Central Maine Orthopedics Surgery Center
Orientation Manual

Version January 2013       Robert Epstein

Description: Central Maine Orthopedics Orientation Manual for new Anesthesiology Staff


Introduction:

Central Maine Orthopedics Surgery Center is an ASC providing ambulatory surgical procedures. It is located at the group’s main practice facility at 690 Minot Avenue, Auburn, Maine 04210. The facility is accredited by the Accreditation Association for Ambulatory Health Care (AAAHC). It operates Monday through Friday, 7am to 4 pm.


CMO Contact List :

CMO Contact List
 
Spectrum Site Liason:
Robert Epstein MD (741-8419)
Main Switchboard:
783-1328
Front Desk:
344-2100
ACU/PACU
344-2106
OR1:
344-2297
ASC Manager:
Anne Marie Kayashima, RN
CEO
Michael H Cox, Ph.D.

Schedule & Work Hours

CMO operates Monday Through Friday.

Surgery start times vary. The usual start time is 0730, but occasionally cases may be scheduled to start at 0700 or after 0800. It is important to check email to confirm the next day’s schedule and start time.

The schedule includes a formal lunch break, sometimes coinciding with surgeon block time.


Anesthesiologist Staff Personal Needs

There is ample parking at the facility. When entering the parking lot, the surgery center is located at the extreme left of the building. The sliding double doors should be open. If they are not (rarely), there is an employee entrance around the back of the far right side of the building. No special access card is needed.

Lockers are available in the Men’s changing room the code to the door is 2-3-4. One locker is dedicated to an anesthesia provider. If a second anesthesiologist is present, one can use Sam Scott’s locker. No locks are available-it is recommended to not leave valuables unattended in the locker room.

Blue scrubs are available in the locker room and usually in good supply.

The lunch room has a refrigerator and microwave. There are no utensils available so bring your own.

Computers with internet access are available in the ambulatory area. There is no password to use the facility’s wireless internet access.


Paperwork, Charts, Schedules

The daily case schedule is usually emailed to the provider(s) assigned the upcoming day. The daily case list accompanies paperwork given out with the narcotic box. Cases can be General (with or without block), MAC or Local (no anesthesiologist involvement).

The Spectrum anesthesia chart shares many of the features as those of the other Spectrum surgery center charts, including the FIDES QA form. At the end of a case, the chart should be left intact with the PACU nurse.


Policies and Procedures, Selection and Exclusion of Patients

The facility may request preoperative chart reviews for patients with various issues (BMI, Sleep Apnea, medical co-morbidities) to assess their appropriateness for the facility. The anesthesiologist may determine whether the patient needs to come in for an interview or airway assessment, depending on type of surgery and co-morbidities. For example, a BMI 45 patient may not need an interview for a MAC Carpal Tunnel release, but would need to be seen for a procedure involving General Anesthesia.

Blood glucose monitoring is available for diabetic patients, as well as insulin to treat hyperglycemia.


Supplies & Equipment

Each OR has a Drager Tiro anesthesia machine with a Datascope Passport 2 monitor. The two available potent inhalation agents available are Sevoflurane and Desflurane. The anesthesia circuit is changed by the surgical tech between cases. There is a large multidrawer cabinet bolted to the back wall of the OR. This cabinet holds all of the anesthesia supplies, including a variety of LMAs and extra bottles of inhalation agent. It is restocked by the surgical techs. An AMBU bag should be present on the back of the anesthesia machine.

Each OR has a block cart. The block cart is stocked with most of the items needed to perform a block, including skin prep (Betadine or chlorhexidine/alcohol), syringes, stopcocks, Braun Stimuplex needles, Braun Stimuplex HNS 11 and HNS 12, and local anesthetics. Gloves are available in the cabinet under the OR nurse’s desk. There is no specific nerve block kit.

There is a small difficult airway cart located in the area outside the operating rooms, usually behind the X-ray equipment. It contains an Air Trach, a “Trachlight” lighted stylet, disposable Fastrach, LMAs sizes 3, 4, and 5, and an emergency tracheotomy kit. Patients are screened to minimize the chance of anesthetizing someone with a difficult airway. As mentioned above, the anesthesiologist should be asked to review a patient chart or do a brief interview to assess whether the patient is a candidate for surgery at the ASC.

The main oxygen supply is turned off after hours. The main control valve is located behind a plastic panel in the wall module in the corridor between the ORs and PACU. There is an additional shutoff on the back wall of each OR at the green receptacle. If unable to perform the machine check due to lack of oxygen one should check to see that both valves have been turned on.

Suction is sometimes left on overnight. Occasionally a crack will develop in the yellow cartridge cover, necessitating replacement.

One Baxter AS50 infusion pump is available. It is usually located in OR 1.

Controlled drugs are given by the RN out each day in a kit. Along with the kit comes a form labeled “Anesthesia Controlled Drug Administration Record” and a daily OR schedule. Muscle relaxants are dispensed daily in this kit. If you need additional muscle relaxant, ask the circulating RN.

Each OR has a warm air blower device for patient warming. It is used for patients whose surgeries last one hour or more. Consistent with Spectrum practice, the blower is not used without a commercial warming blanket.

Ordering and stocking is done by the RN and Surgical Technician staff. They are also helpful locating supplies and obtaining items needed urgently or intra-operatively. We do not have direct access to the room which contains medications. If you encounter a shortage, you should alert either the RN or Surgical Technician.

The OR suite is locked after hours. Frequently your day will finish before the OR crew- straight local cases are done at the end of the schedule.

The code cart lives in the Ambulatory area at the charting station.


Clinical Practice

Surgeries include simple and complex orthopedic procedures. Most frequently performed procedures are carpal tunnel release, shoulder arthroscopy and knee arthroscopy.

Surgeons will usually infiltrate incisions with local anesthetics for postoperative pain and to minimize the need for opioid analgesia. Non-opioid analgesic (ketorolac) is usually available for postoperative pain as well.

Regional blocks are frequently requested for shoulder arthroscopy and ACL repair. Occasionally a popliteal block may be requested for ankle surgery or axillary block for wrist surgery. Blocks are usually performed in the operating room prior to induction of general anesthesia. The circulating OR nurses are quite helpful in assisting us to perform blocks. It is acceptable to sedate patients prior to performing blocks.

Carpal tunnel repair is done under MAC or straight local anesthesia (no anesthesiologist involvement). For MAC cases, the expectation is for a hypnotic dose of propofol for local anesthetic infiltration. Expect a three to six minute tourniquet time.

Shoulder surgery may be performed either in the lateral position (Drs Cain and Fallon) or in the beach chair position (Dr Bush). An LMA is typically used unless otherwise indicated.

Preoperative evaluation of patients with BMI greater than 35 should concentrate on airway quality and neck anatomy. A patient may have a reasonable airway but be less of a candidate for interscalene block.  The patient and surgeon should be notified that the patient may not have a successful block so other measures can be considered.


Patient Transfer Protocols, Emergency & Non-Emergency

Transfer of a patient to a facility with a higher level of care may occasionally be indicated. The reason for transfer may be such conditions as uncontrollable pain, nausea, vomiting, cardiac arrythmias or other medical conditions that require further diagnostic work-up or monitoring.

In the event of a non-emergency transfer, the physician/surgeon in charge of the patient will call ahead to the emergency room physician and/or attending to report reason for transfer and arrange for hospitalization prior to transfer. Transfer to the facility will be done according to usual admitting procedures.

In the event of an emergency transfer, the patient will be transferred to the nearest hospital by the emergency medical system ambulance. Such emergency conditions may include cardiac arrest, respiratory distress, anaphylaxis or malignant hyperthermia. All cardiac emergencies will be sent to CMMC Heart and Vascular Institute or the nearest facility with the ability to perform heart catheterizations emergently.

The physician/surgeon in charge of the patient will call ahead to the emergency room physician or to the attending provider to report the reason for transfer prior to transfer. A progress note with transfer orders is to be completed by the provider involved in care. A note will be completed by the anesthesia provider when the transfer is initiated by the anesthesiologist.