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Surgical Schedulers' Toolkit

Introduction
Best-Practice in Scheduling and Pre-Procedural Preparation
This toolkit is designed to assist our physician practice schedulers with the steps involved in scheduling a patient for surgery.  Our goal is to help make this a smooth, seamless process for all who are involved.

Scheduling
Accurate scheduling is essential to the pre-admission process.  Not only does it help with planning, but it also helps prevent cancellations or delays on the day of surgery while ensuring staff, patient and surgeon confidence.  Order Facilitator® is the preferred method for scheduling, as telephone scheduling can lead to miscommunication.  Please obtain a complete record of the demographic information needed to contact the patient as well as signed physician orders for the pre-admission nurses. Guidelines and algorithms for scheduling the case and the Pre-Anesthesia Testing (PAT) appointment will follow in PDF form.

Pre-Procedural Preparation
The pre-procedural evaluation of a patient depends on the invasiveness of the procedure and the patient's co-morbid conditions.  Laboratory studies needed prior to surgery, if not communicated to the PAT clinic personnel preparing the patient for surgery, may result in a delay or cancellation on the morning of surgery.

What's in this Toolkit?

Scheduling

 

 Pre-Anesthesia Testing (PAT)

 

 

 Registration & Financial Information

 

Scheduling
Requirements for Scheduling
To schedule/pre-register a patient for surgery or a procedure, a physician order is required and it must indicate the expected patient status .  This applies to all patients who are not in a WakeMed acute care facility at the time of scheduling.

WakeMed OneCall Surgery Scheduling & Pre-Registration Process
A patient status order requires that the patient fall into one of four categories, each indicating the expectation for the patient after surgery:

  • Return home (OPH)
  • Be placed in a bed for a short period of time (OPB)
  • Be placed in a bed for an extended period of observation services (OBS)
  • Be an inpatient (OPA or Acute Inpatient)

Inpatient status generally indicates that the patient is expected to spend at least one night in the hospital (Status=OPA or Acute Inpatient). To clarify, patients placed in a bed for a short period of time (Status=OPB) or for extended observation services (Status=OBS) may spend the night in the hospital even though they are not classified as an inpatient.

Medicare has established a list of procedures that can only be performed on an inpatient basis. This list is commonly referred to as Addendum E. If a procedure is on Addendum E, and the patient is Medicare, then Medicare will not cover the procedure unless the patient status is inpatient. With the exception of Addendum E procedures, it is okay for the status order to change after scheduling the patient if it is determined that another status would be more appropriate. A change of status always requires a physician order.
2014 CMS Addendum E Inpatient Only List 

If the patient you are scheduling is not currently in a WakeMed acute care facility, there are three options for providing this order to the OneCall scheduler:

Option 1
Enter the order via Order Facilitator®. NOTE: This is an electronic scheduling option that is being rolled out to practices. If your practice does not have Order Facilitator®, please call the WakeMed Information Services Help Desk at (919) 350- 8700 to arrange for set up and training.

Option 2
Fax the WakeMed OneCall Surgery Scheduling fax form AND the WakeMed Day Surgery Pre-Op Orders/History and Physical (H&P) form to the OneCall fax line: (919) 350-7946. The WakeMed Day Surgery form must include a patient status and a physician signature, which is dated and timed. These forms are available at: www.wakemed.org > For Our Providers > Patient/Physician Forms.

Option 3
Call the OneCall Surgery Schedulers at (919) 350-7000, choose Option 1, and fax the forms to (919) 350-7946 while you are on the phone.

History & Physical Requirement
A History and Physical (H&P) is required prior to PAT if applicable; otherwise, the H&P is required prior to surgery. WakeMed prefers to receive the H&P prior to the day of surgery. All H&P forms must be signed, dated and timed by the licensed independent provider (LIP). 

WakeMed Day Surgery Center History & Physical/Pre-Op Orders form.

Online Scheduling: Order Facilitator®
To complete your office set-up for the online scheduling of outpatient testing exams and studies via the online scheduling portal, please fill out the following forms:

1. Fax cover sheet for Physician Practice Online Scheduling Portal Access
2. Online Scheduling Portal Users form
3. WakeMed Information Services Remote Access Agreement for Physician Practices form
4. SCI-Order Facilitator® Signature form (To obtain this form, please contact Lisa Forte, manager of WakeMed OneCall Scheduling, at lforte@wakemed.org or (919) 350-7680.)

Once all information above has been obtained and submitted back to WakeMed OneCall Scheduling either by scan/email, www.onecallscheduling.com or fax (919) 350-0495, a representative from the call center will contact the listed office contact to confirm training dates and times.

OneCall Scheduling ALERTS
Please share any of the ALERTS below at the time of scheduling:

AICD
ALT Facility Resident
BETA Blockers
Bleeding Disorder
Cochlear Implant
Custodial Forensics
Glucophage
History of Malignant Hyperthermia
Impaired Hearing 
Implant
Mental Impairment 
Impaired Mobility
Impaired Vision
Interpreter Needed
Iodine Allergy
Isolation Airborne Precautions (i.e. TB, varicella zoster, shingles/chickenpox, measles)
Isolation Airborne Full Barrier 
Isolation Contact (i.e. MRSA)
Isolation Droplet (i.e. pertussis, influenza virus, rhinovirus, meningitis, group A strep)
Isolation Enteric (i.e. E. coli, shigella, hepatitis A, rotavirus)
Latex Allergy
Privacy Requested
Religious or Culture Request 
Ventilator Dependent
Weight >250

Pre-Anesthesia Testing: Guidelines for Surgeon Offices
All patients having surgery at WakeMed require either a pre-anesthesia testing (PAT) telephone call or PAT Clinic visit prior to the day of surgery to allow for thorough preoperative evaluation, diagnostic testing and education.

The PAT Clinic Visit will be scheduled at the time of surgery scheduling for patients meeting any of these criteria:

1. Medical problems that warrant further evaluation or special preparation based on the PAT Triage Questionnaire  or surgeon request
2. Patients to be admitted to the hospital postoperatively (OPA)
3. Patients having robot-assisted surgery

The PAT telephone interview will be performed for:

1. All patients under the age of 13
2. Patients having cataract surgery
3. Patients in a facility who do not meet other criteria for a PAT Clinic visit

During a PAT telephone interview, if the patient is found to require a PAT Clinic visit, the clinic appointment will be scheduled with the patient at that time and your office will be notified.

All patients being scheduled for surgery should be screened in your office using the PAT Triage Questionnaire and scheduled for a PAT Clinic visit if medically appropriate. Additionally, patients with multiple medical problems frequently benefit from a PAT Clinic visit, even if they don't meet specific criteria. If a patient with known medical problems does not attend a scheduled PAT Clinic appointment, your office will be contacted to reschedule the patient's surgery.

WakeMed Perioperative Services: PAT Scheduling Algorithm for OneCall Schedulers 

Scheduling Algorithm - Order Facilitator eFax Pilot algorithm 

Appendix 1: Preanesthesia Testing Guidelines for Surgeon Offices
All patients who will have surgery at WakeMed require either a preanesthesia assessment and testing (PAT) phone call or PAT Clinic visit prior to the day of surgery to allow for thorough preoperative evaluation, diagnostic testing and education. Click for more details on the PAT Clinic visit, the PAT phone interview and the questions that will be asked of the patient.

Pre-Anesthesia Testing (PAT)
Scheduling & PAT Guidelines

Preoperative Documentation Requirements:
1. Surgeon H&P: Signed, dated and timed < 30 days preoperatively
2. Surgical consent: ideally completed, but must at least have complete procedure written on form (frequent discrepancy between consent and OR schedule)
3. Surgeon Orders: completed including admission status, signed, dated and timed
4. Medical Clearances/Specialist Consults: completed, with all supporting documentation present

Documentation Reconciliation Process:
1. Surgeon orders, including admission status, must be on file prior to any PAT.
2. PAT Clinic staff will contact the surgeon's office two business days before the surgery date if any of the four elements above are not present.
3. At the huddle at 1 pm at Cary and 2 pm at Raleigh on the day before surgery, if any of the elements are still missing, the surgeon's office will be contacted.
4. If any of the missing documentation is likely to delay a first case, then the case will be rescheduled or the case order will be changed after consultation with the surgeon's office.
5. Absence of consent or H&P in a 'consentable' patient will not affect case timing.
6. Patients with guardianship must have anesthesia and surgical consents completed and on file prior to the day of surgery.
7. The chart reconciliation nurse will check the H&P on file to ensure that it will not be out of date on the day of surgery.

First Case Scheduling Guidelines:
1. No first cases with significant chart deficiencies
2. No first cases for facility patients (nursing home, prison) without director approval

PAT Clinic Visit Guidelines:
1. Patients meeting medical criteria based on PAT Triage Questionnaire
2. Patients to be admitted (OPA) to the hospital
3. Patients having robotic procedures
If a patient is found to have significant comorbidities during a telephone PAT, they will be scheduled for a PAT visit via OneCall while on the telephone with the PAT nurse.

Coronary Stents and Antiplatelet Drugs
WakeMed Perioperative Services has collaborated with physicians from the Departments of Cardiology, Surgery and Anesthesiology to create a process by which patients receiving antiplatelet therapy for the protection of cardiac stents are managed during the perioperative period.

Background:
Patients are prescribed antiplatelet drugs such as Plavix (clopidogrel), Effient (prasugrel), and Ticlid (ticlopidine) for prevention of blood clots following the placement of a coronary artery stent. These drugs are continued for at least three months and sometimes for life.

Antiplatelet drugs are associated with increased bleeding during surgery. Many invasive surgeries and anesthesia procedures (i.e. nerve blocks, spinals, epidurals) cannot be performed if a patient is on these drugs.

Patients with coronary artery stents are at risk for perioperative myocardial infarction (MI) and death when antiplatelet drugs are discontinued for surgery, especially if the stent has been in place fewer than 12 months.

Antiplatelet drugs must not be stopped without the explicit approval of the physician who prescribed the drug.

Patients with coronary artery stents who are on antiplatelet drugs must be seen in the PAT clinic and complete documentation of preoperative cardiac evaluation and antiplatelet drug management instructions must be provided on form N-372 (Request for Preoperative Cardiac Evaluation)

Preoperative Cardiac Evaluation
The following patients must have a preoperative cardiac evaluation by a cardiologist prior to all procedures1, including endoscopy procedures:

  • Patients who have undergone placement of a coronary artery stent in the last 12 months.
  • Patients who are on Plavix for protection of a coronary stent placed at any time in the past.

If a patient with any of these problems does not have the appropriate preoperative evaluation and documentation, the procedure will be cancelled on the day of surgery.

Patients with a history of cardiovascular disease will need preoperative cardiac evaluation prior to most procedures. This includes history of the following:

  • Coronary artery disease (including angioplasty, stents, or bypass surgery)
  • Congestive Heart Failure
  • Heart valve disease
  • Arrhythmias (atrial fibrillation, supraventricular tachycardiac (SVT), Wolff-Parkinson-White)
  • Stroke

Please facilitate the preoperative evaluation process by having the patient see the cardiologist before the PAT clinic visit and ensuring that the necessary documentation is completed and sent to the PAT clinic prior to the PAT clinic appointment.

The process for obtaining preoperative cardiac evaluation is as follows:

1. Surgeon's office schedules appointment with the cardiologist, completes the top of the "Request for preoperative cardiac evaluation" form  (form N-372) and faxes to cardiologist. 
2. Cardiologist performs evaluation and returns completed form and consult to surgeon's office.
3. Surgeon's office faxes copy of form and cardiology materials to WakeMed pre-op clinic.

1The only exception is patients having cataract surgery who will remain on the antiplatelet drugs perioperatively.


Perioperative Management of Pacemakers and ICDs
WakeMed Perioperative Services collaborated with physicians from the Departments of Anesthesiology and Cardiology to create a process by which patients with implanted pacemakers and defibrillators are managed during the perioperative period.

Summary:
Any patient with a pacemaker or defibrillator (ICD) device must be scheduled for a PAT clinic visit, with the exception of cataract patients.

If perioperative device reprogramming is necessary on the day of surgery, WakeMed will arrange this with the device representative.

The information form (N- -765) is sent to the cardiologist who manages the patient's device, not necessarily the patient's primary cardiologist.

This process is best initiated by the surgeon's office prior to the PAT clinic visit to ensure that information is available at the time of the visit.

As a courtesy, the PAT clinic will initiate the process for any patient who is seen in the PAT clinic more than seven days before surgery. Otherwise the surgeon's office will be asked to initiate the process.

WakeMed Perioperative Services Perioperative Management of Pacemakers and ICDs.


Adult Diagnostic Testing Guidelines
WakeMed Perioperative Services Adult Preoperative Diagnostic Testing Guidelines.

Pediatric Diagnostic Testing Guidelines
WakeMed Perioperative Services Pediatric Preoperative Diagnostic Testing Guidelines.

Preoperative Fasting Guidelines
WakeMed Perioperative Services Preoperative Fasting (NPO) Guidelines.

Outpatient Preoperative Medication Guidelines
WakeMed Perioperative Services would also like to provide you with outpatient preoperative medication guidelines for patients. In chart format, these guidelines detail the different classes of medications the patient may be taking; the medications within those classes; when to hold, not hold or discontinue medications prior to or the day of surgery and for what reason (i.e. low blood pressure, increased risk of bleeding, rebound effects). Click to access the chart.  And following are additional guidelines to assist patients in preparing their bodies for surgery: 

Review this list of herbals and dietary supplements with the potential to increase bleeding.  It is recommended that patients discontinue herbal supplements at least one week prior to surgery.

Review this guide to Preoperative Diabetes Management including when to take and discontinue medications prior to surgery, when to check blood sugar prior to surgery and what a patient should do if he or she becomes hypoglycemic.
 

Registration and Financial Information
Insurance Verification Overview

Estimates Inquiry
Patients can call (919) 350-7808 (automated number). Items needed for the estimate:

  • Name of procedure with CPT codes
  • Physician
  • Length of time

Point of Service Collections

  • Collects expected co-pays
  • Collects previous balance
  • Special lenses, bariatric and cosmetic surgeries

Contacts
For questions and concerns regarding insurance verification:

CareLine: (919) 350-2273
Karen Forte: (919) 350-0671
Natalie Uy: (919) 350-8561

Managed Care Contracts
WakeMed contracts with a wide variety of managed care plans and insurance companies. Click to access more information about WakeMed's managed care contracts and the plans currently accepted at all WakeMed facilities.