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Surgical Schedulers' Toolkit

Introduction

Best Practice Scheduling and Pre-Procedural Preparation

Scheduling
Accurate scheduling is essential in order to institute optimal planning for the Preadmission process as well as preventing cancellation/delays on the day of surgery. Schedule chaos prevents optimal planning, “burns out” staff and saps surgeon confidence.

Order Facilitator is the preferred method to use because telephone calls often lead to mistakes in procedure, site(s), and length of case time. Please obtain a complete record of demographic information needed to contact the patient and signed physician orders for the pre-admission department nurses. Guidelines and algorithms for scheduling the case and the PAT appointment are in this section.

Pre-Procedural Preparation
The Pre-Procedural evaluation of a patient is guided by the invasiveness of the procedure and the co-morbid conditions of the patient.

Laboratory studies needed prior to surgery, if not communicated to the PAT Clinic personnel preparing the patient for surgery, may result in a delay or cancellation on the morning of surgery.

I. Scheduling
     a. Scheduling Information and Algorithms
     b. Orders and Forms required for Scheduling
     c. Pre Anesthesia Testing Guidelines and Algorithms

What's in this Toolkit?

Scheduling

 

 Pre-Anesthesia Testing (PAT)

 

 

 Registration & Financial Information

 

Scheduling
Requirements for Scheduling

In order to schedule/pre-register a patient for surgery or procedure, a physician order that indicates the expected patient status is required.

This applies to all patients who are not in WakeMed acute care facility at the time of scheduling.

Accurate scheduling is essential in order to institute optimal planning for the preadmission process as well as preventing cancellations/delays on the day of surgery. Schedule chaos prevents optimal planning, “burns out” staff, frustrates patients and saps surgeon confidence

Patient Status

INPATIENT
OPA – Acute Inpatient admission [Outpatient to be admitted]

  • Medicare – surgery planned IS listed on Addendum E (CMS inpatient only) list
  • Medicaid – surgery planned IS listed on the InterQual “inpatient only “ list and MD intent is inpatient
  • Other payers as authorized

OUTPATIENT
OPB – Outpatient to a bed

  • Medicare, Medicaid, Self pay, most commercial insurers
  • Patient is coming in as an outpatient for OP surgery/procedure and possible overnight stay planned
  • Placed in a bed for a short period of time
  • For Medicare/Medicaid – surgery to be performed is NOT on the “inpatient only” list

OBS - Observation

  • NEVER use for Medicare/Medicaid planned surgery/procedure
  • Plan is to be placed in a bed for an extended period of observation services
  • Used by a limited number of Commercial payers
  • May require an overnight stay

OPH – Outpatient Home

  • Patient is coming in as an outpatient for planned OP surgery/procedure and plan is to return home.

WakeMed Surgery Scheduling and Pre-Registration Process

In order to schedule/pre-register a patient for surgery or procedure, a physician order that indicates the expected patient status will be required. This applies to all patients who are not in a WakeMed acute care facility at the time of scheduling.

A patient status order indicates one of four categories indicating that after surgery the patient is expected to:

  • Return home (OPH); OR
  • Be placed in a bed for a short period of time (OPB); OR
  • Be placed in a bed for an extended period of observation services (OBS); OR
  • Be an inpatient (OPA or Acute Inpatient).

Inpatient status generally indicates that the patient is expected to spend at least one night in the hospital (Status=OPA or Acute Inpatient). To clarify, patients placed in a bed for a short period of time (Status=OPB) or for extended observation services (Status=OBS) may spend the night in the hospital even though they are not classified as an inpatient.

Medicare has established a list of procedures that can only be performed on an inpatient basis. This list is commonly referred to as Addendum E. If a procedure is on Addendum E, and the patient is Medicare, then Medicare will not cover the procedure unless the patient status is inpatient. With the exception of Addendum E procedures, it is okay for the status order to change after scheduling the patient if it is determined that another status would be more appropriate. A change of status always requires a physician order.

2013 CMS Addendum E Inpatient Only List

If the patient you are scheduling is not currently in a WakeMed acute care facility, then there are three options for providing this order to the surgery scheduler:

Option 1

  • Enter the order via Order Facilitator. NOTE: this is an electronic scheduling option that is being rolled out to practices. If your practice does not yet have this, please call the WakeMed IS Help Desk at (919) 350-8700 to arrange for set up and training for this option.

Option 2

  • Fax the WakeMed Surgery Scheduling fax form AND the WakeMed Day Surgery Pre-Op Orders/H&P form to the fax line. Raleigh: (919) 350-7554; Cary: (919) 350-2285; North: (919) 350-6892 WakeMed Day Surgery form must include a Patient Status and a Physician signature which is dated and timed.

These forms are available at www.wakemed.org > For Our Providers > Patient/Physician Forms.

Option 3

  • Call the Surgery Schedulers at (919) 350-7000 and fax the forms to Raleigh: (919) 350-7554; Cary: (919) 350-2285; North: (919) 350-6892 prior to calling. (Please note: Fax program takes a few minutes to receive and catalog the fax. Please allow 10 to 15 minutes before calling so the fax can be received.)

History & Physical Requirement

  • A History and Physical (H&P) exam must be completed within 30 days of the scheduled surgery and preferably prior to the Pre-Anesthesia Testing (PAT) visit. All H&P forms must be signed, dated and timed by the licensed independent provider (LIP). It is important to note that the History and Physical must be current (exam must take place within 30 days of surgery).

Scheduling ALERTS
Please share any of the ALERTS below at the time of scheduling:

  • AICD
  • ALT FACILITY RESIDENT
  • BETA BLOCKERS
  • BLEEDING DISORDER
  • COCHLEAR IMPLANT
  • CUSTODIAL FORENSICS
  • GLUCOPHAGE
  • History of Malignant Hyperthermia
  • IMPAIRED HEARING
  • IMPLANT
  • MENTAL IMPAIRMENT
  • IMPAIRED MOBILITY
  • IMPAIRED VISION
  • INTERPRETER NEEDED
  • IODINE ALLERGY
  • ISOLATION AIRBORNE PRECAUTIONS (i.e. TB, varicella zoster, shingles/chickenpox, measles)
  • ISOLATION AIRBORNE FULL BARRIER
  • ISOLATION CONTACT (i.e. MRSA)
  • ISOLATION DROPLET (i.e. pertussis, influenza virus, rhinovirus, meningitis, group A strep)
  • ISOLATION ENTERIC (i.e. E. coli, shigella, hepatitis A, rotavirus)
  • LATEX ALLERGY
  • PRIVACY REQUESTED
  • RELIGIOUS OR CULTURE REQUEST
  • VENTILATOR DEPENDENT
  • WEIGHT >250

WakeMed Perioperative Services: Preanesthesia Testing

Guidelines for Surgeon Offices

All patients having surgery at WakeMed require either a preanesthesia testing (PAT) telephone call or PAT Clinic visit prior to the day of surgery to allow for thorough preoperative evaluation, diagnostic testing and education.

PAT Clinic Visit should be scheduled within 14 days of the surgery at the time of surgery scheduling for patients meeting any of the following criteria:
1. Medical problems that warrant further evaluation or special preparation – based on PAT Triage Questionnaire or surgeon request
2. Patients to be admitted to the hospital postoperatively (OPA)
3. Patients having robot-assisted surgery

PAT Telephone Interview will be performed for the following patients:
1. All patients under the age of 13
2. Patients having cataract surgery
3. Patients who do not meet other criteria for a PAT Clinic visit

If, during a telephone PAT interview, the patient is found to require a PAT Clinic Visit, then the clinic appointment will be scheduled with the patient at that time and your office will be notified.

All patients being scheduled for surgery should be screened in your office using the PAT triage questionnaire and scheduled for a PAT Clinic visit if medically appropriate.

In addition, patients with multiple medical problems frequently benefit from a PAT clinic visit, even if they don’t meet specific criteria.

If a patient with known medical problems does not attend a scheduled PAT clinic appointment, your office will be contacted to reschedule the patient for a different surgery date/time.

 

 

 

WakeMed Perioperative Services: PAT Scheduling Algorithm for OneCall Schedulers 

Scheduling Algorithm - Order Facilitator eFax Pilot algorithm 

Appendix 1: Preanesthesia Testing Guidelines for Surgeon Offices
All patients who will have surgery at WakeMed require either a preanesthesia assessment and testing (PAT) phone call or PAT Clinic visit prior to the day of surgery to allow for thorough preoperative evaluation, diagnostic testing and education. Click for more details on the PAT Clinic visit, the PAT phone interview and the questions that will be asked of the patient.

Pre-Anesthesia Testing (PAT)
Scheduling & PAT Guidelines

Preoperative Documentation Requirements:
1. Surgeon H&P: Signed, dated and timed < 30 days preoperatively
2. Surgical consent: ideally completed, but must at least have complete procedure written on form (frequent discrepancy between consent and OR schedule)
3. Surgeon Orders: completed including admission status, signed, dated and timed
4. Medical Clearances/Specialist Consults: completed, with all supporting documentation present

Documentation Reconciliation Process:
1. Surgeon orders, including admission status, must be on file prior to any PAT.
2. PAT Clinic staff will contact the surgeon's office two business days before the surgery date if any of the four elements above are not present.
3. At the huddle at 1 pm at Cary and 2 pm at Raleigh on the day before surgery, if any of the elements are still missing, the surgeon's office will be contacted.
4. If any of the missing documentation is likely to delay a first case, then the case will be rescheduled or the case order will be changed after consultation with the surgeon's office.
5. Absence of consent or H&P in a 'consentable' patient will not affect case timing.
6. Patients with guardianship must have anesthesia and surgical consents completed and on file prior to the day of surgery.
7. The chart reconciliation nurse will check the H&P on file to ensure that it will not be out of date on the day of surgery.

First Case Scheduling Guidelines:
1. No first cases with significant chart deficiencies
2. No first cases for facility patients (nursing home, prison) without director approval

PAT Clinic Visit Guidelines:
1. Patients meeting medical criteria based on PAT Triage Questionnaire
2. Patients to be admitted (OPA) to the hospital
3. Patients having robotic procedures
If a patient is found to have significant comorbidities during a telephone PAT, they will be scheduled for a PAT visit via OneCall while on the telephone with the PAT nurse.

Coronary Stents and Antiplatelet Drugs
WakeMed Perioperative Services has collaborated with physicians from the Departments of Cardiology, Surgery and Anesthesiology to create a process by which patients receiving antiplatelet therapy for the protection of cardiac stents are managed during the perioperative period.

Background:
Patients are prescribed antiplatelet drugs such as Plavix (clopidogrel), Effient (prasugrel), and Ticlid (ticlopidine) for prevention of blood clots following the placement of a coronary artery stent. These drugs are continued for at least three months and sometimes for life.

Antiplatelet drugs are associated with increased bleeding during surgery. Many invasive surgeries and anesthesia procedures (i.e. nerve blocks, spinals, epidurals) cannot be performed if a patient is on these drugs.

Patients with coronary artery stents are at risk for perioperative myocardial infarction (MI) and death when antiplatelet drugs are discontinued for surgery, especially if the stent has been in place fewer than 12 months.

Antiplatelet drugs must not be stopped without the explicit approval of the physician who prescribed the drug.

Patients with coronary artery stents who are on antiplatelet drugs must be seen in the PAT clinic and complete documentation of preoperative cardiac evaluation and antiplatelet drug management instructions must be provided on form N-372 (Request for Preoperative Cardiac Evaluation)

Preoperative Cardiac Evaluation
The following patients must have a preoperative cardiac evaluation by a cardiologist prior to all procedures1, including endoscopy procedures:

  • Patients who have undergone placement of a coronary artery stent in the last 12 months.
  • Patients who are on Plavix for protection of a coronary stent placed at any time in the past.

If a patient with any of these problems does not have the appropriate preoperative evaluation and documentation, the procedure will be cancelled on the day of surgery.

Patients with a history of cardiovascular disease will need preoperative cardiac evaluation prior to most procedures. This includes history of the following:

  • Coronary artery disease (including angioplasty, stents, or bypass surgery)
  • Congestive Heart Failure
  • Heart valve disease
  • Arrhythmias (atrial fibrillation, supraventricular tachycardiac (SVT), Wolff-Parkinson-White)
  • Stroke

Please facilitate the preoperative evaluation process by having the patient see the cardiologist before the PAT clinic visit and ensuring that the necessary documentation is completed and sent to the PAT clinic prior to the PAT clinic appointment.

The process for obtaining preoperative cardiac evaluation is as follows:

1. Surgeon's office schedules appointment with the cardiologist, completes the top of the "Request for preoperative cardiac evaluation" form  (form N-372) and faxes to cardiologist. 
2. Cardiologist performs evaluation and returns completed form and consult to surgeon's office.
3. Surgeon's office faxes copy of form and cardiology materials to WakeMed pre-op clinic.

1The only exception is patients having cataract surgery who will remain on the antiplatelet drugs perioperatively.


Perioperative Management of Pacemakers and ICDs
WakeMed Perioperative Services collaborated with physicians from the Departments of Anesthesiology and Cardiology to create a process by which patients with implanted pacemakers and defibrillators are managed during the perioperative period.

Summary:
Any patient with a pacemaker or defibrillator (ICD) device must be scheduled for a PAT clinic visit, with the exception of cataract patients.

If perioperative device reprogramming is necessary on the day of surgery, WakeMed will arrange this with the device representative.

The information form (N- -765) is sent to the cardiologist who manages the patient's device, not necessarily the patient's primary cardiologist.

This process is best initiated by the surgeon's office prior to the PAT clinic visit to ensure that information is available at the time of the visit.

As a courtesy, the PAT clinic will initiate the process for any patient who is seen in the PAT clinic more than seven days before surgery. Otherwise the surgeon's office will be asked to initiate the process.

WakeMed Perioperative Services Perioperative Management of Pacemakers and ICDs.


Adult Diagnostic Testing Guidelines
WakeMed Perioperative Services Adult Preoperative Diagnostic Testing Guidelines.

Pediatric Diagnostic Testing Guidelines
WakeMed Perioperative Services Pediatric Preoperative Diagnostic Testing Guidelines.

Preoperative Fasting Guidelines
WakeMed Perioperative Services Preoperative Fasting (NPO) Guidelines.

Outpatient Preoperative Medication Guidelines
WakeMed Perioperative Services would also like to provide you with outpatient preoperative medication guidelines for patients. In chart format, these guidelines detail the different classes of medications the patient may be taking; the medications within those classes; when to hold, not hold or discontinue medications prior to or the day of surgery and for what reason (i.e. low blood pressure, increased risk of bleeding, rebound effects). Click to access the chart.  And following are additional guidelines to assist patients in preparing their bodies for surgery: 

Review this list of herbals and dietary supplements with the potential to increase bleeding.  It is recommended that patients discontinue herbal supplements at least one week prior to surgery.

Review this guide to Preoperative Diabetes Management including when to take and discontinue medications prior to surgery, when to check blood sugar prior to surgery and what a patient should do if he or she becomes hypoglycemic.
 

 

 

 

Registration and Financial Information

INSURANCE VERIFICATION OVERVIEW

ESTIMATES INQUIRY
Patients can contact the automated number at (919) 350-7808. Items needed for the estimate:

  • Name of procedure with CPT codes
  • Physician
  • Length of time

POINT OF SERVICE COLLECTIONS

  • Collects expected co-pays
  • Collects previous balance
  • Special lenses, Bariatric and Cosmetic Surgeries

CONTACTS
Questions and Concerns regarding insurance verification
Careline: 919-350-2273
Karen Forte: 919-350-0671
Natalie Uy: 919-350-8561