Be Indispensable !

Strategies for New Graduate Success in the ASC

A recent headline from Amednews; the on-line news service of the American Medical Association is foreboding: “Hospital mass layoffs hit new high in 2009”. Unlike my graduating class of 5 in 1987 who all took jobs in large hospitals, our current graduating SRNAs may not have that option. Among the various clinical rotations SRNAs are exposed to, Ambulatory Surgery Centers (ASCs) are unlikely to have been a major concentration, yet for our new graduates these facilities may provide their best option. While the foundation of patient safety and professionalism are at the core of our practice, expertise in the ASC requires it’s own mind and skill set.

Be a Boy Scout

Be Prepared!! Upon graduation I made sure to get assigned to every complex procedure I could find. This gave me confidence and helped me to develop my perception of myself as a professional. I’d certainly advocate that our current SRNAs follow a similar track but you may have to do it in your last months of school! Not only should you find the tough cases but also, if you know your first job is going to be in an ASC, seek out some additional experiences.

While efficiency and cost-effectiveness initiatives have made some inroads in hospitals, they are mantras in the ASC. Rapid turnovers and timely discharges from the ASC are crucial to facility success. As an employee or contractor at an ASC you have a huge stake in its success; it’s career security! This translates clinically into patients who reanimate quickly from their anesthetics and are pain and nausea free.

You are unlikely to have help in turning over rooms, no one to keep things clean and organized, change a circuit, draw up drugs, and check CO2 absorbers, vaporizers or O2 tanks. Patient charts will be thin with few lab results. Develop a routine for patient interviews that prioritizes and maximizes obtaining relevant info, while putting patients at ease. Frequently you’ll interview patients who would be poor candidates for major surgery but will be acceptable for cataract extraction, endoscopy and many other less invasive procedures. Not knowing the difference can lead to inappropriately delayed or cancelled cases and intra-provider angst.

In your last months as a student take advantage of opportunities to get exposed to, manage and place as many regional anesthetics as possible; not only spinals and epidurals, but intra-scalene, axillary, Bier, femoral, digital, ankle and peri-bulbar.

Get comfortable with deep sedation techniques (ketamine is your friend!) and the characteristics and use of local anesthetics. During deep sedation cases get used to listening with a pre-tracheal/cordial stethoscope; treat patients not monitors!

And, by all means, get comfortable doing pediatrics. By the time you graduate, you need to be confident that you can do it all; start small IVs in the elderly, push your own induction agents and intubate, treat hypo or hyper-tension, manage fluids, convert to a general or deep sedation case after a failed or expired regional, mask induce a child, maintain spontaneous ventilation, place the IV, give a paralytic AND intubate that youngster.

Sounds obvious but…you must be proficient at handling the airway. A typical ASC staffing pattern means you must be a full service provider. It is likely that in an emergency such as laryngospasm there will not be an extra set of hands. You must be able to recognize and treat immediately: positive pressure? Succinylcholine? LMA? In your last months as a student find a way to do some longer mask cases. Being skilled with a mask can save a life. Also be skilled with many types of advanced equipment and techniques: Fiberoptic, Glidescope, light wand, Shikani, etc. Internalize the difficult airway algorithm.

Develop a tried and true regimen for the prevention of nausea and vomiting. (I like glycopyrolate and metaclopramide pre-op, dexamethasone, propofol, and oral gastric tubes intra-op, and a 5HT3 antagonist before emergence)  Spend some time in PACU to learn nausea and vomiting rescue techniques.

Anesthesia is a Business

This is never more obvious than in the ASC. Staffing is designed to promote efficiency and contain costs. But in order to accomplish this, both you and your employer need to establish expectations and obligations. This is best accomplished with a contract. While this subject is too large to fully discuss here, at a minimum make sure your time for performing your job is well clarified, and your rate of pay and benefits clearly noted. Pay careful attention to malpractice insurance. If your employer is providing it, make sure you see a policy with your name on it. Is it “claims made” or “occurrence” coverage? Will you need a “tail” if you change employers? If you are assigning your billing rights to your employer, are policies in place to assure compliance with the TEFRA regulations? Remember that the TEFRA regulations are rules for billing not clinical standards of anesthesia care.

http://www.cms.hhs.gov/center/anesth.asp
http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf (Chapter 12, Section 50)

As a professional you must be aware of and comply with these federal regulations or risk fraud charges, the penalties for which are not only monetary, but can lead to removal as a Medicare provider which renders you essentially unemployable.

http://www.outpatientsurgery.net/issues/2007/12/coding-billing

Make sure you understand any “non-compete” clauses that would limit your employment options down the road. Will you be a W-2 employee or 1099 contractor? The difference is huge!

While it should be a part of any new employee orientation, make sure you carefully review the ASCs Policies and Procedures Manual. You can be certain that in the event of a malpractice action that the plaintiffs’ lawyer will. Not following these written policies can be very damaging at trial.

In Florida, make sure you and your employer file the proper protocol (a sample is available at FANA.org) with the state agencies and that you are properly credentialed at the ASC. Also make sure you are familiar with the Medicare regulations for ASC’s. http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter09_3...

You might also want to check out the ASC and the other professionals you’ll be working with via the Practitioner Profile at http://www.doh.state.fl.us/mqa/ Don’t forget to check yourself out to insure accurate data is available to the public. And finally you might want to use an Internet search engine like Google or Bing to see what other information is available about your new place of employment and colleagues.

Just the Beginning

Should you find your first job in an ASC you’ll need to do double duty in insuring your ongoing education. Continuing Education is a hallmark of the professional. While many of your hospital based colleagues (particularly in teaching facilities) will have continuing education delivered to them on site complete with the newest technologies and techniques, you not only need to find that information but also find ASC-specific education. You’ll need to find learning experiences with hands on opportunities for regional techniques, especially if you did not get a thorough grounding while in school. AANA and FANA provide many such opportunities, as do many of the private educational companies.

You might also consider doing some locums work to keep clinically current and utilize those skills you learned in training but don’t frequently use in the ASC. (We just don’t treat that many trauma victims or start central lines or run dobutamine drips!) Since ASCs are usually Monday-Friday no call jobs, you should be able to find some time to do this. Besides, a little extra cash flow will help pay off those school loans!

The best ASC professionals strive to make themselves indispensable by virtue of their clinical competence, excellent interpersonal skills, attention to detail, attentiveness to the regulatory and financial issues peculiar to ASCs and a willingness to “go the extra mile” to insure facility success. In the small world of an ASC there’s really no place to hide!

Be indispensable.

Jay Horowitz, CRNA