200 238 214 267 266 270 1898

Budget 267 240 243 266 229 269 268 263 2045

Prior Year 236 218 228 224 159 259 199 260 1783

BTA -31 -33 -43 -28 -15 -2 -2 7 -147

BTA % -12% -14% -18% -11% -7% -1% -1% 3% -7%

Inp & OP 395 348 325 399 337 385 383 416 2572

Budget 407 380 392 411 378 425 447 452 2840

Prior Year 395 343 352 373 290 290 331 384 2374

BTA -12 -32 -67 -12 -41 -40 -64 -36 -268

BTA % -3% -8% -17% -3% -11% -9% -14% -8% -9%

Total

Outpatient*

Inpatient

ONE QUARTER TO GO …..

Volume up from last year (200 cases) – but behind budget overall

FY18 vs. Prior Year

Excludes minor procedures

COMPARED TO LAST YEAR

May Volume by Service

T arget Feb-2018 Mar-2018 Apr-2018 May -2018

SURGICAL SERVICES

Primetime OR Utilization (%) 75% 67% 68% 73% 73%

Cysto Room Utilization (%) 50% 53% 43% 39% 47%

7:30 On Time Starts (Wheels In) (%) 75% 75% 89% 78% 75%

9:00 Late Case On Time Start (Wheels In) (%) 75% 100% 100% 100% 100%

Average Turnaround Time < 28 mins 33 31 32 34

Cancellation within 2 days of scheduled surgical case (%)5 <2% 2% 3% 2% 2%

Cancellation within 2 days of scheduled minor proc (%)5 <2% 2% 1% 0% 3%

Add-on Cases (%) <=5% 7% 4% 12% 15%

Block Utilization (%) 85% 75% 70% 70% 68%

BID Hospital Milton Throughput Monthly Metrics

WEEKEND VOLUME

Robotic Program Volume

ROOM 8

ROBOTIC LAYOUT - TO BE CONTINUED

Room set up designed with Chang – works well for Urology / GYN

General Surgery / Bariatrics will be using Robot and the layout in the room is

different

Work underway to create schematics –which way to turn the bed and approach

from above or side (and need for extra ventilator tubing / long lines etc )

Will need to participate in mock ups this week

Want to use trenguard as much as possible – to reduce variation

6/21/2018 17

ENDOSCOPY

Updates

Volume 8-10 per room – approx 25- 30 per day and over 30 is increasingly common

In May 545 cases - 100 cases more than prior year ..

3 rooms always M,T, T, F and 4th Wed

4 rooms 1st, 2nd 3rd, & 5th Wed (Fiore)

Key points

No general endotracheal anesthesia in Endo – must go to ORs

GI on call coverage is a concern for hospital – possibly will see more off hours GI consults once this is addressed

Bronchoscopy (Dr Czieck)

Minimum do not start without Anesthesia MD aware and present (or immediately available )

Infusion Pumps

Ordered for Endo (good for Fiore and longer colons)

Might conserve Propofol

6/21/2018 18

SO … HOW ARE WE GOING TO HANDLE ALL

THE VOLUME ?

‘SMART’ Scheduling with OR booking and RN

Hire fulltime CRNA and fulltime MD

Flexibility and experimentation …

Need to maintain ‘integrity’ i.e. breaks and end of the day … .

In advance – thanks for patience .. .there will be growing pains !

6/21/2018 19

STAFFING: MDS

Barnett, Sheila 0.6 (-0.8)

Koropey, Andy 1.0

Part time <.06

Ma, Haobo

Ngo, Anh (til July 1)

Levy, Lior

Rakalin, Andrey

Zimmer, Scott

Akhouri, Vimal

Jankun, Jeff

New – from BIDMC

Tori Dervianko ( Aug /Sept 2018)

Simon Zhang Sept 2018

Open position for 1.0 MD FTE

Current 3 MD / day

Might need 4 / day in the fall at least a few days a week …

6/21/2018 20

STAFFING: CRNAS

Marriggi, Dan

Ambrus ,Claudia

McCabe , Darcy

Demartini, Betsy

Sheedy, Greg

Canini, Katy

Brown, Traci

Mangili, Hope

Stansberry , Liz

Cetrino, Lori

Boetello, Joan

Perdiem

Mary Beth Sebeti

Stacey Galvin

Kelly Ballestressi

I FTE open

Will need 10 daily (maybe some 9’s)

6 -7 in ORs

3 in Endo

4 in Endo on Wed * maybe 4th MD these days …

6/21/2018 21

IDEAL MODELS – FOR CONTINUED DISCUSSION

MD : CRNA Ratio

1:3 or 1:4

Free break person – either MD or CRNA on days all attendings covering 3 or 4 rooms

Always 4 late (10 hour) CRNAs after Sept and possibly 5 to cover Endo late finish

Late rooms could be an issue :

? Endo MD wraps up last room

Creative hours –

9 hour CRNA shift ( wrap up Endo )

Break ‘Shift / assignment’

Extra CRNA does dedicated hours in the day (ie come in later)

Perdiem partial days

Vacation issues when 10 hour CRNAs away - will still need coverage for 10 hours

6/21/2018 22

ITS NOT JUST VOLUME – QUALITY TOO

Several new surgeons – increasingly complex challenges

How do we stay up to date ?

How do we provide equal evidence based care everyday ?

MD or CRNA Liasons ? Experts in the group

Have an interest in the area – stay up to date

Help decide /communicate some ‘best practices’ or special requests

When changes made liasons included in RN / OR /MD discussions

Be the resource or ‘go to’ provider when someone has not done a case recently with that surgeon or done that case before

Survey Monkey Follow up

Questions / Suggestions anonymously

Volunteers 6/21/2018 23

TECHS AND EQUIPMENT UPDATE

Anesthesia Tech Coverage

6:30 to 7:00 pm Warren going Med School ! Last day in July –

Position posted

Ultrasound Machine

To be replaced, Demo’s today

Infusion Pumps

5 requested ( 4 Endo, 1 OR &)

Looking into preprogramming

Hemacue

Hopefully October – needs to be linked to Meditech 6.1

Stat labs in OR

Will follow up - ? Venous ABG

6/21/2018 24

VACATIONS, TIME OFF, BENEFITS

All CRNA scheduling in Q-Genda

Access online anytime …

Can see booked and remaining vacation time

Dan M updates Qgenda with changes frequently

CRNA Benefits – we can schedule Joanne ( from BIDMC) for a session later if would be valuable

If CRNA calling in sick

Call the on call attending or if you know Sheila /Andy on that day – just call them

Text Dan unless on vacation (has schedule access)

Must ‘close’ the loop before 7 am so adjustments can be made

ie if text need to receive confirmation read or call the person

If MD calling in sick

Call West call attending AS SOON AS possible

If able please also call or text Sheila / Andy

6/21/2018 25

PHARMACY :

RECONCILE MEDICATIONS REGULARLY 6/21/2018 26

0

200

400

600

800

1000

1200

May June July August September October NovemberDecember January February March April May June July

2017-2018 $$$$ Lost to Medications NOT Charged

$$$$$

CARDIOVERSIONS

In ICU or PACU

MD – enter Cardioversion Orders in Meditech – has propofol, neo, ephedrine. The

RN on the unit will bring to the bedside. Order can be placed the night before

when doing the tylenol orders. Please Sheila or andy if not sure where orders are

CRNA assigned ( from OR or Endo) should start the preop / consent (attending

generally busy with OR preops).

Do not take meds from other locations.

6/21/2018 27

SHAREABLE INK

Coming to ORs in next 1-2 weeks (waiting for Meditech parallels to end)

Will pilot a few cases – very easy same as endo and there are templates

Prints in PACU – we will print in PACU until the fall for nursing

Feel free to try it out with an ipad - just need to enter all patient info ( waiting

for schedule link)

Additional charger lines ordered – can be plugged into omnicell

Will help with billing / discrepancies

A Shareable ink rep will be onsite in June / July to see what other features

available

6/21/2018 28

MEDITECH 6.1 – OCTOBER 1ST GO LIVE

ORs will be PAPERLESS

NEW computers to be installed all ORs, PACU and HA

PAT NPs have been included since start for flow

MDs getting trained on orders this week (order sets in place)

ALL (CRNAs and MDs) will need training on how to complete a Preop from PAT and how to do do a Preop if telephone only interview …

Anesthesia Part is pretty intuitive and templated and tested ( at Needham)

OR schedule being reduced first week of October

In the OR we will be on Shareable Ink … so mostly orders, preop eval and any PACU Closeout

6/21/2018 29

JOINT COMMISSION – CHARTS AND ORS

FILL IN EVERYTHING!

Diagnosis, ASA, Type of Anesthesia, Airway

Preop Vital signs,

prior to

induction note

30

Check all the

little boxes

JOINT COMMISSION AND MEDICATIONS

Lock Pyxis

Do not leave medications / drugs around

Empty syringes before putting in red bin – esp propofol

Do not open blades / ET tubes in advance (or leave opened in the drawer)

Narcotic Discrepancy reports by pharmacy

Entered into patient safety reporting system

Provider notified must reconcile and return to HCQ within 7 days

Repeat offenders will be questioned

6/21/2018 31

ON THE INTRANET – BASIC INFO AVAILABLE

ABOUT MILTON -

6/21/2018 32

QUESTIONS & DISCUSSION

6/21/2018 33