Case Scheduling

It amazes me how similar our concerns are, big hospital, or not....USA or not!

I work in a small rural Ohio hospital. We run 3 OR'S during the week. Call is 3:30pm till 7am Mon-Fri, then emergency call only 7 am Sat to 7 am Mon.

We have had problems over the years, doc booking "emergency" cases, that just happen to appear after office hours!

Also booking "emergency" ortho cases on Saturday morning. One doc thinks of Saturday as his Saturday morning ortho block. For the most part, Sat and Sun cases are tolerated, but anesthesia makes sure that they do not approve!!!! The straw that broke the camel's back was a Sat. morning hip, that turned out to be a 6 hour REVISION. And the doc had no help, so we had to provide an extra off duty scrub!! :angryfire :angryfire

Our stand is what happens if a true emergency comes in (trauma, stat c-section, etc) and we are tied up doing a lap chole!

Our scheduling secretary, and charge nurse is very aggressive, consistant and watchfull of doc trying to pull a fast one. Also, since we are a small hospital, the docs all know each other very well, and that makes for a better working situation.

We all stay over our normal 7a to 3:30 pm schedule depending on the situation. But the charge nurse is good at getting it down to one room by 3:30. And the surgeons just understand that they may have to wait...unless it's a true emergency, then no one minds staying over.

Mike

One doc thinks of Saturday as his Saturday morning ortho block. For the most part, Sat and Sun cases are tolerated, but anesthesia makes sure that they do not approve!!!! The straw that broke the camel's back was a Sat. morning hip, that turned out to be a 6 hour REVISION. And the doc had no help, so we had to provide an extra off duty scrub!! :angryfire :angryfire

Mike

See, to me--that's just unacceptable. Why did you HAVE to provide him with ANYBODY to assist him? That means you apparently had to go down the list of staff, calling people, begging them one by one to come in (and I am betting most of them said, "No, I am not on call, and anyway, I just had a drink" (or two, or TEN, as is their right on offtime) until you finally got some poor soul who needed the money or was new to agree to come in--while the surgeon sat around, watching the ball game. Why didn't he ask one of his OWN partners to come in and assist? I am betting you didn't have a rep, either, even though the reps for those companies are on call ALL WEEKEND--but often are smart enough to "not hear" their beepers or cell phones. They aren't stupid.

One of the management types I used to work for had the nerve to berate the entire staff one Monday morning because, "They went down the list, trying to get volunteers to come in an run another room on Saturday, and EVERY SINGLE PERSON that was called said they had been drinking and didn't feel comfortable coming in to work, let alone driving. What do I have here, a staff of alcoholics?"

HUH?!!!!!!!!! WTF!!!! She was berating the wrong group--she should have been praising the staff for not permitting themselves to be taken advantage of, and being assertive, and lamblasting the surgeons who tried to pull this nonsense off--pulling in a second crew to do an elective case even as the CALL crew was tied up doing yet ANOTHER elective case.

I'll say it again----Soooooooo glad I am not a part of this silliness anymore. At the risk of being chastised by a moderator-------f*** 'em.

A surgeon ask me on the weekend to try to get another person in to help and I just tell them no one was available. I didn't even get on the phone to see if there was anyone. Too bad! I just struggle along with what I have and it usually goes OK. I only really try to finf someone if there is a real NEED for that extra person. The weekends are for people to be off, not working( unless you are on call). We do have the surgeons who think the weekend is for "catching" up on the previous week workload. Some do think, IMHO, that the weekend is their own little "block". Drives you nuts! Mike

Wow, the more I read threads on this forum, the more I realize how good I have it and that I should quit whining about the the little things that go on in our O.R.

All after-hours must be booked through the anaesthetist. He is the gate-keeper of the O.R. We have an emergency classification system, E1, E2, E3. E1's must be done within 4 hours, E2 within 12 or 24, (not sure of that one) and E3 must be done within 48 hours. We have a sessional room that runs during the day for emergencies that come into the O.R. during the day. That gasman is on for 24 hours and is in house during that time. The "on-call" staff are on from 15:15 until 23:30 and 10 - 6 on weekends and are on call until the next shift come on. If a surgeon wants to "bump" a case he must speak with the surgeon who was to go next with his case, this is an expected courtesy between professionals. In the end the gasman has the final say. Slated cases are ususally done by 3:30 or 4p.m at the latest. If a slate is running grossly over, cases may be cancelled. Staff are asked if they can do overtime, not told that they are doing overtime if slates run late. We do not do "locals" with the call team after hours. Considered a strict no-no. Elective cases are always done on a slate. VIP's are done just like anyone else, on a slate. Their name however may not appear on the slate beside their procedure, for privacy, but again this rarely happens. Occassionally if slates run late for unforseen reasons and cases are running late in the sessional room, on-call staff may be late going for dinner or may not get dinner at all. This rarely if ever happens. Staff staying late and doing overtime are entitled to a free meal from the cafeteria no questions asked. if staff can not get to cafeteria themselves, nursing supervisors procure them a meal and bring it to staff room, so that staff have something to eat in between cases.

I think you guys and gals are really taken advantage of, and definitely caught in the middle. My hats are off to all of you for maintaining your professionalism despite sometimes a difficult work situation.

porsch 65

I know others have said this but I just have to say it again...I was reading through the posts and all this time I thought my work was the only one having to deal with case scheduling after hours. I don't feel so alone anymore....someone said in a previous post that their OR scheduler and charge nurse are very aggressive when dealing with MDs who try to squeeze cases in after hours. That impresses the heck out of me 'cuz where I work we have four schedulers, one charge nurse from 6:30a-3p and one charge nurse from 2pm-when the last case is done...and they still can't get it right!! The six at my front desk could learn a thing or two from those folks you work with! Just had to say that....:wink2:

From the NM point of view, they are scared the surgeons will 1) Go to another hospital, or 2) Build an outpatient surgical facility. Its not completely invalid.

We now run two shifts in the OR, 06:00-14:30, 15:30-24:00 M-F. On the weekends we run half a team on both sat and sun from 11:00-23:00. I guess the advantage is that there is at least a schedule and no stupid call. The disadvantage is that on occassion (depending on schedule) ppl will get sent home for a few hours.

Our doc's love it. Many want to do surgeries normally, but we definately have those that only want to do it after a full day at work -- psychiatrists esp. (for ECT). OBs to a lesser extent, and some others that do a large office practice. We also have those who are (admitted by them) night owls and would rather do anything other than be at work before 10:00am. Since they are the ones that drive the revenue, the hospital (IMHO) has taken a good tact to make it as easy as possible on both staff and anesthesia.

We have been having a real problem with scheduling of cases especially after hours. The surgeons think they should be able to schedule what they want when they want it. Anesthesia is caught between a rock and a hard place, do they let the surgeons get away with it or do they try to preserve a sense of control. Staff, on the other hand, doesn't want to work themselves to death and have people, who are not on call, stay over to finish up rooms.

My question is: how do all of you schedule your after hour cases? I think this is restricted to hospitals that don't run 24/7 and usually close the department at 11pm and nothing on the weekends.

1. Who is ultimately responsible for making decisions on scheduling

2. What kind of cases are allowed to be added on

3. How is your on-call staff utilized

4. Are staff constantly asked to stay over to finish rooms

5. Are there certain days of the week that are designated late days.

I just wanted to get a feel of what other ORs do that try to alleviate this constant problem. Thanks, Mike

Our facility recently improvised a committee to review all "add-on" cases, to try to get a handle on this problem. We have to classify all cases as elective, urgent or emergent. The "add-ons" are reviewed monthly, by the committe which consists of Chief of Surgery, Chief of Anesthesiology, OR Manager, Surgical Services Director, and Post-Anesthesia Manager. The committee identified surgeons who abused the policy of adding non-urgent/emergent cases as such, and were informed their add-on cases would be referred to the Chief of Surgery, for a "go-ahead", if anyone on the team (nursing or anesthesia) questioned the urgent/emergent nature of the case. It was interesting to see the number of "urgent/emergent" lap choles, appendectomies, etc. decrease dramatically. Most of the "offenders" didn't want to have to explain to the Chief why their lap chole patient, who had been in the hospital for 2 days, was suddenly an emergency add-on. Also, we had 1 surgeon famous for calling around 10-11 pm to add-on an "emergency" for 6 am, the next morning, knowing the scheduled cases start at 7am. After the first review, his early morning "emergencies" stopped all together.

When I first started working PACU at our Level 1 Trauma Center, our add ons and other after hour surgeries were almost always emergent in nature. Over the past year or so, we are almost always called in for add ons that are say...an I&D, cholies, even had a breast bx during my last call (I worked 14.5 of my 16 hours). I truly don't mind call when it is for a real emergency but the other stuff is getting to be a bit much!

Surginurse, I am assuming you work at a rather LARGE facility that has the schedule to have a "commitee" determine what will be done or what won't be done. I guess I should have made it a bit more clear to say these are add-ons for that day and not ones to be added on at a later date. A commitee wouldn't work here at all and I do find it a bit funny that a group decides whether you get to add on something or not. If I told these guys that others would decide if they could add on a Lap chole or not, they would just stare at me and transfer their patients elsewhere. We don't have the luxury and over-abundance of surgeons to pick and choose who we like and who we pi** off. Revenue is revenue and you don't want it going somewhere else.

Surginurse, I am assuming you work at a rather LARGE facility that has the schedule to have a "commitee" determine what will be done or what won't be done. I guess I should have made it a bit more clear to say these are add-ons for that day and not ones to be added on at a later date. A commitee wouldn't work here at all and I do find it a bit funny that a group decides whether you get to add on something or not. If I told these guys that others would decide if they could add on a Lap chole or not, they would just stare at me and transfer their patients elsewhere. We don't have the luxury and over-abundance of surgeons to pick and choose who we like and who we pi** off. Revenue is revenue and you don't want it going somewhere else.

Yes, this was a larger OR ( 10 inpatient/ 6 outpatient). I was referring to add-ons for the same day. The committee reviews add-on cases, on a monthly basis (those already performed). If they determine that a specific surgeon is adding "emergent" cases they feel are not really emergent, they address this with the surgeon, who then must be referred to the Chief, if (and only if) the charge nurse and anesthesiologist deem the potential add-on not to be of an emergent nature. It has nothing to do with "picking and choosing". It has been a great way to reduce the number of surgeons who manipulate the system to obtain OR time for their own convenience. This has reduced the amount of revenue spent on paying overtime, and leaves the team available for true emergencies. No more explaining to a surgeon that his crani will have to wait until the "emergent" lap chole is finished. We have one team in house, from 7pm - 7 am, for emergencies, and no on-call team. So sorry for the mix-up.

No problem. So this commitee looks at the previous after hour cases and discusses whether it was an emergency or not. Interesting concept, but unfortunately our anesthesia has no cahones and talks big but eventually, most of the time, gives in to pressure. Bad for us.

>I just wanted to get a feel of what other ORs do that try to alleviate this constant problem. Thanks, Mike>

Mike,

This was the deal at the facility I worked at for 28 years; I resigned a month ago, so unless things have changed, this is what we did.

The Anesthesiologist and surgeon are ultimately responsible for making decisions relative to scheduling add-ons in the evening and on weekends. Of course, the RN in charge contributes to the decision-making process; however, both anesthesia and the surgeon decide whether or not something is an emergency/urgent.

Therein lies the problem; all the surgeon needs to do is declare the pt an emergency, and unless there is an anesthesia issue, the case is added.

All cases deemed an emergency are added; all cases needing to be done for the convenience of the surgeon are added (even at 10 PM ). All cases in which the goal is to get the patient done and out of the hospital asap are added.

OR call is 11-7 Mon-Fri; this staff does emergencies and has been known to be called in to actually do one of those cases an MD deems necessary because he his leaving for vacation in the morning.

On the weekend, 7-3 Saturday, the OR call team is responsible to clean, stock, prepare for Monday and do emergencies; many surgeons book 'emergency' cases Friday afternoon if they cannot get them on the schedule on Friday, or they wish to get them out of the hospital by Monday.

typical cases include ORIF hips. closed reductions, appi's, lap chole's and VATS.

The Saturday day staff covers call 3P-7A for emergencies only

The Sunday call staff covers 7a-7-a and they, too, do cases deemed an emergency by the surgeon.

During the week, staff was consistently asked to stay after 17:30 to finish up and/or they are unable to leave because just 1 team is available after 17:30, and cases are often begun late in the afternoon without consideration as to the working staff.

Our late cases include running 3 rooms every weekday 15:30-17:30 with the plan to go down to 1 room after 17:30

The facililty has done little to satisfy the needs of surgeons and staff, I sense they just don't know how to fix it.

I hope this helps,

Paula