Intermed/Generations Surgery Center
version September 2013
David Andrews

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Anesthesia Services at Generations Surgery Center:  Orientation Information

Generations Surgery Center is an ASC providing women's health surgical procedures. It began operations at 619 Brighton Avenue in March 1997. In December 2008 it moved to the 10th floor of the new Intermed Building at 84 Marginal Way, Suite 1000, Portland, 04101. It now operates Tuesdays, Thursdays, and Fridays. It is certified by the Accreditation Association of Ambulatory Health Care (AAHC).

SECTION I:
Administrative Information
SECTION II:
Clinical  Information

 
Section I: Administrative Information

Spectrum Site Liason

David Andrews, MD (741-8417)

IGSC Staff Contact List

Phone 347-2900

Sharla Moretti-ASC Manager [smoretti@intermed.com]

Susan Lefebvre-ASC clinical lead/OR circulator RN

Kaitlin Brent-ASC preop/PACU/OR circulator RN

Amy Frink-ASC preop/PACU RN

Cindy Curry-ASC per diem OR circulator/preop RN

Karyn Fisette-ASC OR circulator RN (will be starting soon)

Julia Gagne- ASC per diem pre op RN

Rebecca MacLeod- ASC per diem PACU/preop RN

Lauren Jones- ASC per diem preop RN

Jessica Brann- ASC CST

Gina McHugh-ASC CST

Paul French-ASC CST

Stacy Mahoney-ASC CST per diem

• Dr. Emil Gotschlich is the ASC Medical Director.

Schedule & 
Work Hours

• The ASC currently operates Tuesday, Thursday, Friday

• Surgery start times are 0730 on all days except 0830 on Thursday to allow attendance of anesthesia conference. There are occasional special requests to start at 0700, usually to accommodate an add-on ERS. 

• The current OR volume does not generally necessitate a formal lunch break as most days finish up by early afternoon. 

Anesthesiologist Staff Personal Needs

Parking: There is a parking garage within the Intermed building. Access to the garage is open, but a vehicle tag is required and will be provided after credentialing is complete. You will need your auto registration number with you when you complete the application for the sticker with Jill Binford. Although you do not need it to gain access to the garage, security occasionally monitors who is parking where. Parking should be done on level 3 of the parking garage in locations labeled Intermed Staff .

Security/Access to Building: Access to the staff/service elevator and the ASC require a security badge to unlock the doors. If a physician does not have a badge, the patient elevator is always available. Take this to the 10th floor. The receptionist is on duty at 0630 and will call ASC personnel to unlock the ASC door for you. If you have the security badge, take the staff elevator to the 10th floor and walk straight off. The locked ASC door is unlabeled and about 30 ft from the elevator doors just past the restrooms. It can be opened by swiping your badge. Once through this door the locker rooms are apparent.

Locker: Full size lockers are available and labeled. No locks are provided. Security has not been an issue to date.

Scrubs: Scrubs are available in the locker rooms. Medium scrubs are scarce in the men's locker room but readily available in the women's.

Lunch/break facilities:There are no formal break times currently as the workload often doesn't warrant such. Lunch may be carried in and there is cafe on the ground floor of the building. There is an isolated anesthesia "office" however it is used primarily as a supply room.

Computer, telephone access:Computers are available with internet access. Cell phones function within the building. A guest WiFi network is in the building.

 

Paperwork, Charts

 

Daily case schedule: A daily case list is generally left on the anesthesia supply cart (Blue Bell). Otherwise it is readily available at the nursing station in the PACU area. All cases are expected to receive anesthesia services.

Charting: Use the Spectrum anesthesia chart and Spectrum QA form. Patient charts will generally be with the patient in the pre-op room. Anesthesia specific paperwork is clipped together. The H&P as well as the nursing assessment form will also be with the patients file in the room.

Billing: Charge slips with demographic sheets should be left in the designated wall slot in the PACU nursing station. Spectrum charge forms arrive soon.

Policies & Procedures

• Current documents include Pre-operative Guidelines and Pre-op Medication Protocols. These are available for review by asking Karen or Byrni. 

Pre-op anesthesiologist evaluations are required for ASA 3 patients and those with BMIs greater than 40. If the BMI is greater than 35 the nurse will request a review of the chart to determine if the patient needs to come in pre-operatively for an anesthesiologist evaluation prior to the date of surgery. If the BMI is over 40, patients may only considered for the ASC if their procedures are minimally invasive and of limited duration (i.e., less than 1 hour and no laparoscopies), and if patients are considered to be medically appropriate by the examining anesthesiologist at the mandatory pre-operative evaluation.

Diabetics on oral or insulin therapy are instructed to bring their personal Glucometer, as well as insulin, with them to Generations ASC. There is no glucose measurement device at the facility (due to quality control considerations). Patients understand that if they forget to bring this equipment, their surgery will be cancelled and rescheduled for another day.

NEW A detailed List of Selection/Exclusion Criteria for InterMed Patients is outlined in this document (2013)

 

Section II: Clinical  Information

Supplies & Equipment

Anesthesia Cart: A GE Healthcare Aespire 7900 anesthesia machine with ventilator is in the OR with a Bluebell cart stocked with drugs and supplies. . Sevoflurane, desflurane, and nitrous oxide are the available inhalation anesthetic choices.  An AMBU Bag is hung on the back of the machine.

Suction: Suction is turned off in two locations after hours in the interest of preserving the suction pump. In addition to the patient suction,  the scavenge manifold valve also needs to be turned off. The staff know about this and usually take care of this, but we should also check these functions on the machine before and after the day's cases. If the scavenge valve is not turned back on for a case, bag ventilation will work, but the ventilator will deliver ~10 cm of unrequested PEEP, the scavenge bag will be tensely inflated and waste gas will not be properly evacuated. 

Piped Gases/ back up tanks: The tanks for the piped gas system are also on the 10th floor. Central gas levels are verified with one of the nursing staff once weekly on Tuesday. Backup E tanks are on the anesthesia machine.

Infusion Pump: A Medex syringe pump is in the OR with the anesthesia machine.

Controlled Drugs: Controlled drugs may be obtained by the nursing staff either before or during the case. Versed is very rarely indicated. Unused fentanyl should be passed off to the PACU nurse. Muscle relaxants are kept in the refrigerator in the anesthesia supply office.


Difficult Airway Equipment, contained in the Blue Bell, includes intubating LMA's (Fast Tracks) and Air Traqs video laryngoscopes (single use), medium and small sizes. Patients with known difficult intubations are not anesthetized at the ASC. 

Patient Warming: The OR has Bair Hugger warming device and patient blower blankets are available. Most cases are less than an hour, in which case SCIP guidelines do not dictate active rewarming practice. Consistent with Spectrum practice, the blower is not used without a commercial warming blanket.


Ordering/Stocking: The anesthesiologist is responsible for checking supply levels in the Blue Bell as well as restocking anesthetic drugs and supplies at when the cases are done. The staff are helpful in locating supplies and obtaining items needed urgently or intraoperatively. Muscle relaxants are in the refrigerator in the anesthesia office/supply room. Other pharmaceutical supplies are in a separate cabinet outside the office. 

Blue Bell Security: The anesthesia supply cart is locked after hours. The key may be obtained from the staff on arrival and should be returned on departure after locking the cart.


Code Cart: is located in the PACU area, a short distance from the OR. The defibrillator is monophasic. The MH Cart is also nearby and holds only equipment and drugs not within the code cart, ie an MH event would require both the MH and Code Carts.

Typical Clinical Course and Anesthesia Implications

Common Practices / Suggested Anesthesia Techniques: 

Surgical Cases include diagnostic and therapeutic laparoscopies including tubal coagulation, hysteroscopy, endometrial ablation, various superficial perineal procedures, and ERS rarely more than 10 weeks gestational age, never more than 12 weeks GA. Abortions are not performed at ASC. When a patient needs admission to the hospital, emergently or electively, Portland EMS is under contract to provide transfer services. The patient would be transferred to an ambulance on the first floor of the parking garage via the elevator using the EMS stretcher. 

All patients booked in the ASC expect an anesthetic procedure. Spinal anesthetics are rarely used. After the anesthesiologist is done speaking with the patient and consent obtained, the circulating nurse should be informed, at which time she will complete her process and escort the patient to the room.

Room times are generally noted by the anesthesiologist. Application of monitors is a joint effort. Room entry to induction is usually no more than 3 minutes. 

The use of opioids is minimized in place of ketorolac and local anesthetics. In the absence of opioids and muscle relaxants with induction, some motor activity early in the anesthetic is not uncommon and accepted by staff. 

ERS procedures are frequently done with an IV technique in the interest of minimizing blood loss, particularly when the fetal demise is in the 8-10 week range. 

Post-operatively, presence of the anesthesiologist is required until the patient completes phase I recovery. If the anesthesiologist departs during phase 2, prior to the patient being ready for discharge, the operative surgeon, or his coverage, must be available to discharge the patient.

Questions, Problems Direct to David Andrews MD or Sharla Moretti

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