Portland Endoscopy Center
version April, 2011
Carol Dean, Tom VerLee

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Anesthesia Services at Portland Endoscopy Center:  Orientation Information

Portland Endoscopy Center is a free-standing ambulatory center in which upper and lower endoscopic procedures are provided by the physicians of Portland Gastroenterology Associates, located at 1200 Congress St, Portland, Maine. The Portland Endoscopy Center is accredited by AAAHC (American Accreditation Association for Ambulatory Health Care).

SECTION I:
Administrative Information
SECTION II:
Clinical  Information

 
Section I: Administrative Information

Spectrum Site Liason

Carol Dean MD (pager 741-1456)

PEC Staff Contact List

Telephone 773-9823
Cheryl Weimer RN (The primary go-to person with any day-to-day clinical process issues or problems.)

Sally Willis RN (Manages ordering, stocking and storage of anesthesia supplies and drugs.)

Nancy Selby, MA, Medical Assistant Coordinator
(Manages the initial patient identification, selection and screening process by the Medical Assistants.)

Melissa Gousse, Practice Administrator 
(Handles contractual and financial matters)

•  Sue Penney, Credentialing (321-6031, pennes@mmc.org)

Dr. Alan Kilby, Medical Director PEC

Dr. Doug Howell (Liason for medical issues or processes related to anesthesia service.)

Schedule & 
Work Hours

Coverage is generally Monday or Tuesday.

Cases start at 7:00 am or 7:30 am, depending on the Gastroenterologist. PEC usually calls the MMC Anesthesia Desk (Jennifer, Ann) the day before with the start time.  Please arrive at Portland Endoscopy Center 30 minutes before start time.

• Cases are booked every 30' until 11:30 am, and from 1:00 pm to 4:00 pm. Double procedures (upper and lower endoscopy on same patient) are usually booked for two slots. 

Occasionally there will be a non-anesthesia case booked in a slot. This will be done by the PEC sedation nurse in a different room, and gives you a little break.

The Anesthesiologist has a break between approximately 12:30 and 1:00 pm.

Anesthesiologist Staff Personal Needs

Parking: Parking is free and located to the right of the back of the building.

Security/Access to Building: Building is open at 6:30am by PEC staff. Enter at rear of the building and take elevator or steps to the 2nd floor

Locker: A labeled anesthesia locker (½ size) with key is available near nurses desk on the 2nd floor.

Scrubs: A very limited number of scrubs/jackets are available at PEC, kept in closet next to staff rest room. For larger/taller, or shorter persons, or those who prefer to be color-coordinated, you will probably want to bring your own.
Use the rest room to change. SMG name badges are made up (on top of anesthesia cart), or wear one of your Hospital IDs. 

Lunch/break facilities: Lunch room is located on the 3rd floor. Staff bring their own lunch (don't regularly order out). Coffee and vending machines are available. To access the secure back stairway up to break room, ask staff for the code for keypad.

Computer, telephone access: Computers are located in the procedure rooms and at the desk, with access to Spectrum Webmail and MMC links. Phones are in each room, dial 9 for outside line. Your cell also works pretty well in the facility. There is a wireless network available; the access code changes monthly. Just ask the secretary in the waiting room for the current code on your initial entry in the morning.

Paperwork, Charts

 

Daily case schedule: A copy of the schedule for the day will be printed and left on anesthesia cart. (Note that schedule includes all cases, both anesthesia and non-anesthesia. Look for anesthesia time slots and notation "propofol" for your cases.

Billing: Leave unseparated anesthesia record at the bedside with RR nurse. PEC staff will take care of separating billing sheets, adding demographic info and updated schedule of the day for SMG courier to pick up. (The slot for anesthesia billing sheets above nurses desk can also be used for sending interoffice mail to the SMG office.)

QA/Data sheets: are linked to the Anesthesia Record and should be completed and left at the bedside for nursing data entry.

Chart Assembly: Anesthesia record and consent are already included in the PEC chart at the bedside. Nurse will place anesthesia record, consent, PCP H&P, PCP notes, labs, and the pink PEC nurses admission sheet (summarizing most of what you want to know) together for you to review for pre-op evaluation. (Note that there is both an office chart and a PEC chart for each patient.)

Policies & Procedures

Policies and procedures required by AAAHC related to anesthesia service at the facility have been written. A copy of the entire manual is available from Jan Campana, RN. Relevant selected policies will be compiled in the PEC Anesthesia Resource Notebook kept in the chart rack of the anesthesia cart.

• In addition, the following related ASA Standards and Guidelines will be compiled in the Anesthesia Resource Notebook:
   - Guidelines for Office-Based Anesthesia
   - Guidelines for Non-operating Room Anesthetizing Locations
   - Continuum of Depth of Sedation Definition of General Anesthesia and Levels      of Sedation/Analgesia
   - Statement on Qualification of Anesthesia Providers in the
     Office-Based Setting
   -Distinguishing Monitored Anesthesia Care ("MAC") from 
    ModerateSedation/  Analgesia (Conscious Sedation)
   -Statement on Safe Use of Propofol

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Section II: Clinical  Information

Supplies & Equipment

Anesthesia Cart: Stocked bluebell cart should contain all supplies needed. Plug the PowerStrip in the wall socket as part of your setup.

Ordering/Stocking: PEC staff will order supplies and restock the cart after each day's use, and mid-day if necessary.

Secure Storage: Anesthesia cart will be locked and kept secure by PEC staff when not in use. PEC nurse will unlock the cart and safeguard the key when cart is in use. (Anesthesiologist should not attempt to keep track of the key.)

Controlled Drugs: Request controlled drugs from PEC nurse, and return unused portion to her.

Piped Gases/ back up tanks: O2 is piped in. The nurse will bring a back-up E-cylinder into the room when anesthesia services are provided, which you should also check. The wall O2 line pressure indicator and alarms are on a panel near the Nurses Desk.

Suction: No wall suction, only portable units. There is a unit for use in the procedure as well as a second portable unit on a shelf on the side of the anesthesia cart, and a unit will be kept next to the recovery beds.

Code Cart: Emergency cart is kept at the nurses station, regularly checked and maintained by the PEC nursing staff. Currently has an AED for defibrillation, but will be upgraded to a standard defibrillator shortly.

Monitors: Welch Allyn portable monitor on stand, including side-stream ETCO2

Infusion Pump: Bard pump

Note: there is NO anesthesia machine or ventilator. Anesthesia technique is expected to typically be propofol infusion with spontaneous ventilation. If positive pressure ventilation should be required, an Ambu bag and Jackson Reese circuit are on the cart.

PEC Staff Anesthesia Set-up Support

Transport anesthesia cart to procedure room, unlock and keep key secure.
• Obtain succinylcholine from refrigerator.
• Plug in suction machine extension cord and test.
• Plug in portable monitor (ceiling socket available if you can reach it)
• Large sharps box near cart.
• Bring extra O2 E-cylinder in stand, with regulator and flow meter, to procedure room.
• Attach O2 extension tubing to wall flowmeter.
• IV pole with Bard infusion pump bracket attached.
• Restock anesthesia supplies and drugs after use.

Patient Selection Process & Screening

PEC physician makes initial determination of medical indications for anesthesia for procedure and assesses appropriateness for ambulatory anesthesia. PEC Medical Assisstants (M.A.s) will follow guidelines when communicating with potential anesthesia patients, gathering health information, and giving instructions. (See attached PEC Anesthesia Case Worksheet.)

Medical indications for need for anesthesia may include:
• history of failed or difficult procedure
• history of requirement for large amount of medication for past procedures
• thin female with history of pelvic disease, surgery or radiation
• history of chronic narcotic or sedative use
• mentally challenged or excessive anxiety

Clinical guidelines for Ambulatory Anesthesia screening include:
• appropriate procedure for ambulatory setting at PEC
• appropriate age (greater than 15 yrs, no upper age limit)
• patient desires deep sedation or anesthesia
• low severity of underlying disease, and low risk for procedural or anesthesia complications: ASA I and II patients.
• anesthesia care expected to be in deep sedation to general anesthesia portion of continuum 
• no unusual airway risks identified.
• intubation not expected.
• no significant airway abnormalities identified on history or exam.
• no significantly elevated aspiration risk (eg. morbid obesity, history of significant or untreated GER, 2nd or 3rd trimester pregnancy).
• appropriate family/social support for care and transportation after discharge.

Requested Pre-Anesthesia Testing and Evaluation:
• Current H&P from primary physician
• Relevant consult or office notes, with particular note of significant cardiology or pulmonary conditions.
• Testing: ASA Practice Advisory for Preanesthesia Evaluation (2003) suggest that no specific "routine" testing is indicated and choice of any lab tests, CXR, or EKG should be guided by the patient's underlying medical conditions. 
However, guidelines have been developed to assist PEC office staff to implement appropriate testing and/or assure that records of tests are available from the PCP's or consultant's office.
(See Anesthesia Case Worksheet for list of guidelines)

CHART REVIEW /Signoff by Anesthesiologist

At some point during the workday the Anesthesiologist will be asked to review the Anesthesia Case Worksheets and Charts for patients scheduled for the following week. This is a double-check to confirm the appropriateness of a patient for Anesthesia at the PEC, and review of requested lab tests and consults. The goal is to reduce cancellations on the  Day of Procedure.

Responsibilities of Gastroenterologist vs. Anesthesiologist

 

Table of Responsibilities: 
Gastroenterologist vs Anesthesiologist
  PGE Gastroenterologist SMG Anesthesiologist
Pre Makes the initial selection of patients for appropriate procedures. Screens for appropriate history and health status for anesthesia. Performs pre-anesthesia evaluation just before procedure and makes final determination of appropriateness for anesthesia. Discusses plan with patient and obtains anesthesia consent.
Post Phase 2 Primary responsibility for care and discharge from Phase 2 Phase 1 Primary responsibility for care and discharge from Phase 1

PEC Staff Role in care of Anesthesia Patients

 


Pre-Anesthesia instructions: Patients selected for anesthesia will receive NPO instructions as follows: no solids after midnight and discontinue clear fluids 3 hrs prior to scheduled procedure. 

Admission: PEC nursing staff will admit the patient and complete the nursing admission sheet which includes medication list, allergies, brief review of systems.

Start IV infusion: IV's will be started by nursing staff, usually on right side with ID band as the patient will often be positioned on the left. 

Obtain controlled drugs: PEC Nursing staff will provide controlled drugs if requested by the Anesthesiologists, although need for pre-op meds or narcotics should be infrequent.

Transport of patients: PEC staff will assist with transport of patients. Patients will be assigned a bay on admission, will return to recover in the same bay, and remain on the same stretcher throughout. 

Identify Patient and perform "time-out" prior to start of procedure.

Assist with positioning and comfort: PEC staff will assist with patient positioning and comfort, and application of monitors.

Assist during procedure if needed: PEC staff will be present and available to provide any additional needed assistance to the anesthesiologist.

Provide Post-Anesthesia care: Phase 1 and 2 care will be provided according to ASA and ASPAN guidelines. Many patients will already be in Phase 2 on arrival in the recovery area. 
The Anesthesiologist is responsible for patient discharge from Phase 1. 
The Gastroenterologist is responsible for discharge from Phase 2, and will remain within the PEC facility until all his patients are discharged. In the event that the gastroenterologist needs to leave the facility, he may establish patient coverage with another PEC physician within the facility. ACLS certified nurses are always present in the unit. All post-anesthesia patients must have a driver and are given specific discharge instructions.

Typical Clinical Course and Anesthesia Implications

Suggested Anesthesia Technique: 
• Interview patient in admitting/recovery bay. Tell patient to expect to be aware near end of procedure as they are finishing, but reassure that won't be uncomfortable at that point. 

Avoid pre-meds if possible. . Bring patient into procedure room, apply monitors, have infusion ready. Gastroenterologist will come in and greet patient and do very brief exam. 

Have patient turn to left side. Narcotics should be unnecessary for colonoscopy. For EGDs, some prefer to give a small dose of fentanyl immediately prior to induction. Induce with slow bolus of propofol to point of deep sedation while preserving spontaneous ventilation, and start infusion at 160mcg/k/min. Supplement with added small boluses for more stimulating moments of procedure. Patients need to be deepest as scope is advanced. 

• For colonoscopy the withdrawal, which takes approximately 7 minutes if no intervention is required, is less stimulating. The gastroenterologists are all pretty consistent with the 7-minute withdrawal. Begin to lighten on withdrawal, and turn off infusion at 2 minutes before completion. Most patients will be in Phase 2 by the time you transport to recovery. 

Give the PACU Nurse a verbal report, and she will complete the Post-Op Vital Signs section of the chart, so you can interview your next patient.

Sequence:
Turn-overs are quick. Typically, by the time you have transferred care of the patient in recovery, set up for the next case and interviewed the patient, brought that patient into the room and have him/her ready for induction, the Gastroenterologist will have completed his in-between case in the adjacent room.

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ANESTHESIA/DEEP SEDATION WORKSHEET

Patient name:______________________ DOB:__________________


Phase One Recognizing candidate for Propofol
MA will need to review and present patient chart/information to physician for decision to do patient w/Propofol
-----prior difficult/unsuccessful colonoscopy MA will need to review notes, review meds
-----large amount of meds used (Fentanyl 150+ mcq, Versed 7-10 mg)
-----major discomfort noted in report
-----failed case
-----thin woman with hx of pelvic surgery (especially total hysterectomy, bi-lateral salpingo 
oophorectomy (TH, BSO) or radiation therapy, endometriosis, chronic pelvic pain, BMI (body mass index) less than 25 especially less than 20
-----young anxious patients, less than age 40 with diarrhea (IBS, IBD), sexual abuse
-----patients on narcotics or benzodiazapam (Valium) maintenance
-----mentally challenged. Pay particular attention to have guardian information w/contact numbers.

This case has been reviewed and is determined to be medically appropriate to perform this case with anesthesia at this outpatient setting. (PGA Physician needs to determine if there are contraindications to anesthesia being provided at the PEC setting)
PGA Dr. initials ________


MA makes phone call to patient to explain they have a choice that the physician is recommending procedure be done w/Propofol. It is medically indicated (see above). They will be deeply sedated which will require the care of an Anesthesiologist. MA needs to ask: Have you ever had any problems w/anesthesia? YES or NO

Propofol pts arrive 45 minutes prior to procedure Pt agrees: YES or NO
Prep sent: YES or NO


Phase Two Pre anesthesia testing Check when appropriate info rec'd
All patients-complete H&P in PGA chart within 1 yr. (Preferably by the PCP) ______
Include any additional notes from any regularly treating specialists, e.g. Cardiologist, 
Pulmonologist etc. ______

Further documentation:
_____ Healthy patients up to age 60 w/no hx and no meds for systemic disease 
NOTHING FURTHER needed. H&P received. ______
_____ Pts over 60 or w/ hx of cardiac disease, hypertension or IDDM
NEED EKG within one-year ______
_____ Anyone with significant symptomatic respiratory disease
NEED chest x-ray within 1 yr. ______
_____ Pt on diuretics (HCTZ, Lasix):
NEED BUN, creatinine, lytes within 6 mos ______
_____ Pt w/significant renal disease:
NEED BUN creatinine, lytes with 6 mos. ______
_____ Pt currently on chemotherapy or radiation therapy:
NEED H&H (hemoglobin and hematocrit) within 6 mos. ______
_____ Recent active bleeding:
NEED H&H if hx of significant blood loss ______

Anesthesiologist signs off ________________________ Date:_____________