Improving Anesthesia Start Time Documentation Through a Departmental Education Initiative at Yale New Haven Hospital, New Haven, United States.

Background Reimbursement for anesthetic services in the United States utilizes a formula that incorporates procedural and patient factors with total anesthesia time. According to the Centers for Medicare & Medicaid Services and the American Society of Anesthesiologists, the period of billable time starts when the anesthesia practitioner assumes care of the patient and may include transport to the operating room from the preoperative holding area. In this report on a quality improvement effort, we implemented a departmental education initiative aimed at improving the accuracy of anesthesia start-time documentation. Methods Utilizing de-identified, internal data on surgical procedures at Yale New Haven Hospital (YNHH), New Haven, United States, the difference between documented anesthesia start and patient in-room time was determined for all cases. Those with a difference between 0-1 minute were assumed "likely underbilled," and the total revenue lost for these cases was estimated using a weighted average of institutional reimbursement per unit of time. A monthly, department-wide educational email was then introduced to inform practitioners about the guidelines around start-time documentation, and the percentage of "likely underbilled" cases and lost revenue estimates trended over a one-year period. Results Baseline data in December 2020 showed that of the 6,877 total surgical cases requiring anesthesia at YNHH, 55.1% (N=3,790) had an anesthesia start to in-room time of 0-1 minute, which were considered "likely underbilled." The average start-to-in-room time for properly recorded cases (44.9%, N=3,087) was 4.42 minutes. The baseline revenue lost in December 2020 for underbilled cases was estimated at $52,302. Over the one-year quality improvement initiative, the proportion of underbilled cases showed a downward trend, decreasing to 29.2% of total cases by November 2021. The estimate of revenue lost due to underbilling also showed a downward trend, decreasing to $29,300 in November 2021. Conclusion This quality improvement study demonstrated that a relatively simple, department-wide educational email sent monthly correlated with an improvement in anesthesia start-time documentation accuracy and a reduction in estimated revenue lost to underbilling over a one-year period.

Quality indicators and outcomes in ambulatory surgery.

PURPOSE OF REVIEW: Quality indicators are used to monitor the quality and safety of care in ambulatory surgery, a specialty in which major morbidity and mortality remain low. As the demand for safe and cost-effective ambulatory surgical care continues to increase, quality indicators and metrics are becoming critical tools used to provide optimal care for these patients. RECENT FINDINGS: Quality indicators are tools used by both regulatory agencies and surgical centers to improve safety and quality of ambulatory surgical and anesthetic care. These metrics are also being used to develop value-based payment models that focus on efficient, safe, and effective patient care. Patient reported outcome measures are a growing method of collecting data on the satisfaction and postoperative recovery period for ambulatory surgical patients. Monitoring of perioperative efficiency and utilization using quality metrics are important to the financial health of ambulatory surgical centers. SUMMARY: Quality indicators will continue to play a growing role in the monitoring of quality and safety in ambulatory surgery, especially with the trend towards value-based reimbursement models and efficient, cost-effective surgical care. Additionally, quality indicators are useful tools to monitor postoperative patient outcomes and recovery pathways and the efficiency of operating room utilization and scheduling.

A Preoperative Cognitive Screening Test Predicts Increased Length of Stay in a Frail Population: A Retrospective Case-Control Study.

BACKGROUND: Frailty is associated with adverse perioperative outcomes including major morbidity, mortality, and increased length of stay. We sought to elucidate the role that a preoperatively assessed Mini-Cog can play in assessing the risk of adverse perioperative outcomes in a population at high risk of frailty. METHODS: In this retrospective case-control study, patients who were >60 years of age, nonambulatory, or had >5 documented medications were preoperatively assessed for handgrip strength, walking speed, and Mini-Cog score. The Emory University Clinical Data Warehouse was then used to extract this information and other perioperative data elements and outcomes data. RESULTS: Data were available for 1132 patients undergoing a wide variety of surgical procedures. For the subset of 747 patients with data for observed-to-expected length of stay, an abnormal Mini-Cog was associated with an increased odds of observed-to-expected >1 (odds ratio, 1.52; 95% CI, 1.05-2.19; P = .025). There was no association of abnormal Mini-Cog with intensive care unit length of stay >3 days (P = .182) discharge to home with self-care (P = .873) or risk of readmission (P = .104). Decreased baseline hemoglobin was associated with increased risk of 2 of the 4 outcomes studied. CONCLUSIONS: In a high-risk pool of patients, Mini-Cog may not be sensitive enough to detect significant differences for most adverse outcomes. Further work is needed to assess whether cognitive screens with greater resolution are of value in this context and to compare tools for assessing overall frailty status.