Episode Number: 103
Episode Title: Tackling the Surgical Backlog
Recorded: July 2023
(SOUNDBITE OF MUSIC)
Welcome to ASA Central
Line, the official podcast series of the American Society of Anesthesiologists,
edited by Dr. Adam Striker.
DR. ADAM STRIKER:
Welcome back to Central
Line. I'm Dr. Adam Striker, your host and editor. And I'm welcoming today Dr.
Mary Dale Peterson, who is chief operating officer and executive vice president
of Driscoll Children's Health System in Corpus Christi, Texas. And she's also ASA's
past president and also a repeat guest. And so certainly no stranger to our
show. She's joined me today to discuss how health care leaders are expanding
and monitoring the use of existing capacity, how they're using
anesthesiologists and surgical teams to improve perioperative performance and
exploring new practice models. So, Mary Dale, welcome to the show.
DR. MARY DALE PETERSON:
Thank you, Adam.
Well, I think it goes
without saying, you're a successful health care executive, so let's just really
briefly start off with your experiences. We know many hospitals are struggling
with the surgical backlog and demand. Do you mind talking a little bit about
the challenges your organization faces -- staffing shortages, bed availability,
capacity, etcetera? And then also, what are the main obstacles when it comes to
what you think are facing health care organizations now?
Sure. So I'm in a children's
health system, but I've been involved in the American Hospital Association and
Texas Hospital Association, and I don't think we're unique. I think adult
systems across the board are experiencing similar challenges. And, you know,
for us, I don't think it's necessarily a backlog. We just have a large increase
in demand for our services. It's interesting to me how ENT in kids have just
exploded and that's partly it went way down during the pandemic and it wasn't
really pent up demand. But all of a sudden when we started unleashing all these
viruses again and people were going back to school and work, kids were getting
a lot sicker and necessitated ENT procedures is just one example.
I know some facilities
are still experiencing the backlog from delayed endoscopies and other things,
so it is a supply and demand issue. And so at the same time we're seeing demand
increase for anesthesia professionals and ORs or procedural rooms. That's
really the big explosion is in the non OR locations.
You know, we've also had
some challenges, I believe, with our workforce. And we know that every day with
the nursing workforce. And it goes beyond nursing. It's, you know, respiratory
therapy, it's x ray technicians, you know, you name it. And workforce has been
a challenge. So where did they all go? You know, some people took early
retirement. Certainly anesthesiologists we saw four years of retirements and
one year. I think that's stabilized now. But that's a loss. That's an attrition
of people that we could use now. As far as pipeline, the good news is, is that
we have a lot of people interested in practicing anesthesia and becoming
anesthesiologists. So we've got more people coming into the pipeline. Actually,
we have more anesthesiologists being produced than surgical specialists. But
once again, on that demand side, we've got this imbalance because of all the
non OR proceduralist requesting our services. So and it varies by facility. I
mean every facility is different in what they're most short of.
Regarding the imbalance
between supply and demand, what are the financial implications of this? We know
that the operating room certainly generates a lot of revenue for health care
organizations. How how does this imbalance affect that?
Well, I think we want to
make sure our main economic engines are still running well. And I think that's
why hospital executives need to be involved in helping with the solutions. And
that means ensuring that you've got the right leaders in place that can either
look at different models of care or where we're lacking in resources or where a
change in, you know, what you would normally have in your FTEs could be helpful
in either creating a more efficient or Nora environment, you know, or it could
be that you don't have enough ICU beds. It may not even be an O.R. problem. It
may be a problem in another part of your system that's creating an impasse
where you can't schedule certain high intensity cases.
Are practice models evolving because of this demand and the workforce shortages. What do you see?
Well, I think, first of
all, there's been a change in practice models that has affected us that I think
we're just now realizing. Adam And that's that a lot of the proceduralists
coming out of training, whether it's cardiology, nephrology, GI, whatever,
they're not trained in providing procedural sedation. And on the pediatric
side, we've been dealing with this for a while and where I am in South Texas,
we've always had, you know, a relative shortage of, you know, physicians and
other providers. And so I've pretty much said, no, there are certain things
that a cardiologist or a nephrologist or, you know, oncologists especially, you
know, that they can learn to do and we can teach them how to do it safely if we
provide the right resources, things like sedation nurses, the training, the
protocols and, you know, support them. And so I do think that when you're
looking at an issue with resources like anesthesiologists or crnas as
anesthesia professionals and, you know, some of your locations and your ORs,
the constraints that we have right now, looking at other professionals in your
organization who could be upskilled with the appropriate support to provide
safe care is something hospital systems should be looking at.
How do you feel that's
received by anesthesia practices or specifically anesthesiologists? The idea of
maybe shifting a little bit of what was traditionally practiced for the
anesthesia team to other health care individuals?
A lot of it depends,
obviously, on economics and governance. But I firmly believe that your
anesthesia department should direct and oversee the quality of all sedation
care in your hospital system. Now, how it's provided, you know, there can be a
lot of different ways of doing that that I think are safe. But the anesthesiologist
or director of anesthesia needs to ensure that you have the right quality
improvement processes, the right way of credentialing physicians, training
them, as well as your nursing staff and setting up the protocols to do that. So
I think it's, once again, creating alignment where, you know, a CEO or a COO or
whatever says, look, you know, we have a bandwidth issue but how can we work
with other people in our organization to make sure that people have
appropriate, timely access to care? So people are part of the solution and
they're not penalized economically or some other way by doing the right thing.
I mean, it was our group that suggested we use pediatric intensivists to help
us with some procedures requiring sedation. You know, whether it was, you know,
the bear hearing test exam or some types of MRIs, they were the ones that said
we will train them and we can we can do that. But you've got to align the
economics and the incentives to make sure that everybody wins.
What do you think the role
is of burnout in the workforce shortages?
I think it plays a role
in what I worry about more is pressure to do more with who we already have. So
I think it's making sure that as we have the demands that we don't burn out the
people we currently have and burnout rates are already reported to be high by
saying, Oh, we're just going to work people harder, longer start Saturday
shifts, all those kinds of things. At a certain point, it doesn't matter how
much you pay people, they reach a burnout or a breaking point. And so I think
we have to be really careful. And this is another, I think, message to hospital
executives is be careful about stretching people too much because then you may
lose the good people you already have. And I think this is especially true with
the aging anesthesiologist or perhaps people who have other challenges with
caregiving or whatever and their families that you need to have those
conversations with people. And I would rather have people working half time or
80% or whatever. And even though it's a management challenge to figure it out,
but I'd rather work to do that than to have them quit entirely.
Are there any other
tactics or strategies that our listeners should be aware of when it comes to
the burnout issue? Or is it simply that a time versus money thing?
No, I don't think it's
just time versus money. I think it goes beyond that. I think that's part of it.
But I think it's also feeling appreciated. It's the workplace environment. I
think sometimes operating rooms can be toxic environments and that creates a
huge stress factor. A lot of times people will work longer hours. If it's a
pleasant environment, you're working with people you enjoy working with. So I
think it's making sure that you have good relationships with all of your staff,
your surgeons and ensuring that you have an environment of respect. That's a
big part of it, I think. And then showing how much you appreciate it. You know,
from a leadership, I try to meet with people individually and as a group and
share that. You know, a lot of times people can easily get into a negative
mindset. And of course, we we know that sometimes with surgeons, sometimes
they're never happy about things. And so I think trying to change people's
mindset and celebrate, you know, what's going well and appreciate the people
around you can go a really long way.
Well, I do have some
more questions for you, but first, we're going to take a short break. Please
stay with me.
(SOUNDBITE OF MUSIC)
DR. DEBORAH SCHWENGLE:
Hi, this is Dr. Deborah
Schwengel, chair of the ASA patient safety editorial board. Perioperative
hypothermia continues to be a common occurrence, despite extensive knowledge of
its ill effects and the common practice of warming patients during surgery. The
amount of time a patient experiences hypothermia matters work to prevent heat
loss, reducing the percentage of time patients experience hypothermia and
ensure the patient is normothermic upon arrival to the PACU, it's essential
that all team members understand the importance of pre warming patients prior
to entering the operating room and then actively warming during surgery. A team-based
approach with the anesthesiologist who's responsible for ensuring patients
remain normothermic as the team leader improves perioperative temperature
For more information on
patient safety, visit a asahq.org/patientsafety22.
We're back with Dr. Mary
Dale Peterson and talking about, well, surgical backlogs, but really it's more
of a imbalance between supply of workforce and the demand for workforce. Dr.
Peterson, what role do you think value-based care plays here? Things like new
perioperative practice models? Do those make a difference?
Yes, I think they do
make a difference because the worst thing that can happen for scheduling is
when you have to cancel a patient on the day of surgery because of either
inadequate preoperative workup or preparation or prehabilitation. I think we
still see disconnects between surgeon scheduling patients and appropriate
counseling, you know, before surgery. And we, you know, patients now are older,
sicker. They're on a lot more medications, some of which people shouldn't be
taking right before surgery, some that they should be taking right up until
surgery. Those anesthesia practices that work closely with their surgeons and
have preoperative clinics or high risk clinics, especially as you get into more
complex procedures that may take up three, 4 or 5 hours or plus in a day, you
definitely don't want those cancelled on the day of surgery. So that's just one
example. There's a lot of others, but I think that's a big one.
How do you analyze
efficiency when it comes to all of this? Is there anything different, I
suppose, than before?
Yeah, there's plenty of
papers published out there on that. I'm certainly not the leading expert.
There's plenty of literature on that. But I think it's, you know, we know what
your key performance indicators or KPIs could be that people look at, you know,
like, okay, did you start on time? You know, did you schedule for the right
amount of time? You know, what your cancellation rate, what's your turnover
time between cases, those kinds of things. But you know, we've got that. But
the more important thing is really, I think having a governance structure and a
model where there's transparency and alignment where there's consequences. So
if you have somebody that can't seem to show up for 730 start time
consistently, then it really is about saying, look, you know, maybe. 730 start
time isn't a good thing for you for whatever reason. And maybe they get started
later in the day. Or you have another surgeon who can at least book one case
before them. But it's really getting alignment with your leadership and your
hospital organization to make that happen.
I recently started a
smaller work group that's under our governance structure and efficiency task
force really, you know, taking the chair of anesthesia who is an efficient
anesthesiologist and our one of our most efficient surgeons as a team, and we
branded it out with other people on this group. But to really look at that,
we've got policies and procedures. But are we really following them and
enforcing them when people don't open up their block schedules, when they
haven't filled them? And, you know, how are we enforcing all of that? And so as
they start to make decisions and it's important for everybody in the
administration to be aligned, if a particular surgeon isn't happy with that
outcome, that we're supportive of those leaders.
Well, speaking of that,
talk a little bit about the importance of having anesthesiologists in
leadership positions, both perioperative as well as hospital leadership
Well, I don't think you
can do it without the leadership of your anesthesiologists, whether it's in
perioperative care. Our surgeons have really embraced that. You know, we say,
look, we don't want to cancel your cases on the same day. If you have a patient
that has chronic conditions or you think is high risk, we will see that patient
ahead of time and we'll make sure that the appropriate workup is done and that,
you know, there won't be, you know, hopefully a cancellation. I think it's
about having your key people maybe not rotating it, but everybody in your group
has certain skill sets. And having the right leaders run your board with your
nurse leadership every day is key. And some people are better that than others.
I mean, let's face it, Adam, the ORs are dynamic places. You can have your
schedule that you think you're going to have and then stuff happens. You know,
you've got your add ons, you've got your emergencies, got people that don't
show up and you're having to move things around. And so having somebody who is
really good at thinking on their feet and understanding scheduling and what
they can safely move around and having all the right pieces in an O.R., all
those specialized people can be really a huge improvement in efficiency. And I
think not necessarily being egalitarian, but giving the right jobs to the right
people and finding those leaders is key to making an O.R. run smoothly, just
like your nursing staff are as well.
Well, and we've talked
about this so many times about the importance of being involved in leadership
as anesthesiologists because of the skill set that most anesthesiologists
possess. But to demonstrate the value to your health care organization and how
vital it is just to participate at the organizational level.
Yeah, it it really is
key because we've got, you know, the food and medicine, the food and surgery.
We work with our medical proceduralist colleagues. We work with our consultant
physicians making sure patients are prepared for surgery, especially cardiology
or pulmonology. We, of course, interface with our surgical colleagues. And I
think, you know, they do appreciate when anesthesiologists are working with
them to find solutions, whether it's on a particular patients or scheduling
patients, trying to juggle emergencies with their elective cases. I think when
anesthesiologists step up and communicate well, there's a huge value and
respect to that.
So ASA recently
co-hosted an executive dialogue event online with the American Hospital
Association and produced a related book to share thoughts on on this issue. You
were involved in that. Do you mind talking about that experience a little bit?
It was an interesting
experience. We were oversubscribed. They had to cut off having people
participate because they like to keep it in a relatively small group of 30 to
40. And what I found the most fascinating, we had people from all across the
country, hospital leaders in various types of hospital systems, small, medium,
large, academic, private and in different roles. When we talked about
anesthesia or resources, really it varied really across the board. And
anesthesia, or OR resources really, it varied across the board. And anesthesia,
Arizona was like, oh, just so short of anesthesiologists. But in the Northeast,
it was a little bit different. It was I need our nurses, I need x ray techs. So
what we're shortages were different in each facility. But what was clear to me
is it it does take a village to safely provide, you know, care for our surgical
patients and patients undergoing complex procedures. And we're one part of that
equation. And certainly, you know, if you don't have people that can get
patients and bringing the operating room or people to help you clean the rooms
between cases or anesthesia techs, it slows down everybody. So, you know, the
whole workforce is necessary. And I think, you know, when we have certain
shortages in our workforce, like recently, we've had a crisis in our sterile
processing. You know, you don't realize how important all of these units are
until you have a staffing shortage. And so I think that's where people really
need to come together and say, okay, how can we temporarily help this
particular area while we're trying to fill these gaps?
And this book is
available to members, right?
It is available. It's on
the ASA website.
Okay, great. Well,
before we wind down here, you know, we've talked a little bit about staffing
shortages before the two of us on this podcast. Is there anything you've
learned since we've talked last about this issue that you think it's important
for for our listeners to know?
I think it's hard to
come up with one thing, Adam, But if I had to come up with one thing, I think
what I love about some of my leaders is a can do attitude, and that
accomplishes a lot. It means that in the face of adversity, you are still going
to look for a solution. Doesn't mean you have it right now, but it means you're
going to work towards that solution. And that attitude goes a long way with
either hospital leaders or your surgical colleagues. It might be saying, you
know, Doctor, I don't feel comfortable providing anesthesia for your patient
right now because of X, Y, or Z. I'm concerned about. But I'm going to do this
or that and I'm going to get this consultant in and we're going to keep going
with our schedule. And I'm hoping that we can get this patient worked in later
today. That's what I call the can do attitude. It's how do we accomplish
something and find creative solutions together. It's how you communicate and
it's being flexible that's part of that can do attitude.
Well stated, and I think
that probably contributes to the environment and the culture that you were
talking about earlier that I think makes it just more appealing to be at work
and work with your colleagues, you know, with with that attitude.
Yes, I've just seen that
go a long way. It's how you phrase something. It's kind of like when they asked
me to, you know, a long time ago to have our anesthesiologists put an IV lines.
And it was like, no, I can't do that. But what I can do is I can train nurses
how to do this and we will get it done. But it's going to be not maybe in the
way you had imagined.
Dr. Peterson, thank you
so much for joining us again and sharing your insight. You're a valuable
resource when it comes to this topic, and it's really enjoyable to talk with
you about it.
Always a pleasure to
visit with you, Dr. Striker.
To access the
information we were talking about earlier, please visit asahq.org/madeforthismoment/health-care-executives.
And there's a hyphen between health and care and executives that should lead
you to the resources the ASA is providing, but also the link to the ASA and the
American Hospital Association discussing this together. So thanks for listening
to this episode and please tune in again to Central Line next time. Take care.
(SOUNDBITE OF MUSIC)
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