Procedure Areas

Endoscopy Unit Efficiently

One thing we can all agree on is that identifying cancers by screening at an early, treatable stage saves lives. I’m going to make the argument that the most expensive cancer screening test is the colonoscopy if your endoscopy unit is not run efficiently. Other cancer screening tests are quick to perform and don’t require a lot of hospital resources – a patient can leave work to get a PSA, Pap smear, chest CT, or mammogram and be back at work an hour or two later. These screening tests don’t require sedation and they don’t require any special preparation. Colon cancer screening with colonoscopy is totally different:

  1. The patient has to take an entire day off work
  2. Because they receive sedation, the patient has to have an adult driver to take them home and stay with them for a few hours and that person needs to take the day off of work
  3. The patient requires a prep that adds a small additional cost but is often disliked
  4. If the prep is not adequate, then the patient has to take another day off work to come back for a repeat procedure
  5. The procedure takes somewhat more time than other cancer screening tests (30 minutes in a procedure room and additional time in a post procedure room)
  6. A physician and 1-2 assistants have to be scheduled to be in the procedure room for that 30 minutes and a recovery nurse has to be scheduled for 30-45 minutes to care for the patient

Therefore, it is essential that the colonoscopy process and the endoscopy unit have maximal operational efficiency. The goals are to have every patient show up, have every colon prep be excellent, and have a process to move patients through the endoscopy unit smoothly. If patients have poor preps and have to take an additional day from work to have a second procedure, then the indirect costs of lost work hours and cost to the employer can result in the making this a very expensive screening test. You also want to avoid having the physician or the nursing staff standing around doing nothing if the patient does not show up for a scheduled procedure. So here are some of the considerations:

The colon prep

As a general rule, patients will dislike the prep more than they dislike the procedure. There are several preps that can be used, the most common are the GoLYTELY prep and the Miralax/Dulcolax prep. 

  1. GoLYTELY. This is a solution of polyethylene glycol. The patient drinks about a gallon of it and it goes through the GI tract without being absorbed so it flushes anything in the intestines out. Many gastroenterologists believe that this prep gives the best results by leaving the colon free of any stool or undigested food. However, patients generally do not like the large volume required to be consumed. This can be partially overcome by doing a “split prep” when the patient drinks 2 liters of GoLYTELY the night before the colonoscopy and 2 liters early in the morning of the colonoscopy. The other downside of GoLYTELY is that it has to be prescribed by a doctor – this can often be a challenge because sometimes, the primary care physician is uncomfortable ordering preps for procedures if they are unfamiliar with the preps and the gastroenterologist or surgeon doing the colonoscopy is usually seeing the patient for the first time when he/she is wheeled into the procedure room and they often don’t want to prescribe something for a patient before they ever see them. GoLYTELY is FDA-approved as a colonoscopy prep
  2. Miralax/Dulcolax. Both of these are available over the counter. The patient takes the Dulcolax tablets the day before the colonoscopy and then mixes the Miralax in 2 quarts of Gatorade and drinks it. The total volume is half that of GoLYTELY, which makes this a preferred prep by many patients. But some gastroenterologists believe that it does not clean out the colon as well as GoLYTELY. Because Miralax and Dulcolax are available over the counter, there is no controversy about which physician will prescribe the prep. This is not an FDA-approved indication for these medications. There are rare reports of ischemic colitis developing with this prep.

The bottom line: Because a poor prep (requiring a repeat procedure) is very costly to the patient and the patient’s employer, it is critical that you give a patient a prep that they can take and that works. Split-dose preps are better in most situations and the lower volume of the Miralax/Dulcolax prep may give it an advantage over GoLYTELY for many patients.

Scheduling the colonoscopy

For patients who don’t work or who are retired, getting their procedure done on a weekday morning is often preferred. That way, they don’t have to be NPO or restricted to nothing but clear liquids for excessively long. Some patients can’t afford to take a day off of work and for them, having Saturday colonoscopy schedules may be preferred. Other patients may prefer an afternoon or evening colonoscopy so that they (or their driver) only has to take part of a day off work. So, you need to survey your patient population and cater to their preferred time. Moreover, an endoscopy unit is an expensive investment for the hospital and you want to be sure that you use it to capacity. Consider opening the endoscopy suite one Saturday a month and doing both morning and afternoon weekday schedules.

The navigator

As you can see, it is critical that the patient does the prep right. And although a colon prep seems like an uncomplicated thing, there is a lot that can go wrong. This is where the “navigator” comes in. They are kind of like colonoscopy coaches – they call the patients several days before the prep to be sure that the get the right medications/supplies and know what to expect. They call the patient the day of the prep to be sure that they are doing it correctly and that they have a driver arranged. The patient can call them if they have any questions. The navigator doesn’t have to be a nurse – it can often be someone with considerably less education but who communicates well and has common sense. Studies have shown that by using a navigator, the no-show rate and the poor-prep rate improve considerably. This is particularly true if your patient population is older, lower income, or has lower healthcare literacy.

Identifying patients at high risk for sedation

Not all patients can safely undergo moderate sedation administered by the physician performing the colonoscopy. These high-risk patients need sedation administered by an anesthesiologist who can devote total attention to keeping the patient safe during sedation. Patients who are sometimes better suited to have an anesthesiologist include those with sleep apnea, those with significant heart or lung disease, those who have been difficult to sedate in the past, etc. You need to develop a mechanism to identify these patients before they show up in the endoscopy unit for their procedure so that you can schedule them at a time and location where there is an anesthesiologist available. Since the physician performing the colonoscopy does not see the patient before the hour of the procedure, there has to be some way to catch these patients so that you don’t have to turn them away and reschedule them on another day. Options can include having scripted questions that your schedulers or the navigator ask the patient, having a nurse review the patient’s information in the electronic medical record the week prior to the procedure, or asking the primary care physicians to request the procedure to be done with or without an anesthesiologist. The latter option generally does not work because the primary care physician is generally uncomfortable making a decision about the type of sedation or anesthesia since they are not trained in doing so. Having a nurse review the EMR may work when all of the primary care physicians in your community are using the same EMR that you do but in most communities, this is not the case.

Room turnover time

Just like operating room turnover times are a metric of OR efficiency, endoscopy procedure room turnover times are an important metric of endoscopy unit efficiency. The first step is to develop a way to measure it regularly. Then figure out what slows it down. If you have one person who cleans the room between procedures and you have 3 procedure rooms, then consider staggering the scheduled start times for each procedure room so that when the room cleaner finishes with one room, the next room is ready to be cleaned and prepared. Sometimes, it is cleaning the equipment rather than cleaning the room that increases the length of time between procedures. If this is the case, then you may need an additional scope washer or just plain more scopes. You need a minimum of 2 colonoscopes and 2 upper scopes per procedure room.

Sedation time

The quicker the patient is sedated, the shorter the time that the physician and endoscopy staff have to wait in the procedure room to start the procedure. Also, the faster a patient wakes up after their procedure, the faster he/she can be discharged and  thus free up a pre/post procedure room and nurse. Fentanyl and Versed are a commonly used sedative combination but typically, you have to wait 3 minutes between re-dosing patients. If a patient unexpectedly turns out to require a lot of fentanyl and Versed to get adequately sedated, it may be 9 or 12 minutes before the procedure can start. Some endoscopy units have gone to using propofol for sedation because of its rapid onset and rapid recovery; however, in Ohio, nurses are not able to administer propofol for procedural sedation so you have to have a second physician (usually an anesthesiologist) on hand. If your physicians are using longer onset of action drugs like lorazepam and Demerol, then the sedation times will increase.

Physician charting time

The physician may do 16 or more procedures during a full day and you want that physician spending as much time in the procedure room doing procedures as possible. Therefore, you want to have a process for them to chart their pre-procedure assessment and their post-procedure note as rapidly as possible. If you require them to spend 15 minutes hand-writing their notes, then the physician will not be able to do as many procedures in a day. We use Provation for our documentation and it works pretty well. Try to get the charting time down to < 3 minutes.

Adenoma detection rate

If you focus too much on pushing your doctors and staff to do procedures faster, then they may not be doing as thorough of colonoscopies. One way to measure this is the adenoma detection rate. If your doctors find adenomas in relatively few patients, then they are probably missing some. You have to be a little careful because the incidence of adenomas can vary depending on the different patient demographics. For example, the incidence of adenomas in men is higher than in woman and the incidence is different in older patients than in younger patients. Also, the incidence of adenomas is higher in surveillance colonoscopies than in screening colonoscopies. Therefore, a lower adenoma detection rate does not necessarily mean that one doctor is sloppier than another – he or she may just have a different patient demographic. As a general guide, adenomas should be found during screening colonoscopies in 15% of women and 25% of men. Therefore, if your doctors are consistently finding adenomas in only 10% of their screening colonoscopies, then you have a problem.

This can all seem pretty overwhelming for a medical director who is not a gastroenterologist. So, here is my recommendations on where to start with collecting efficiency metrics from your endoscopy unit:

  1. Cancelation rate
  2. No-show rate
  3. Poor prep rate
  4. Number of procedures per room per day
  5. Room turnover time
  6. Adenoma detection rate

Develop a mechanism for regular reporting of these metrics. Once you get comfortable with these basic metrics, then you can drill down on other metrics to fine-tune your operational efficiency. If you have an efficient endoscopy unit, then colon cancer screening is no long the most expensive cancer screening test.

July 1, 2017

Inpatient Practice Procedure Areas

Optimizing Hospital Inventory: Sometimes Something So Simple…

Ever have one of those moments when someone presents a new idea and you think, “That just makes way too much sense”? This week, I listened to a presentation by one of our health system’s supply chain directors who presented a new way of managing terminal distribution supplies.

If you have worked for more than about a week in a hospital as a physician or a nurse, then you have had the experience of walking into a supply room on a nursing unit and seeing something like this. Bins of supplies stacked on top of each other and overflowing with syringes, gauze pads, and telemetry leads. Its a mess. If you can even find the bin you are looking for, there is a good chance the person before you took the last one of the items that you wanted. And when you have a JCAHO site survey, the surveyors always head straight to the supply room when they walk into a nursing unit and then dig their hand into the most full bin and pull an item from the bottom of the bin… and the date on it will inevitably be expired, resulting in a citation. Supply rooms were like the first day I walked into the hospital as a 3rd year medical student in 1982 and supply rooms are like that now, 35 years later, in 2017.

So, here was the solution from our supply chain genius. Instead of having one large bin for each item, have 2 small bins, one in the front and one in the back. You stock each bin with a projected 5-days worth of that item. Each bin is bar-coded for inventory management. This is known as a “Kanban” inventory control system

When you use up all of the item in the front bin, you pull the empty bin and leave it out for your central supply personnel to pick up. You then pull the back bin forward and start to use items from it. The central supply staff re-stock the empty bin and replace it behind the front bin. Here’s what happens:

  1. Your central supply personnel know exactly how fast you are going through each item so that your nurses don’t need to ‘guesstimate’. By using the bar code on each bin, you can monitor item use on the computer real-time.
  2. You can adjust the number of each item at your terminal distribution supply room based on use, thus optimizing your space utilization.
  3. The supply room becomes less cluttered.
  4. The square foot requirement in the supply room actually drops.
  5. You dramatically reduce the risk of having expired items in your supply room.
  6. You eliminate all of the time that the nurses are “taking inventory” of everything in the supply room and give them back time to do patient care.
  7. You save money

There are some caveats, however. The nurses have to be trained so that they always remove items from the front bin and know to pull the empty bins out for re-stocking. If your patient population on any given nursing unit changes, then your product use rate can change, so you have to continually monitor how quickly you are going through bins in each supply room.

This is one of those ideas that when you hear it, you ask yourself, “So, why didn’t I think of this before?”.

March 31, 2017

Procedure Areas

The Dialysis Blues

dialysisEnd-stage renal disease has been driving me crazy recently. When no one else will dialyze you, the hospital has to. There’s this thing called EMTALA law that requires us to treat you if you show up in our emergency department. Let me tell you about a few of our more exasperating patients that could fill out the entire cast in a theater of the absurd. In order to prevent being presented with a subpoena from the HIPAA police for violating patient confidentiality, I’ve made a few changes to the details, but not too many.

First case is a lady who decided that what she really wanted from Santa for Christmas was a new Glock handgun. The perfect fashion accessory for the woman who has everything. She was really proud of it so she showed it off to all of her friends at her dialysis center. The problem is that the dialysis center had a zero tolerance policy for patients bringing in hand grenades, surface-to-air missiles, nuclear bombs, and other weapons into the dialysis center. So she was banned for life from returning. Because she still needed dialysis that day, she came to the emergency department and got admitted. And we dialyzed her. And for a hospital, once you dialyze a patient, you own them forever. So it became our problem to arrange for regular 3-times a week outpatient dialysis. But the word got out and none of the other dialysis centers in town would take her. So, we were stuck with doing her dialysis. But the problem is, we are certified as an inpatient dialysis unit and not as an outpatient dialysis unit. Therefore, her insurance company said that the only way they would pay us to dialyze her was if she was an inpatient.  So, rather than having her just show up 3 days a week in the dialysis unit, get dialyzed , and go home, we had to admit her. The problem is that the insurance company wouldn’t pay for an elective hospitalization for renal failure, only an emergency hospitalization for renal failure. The only way we could get paid was to have the patient come into the ER, be seen by the ER physician, get labs to prove that her potassium was too high and her bicarbonate was too low, get admitted to the hospital, have a resident do an H&P and admission orders, get a nephrology consult, get dialyzed, and then have the admitting service do a discharge summary. Fortunately, after a couple of months, one of the private dialysis centers came through and accepted her… but only after we had proven that she wasn’t packing a gun any more by going through the metal detector in the emergency room every Monday, Wednesday, and Thursday for 8 weeks.

Second case is a guy from Nicaragua who decided to come visit his son in the United States. The only problem was, he didn’t have a passport. And his kidneys didn’t work. So, he jumped the fence in Texas and hitched a ride to Central Ohio. A couple of months later, he ended up in our emergency room with uncontrolled hypertension and kidney failure. We dialyzed him… and then we owned him. He got a dialysis access fistula but since he was an undocumented foreign national (the politically correct term for illegal immigrant) with no health insurance, no dialysis center would take him. And so now he comes into the ER every Tuesday and Friday and gets dialyzed. He needs medications for his blood pressure and his other medical problems but he can’t afford to buy them so he doesn’t take them. It turns out that this is not such an infrequent occurrence. What one of the private hospitals in Columbus does is when they get a patient like this, they don’t want to have to mess with doing the dialysis so the hospital actually pays a private dialysis center to do the dialysis. A hospital in Chicago tried to deal with a similar situation by arranging for their patient to be deported but there was such a public opinion outcry that they backed off. Since we are a State hospital, we can’t pay for a private dialysis center to do dialysis on an undocumented foreign national (lest it be perceived we are using taxpayer dollars to pay someone to dialyze an illegal immigrant) and we don’t want to risk the public relations nightmare of deporting someone’s poor grandfather because we won’t treat his medical problems.

The third patient got off of a plane at John Glenn International Airport after a long flight from Kenya. She hopped in a cab and came straight to our emergency department because she needed her regular dialysis. It seems that she sort of forgot to check the box on the visa form about having end-stage renal disease and needing dialysis three times a week. She wasn’t going to get back on the plane so we admitted her and dialyzed her… and then we owned her. Fortunately in her case, a local church group raised dialysis money and one of the local private dialysis centers took her on a cash basis.

In these situations, no one wants to pay for the dialysis for these patients. So what happens? We all pay for it. Because even though our hospital covers the cost of dialysis, we do it using the margin that we make from all of the insured patients, Medicare patients, and Medicaid patients that come through our doors. And it is the same for every patient that we take care of who is uninsured. Their care is paid for by everyone who pays payroll taxes and health insurance premiums. So when we dialyze them, American owns them.

November 2, 2016