Transforming the Delivery of Operative Anesthesia Services in Ontario

Transforming the Delivery of Operative Anesthesia Services

in Ontario

Report & Recommendations of the Operative Anesthesia Committee May 2006

Transforming the Delivery of Operative Anesthesia Services in Ontario May 2006 Report & Recommendations of the Operative Anesthesia Committee

TABLE OF CONTENTS

SUMMARY OF RECOMMENDATIONS ......................................................................... 1

EXECUTIVE SUMMARY ................................................................................................ 3

BACKGROUND AND CONTEXT ................................................................................... 4

OPERATIVE ANESTHESIA COMMITTEE ..................................................................... 6

UPDATE ON ACADEMIC ANESTHESIA SERVICES IN ONTARIO.............................. 8

ANESTHESIA CARE TEAM......................................................................................... 10

Context............................................................................................................................10

Description of ACT Model ...............................................................................................10

Anesthesia Assistants .....................................................................................................12

Benefits of the ACT Model ..............................................................................................13

Challenges with the ACT Model ......................................................................................14

NEXT STEPS ............................................................................................................. 19

APPENDIX 1 - STATUS REPORT ON ANESTHESIA SERVICES AT ONTARIO’S ACADEMIC HEALTH SCIENCE CENTRES ....................................... 20

Transforming the Delivery of Operative Anesthesia Services in Ontario May 2006 Report & Recommendations of the Operative Anesthesia Committee Page 1 of 101

SUMMARY OF RECOMMENDATIONS The 2004 Physician Services Agreement provided for the formation of the Operative Anesthesia Committee (OAC) in recognition of the pressures facing operative anesthesia in Ontario’s hospitals. The OAC is to provide recommendations to support stable and adequate access to anesthesia services in Ontario hospitals. The Agreement provides $5 million in new funding to support operative anesthesia, based on the Committee’s recommendations. After considerable deliberation and wide ranging consultation, including the OMA Anesthesia Section meeting in September 2005, the OAC:

1) Asked Dr. Marshall to update his 2003 review of anesthesia services at Ontario’s AHSCs and to gain an understanding of the current use of, support for and the potential of the Anesthesia Care Team (ACT) concept to address the anesthesia shortage.

2) Defined the ACT model, outlining roles, responsibilities and training requirements. In

addition, the OAC identified the benefits and challenges associated with this new approach to providing anesthesia services.

3) Established a costing sub-committee to explore current funding of operative anesthesia,

estimate the impact of investments in the 2004 Physician Services Agreement and evaluate additional options to better support operative anesthesia.

Based on the work outlined above, a paper entitled Transforming the Delivery of Operative Anesthesia Services in Ontario was developed by the OAC. This document recommends:

#1 Formal introduction of the ACT model Establish ACT demonstration sites in Academic Health Sciences Centres (AHSCs) and

community hospitals. Evaluate the demonstration sites, modify the model and set minimum requirements for viability and expected outcomes. Explore different funding models for ACTs (e.g. APP, AFP, fee-for-service). Roll out the ACT model across the province.

#2 Widespread training and use of anesthesia assistants in the delivery of anesthesia

services in a variety of practice settings (e.g. AHSCs and community hospitals) Bring together a group of stakeholders to develop a common definition of anesthesia

assistant, define their roles and responsibilities and agree on training requirements. Introduce and/or expand training opportunities across Ontario.

#3 Changes to the Schedule of Benefits, which will allow the use of supervision in a

fee-for-service practice environment and encourage the provision of operative anesthesia services

Replace the anesthesia fee (base & time units) with a supervisory payment when

someone other than an anesthesiologist provides anesthesia care. Reinvest the savings achieved through this change to the Schedule of Benefits in other anesthesia services.


Further support the provision of operative anesthesia services through other specified investments.

The Committee agreed that the above-noted recommendations must be considered in their entirety and not as a collection of stand-alone recommendations. The Committee is now focused on costing the proposed recommendations:

ACT model demonstration sites for AHSCs and community hospitals Supervisory payments Schedule of Benefit changes (e.g. triple time units for intra-operative anesthesia)

The OAC plans to finalize all documents and recommendations for submission to the Physician Services Committee by June 2006.


EXECUTIVE SUMMARY For several years the Canadian anesthesiology community has been concerned about a growing shortage of anesthesia personnel. This national shortfall was made particularly relevant to Ontario in light of the provincial government’s announcement of its Wait List Initiative in the Fall of 2003. Even though anesthesiologists sacrificed academic activity to ensure the provision of clinical services, surgical wait times continued to grow, operating rooms were closed and surgeries cancelled. Despite recent efforts to address the situation, including increasing medical school enrollment and anesthesia residency training positions and investing in academic anesthesia services, the anesthesia shortfall continued to grow. The Ontario Medical Association (OMA) and the Ministry of Health and Long-Term Care (MOHLTC) recognized that immediate action was required and called for the establishment of the Operative Anesthesia Committee (OAC) in the most recent Physician Services Agreement. To support stable and adequate access to anesthesia services in Ontario hospitals, the OAC is calling for the formal introduction of Anesthesia Care Teams (ACTs). The ACT is an innovative model of care which calls for a significant change to the way anesthesia services are currently provided. Specially trained other health professionals assist in the provision of anesthesia services under the direct supervision of an anesthesiologist. This model of care will provide better access to anesthesia services in a more efficient and cost cost-effective manner. It will also allow all ACT team members to fully utilize their skills and experience in the provision of anesthesia services, a key component in transforming the provision of health care. Outlined below are the Committee’s 3 major recommendations. The steps suggested to implement these recommendations are detailed in the report: #1 Formal introduction of the ACT model

Establish ACT demonstration sites in Academic Health Sciences Centres (AHSCs) and community hospitals. Evaluate the demonstration sites, modify the model and set minimum requirements for viability and expected outcomes. Explore different funding models for ACTs (e.g. APP, AFP, fee-for-service). Roll out the ACT model across the province.

#2 Widespread training and use of anesthesia assistants in the delivery of anesthesia

services in a variety of practice settings (e.g. Academic Health Sciences Centres and community hospitals)

Bring together a group of stakeholders to develop a common definition of anesthesia assistant, define their roles and responsibilities and agree on training requirements. Introduce and/or expand training opportunities across Ontario.

#3 Changes to the Schedule of Benefits, which will allow the use of supervision in a fee-for-service practice environment and encourage the provision of operative anesthesia services Replace the anesthesia fee (base & time units) with a supervisory payment when someone other than an anesthesiologist provides anesthesia care. Reinvest the savings achieved through this change to the Schedule of Benefits in other anesthesia services. Further support the provision of operative anesthesia services through other specified investments.


BACKGROUND AND CONTEXT Shortage of Anesthesiologists The shortage of anesthesiologists is a growing concern across all jurisdictions in and outside of Canada. Many studies have examined the supply of anesthesiologists and have confirmed that there are insufficient numbers to meet current and predicted future demands. Two recent Canadian studies found the current supply of anesthesiologists to be inadequate and forecast an increasing deficit over time. While the magnitude of the problem varies from province to province and continues to worsen, Ontario appears to have the largest absolute shortfall of anesthesiologists in Canada. • The Ryten Report, commissioned by the Association of Canadian University Departments of

Anesthesia, identified an 8% shortfall of anesthesiologists in Canada (114 in Ontario) in 2000. This same study projected the deficit would grow to 656 anesthesiologists in Canada (459 in Ontario) by 2016.

• The 2002 Engen Study identified an immediate need for 228 full-time equivalent (FTE)

anesthesiologists in Canada and suggested that by 2007 560 FTE anesthesiologists would be required.

There are several factors associated with the increasing shortage of anesthesiologists in Canada: • The 1991 Barer Stoddart report, Toward Integrated Medical Resource Policies for Canada,

resulted in an 11.3% reduction in Canadian medical school enrollment over three years in the early 1990s. This was followed by a similar reduction in postgraduate positions in 1997.

• The opportunity for pursuing specialty training after becoming licensed as a physician in Ontario

(re-entry) was closed with the introduction of the Regulated Health Professions Act in 1993. Prior to 1993, physicians could get a license to practice medicine in Ontario once they completed their 1-year rotating internship. Under this system, licensed physicians were able to access residency positions to complete specialty training and a significant number of residency spots were available for practicing physicians returning to training. The Act eliminated the 1-year rotating internship as a pathway to licensure and required that physicians complete either a 2-year family medicine program or a 4 - 5 year specialty training program in order to qualify for independent practice. In doing so, the informal pathway to reentry was closed.

• Effective July 1997, the Royal College of Physicians and Surgeons of Canada no longer

recognized non-North American medical school training as meeting part of the requirements for its own specialty training programs thereby limiting the supply of International Medical Graduates.

Impact on Operative Anesthesia The anesthesiologist shortage in Ontario has resulted in growing surgical wait times, cancelled surgeries, operating room closures and delays in diagnostic testing. The role of the anesthesiologist outside the operating room has also expanded over time and this has compounded the negative impact on operative anesthesia. The institution of same-day admission policies in the 1990s imposed the need for pre-anesthetic clinics to assess and evaluate patients before surgery. Simultaneously, the development of sophisticated post–operative pain services has resulted in


multiple post-operative visits by anesthesiologists, further encouraged by fee-for-service remuneration. Recent Efforts to Address Ontario Shortfall Since the late 1990s, a number of steps have been taken to address the anesthesiologist shortage in Ontario. These efforts include: • Ontario medical school enrollment has increased by 34%, growing from 526 positions in 1994 to

704 positions in 2004. • Ontario anesthesia residency training positions have increased by 32%, growing from 140

positions in 1998 to 185 positions in 2004. • International Medical Graduates (IMGs) are now recruited under academic certificates issued by

the College of Physicians and Surgeons of Ontario. • A formal re-entry program has been established beginning with 25 positions for both third year

family medicine and specialties. In 2000, a further 15 spots were added bringing the total to 20 spots for family medicine and 20 spots for specialties. Physicians are required to return a maximum of two years in an under-serviced area in return for government funded training.

• $6 million annually was invested in academic anesthesia services beginning in 2003 resulting in

the recruitment of 39 FTE anesthesiologists at Ontario’s Academic Health Science Centres (AHSCs). Dr. John Marshall was asked to review anesthesia services, staffing, compensation and workload at Ontario’s AHSCs and provide recommendations that led to this new investment.

• An Anesthesia Assistant Graduate Certificate Program was launched at the Michener Institute.

This is a joint initiative involving the Michener Institute and the University of Toronto. The program, which originally offered basic or technical training, has recently expanded to include advanced or clinical training. Applicants’ skills and experience are assessed to determine their point of entry into the program.

• The Operative Anesthesia Committee was established in June 2005.


OPERATIVE ANESTHESIA COMMITTEE 2004 Physician Services Agreement The 2004 Physician Services Agreement provided for the formation of the OAC in recognition of the pressures facing operative anesthesia in Ontario’s hospitals. According to Section 27.3 of the 2004 MOHLTC-OMA Physician Services Agreement:

“The Parties agree that there is an urgent need to address the challenges facing operative anesthesia in Ontario’s hospitals. Accordingly, the Parties agree to establish a committee with representation from the OMA and MOHLTC to develop recommendations for addressing this issue in a timely fashion including opportunities for Schedule of Benefits redefinition, other physician payment strategies and the use of anaesthesia extenders. This committee will consult with the OHA as appropriate. The MOHLTC agrees to provide physician funding beginning October 1, 2005.”

The Agreement also provides over $52 million in annual funding for anesthesia services including increases to unit fees and base units ($26 M+), targeted fee increases ($7M+), increased and expanded hospital on-call coverage payments ($13 M) as well as new funding to support operative anesthesia ($5M). Use of funding to support operative anesthesia is to be based on the recommendations of the OAC OAC Terms of Reference The OAC is to provide recommendations to support stable and adequate access to anesthesia services in Ontario hospitals. Areas of focus include: • Understanding current and anticipated service demands and workforce issues • Short and longer term strategies to support the use of anesthesia assistants • Applicability of various funding approaches • Consideration of changes to fee-for-service payment program • Discussion of longer term alternate funding approaches • Impact of short and long term recommendations on the Wait Time Strategy • Other longer term recruitment and retention strategies for anesthesia • Potential impact on anesthesia requirements in the Local Health Integration Network

environment The OAC consists of five members appointed by each of the OMA and MOHLTC (see table below for details). The Chair, Dr. Jack Kitts, was appointed jointly by the OMA and MOHLTC.

Operative Anesthesia Committee – Membership

Chair/Facilitator – Dr. Jack Kitts OMA MOHLTC Support

Dr. David Bevan Dr. Steve Brown Dr. John Cain Dr. Geraint Lewis

Ms. Bernita Drenth Ms. Susan Fitzpatrick Dr. Alan Hudson Mr. Hugh MacLeod Dr. John Marshall

Ms. Danielle Claus, Consultant Ms. Honorata Bittner, PSC Secretariat Mr. David Mackey, PSC Secretariat Mr. Jim Simpson, OMA Ms. Peggy Taillon, The Ottawa Hospital


Committee Focus The OAC has closely examined current and planned initiatives to address the anesthesiologist shortage. While encouraging, it is clear that significant additional effort is required, effort that looks beyond existing service and funding models in order to better meet current and future service demands. After considerable deliberation and wide ranging consultation, including the OMA Anesthesia Section meeting in September 2005, the OAC: 1) Asked Dr. Marshall to update his 2003 review of anesthesia services at Ontario’s AHSCs and to

gain an understanding of the current use of, support for and the potential of the ACT concept to address the anesthesia shortage.

2) Clearly defined the ACT model, outlining roles, responsibilities and training requirements. In

addition, the OAC identified the benefits and challenges associated with this new approach to providing anesthesia services.

3) Established a costing sub-committee to explore current funding of operative anesthesia estimate

the impact of investments in the 2004 Physician Services Agreement and evaluate additional options to better support operative anesthesia.

This report focuses on the ACT model. A separate paper, which deals with the funding of operative anesthesia, is currently under development.


UPDATE ON ACADEMIC ANESTHESIA SERVICES IN ONTARIO Methodology Questionnaires were sent to the Chiefs of Anesthesiology and to the Directors or Managers of Peri-operative Services at each of the AHSC institutions. Following the return of the questionnaires, Dr. Marshall conducted telephone interviews with each Anesthesiology Chief and Peri-Operative Services Manager. The interviews at the two children’s hospital were conducted in person, as these sites were not included in the original report. The purpose of the interviews was two-fold. First, confirm the data submitted in the returned questionnaires and clarify any ambiguity. Second, obtain an understanding as to how specific services were delivered at each site with particular focus on the roles played by anesthesia assistants and nurses in supporting anesthesia activities at each stage of the peri-operative process. Findings A summary of Dr. Marshall’s findings is outlined in the chart below. There are two points of particular interest. First, it appears the anesthesiologist shortfall across Ontario AHSCs has not changed significantly between February 2003 and November 2005. This is due to an almost parallel increase in the volume of services (expressed as Daily Anesthetic Locations) and the general increase in FTE anesthesiologists, 35 and 42 respectively. This reflects the pent up demand for services met by the increasing staff complement. In the absence of the $6 million investment annually, which assisted in the recruitment of the 42 FTE anesthesiologists, the situation at AHSC would be profoundly worse. Staffing Formula Components Feb.2003 Nov.2005 Difference % Change Daily Anesthetic Locations 323.5 358.2 34.7 10.7% Required Anesthesia FTE 398.7 446.2 47.6 11.9%

Actual Anesthesiologist FTE 333.7 375.4 41.7 12.5%

Actual Assistant/RN Equivalent Anesthesiologist FTE

5.9 15.6 9.7 163.6%

Shortfall FTE 59.1 55.3 -3.8 -6.4% Second, the use of other health professionals to assist in the provision of anesthesia services has grown significantly in the last two to three years. In February 2003, these individuals represented approximately 6 anesthesia FTEs, while in November 2005, they represented almost 16 FTEs, a growth of 164%. These individuals contributed significantly to reducing the anesthesia shortfall. Without anesthesia assistants and registered nurses (RNs), the anesthesiology shortage would have been 65 FTE instead of the 55 FTE.


Other Health Professionals and the Provision of Anesthesia Services As part of the review of anesthesia services within Ontario’s AHSCs, Dr. Marshall also learned about the current use of and interest in professionals in the provision of anesthesia services. A synopsis of his findings is as follows: Pre-operative Assessment Unit • Most AHSCs support the concept of specially trained nurses in the clinic and agree that this role

could reduce the anesthesiologist workload. • Very few AHSCs currently use specially trained nurses to triage patients in the preoperative

assessment unit. A small number of organizations disagree with this approach claiming that all patients should be seen by an anesthesiologist (based on physician and patient preference). Intra-Operative Care • Almost all AHSCs use some model of anesthesia assistant to augment services – specifically,

RNs and registered respiratory therapists (RRTs) in cataract rooms. That said, there is significant variation in the role of the anesthesia assistant (RRTs and RNs) and the degree to which anesthesiologists can increase clinical services.

• In two pilot projects, anesthesia assistants assisted in hip and knee procedures. Once regional

anesthesia was established, the procedure started and the patient stabilized, the patient was monitored by an anesthetic assistant while the anesthesiologist prepared the next patient. The use of anesthetic assistants resulted in a 33% increase in productivity allowing one additional joint procedure per day (from 3 to 4 cases).

• Only one AHSC is using anesthesia assistants to occasionally monitor stable long cases under

general anesthetic. • Those organizations and anesthesiologists currently using anesthesia assistants in a clinical role

are more receptive to expanding the assistant role. • In AHSCs, there is widespread use of anesthesia assistants to assist in room preparation and

turn over and to be on hand at induction, particularly for the more complex cases. Some believe that significant increases in productivity can be achieved by this role.

Post-Operative Care – Acute Pain Service • A number of AHSCs use specially trained nurses to augment the Acute Pain Service. Those

organizations using specially trained nurses report significantly improved patient care and variable savings in anesthesiologist time.

• All AHSCs endorse the use of specially trained nurses in this role but opinions vary on the extent

to which specially trained nurses could reduce anesthesiologist workload. All agree that patient safety and satisfaction would be improved.

Across the AHSCs, there is a general willingness to introduce some components of the ACT. The enthusiasm for such an introduction varies considerably by site. In general, it could be said that in Centres where alternative approaches have been employed the greater the willingness to consider an expansion of assistant roles.

ANESTHESIA CARE TEAM

Context Support for the ACT concept is well established. • The Surgical Process Analysis and Improvement Expert Panel, established by the MOHLTC in

October 2004 to improve surgical efficiencies in Ontario’s hospitals, recommends expanding anesthesia resources by supporting:

• Advance practice roles that complement and expand anesthesia services currently provided

by anesthesiologists such as GP anesthetists, anesthesia assistants and acute care nurse practitioners with special training in anesthesia.

• Teams to provide anesthesia services.

• The Canadian Anesthesiologists’ Society (CAS) is calling for a nationally approved training

program for anesthesia assistants with formal certification of successful candidates including a well-defined scope of practice. The Canadian Society of Respiratory Therapists supports this concept and is currently drafting a scope of practice for consideration of its members.

• According to the Council of Academic Hospitals of Ontario and the Ontario Hospital Association,

“it is believed that anesthesia assistants can play a valuable role in the long-term sustainability of Ontario’s health care system.”

While ACTs have existed informally at some of Ontario’s AHSCs for several years, the ability and willingness to introduce or expand the concept has been limited by several factors. By formalizing the ACT model and clearly articulating roles, responsibilities and training requirements, many of the challenges of implementing the model could be addressed and the full potential of the team concept could be realized.

Description of ACT Model The ACT consists of anesthesiologists and specially trained other health professionals, RNs and RRTs, working under the supervision of anesthesiologists for a specified set of anesthesia services. The chart below outlines the functions, staff components and reporting structures of the ACT model. This model calls for a change in current reporting relationship. In the ACT model, RNs and RRTs report directly to anesthesiologists.

Anesthesia Care Team

Pre-Operative Care Intra-Operative Care Pre-Operative Care

Anesthesiologists

Clerks Anesthesia Assistants (RNs and/or RRIs)

Specially trained RNs Technicians Specially trained RNs

Anesthesiologists Anesthesiologists



Pre-operative Assessment Unit Specially trained nurses, under the supervision of an anesthesiologist, would conduct chart reviews, where indicated, initiate investigation using a series of protocols and algorithms and evaluate/assess patients. Technicians would collect blood work and conduct electrocardiograms. Anesthesiologists would oversee the clinic and provide consultation services as required. Staffing suggestions: • 1 FTE specially trained RN for every 5000 clinic patients (Approximately 20 patients per day) • 1 FTE anesthesiologist for every 3500 clinic patients who require a consultation (Approximately

10-15 patients per day) • The assumption is that an anesthesiologist may need to see approximately 30% of all clinic

patients, seen by the physician only. Note: there may be other “flagged” patients that the nurse asks the anesthesiologist to see. These “flagged” patient visits will be much shorter as the nurse has already seen the patient.

• Note: staff to patient ratios may vary depending on the acuity of the case mix Intra-Operative Care Specially trained anesthesia assistants (RNs and/or RRTs) would provide both technical and clinical assistance to anesthesiologists. The technical role would involve preparation of equipment, facilitating vascular access and insertion of regional nerve blocks as well as assisting with airway management. The clinical role would include assisting the anesthesiologist in the care of stable patients during anesthesia. Anesthesiologists would continue to provide a full range of services in the operating room. Staffing suggestions: • 1 FTE anesthesia assistant for every 2 operating rooms • The assumption is that this staffing ratio could result in a 20% increase in operating room

efficiency and that this increase in efficiency could result in more operative cases • Note: to fully utilize the ACT model, anesthesia assistants should be available 24 hours a day,

seven days a week Post-operative Care - Acute Pain Service Specially trained nurses would provide patient monitoring and documentation and carry out therapeutic adjustments of both drugs and devices under agreed protocols. These RNs would also have a very active role in patient and unit staff education under the supervision of an anesthesiologist. Anesthesiologists would supervise the acute pain service and have a consultant role when conventional pain management fails. Staffing suggestions: • 1 FTE specially trained RN for every 1500 post operative pain patients • 0.5 FTE anesthesiologist for every 5000 post operative pain patients • The assumption is that the majority of patients could be cared for by the nurse under the

supervision of an anesthesiologist. This staffing approach could reduce the anesthesiologist workload by at least 60%

• Note: to fully utilize the ACT model, specially trained nurses should be available 24 hours a day, seven days a week.


Anesthesia Assistants The ACT model calls for the use of RNs and/or RRTs in extended roles for which they have appropriate training. As previously mentioned, it is necessary to achieve an agreed upon definition of anesthesia assistant, their roles and required training for these individuals. The OAC defines an anesthesia assistant as: “A specially trained health professional that participates in the care of the surgical patient.”

Anesthesia assistants will not be a substitute for anesthesiologists nor will they be certified to work independently in environments without the direct supervision of a licensed anesthesiologist. Currently, there are only 2 post-graduate anesthesia assistant training programs in Canada: • Caribou College (BC) • Michener Institute (Ontario) An overview of the Michener program is provided below. For specific details, refer to the Michener web site www.michener.ca/ce/postdiploma/anesth_asst.php

Admission requirements:

• RN or RRT • 2 years critical care or operating room experience within the past 4 years • Completion of basic level anesthesia assistant training program or equivalent

Course competencies include:

• Evaluating the pre-, peri- and post-operative patient • Advanced airway management • Assisting with pharmacologic therapy • Maintaining fluid therapy • Assisting with the administration of peripheral nerve blocks, spinal anesthetics and epidural • Assisting with the administration and maintenance of general anesthesia for stable patients • Managing special anesthetic considerations

Program Duration:

• For those individuals who have completed basic level training, the program is approximately

22 weeks in length (15 weeks coursework and 6 weeks clinical rotation). • For those individuals who have not completed basic level training, the program is

approximately 37 weeks in length (30 weeks coursework and 6 weeks clinical rotation).

http://www.michener.ca/ce/postdiploma/anesth_asst.php


Benefits of the ACT Model There are several benefits associated with this innovative model of care. They range from improved access to services to greater patient safety and include more cost-effective care. The ACT concept also provides a better work environment for all team members as physicians will have assistance and other health professionals will be given an opportunity to fully utilize their skills and experience. Listed below is a brief synopsis of the benefits: • Access

Access to service improves because other health professionals assist in the provision of anesthesia services thereby freeing up anesthesiologists to provide additional clinical and other services.

• Appropriateness

In the ACT approach, anesthesiologists provide surgical services with the clinical and technical support of anesthesia assistants where deemed appropriate. Specially trained nurses provide routine services in pre and post-operative care under the supervision of an anesthesiologist.

• Capacity

System capacity improves as a result of freeing up additional time for anesthesiologists, incorporating the use of assistants and making operative anesthesia more attractive to anesthesiologists.

• Cost Effectiveness

This model is cost effective because it uses a mix of other health professional and anesthesiologists to provide anesthesia services.

• Patient Safety

The addition of staff, trained for specific roles, in all three environments has the potential to increase patient safety. In the operating room, during preparation, induction of anesthesia and extubation, the assistant provides support to the anesthesiologist. On the acute pain service, the nurse under the supervision of the anesthesiologist becomes an important resource to the unit staff thus improving the quality of care. In the pre-anesthetic clinic, systematic review and patient preparation by specially trained nursing staff and anesthesiologists will continue to reduce the possibility of ill-prepared patients and operating room cancellations.

• Patient Satisfaction

By using specially trained nurses in the pre-admission facility, patients could be seen in a timelier manner. Acute pain service nurses could see patients more promptly as the RNs would be dedicated to this service. Intra-operative anesthesia assistants would improve efficiency and turnover, resulting in fewer cancelled cases.


• Physician & Other Health Professional Satisfaction

Anesthesia assistants will improve efficiency and reduce workload for the specialist anesthesiologist in the pre, intra and post operative domains. The anesthesiologist will have access to technical and clinical support resulting in better working conditions.

Anesthesia assistants will also improve the working conditions of operating room nurses who, until now, have been supporting the anesthesiologist. Specially trained nurses on the Acute Pain Service will improve the working conditions of ward staff as there will be a dedicated resource to the pain service available 24 hours a day, 7 days a week.

In addition to establishing a career path, the new positions created by this model provide other health professionals with an opportunity to fully utilize their skills and training.

• Productivity

The throughput in some operating rooms could be increased if anesthesia assistants were used. • Quality of Care

In addition to protocols, care maps, and algorithms, anesthesiologists supervise the work of the other health professionals thereby ensuring quality of patient care.

• Sustainability

This model does not eliminate the need for additional anesthesiologists but it does reduce the pressure on the system and helps the system manage more effectively with existing physician resources.

Challenges with the ACT Model There are several significant challenges associated with the ACT model that must be addressed in considering widespread implementation. These challenges range from costing the model to understanding its potential impacts. Details are provided below. • Perceptions of the ACT Model

While there is broad support across AHSCs for components of the ACT model, the commitment to and interest in implementing all components varies significantly. The ability to implement core components of this model depends upon the culture of the hospital and the physicians practicing there. The extent to which the ACT model is supported depends on the degree to which other health professionals are currently being used.

Recommendations: #1 Initiate a consultation process. Circulate the report to stakeholders, receive and

review feedback.


• Impact and Viability of the ACT Model

There is also a wide range of opinions on the extent to which other health professionals can make anesthesiologists available to perform operative services. The precise potential of the ACT model, particularly in terms of cost effectiveness and increased system capacity, is unknown and there is significant variation in the estimates. There is, however, a fairly general belief that the quality of services would be greatly improved through standardizing and supporting this model. While this paper attempts to estimate the impact of the ACT model, it is only through implementing the ACT model at demonstration sites that the ability of the model to increase efficiency and productivity while maintaining and, indeed, enhancing the quality of care be better understood. Further, the minimum requirements for an ACT model to be viable are not understood. Is this model only viable in AHSCs? What about community hospitals, large and small, urban and rural? Do all three components of the ACT model have to be in place for the model to be of benefit or can one or two components stand alone. If so, which components are they? To better understand minimum requirements, components of the ACT model need to be tested in different practice settings (demonstration sites).

Recommendations: #2 Establish an ACT Implementation & Evaluation Committee composed of stakeholders:

• Create minimum requirements for demonstration sites • Develop an evaluation framework • Select demonstration sites

#3 Issue an “Indication of Interest”. Hospitals seeking consideration as an ACT

demonstration site would submit a proposal (similar to the Family Health Team Strategy).

#4 Create a coaching team(s) to support the development of ACT proposals and to assist

with the implementation of the ACT model at the demonstration sites. #5 Choose demonstrations sites in AHSCs and community hospitals using a transparent selection process. #6 Develop contracts for the demonstration sites which contain accountability

agreements that address productivity, quality, patient and staff satisfaction. #7 Staff demonstration sites on the basis of the assumptions outlined in the report. #8 Evaluate the demonstration sites using the framework developed by the Committee. #9 Set minimum requirements for ACT model viability and expected outcomes prior to

rolling out the ACT model across the province, based on evaluation of demonstration sites.

#10 Explore different funding models for ACTs (e.g. APP, AFP, fee-for-service).


• Composition of the ACT Model (physician and other health professional)

At present, there is no standard approach to staffing ACTs (physician/other health professional/patient ratios). If the model is to be introduced widely, a standard approach is required. Staffing suggestions, outlined in this report, are an attempt to address this issue. There is little evidence that further study will yield more appropriate standards. Evaluation of the demonstration sites can provide data to support the ratios recommended in the report or to suggest modifications to the model.

Recommendations: #11 Modify the ACT model, if necessary, based on the evaluation of the demonstration

sites. • Anesthesia Assistants

Currently, there is no minimum standard of training required for anesthesia assistants. Some organizations provide on-site programs while others require “anesthesia assistant” training while still others fund conscious sedation education in the United States. There is also no commonly recognized definition of the roles and responsibilities (clinical and/or technical) of an anesthesia assistant. While the College of Respiratory Therapists of Ontario believes the anesthesia assistant role falls within the scope of practice for RRTs , the College of Nurses of Ontario does not recognize the role of monitoring patients under general anesthesia. The CAS is calling for a nationally approved training program with formal certification of successful candidates including a well-defined scope of practice for anesthesia assistants. The Canadian Society of Respiratory Therapists supports this concept and is currently drafting a scope of practice for consideration of its members. The challenge will be reaching consensus on roles and responsibilities as the work of anesthesia assistant varies considerably within and across institutions and provinces. Furthermore, RRTs are only regulated in 4 provinces (Ontario, Quebec, Alberta and Manitoba).

Recommendations: #12 Bring together a stakeholder group to:

• develop a common definition of “anesthesia assistant” • define roles and responsibilities • agree on the training requirements

It would be important that this work not delay the implementation of demonstration sites. This work could be done in parallel. #13 Establish training requirements for anesthesia assistants. From this time on,

individuals wishing to become anesthesia assistants must successfully complete an advanced level anesthesia assistant training program.

#14 Assess the skills of those individuals currently performing anesthesia assistant

functions to determine if additional training is required.


There are only two anesthesia assistant training programs in Canada (Caribou College and the Michener Institute) at present. These programs have limited enrollment and takes several months to complete. Recommendations: #15 Introduce and/or expand anesthesia assistant training opportunities at other

institutions across Ontario, using the standards established at the Michener Institute. • CAS Guidelines to the Practice of Anesthesia

While the CAS has identified the need for a nationally approved training program with formal certification of successful candidates, including a well-defined scope of practice for anesthesia assistants, the current CAS guidelines state that:

“Simultaneous administration of general, spinal, epidural or other major regional anesthesia by one anesthesiologist for concurrent diagnostic or therapeutic procedures on more than one patient is unacceptable.”

The CAS Other health Professions Committee is developing a draft document on the scope of practice for anesthesia assistants. This document will be presented to the Board for discussion at its February 2006 meeting.

Recommendations: #16 Review the February 2006 Scope of Practice document being developed by the CAS

Allied Health Professions Committee to see if it reflects core components of the ACT model.

Currently, the CAS guidelines do not support some components of the ACT model wherein anesthesia assistants provide patient care and monitor stable patients during spinal, regional and general anesthesia allowing the supervising anesthesiologist to perform other duties. • Potential Role of the ACT Model in Community Hospitals

Further research is needed to assess the interest in and the applicability of the ACT Model in large urban community hospitals as well as rural and northern settings.

Recommendations: #17 Conduct a survey of Ontario’s community hospitals to determine:

• The extent to which the hospitals are using specially trained nurses and anesthesia assistants to assist in the provision of anesthesia services

• If RNs and anesthesia assistants are being utilized, how are they being used by the hospitals

• What kind of specialized training, if any, have the assistants and/or RNs received. If assistants have received training, what training and from where

• The receptivity to introducing specially trained nurses and anesthesia assistants to assist in the provision of anesthesia services


• Schedule of Benefits

Currently, the Schedule of Benefits does not include payment for supervision or delegation of services as envisaged in the ACT model. The Ontario Schedule of Benefits remunerates physician services provided in direct contact with the patient. The Schedule includes fee codes for physician supervision of the performance of a limited set of diagnostic and therapeutic procedures, the technical component of diagnostic procedures and simple office laboratory procedures. There is no payment for delegation of assessments, time-based services or major procedures. As well, there are strict limits on the circumstances where delegation is paid under the Ontario Health Insurance Plan (OHIP) for office-based services. Services in hospital are not included under the current Schedule’s delegation scope and are not considered insured services when delegated, as the alternate provider is typically an employee of the hospital, not the physician. To facilitate the use of anesthesia assistants in a fee-for-service environment, changes are needed to the Schedule of Benefits to permit and remunerate physician supervision.

Recommendations: #18 Replace the anesthesia fee (base & time units) with a supervisory payment when

someone other than an anesthesiologist provides anesthesia care. #19 Reinvest the savings achieved through this change to the Schedule of Benefits in

other anesthesia services. #20 Establish a Working Group to further examine the issue of supervision and

delegation. #21 Further support the provision of operative anesthesia services through other

specified investments.


NEXT STEPS 1. Following the circulation of the report to various stakeholder groups, an ACT Implementation and

Evaluation Committee should be established to oversee the selection and evaluation of ACT demonstration sites.

2. Concurrently, changes should be made to the Schedule of Benefits to incent operative

anesthesia and facilitate the implementation of the ACT model. 3. Anesthesia assistant training programs should be established to facilitate the roll-out of the ACT

model across the province. 4. Once the demonstration sites have been evaluated and the model adjusted accordingly, the ACT

model should be rolled-out across the province using the minimum requirements and expected outcomes set by the Committee.


APPENDIX 1

Status Report on

Anesthesia Services at Ontario’s Academic Health Science Centres

Submitted to: Operative Anesthesia Committee, April 2006

Prepared by: Dr. John Marshall & Ms. Danielle Claus


Table of Contents

TABLE OF CONTENTS

EXECUTIVE SUMMARY .............................................................................................. 22

BACKGROUND............................................................................................................ 26

SECTION 1: ANESTHESIA SERVICES AT AHSCS................................................ 28

SECTION 2: PERCEPTIONS OF ACT MODEL AT ONTARIO AHSCS................... 30

SECTION 3: CURRENT USE OF OTHER HEALTH PROFESSIONALS IN SUPPORT OF ANESTHESIA SERVICES........................................ 33

SECTION 4: OPPORTUNITIES FOR INTRODUCING AND/OR EXPANDING THE ACT MODEL AT AHSCS IN ONTARIO.............................................. 36

SECTION 5: CONSIDERATIONS ON PRODUCTIVITY AND ACCOUNTABILITY . 40

SECTION 6: INTRODUCING THE ACT MODEL...................................................... 44 Appendix 1 – Questionnaires .......................................................................................46 Appendix 3 – DAL Calculation......................................................................................51 Appendix 4 – Overview of Anesthesia Services at AHSCs by Site..............................53 Appendix 5 – Overview of Anesthesia Services at AHSCs by Site .............................54 Appendix 6 – Hospital Specific Information..................................................................55

Children’s Hospital of Eastern Ontario....................................................56 Hamilton Health Sciences.......................................................................60 Hamilton St. Joseph’s Health Care.........................................................64 Hospital for Sick Children........................................................................68 Kingston Health Sciences Centre ...........................................................72 London Health Sciences Centre .............................................................76 St. Michael’s Hospital..............................................................................80 Sunnybrook & Women’s College Health Sciences Centre .....................84 The Ottawa Hospital ...............................................................................88 University Health Network & Mount Sinai Hospital .................................92 University of Ottawa Heart Institute ........................................................96


Executive Summary The purpose of this report is two-fold. First, update the 2003 review of anesthesia services at Ontario’s Academic Health Sciences Centres (AHSCs). Second, gain an understanding of the current use of, support for and the potential of the anesthesia care team (ACT) concept to address the anesthesia shortage. To fully address these complex and multi-faceted issues, the report has been organized into the following sections:

A picture of the current supply of and demand for anesthesia services at Ontario’s AHSCs

An overview of the perceptions of the ACT model, as well as a description of the perceived barriers to ACT implementation

A summary of the current use of Other Health Professionals in support of anesthesia

services in AHSCs

An assessment of the opportunities for introducing ACTs at the AHSCs

An examination of productivity and accountability measures that could be utilized in the delivery of perioperative anesthesia services

A summary of the steps required to introduce the ACT model in AHSCs

Anesthesia Services at Ontario’s AHSCs As seen in the table below, the overall supply of anesthesia services has increased considerably since the original 2003 review, from 323.5 to 358.2 daily anesthetic locations (DALs). During the same period, the actual number of anesthesiologists grew from 333.7 full time equivalents (FTEs) to 375.4 FTEs. Despite the addition of almost 42 anesthesiologist FTEs, the shortfall has remained the same because the demand for services has kept pace with the supply of anesthesiologists. Staffing Formula Components Feb.2003 Nov.2005 Difference % changeDaily Anesthetic Locations (DALs) 323.5 358.2 34.7 10.7%Required Anesthesia FTE 398.7 440.9 42.2 10.6%Actual Anesthesiologist FTE 333.7 375.4 41.7 12.5%Shortfall FTE 65.0 65.5 0.5 0.8%


The use of other health professionals in the provision of anesthesia services has also increased significantly during this period. In February 2003, registered nurses and anesthesia assistants provided the services of almost 6 FTE anesthesiologists and in November 2005, the work of these other health professionals represented almost 16 FTE anesthesiologists. By employing other health professionals in anesthesia service delivery, the anesthesia shortfall is reduced from 65 to 55 anesthesiologist FTEs. Staffing Formula Components Feb.2003 Nov.2005 Difference % changeDaily Anesthetic Locations (DALs) 323.5 358.2 34.7 10.7%Required Anesthesia FTE 398.7 446.2 47.6 11.9%Actual Anesthesiologist FTE 333.7 375.4 41.7 12.5%Actual Assistant/RN Equivalent Anesthesiologist FTE 5.9 15.6 9.7 163.6%Shortfall FTE 59.1 55.3 -3.8 -6.4% Perceptions of the ACT Model The Chiefs of Anesthesia at the AHSCs were interviewed and their views were sought on the level of acceptance of the concepts inherent in the ACT model for the delivery of anesthesia services. They were asked to express both their own opinions and to indicate how these opinions aligned with others in their department. To summarize, there was a universal willingness to consider introducing of the ACT model. The enthusiasm for such an introduction varied considerably by site and, in general, it could be said that the more the concepts inherent in the model had been already introduced to a site, the greater the willingness of that site to consider expanding the assistant roles.

Use of Allied Health Professionals in the Delivery of Anesthesia Services

The current use of anesthesia assistants and nurses to support the delivery of anesthesia service at Ontario’s AHSCs is relatively modest. As seen in the table below, there is significant variation between sites in both the number of other health professionals supporting anesthesia service delivery and the roles these individuals play. Hospital Pre-Operative Intra-Operative Post-Operative TotalHamilton Health Sciences 2 1.2 2 5.2Hamilton St. Joseph's Health Care 0 0 1 1Kingston 1 3.6 1 5.6London Health Sciences Centre 3 0 2.5 5.5Ottawa Heart Institute 0 0 0 0St. Michael's Hospital 0 2 3 5Sunnybrook & Women's 0 6 3 9The Ottawa Hospital 0 2 2 4UHN/MSH 3 5 7 15Children's Hospital of Eastern Ontario 0 4.6 0 4.6Hospital for Sick Children 1 0 1.5 2.5Total 10 24.4 23 57.4


Opportunities for Introducing ACTs Several assumptions were made as to the roles other health professionals, both nurses and anesthesia assistants, could play in anesthesia service delivery and their ability to release anesthesiologists for other duties. The table below lays out the potential contribution, based on these assumptions which are described in detail in the report. Hospital Current

Anesthesiologist FTE Shortfall

Anesthesiologist FTE

Reassignment from Pre-Op


Reassignment from Intra-Op


Reassignment from Post-Op

Potential Anesthesiologist

FTE Shortfall

Hamilton Health Sciences 8.58 1.0 4.9 -1.5 4.2Hamilton St. Joseph's Health Care 1.79 0.9 2.3 0.5 -2.0Kingston 4.08 -0.5 1.5 0.5 2.6London Health Sciences Centre 10.04 0.0 7.8 1.0 1.2Ottawa Heart Institute 0.96 0.2 0.9 0.0 -0.2St. Michael's Hospital 4.12 0.8 3.4 0.5 -0.6Sunnybrook & Women's 4.04 1.2 2.5 -0.5 0.8The Ottawa Hospital 17.62 -0.3 6.8 1.2 10.0UHN/MSH 4.09 1.8 6.0 -0.5 -3.2Total 55.31 5.3 36.0 1.2 12.8 It is clear that by using other health professionals in the provision of anesthesia services, the anesthesia shortfall can be reduced significantly, from 55 to13 FTE. Examination of Productivity and Accountability Measures The national and international shortage of anesthesiologists, combined with an aging population and an increasing demand for surgery, is creating a profound mismatch between the supply of anesthesiologist staffed operative hours and the demands for such operative hours From the above statement, the focus is clearly on operative hours as a measure of output. That measure can be converted to a productivity measurement by identifying the resources required to produce the output. These measures are:

Number of operative hours per FTE anesthesiologist Ratio of anesthetic preparation time to total operative time Cost of anesthesia services per operative hour

For a more fulsome accountability structure, a broader and balanced approach was explored and the domains suggested are:

Productivity Quality of Care Patient Satisfaction ACT staff satisfaction

Potential measures for each of these domains are contained in the report.


Steps Required for ACT Implementation 1. The DAL model, described in this document, should be used for planning the delivery of

anesthesia services at Ontario’s AHSCs 2. A delivery system involving the ACT model should be used to meet the staffing

requirements identified in the DAL model 3. The ACT model described in this report, including the assumptions, should be tested at

demonstration sites:

The choice of demonstration sites should be based on confirmed commitment to the process

In choosing demonstration sites the Ministry should seek the advice of a committee representative of the stake holders

The contracts for the demonstration sites should have clearly defined reporting requirements based on the accountability measures outlined in this report

The demonstration sites should be activated at the earliest possible time and have short timelines for implementation and reporting

4. Roll-out of the ACT model across the AHSCs should not proceed before full evaluation of

the demonstration sites 5. Ideally, roll-out of the ACT model should occur as part of an Alternative Funding Plan (AFP) 6. No Anesthesiology AFP should be instituted without an undertaking to proceed with the

appropriate elements of the ACT model, at the earliest possible opportunity, being included in the plan. Further, existing AFP agreements should be modified at the earliest opportunity to include these elements


Background In early 2003, the author of this report was commissioned by the Ministry of Health and Long Term Care (MOHLTC) to review anesthesia person power requirements and availability at the University Health Network and Mount Sinai Hospital, in the context of anesthesia services at all of Ontario’s AHSCs. The original report identified a significant shortfall in anesthesia person power. It also identified the potential to augment anesthesia services by using “anesthesia extenders”, referred to in this report as anesthesia assistants. By using specially trained individuals to assist in the delivery of anesthesia services, the availability of anesthesiologists in the operating room could be increased. In addressing how such a model might be applied, the report recommended the introduction of AFPs for the delivery of anesthesia services at the AHSCs. It also recognized the need for such plans to be tied to clear deliverables accompanied by accountability mechanisms associated with penalties for non performance. In responding to the report, the MOHLTC authorized additional funding to enhance the ability of the AHSCs to recruit. Each AHSC could receive $250,000 for each FTE anesthesiologist they recruited, up to a staff complement that would take them to approximately 90% of the recommended complement identified in the 2003 report. The sole accountability measure was the recruitment and maintenance of the staffing complement. In 2004, the MOHLTC and Ontario Medical Association (OMA), recognizing the pressures facing operative anesthesia in Ontario’s hospitals, agreed to the formation of the Operative Anesthesia Committee (OAC). According to Section 27.3 of the 2004 MOHLTC-OMA Physician Services Agreement:

“The Parties agree that there is an urgent need to address the challenges facing operative anesthesia in Ontario’s hospitals. Accordingly, the Parties agree to establish a committee with representation from the OMA and MOHLTC to develop recommendations for addressing this issue in a timely fashion including opportunities for Schedule of Benefits redefinition, other physician payment strategies and the use of anaesthesia extenders. This committee will consult with the OHA as appropriate. The MOHLTC agrees to provide physician funding beginning October 1, 2005.”

The OAC, brought together by and reporting to the Physician’s Services Committee, has been charged with providing “recommendations to support stable and adequate access to anesthesia services in Ontario hospitals.” In considering this mandate, the committee wished to revisit the 2003 report and update it with current data while, at the same time, exploring the current use of, support for and the potential of the ACT concept to address the anesthesia shortage.


Review Team

Dr John Marshall Ms Danielle Claus

Objective of the Review

Reassess the person power situation for anesthesia at the Ontario AHSCs Gain insight into the potential for introducing anesthesia assistants and other health

professionals into these environments as part of ACTs Determine to what extent these individuals were being utilized in the AHSCs Understand the current funding of these positions where they exist Gather some baseline information on service volumes at these institutions Gather some preliminary performance data on services at these institutions Use insights gained from the above data to explore potential accountability measures that

could be used for the assessment of clinical AFP and ACT funding Methodology To gather data, questionnaires were sent to the Chiefs of Anesthesiology and to the Managers of Peri-operative Services at each of the AHSC institutions. Copies of the questionnaires are supplied in Appendix 1. Following the return of the questionnaires, a telephone interview was conducted with each Chief and Perioperative Services Manager. A list of the individuals interviewed is provided in Appendix 2. The interviews at the two children’s hospital were conducted in person as these sites were not included in the original report. The purpose of the interviews was to:

Confirm the data submitted in the returned questionnaires and clarify any ambiguity Find out how specific services were delivered at each site, with particular focus on the roles

played by anesthesia assistants and nurses in supporting anesthesia activities at each stage of the perioperative process

Understand the perceptions of those interviewed with respect to ACT implementation and/or expansion and identify potential barriers to the extension or enhancement of other health professional roles in the delivery of anesthesia services.

The purpose of the data was to:

Update workload and staffing information. Methodology provided in Appendix 3 Identify the current number and type of other health professionals assisting in anesthesia

service delivery Estimate the extent to which anesthesia assistants and other professionals could reduce the

anesthesia shortfall Collect information to form the basis of productivity & accountability measures

Financial data was sought from a number of sources to develop a costing model for productivity measures.


Section 1: Anesthesia Services at AHSCs The tables below summarize the requirements for and supply of anesthesia services at Ontario’s AHSCs. Table 1contains the clinical contribution of anesthesiologists and fellows. Table 2 includes the clinical contribution of anesthesiologists, fellows, anesthesia assistants and other health professionals. Site specific information is provided in Appendices 4 and 5. Please note, the pediatric hospitals are not included in these tables as the hospitals were not included in the 2003 review. As seen below, the actual number of anesthesiologists increased from almost 334 to 375 FTE between February 2003 and November 2005, an increase of almost 42 FTE or a 12% increase. During the same period, the number of required FTEs went from almost 399 to 441, an increase of 42 FTE or an 11 % increase. Despite the significant increase of FTE anesthesiologists, the anesthesia shortfall of 65 FTE remains the same due to the growth in daily anesthetic locations (DALs). The formula used to calculate DALs is outlined in Appendix 3. Table 1: Summary Chart Staffing Formula Components Feb.2003 Nov.2005 Difference % changeDaily Anesthetic Locations (DALs) 323.5 358.2 34.7 10.7%Required Anesthesia FTE 398.7 440.9 42.2 10.6%Actual Anesthesiologist FTE 333.7 375.4 41.7 12.5%Shortfall FTE 65.0 65.5 0.5 0.8% The pent up demand for clinical anesthesia services has been met by the recruitment of additional anesthesiologists. In the absence of anesthesia funding, which assisted in the recruitment of 42 FTEs, the situation at AHSCs would be profoundly worse. Table 2 indicates how the use of other health professionals (anesthesia assistants and RNs) has grown over time and the impact these individuals have had on the absolute anesthesia shortfall. In February 2003, other health professionals represented 6 FTE anesthesiology equivalents and in November 2005 they represented 16 FTE equivalents, an increase of 10 FTE or 164% increase. Other health professionals reduced the anesthesia shortfall from 65 to 59 FTE in 2003 and from 65 to 55 FTE in 2005 taking into account all factors, including vacation replacement. It is clear from the data above that the use of other health professionals have and can continue to contribute to the reduction in anesthesiologist shortfall.


Table 2: Summary Chart including Other Health Professionals Staffing Formula Components Feb.2003 Nov.2005 Difference % changeDaily Anesthetic Locations 323.5 358.2 34.7 10.7%Required Anesthesia FTE 398.7 446.2 47.6 11.9%Actual Anesthesiologist FTE 333.7 375.4 41.7 12.5%Actual Assistant/RN Equivalent Anesthesiologist FTE 5.9 15.6 9.7 163.6%Shortfall FTE 59.1 55.3 -3.8 -6.4% Summary: The overall supply of anesthesia services at the AHSCs has increased in the three years since the original review. The increased demand, however, has consumed the increased supply.


Section 2: Perceptions of ACT Model at Ontario AHSCs The Chiefs of Anesthesiology and the management teams for Peri-Operative Services were asked to describe the extent to which other health professionals were used to support anesthesia services in their respective institutions. In addition, they were asked to share their views on the ACT concept and the extent to which they felt these concepts could be implemented at their centre, and the appropriate rate of introduction. This section of the report attempts to summarize these views without ascribing them to individuals. Indeed, there was a certain degree of uniformity of view that makes such a summary relatively easy: 1. The Chiefs of Anesthesiology felt that any model based on the US Nurse Anesthetist role

would not be accepted by the anesthesiologists. 2. The Peri-operative Management group, on the other hand, were more comfortable with the

Nurse Anesthetist Model and were insistent that any introduction of an ACT Model would occur in such a way as to respect and accommodate the professional role of the nurse.

3. It was clear that the successful introduction of the ACT model will only occur with the willing

cooperation of the anesthesiologists. Cooperation will be based on their perception that the model is truly a team concept and that the members of the team have been appropriately educated and prepared and will work within their clearly defined professional boundaries under the supervision of the responsible anesthesiologist, as appropriate.

4. To achieve cooperation, the anesthesiologists will have to be convinced that their

professional and financial interests are protected and that there is recognition of any increased effort and responsibility inherent in the supervision of the ACT model and any associated increases in productivity.

5. There was a general perception by the Chiefs that they were further ahead in their thinking

on this matter than some members of their Departments and that the concept should be introduced in a careful and deliberate fashion. The introduction of anesthesia assistants into increasingly complex clinical roles should be gradual and based on proven successes. Failure to take this advice is liable to produce significant resistance.

6. With respect to the rate of introduction, it was clear that some centres were further down this

road than others, and perhaps these are the sites that should be chosen to lead further development of the ACT model.

7. There was minor variation of opinion as to the roles other health professionals could play at

each stage in the perioperative process. Each of these stages is discussed below: Pre-Operative Process At each centre, there was some nursing and clerical support for pre-operative/pre-anesthetic clinic. This support was focused on patient education and nursing issues rather than on triaging patients to reduce the need for review by anesthesiologists.


However, where such triage was present, it was seen to be helpful. There was almost universal agreement that the use of nurse clinicians or other specifically trained nurses, in such a role, could markedly improve both the quality and efficiency of these processes.

There was less unanimity on the degree to which such roles could free up anesthesiologists for other duties. This perception was based on the frequently repeated assertion that patients were getting progressively sicker and the need for anesthesiologist review could not be avoided. There was almost universal support, from peri-operative managers, for the development of such roles should funding be made available. On analyzing these responses it seemed that those who were already utilizing a triage role by nurses were more likely to accept that the expansion of this role would free up anesthesiologist time. It should be noted that the preoperative review activity of anesthesiologists generates considerable revenue and that changing the current model might meet with some resistance in the absence of an appropriate alternative funding arrangement. Intra-Operative Process

It was in this area that there was the widest variation in both experience and opinion. Those AHSCs already utilizing anesthesia assistants in clinical roles were more prepared to explore expansion of those roles. Those AHSCs without such experience were more uncertain about the wisdom of proceeding along that path and more apprehensive about their ability to persuade their colleagues to participate. All centres use anesthesia assistants to maintain anesthetic apparatus. There is widespread support for the use of anesthesia assistants to assist in room preparation, room turn over and to be on hand to help at induction, particularly for the more complex cases. Some believe that significant increases in productivity are being achieved by this role and that more could be achieved by its expansion. Currently, no hard evidence of such productivity increases is available. However, in Kingston, a study is currently underway to scientifically document the extent to which efficiencies can be achieved through the use of anesthesia assistants in this technical role. The use of anesthesia assistants in cataract rooms occurs at some level in almost every centre but there is significant variation in the models used and the degree to which anesthesiologists are freed up. This, in part, depends on the type of local anesthesia technique used, which is often determined by the wishes of the ophthalmologist.

Some AHSCs use anesthesia assistants in rooms using regional, epidural or spinal anaesthesia (e.g. rooms doing hip and knee procedures). Once regional anesthesia has been established, the procedure started and the patient stabilized, the patient is monitored by an anesthetic assistant while the anesthesiologist prepares the next patient. In two pilot projects, it was reported that the use of anesthetic assistants resulted in a 33% increase in productivity, resulting in one additional joint procedure per day (from 3 to 4 cases). Only one centre currently uses anesthesia assistants on occasions to monitor stable long cases under general anesthetic.


As stated above, the willingness of centres to accept the progressively more complex clinical role for anesthesia assistants was, to some extent, reflective of their current experience. The degree to which reorganization of operating room schedules is required to permit such opportunities was also seen to be important.

There was some difference of opinion of which group of professionals could or should assume the roles of anesthesia assistants. In general, however, most agreed that, with the appropriate training, both nurses and respiratory therapists could assume these roles. Post-Operative Process

All centres acknowledged the potential for expanding the role of suitably trained nurses to support post operative pain management. All AHSCs have registered nurse (RN) support on the pain service but almost all identified it as inadequate and most believed that, with a properly administered and adequately resourced program, the time commitment of anesthesiologists could be reduced significantly. The roles seen for such staff involved monitoring of patients receiving varying types of post operative pain management, prescribing within defined protocols and seeking support of anesthesiologists when necessary. Importantly, these nurses would play a vital role in the education of both patients and nursing unit staff in pain management. These activities would yield dividends in productivity of the acute pain management service as well as improving the quality of the service provided. Summary: There was a general willingness to consider the introduction of the ACT model. The

enthusiasm for such an introduction varied considerably by site and, in general, it could be said that the more the concepts inherent in the model had already been introduced to a site, the greater the willingness of that site to consider the expansion of assistant roles. There, however, remains much to be done to document the productivity gains of such a model.


Section 3: Current Use of Other Health Professionals in Support of Anesthesia Services This section will describe the current use of other health professionals in anesthesia service delivery at Ontario AHSCs. In addition to the summary tables provided, commentary will be added on the roles individuals play and any increases in productivity said to be associated with these roles. The data will be laid out by preoperative roles, intraoperative roles and post operative roles. However, it should be recognized that while these three segments are essential to the efficient, safe and appropriate delivery of operative anesthesia, the ultimate measure of efficiency in the overall delivery of services will be the ability to deliver increased operative hours with the available resources. Pre-Operative Roles Table 3: Pre-Operative Roles

RN RN Triage AnesthesiologistHamilton Health Sciences 20,511 3,887 16,327 6.6 2 2.8Hamilton St. Joseph's Health Care 12,474 12,474 12,474 2 2Kingston 11,426 8,680 1,903 5 1London Health Sciences Centre 28,728 19,727 8,662 16 3 2.5Ottawa Heart Institute 1,800 700 1,800 3 0St. Michael's Hospital 13,900 10,500 4,530 9.7 2Sunnybrook & Women's 14,606 6,786 1,166 10.5 2.5The Ottawa Hospital 36,566 25,766 10,630 15.7 2.8University Health Network 20,026 15,978 9,844 14.3 3 3.1Children's Hospital of Eastern Ontario 6,122 0 6,122 1* 1Hospital for Sick Children 1,276 354 354 1 1Total 167,435 104,852 73,812 82 10 21*RPN

StaffingSeen by

0.5

.4

1

AnesthesiologistHospital Pre-Op

ReviewsSeen by

RN

In Table 3, a distinction is made between RNs with a triage role and other RNs in a purely nursing role. Only RNs involved in triage are seen to reduce the need for anesthesiologist services in the pre-operative environment. In the vast majority of instances, it was reported by the Anesthesiology Chiefs that the role of the nurses at the preoperative clinic was generally confined to the nursing tasks of patient education and obtaining a nursing history. This did not often involve triage of patients to identify those that required anesthesiologist review and preliminary focused history, examination and investigation to facilitate that review. That sort of role was restricted to a small number of programs, as seen in the Table 3.


There was some divergence of opinion between centres as to whether the introduction of a nursing triage role would indeed allow a reduction of anesthesiologist commitment to this activity thereby permitting greater presence of anesthesiologists in the operating room. Again, those centres already using nurses in a triage role were more likely to agree that such efficiencies were possible. There was, however, universal agreement that using RNs in a triage role did and would improve the quality of the service. Intra-Operative Roles Table 4: Intra-Operative Roles

RT - Technical RT - Tech & Clinical RN- ClinicalHamilton Health Sciences 26.8 3 0 1.2Hamilton St. Joseph's Health Care 11.6 1 0 0Kingston 14.6 0.5 1 2.6London Health Sciences Centre 39 12 0 0Ottawa Heart Institute 4.4 5 0 0St. Michael's Hospital 21 2 0 2Sunnybrook & Women's 24.4 2 6 0The Ottawa Hospital 38 1 0 2UHN/MSH 40 9 5 0Children's Hospital of Eastern Ontario 6 0 2.6 2Hospital for Sick Children 14 2 0 0Total 240 37.5 14.6 9.8

Hospital Operating Rooms Other Professionals Supporting Anesthesia Services

As can be seen in Table 4, there is wide variation in the utilization of anesthesia assistants across the AHSCs. Every centre had at least one anesthesia assistant. In centres with only one anesthesia assistant, that individual’s role was restricted to a technical role involving the general maintenance of anesthesia equipment at the centre. Only clinical/technical RTs and RNs were seen as making a contribution to the need for anesthesiologist services in the intra-operative environment. Where centres had more than one anesthesia assistant in a technical role, the role involved equipment preparation for individual cases, assisting in case turn over and being of technical assistance at the time of induction, particularly for complex cases. Almost every centre commented on how valuable such assistance would be in emergency situations, with complex cases and on nights and weekends. Such assistance, however, was seldom available. There were statements that the use of such staff produced efficiencies in patient processing, and thus could increase productivity. However, with the exception of the Kingston study referred to earlier in the report, no studies to produce evidence of such productivity increases are available. The use of anesthesia assistants in a clinical role was more restricted. All centres that had these roles used them for cataract cases. The extent to which anesthesia assistants released anesthesiologists to perform other duties varied with the ACT model used. A few centres used anesthesia assistants for patient monitoring in regional, spinal or epidural block rooms, releasing the anesthesiologist to establish the block in the next case while the previous case was finishing. This staffing approach resulted in immediate room turnover and increased throughput in the room.


Only one centre identified the use of anesthesia assistants for monitoring stable patients during long procedures under general anesthesia. The extent to which this practice released the anesthesiologist for other duties is unclear. Post-Operative Roles Table 5: Post-Operative Roles

RN AnesthesiologistHamilton Health Sciences 25,444 4,561 2 *Hamilton St. Joseph's Health Care 21,006 2,500 1 1Kingston 14,993 3,124 1 1London Health Sciences Centre 41,017 8,590 2.5 2.5Ottawa Heart InstituteSt. Michael's Hospital 14,932 4,450 3 1Sunnybrook & Women's 18,497 6,104 3 1The Ottawa Hospital 39,855 6,983 2 2.2University Health Network 34,840 8,827 7 1Children's Hospital of Eastern Ontario 7,170 745 0 0.6Hospital for Sick Children 11,811 750 1.5 1.5Total 229,565 46,634 23 11.8*covered by physician w orking in the Pre-Admissions Clinic

not applicable

Hospital Staffing - FTE per dayTotal Operative

Cases

Patients Receiving Post-Op Pain Management

As can be seen in Table 5, each centre utilized nurses to assist in the acute pain service. Almost universally, each centre believed that further assistance was required. A number of centres identified a focus of research for the nurses supporting this program. Almost all identified inadequate time available for nursing unit staff education. All RNs identified in the chart above were presumed to have some role in contributing to the delivery of anesthesia services. Some centres identified that Clinical Nurse Practitioner involvement would increase the role that nurses could play and offer more opportunity to free up anesthesiologists for operating room duties. The provision of nurse support outside the daytime hours was also identified as having the potential for improving the quality of care and offering some relief to the anesthesiologist on call. Summary: The use of Anesthesia Assistants and nurses to support the delivery of anesthesia

services at Ontario AHSCs is relatively modest. There is significant variation between sites in both number of non anesthesiology personnel supporting the delivery of anesthesia services and the roles these individuals play.


Section 4: Opportunities for Introducing and/or Expanding the ACT Model at AHSCs in Ontario

In this section, opportunities for introducing and/or expanding the ACT model at Ontario’s AHSCs are discussed. Basic assumptions are made as to the extent to which introducing this model will release anesthesiologists to perform other duties. It is recognized that these assumptions are, as yet, unproven but the authors of this report believe these assumptions represent a reasonable translation of the potential benefits of the model as described by its proponents. The assumptions are laid out below: 1. One suitably prepared and trained RN FTE for every 5,000 patients in the pre-operative

clinic for the specific role relating to preparation of the patient for anesthetic services. This role would include:

Patient and documentation review Triage and problem identification Appropriate investigation within agreed protocols Patient selection for presentation to the anesthesiologist Documentation preparation and presentation to the anesthesiologist

RNs in this ratio to clinic visits would result in the need for anesthesiologists to see no more than 30% of the patients. Under these circumstances, 1 FTE anesthesiologist could see 15 patients a day or 3500 patients per year. Currently, there is a variation in the percentage of patients reviewed by anesthesiologists. This ranges from a low of 17% to a high of 100% across the AHSCs. By choosing 30% as the number to be reviewed by anesthesiologists, a middle ground has been struck. However, if current practice in those centres with anesthesiologists seeing fewer than 30% of patients is seen as safe and efficient, the addition of new anesthesiologists would not be required.

2. One suitably trained anesthesia assistant for every two active operating rooms to carry out

both technical and clinical roles. This would yield a productivity increase of available anesthesia operative hours of 20%. Translated into anesthesiology FTE equivalents, each anesthesia assistant could produce the equivalent of 0.4 of an FTE anesthesiologist in terms of available operative hours.

3. One suitably prepared and trained RN for every 1500 patients per year on the post operative

acute pain service to carry out clinical roles which would include:

Patient monitoring and documentation Therapeutic adjustments of both drugs and devices, under agreed protocols Patient education Unit staff education Liaison with the anesthesiologist

RNs in this ratio to post operative acute pain patients would result in the need for 0.5 anesthesiologist FTE per 5000 pain patients.

By applying these assumptions to the data obtained from the AHSCs, the full extent of the potential contribution that anesthesia assistants and other health professionals could make to


address the anesthesiologist shortfall is estimated. Tables 6-8 provide information by venue of care and institution. Table 6: Potential contribution of RNs to the Provision of Anesthesia Services in the Pre

Operative Environment in Ontario AHSCs Hospital Pre-Operative

Clinic VisitsCurrent Triage

RNsPotential

Additional Triage RNs

Current Anesthesiologist

FTE

Required Anesthesiologist

FTE

Anesthesiology FTEs Released

Hamilton Health Sciences 20,511 2 2.1 2.8 1.8 1.0Hamilton St. Joseph's Health Care 12,474 0 2.5 2 1.1 0.9Kingston 11,426 1 1.3 0.5 1.0 -0.5London Health Sciences Centre 28,728 3 2.7 2.5 2.5 0.0Ottawa Heart Institute 1,800 0 0.4 0.4 0.2 0.2St. Michael's Hospital 13,900 0 2.8 2 1.2 0.8Sunnybrook & Women's 14,606 0 2.9 2.5 1.3 1.2The Ottawa Hospital 36,566 0 7.3 2.8 3.1 -0.3UHN/MSH 20,026 3 1.0 3.5 1.7 1.8Children's Hospital of Eastern Ontario 6,122 0 1.2 1 0.5 0.5Hospital for Sick Children 1,276 1 -0.7 1 0.1 0.9Total 167,435 10 23.5 21 14.4 6.6 The preoperative clinic model envisages the nurse in a very active role which involves chart review of all patients and triaging patients that require preoperative investigations thereby reducing the number of patients needing to be seen by the anesthesiologist. This role would be carried out under the supervision of an anesthesiologist, using predetermined protocols. The table above suggests that by adding 23.5 additional triage RNs, over 6 FTE anesthesiologists could be released for operative anesthesia services. It should be noted that the table only recognized those RNs the AHSCs have identified as being in a triage role. It is certainly possible that by reassigning and integrating some of the 82 RNs currently working in these clinics, most if not all of the potential additional triage RNs could be derived from this existing pool of resources. Table 7: Potential contribution of Anesthesia Assistants and RNs to the Provision of

Anesthesia Services in the Intra-Operative Environment in Ontario AHSCs


Hospital # of Operating

Rooms

Current Anesthesia Assistants*

Potential Additional Assistants*

Potential Change in Available


Hamilton Health Sciences 26.8 1.2 12.2 4.88Hamilton St. Joseph's Health Care 11.6 0 5.8 2.32Kingston 14.6 3.6 3.7 1.48London Health Sciences Centre 39 0 19.5 7.8Ottawa Heart Institute 4.4 0 2.2 0.88St. Michael's Hospital 21 2 8.5 3.4Sunnybrook & Women's 24.4 6 6.2 2.48The Ottawa Hospital 38 2 17 6.8UHN/MSH 40 5 15 6Children's Hospital of Eastern Ontario 6 4.6 -1.6 -0.64Hospital for Sick Children 14 0 7 2.8Total 239.8 24.4 95.5 38.2*clinical/technical RRTS and RN contributing to the provision of anesthesia services

Table 7 suggests that by adding 96 anesthesia assistants, an equivalent of 38 FTE anesthesiologist could be released to provide other anesthesia services. This calculation does not take into account the anesthesia assistants currently in a purely technical role. In a completely integrated environment, the 35 technical anesthesia assistants could be added to the staffing complement, significantly reducing the need for additional staff from 96 to 61 FTE. Table 8: Potential contribution of RNs to the Provision of Anesthesia Services in the Post-

Operative Environment in Ontario AHSCs

Hospital Post-Operative Pain Patients

Current RNs Potential Additional RNs

Current Anesthesiologist

FTE

Required Anesthesiologist

FTE

Anesthesiology FTEs Released

Hamilton Health Sciences 4,561 2 1.6 0* 1.5 -1.5Hamilton St. Joseph's Health Care 2,500 1 1.0 1 0.5 0.5Kingston 3,124 1 1.5 1 0.5 0.5London Health Sciences Centre 8,590 2.5 4.4 2.5 1.5 1.0Ottawa Heart InstituteSt. Michael's Hospital 4,450 3 0.6 1 0.5 0.5Sunnybrook & Women's 6,104 3 1.9 1 1.5 -0.5The Ottawa Hospital 6,983 2 3.6 2.2 1.0 1.2UHN/MSH 8,827 7 0.1 1 1.5 -0.5Children's Hospital of Eastern Ontario 745 0 0.6 0.6 0.5 0.1Hospital for Sick Children 750 1.5 -0.9 1.5 0.5 1.0Total 46,634 23 14.3 11.8 9.5 2.3*Anesthesiologist working in pre-admissions clinic supports the acute pain service

not applicable

In the ACT model, the RN has the primary responsibility for the acute pain service under the direction of an anesthesiologist on the basis of clearly defined protocols. The RN also has a major role in educating unit staff to be a valuable asset in pain management. Table 8 suggests that the addition of 14 FTE RNs will release 2.3 anesthesiologists. While minimal anesthesiologist time can be reassigned by this element of the ACT model, the uniform opinion is that this change would markedly enhance the quality of care and patient satisfaction.


Table 9: Overall Potential Contribution of Anesthesia Assistants and RNs to the Provision of Anesthesia Services at Ontario AHSCs Hospital Current

Anesthesiologist FTE Shortfall


Reassignment from Pre-Op


Reassignment from Intra-Op


Reassignment from Post-Op

Potential Anesthesiologist

FTE Shortfall

Hamilton Health Sciences 8.6 1.0 4.9 -1.5 4.2Hamilton St. Joseph's Health Care 1.8 0.9 2.3 0.5 -2.0Kingston 4.1 -0.5 1.5 0.5 2.6London Health Sciences Centre 10.0 0.0 7.8 1.0 1.2Ottawa Heart Institute 1.0 0.2 0.9 0.0 -0.2St. Michael's Hospital 4.1 0.8 3.4 0.5 -0.6Sunnybrook & Women's 4.0 1.2 2.5 -0.5 0.8The Ottawa Hospital 17.6 -0.3 6.8 1.2 10.0UHN/MSH 4.1 1.8 6.0 -0.5 -3.2Children's Hospital of Eastern Ontario -1.4 0.5 -0.6 0.1 -1.3Hospital for Sick Children 2.5 0.9 2.8 1.0 -2.2Total 56.4 6.6 38.2 2.3 9.3 Table 9 consolidates the information provided in tables 6-8 and demonstrates that, theoretically, an initial shortfall of 56 FTE anesthesiologists could be reduced to 9 FTEs through the full implementation of the ACT model at the AHSCs. These tables suggest a significant hypothetical opportunity for the introduction of the ACT model. However, very important questions remain:

Can such models be accepted in the real world? Can the targets in the assumptions be achieved in the real world? Are the costs of such models realistic and supportable? When would the people to staff such models become available?

Summary: It is clear that by using anesthesia assistants and other health professionals in the provision of anesthesia services, a considerable reduction in the anesthesia shortfall could be realized. Alternately, a significant increase in the number of operative hours could be achieved.


Section 5: Considerations on Productivity and Accountability This section defines standards of productivity that could be applied to either the introduction of ACT models and/or extension to Alternative Payment Plans. In addition, it examines other measures that could be used in accountability agreements in the same settings. Productivity Measures In addressing productivity, three measures are suggested. The first measures productivity in terms of the scarce resource of anesthesiologists. The second measures efficiency in the delivery of anesthesia services. The third measures the cost of delivering anesthesia services:

1. Number of operative hours per FTE anesthesiologist 2. Ratio of anesthetic preparation time to total operative time 3. Cost of anesthesia services per operative hour

A definition of the terms used in these productivity measures is given below: Operative Hours For the purposes of measuring productivity, operative hours are taken as all hours of patient procedures for which the presence of an anesthesiologist or anesthesia assistant are required, regardless of the site of the procedure. Total operative hours including emergencies were used, as it proved difficult to separate elective from emergency hours at all sites. Additionally, some of the daily scheduled anesthesiologist coverage at some sites was supporting the completion of unscheduled cases. For venues outside the operating room, where actual hours of anesthesia coverage were not always available, a surrogate was used (FTE assigned to DAL * 1950 hours). Anesthesiologist FTE The total anesthesia effort to produce an operative hour includes preoperative preparation, intra operative care and postoperative pain management. Thus, in assessing the resources required to produce operative hours, contributions to all three venues must be included. Conversely, when looking at anesthesiology resources, contributing to production of operative hours, it is important to exclude those anesthesiology resources that are dedicated to activities that do not affect the delivery of operative anesthesia services (e.g. Critical Care and Chronic Pain Management and Trans Esophageal Echo). Anesthesia Preparation Time The effective use of anesthesia assistants in both technical and clinical roles should diminish the proportion of total operative time taken up with the preparation and induction of patients. This could result in increased productivity in that more cases could be preformed within the same total operative hours.


Anesthesia preparation time is the difference between total operative hours and total surgical hours. Changes in efficiency, with respect to anesthesia preparation time, can be assessed by the ratio of anesthesia preparation time to total operative time. Note, total operative time is measured as room in room out time and total surgical time is measured as skin to skin time. Costs For estimating costs of anesthesia services the following sums were included: 1. OHIP payments for Fiscal 2004-2005, for those anesthesiologists identified in Phase 1

funding of the AHSC AFPs 2. Notional rate per FTE for established AHSC AFPs 3. AHSC AFP Phase 1 funding ($25,000.00 per FTE) 4. Funds supplied to each AHSC as a result of the initial report 5. $80,000 for each anesthesia assistant identified as contributing to anesthesia productivity 6. $90,000 for each RN identified as contributing to anesthesia productivity Table 10: Operative Hours per FTE Anesthesiologist at Ontario AHSCs Hospital Total Operative

Hours*Operative

Anesthesiologist FTEs**

Operative Hours per FTE

AnesthesiologistHamilton Health Sciences 48,330 36.6 1322.3Hamilton St. Joseph's Health Care 27,953 18.4 1519.2Kingston 28,709 22.4 1095.8London Health Sciences Centre 83,122 62.1 1338.5Ottawa Heart Institute 8,917 7.8 1143.2St. Michael's Hospital 39,570 34.1 1160.4Sunnybrook & Women's 44,850 38.6 1161.9The Ottawa Hospital 69,681 50.0 1395.0UHN/MSH 90,749 69.1 1313.5Children's Hospital of Eastern OntarioHospital for Sick Children 42,550 28.4 1498.2Total 484,431 367.4 1318.6* includes OR hours, satelite hours & obstetrical hours**total anesthesiolgists excluding Critical Care and Chronic Pain Service

not able to calculate as OR hours are not tracked

Table 10 is presented as a sample of the possibility of using such data to measure productivity. However, caution must be exercised in drawing too many conclusions from it. While an attempt was made to standardize the data across AHSCs, the absence of strict definitions, agreed to in advance, means that the data may not be comparable and the time estimates for out-of-OR procedures are almost certainly an overestimate and probably not consistent across all centres. That being said, the relative consistency of the data suggests that this approach to productivity measurement has promise.


Table 11: Ratio of Anesthesia Preparation Time to Total Operative Hours Hospital Total

Operative Hours

Total Surgical Hours

Anesthesia Preparation

Time*Hamilton Health Sciences 44,625 31,024 30.5%Hamilton St. Joseph's Health Care 21,102 14,880 29.5%Kingston 24,224 18,008 25.7%London Health Sciences Centre 73,372 53,496 27.1%Ottawa Heart Institute 8,917 not tracked unknownSt. Michael's Hospital 32,160 21,283 33.8%Sunnybrook & Women's 38,610 34,622 10.3%The Ottawa Hospital 56,421 37,190 34.1%UHN/MSH 80,999 48,762 39.8%Children's Hospital of Eastern OntarioHospital for Sick Children 28,900 16,912 41.5%Total 409,330 276,177 32.5%* total operative hours-total surgical hours/total operative hours

not tracked

Caution should be taken in interpreting the data in Table 11. Centres may not be directly comparable as definitions of surgical and operative time may vary between sites. Furthermore, the variation in case mix between sites may have some effect. More important is the change within an institution over time. Table 12: Cost per Anesthesia Operative Hour at Ontario AHSCs Hospital Total Operative

Hours*Total Cost** Cost per

Operative HourHamilton Health Sciences 48,330 $13,333,733 $275.89Hamilton St. Joseph's Health Care 27,953 $6,433,481 $230.15Kingston 28,709 $8,056,575 $280.63London Health Sciences Centre 83,122 $18,584,386 $223.58Ottawa Heart Institute 8,917 $3,047,838 $341.81St. Michael's Hospital 39,570 $10,649,700 $269.14Sunnybrook & Women's 44,850 $11,726,622 $261.46The Ottawa Hospital 69,681 $15,671,810 $224.91UHN/MSH 90,749 $24,265,379 $267.39Children's Hospital of Eastern OntarioHospital for Sick Children 42,550 $9,471,000 $222.59Total 484,431 $121,240,523 $250.27* includes OR hours, satelite hours & obstetrical hours**includes physician funding (OHIP, Marshall funding, AFP Phase I funding or APP Branch payment) and funding for RNs and RRTs

not able to calculate as OR hours not tracked

Again, caution must be exercised in drawing too many conclusions from the data presented in Table 12 as one cannot be certain that the data for the calculation are comparable across centres. With that proviso, the range of variation suggests that, with refinement of the data, this could be a valuable measure of productivity


Accountability Measures In additional to productivity measures, accountability agreements should include other elements which would complete a balanced scorecard approach. A suggested approach could be:

Productivity Quality of Care Patient satisfaction measures ACT satisfaction measures

Productivity ACT funding should be tied to specific gains in productivity. The measures of productivity are outlined above:

Operative Hours per Anesthesiology FTE Ratio of anesthetic preparation time to total operative time Anesthesia Service Funding per Operative Hour

Quality of Care A number of quality measures could be included in accountability agreements. Such measures should address each stage of the perioperative process.

Pre operative process:

• Cancellations due to lack of patient preparation, unfitness for surgery or patient unwillingness to proceed with surgery.

While reasons for cancellations are being recorded at all centres, there is a need for common standards relating to time of cancellations and definitions.

Intra operative process:

• Cancellations due to lack of time to complete planned list or unavailability of anesthesia

services • Adverse incident reporting • Unplanned admissions for day surgery patients reporting • Unplanned ICU admissions for inpatient cases reporting

Post operative pain management:

• Post operative length of stay for standard case groups

Patient Satisfaction Measures Standard patient satisfaction questionnaires could be devised to ascertain patients’ perceptions of the operative procedure as it relates to pre operative preparation, intra operative anesthetic care and post operative pain management. ACT Staff Satisfaction Measures


Standard satisfaction questionnaires could be devised to ascertain staffs’ perceptions of the ACT model as a concept and a functioning reality.

Section 6: Introducing the ACT Model This report clearly supports the proposition that the ACT model can make a significant contribution towards addressing the shortage of anesthesiologists. However, the extent of the potential contribution is uncertain. It is recommended that the introduction of the ACT model proceed in three stages: 1. Introduction of ACT model at demonstration site(s) 2. Evaluation of the demonstration sites and potential modification of ACT model 3. Roll-out of ACT model across AHSCs if deemed appropriate Stage 1: ACT Model Demonstration Sites The use of demonstration sites would test the assumptions for the correct ratio of physicians to other health professionals, as well as provide valuable evidence of the safety and effectiveness of the model. This is essential if the model is going to receive the support of the broader community of anesthesiologists. There are two possible options for implementing demonstration models, either of which could be used:

Select sites and implement a demonstration model across all three venues of care

Select sites and implement demonstration models for one venue of care at each site Stage 2: Evaluation And Potential ACT Model Modification Based on feedback and data from the demonstration sites, which should be founded on the accountability measures outlined in Section 5 of this report, refinement of the ACT model should occur prior to wider implementation of the model across the system. Stage 3: Roll-out of the ACT Model Across AHSCS While it is possible in limited demonstration sites to introduce this model in a fee-for-service environment, the full implementation of the ACT model across all venues of care presents great challenges in the fee-for-service environment. As recommended in the original review of anesthesia services at Ontario’s AHSCs, an AFP more readily supports the successful implementation of this type of model. Furthermore, should the demonstration sites confirm the conclusions in this report, AFPs for anesthesia should not be introduced at any centre without including the elements of the ACT model. Additionally, when currently established AFPs come up for renewal, these elements should be incorporated.


Recommendations 1. The DAL model, described in this document should be used for planning the delivery of

anesthesia services at Ontario’s AHSCs 2. A delivery system involving the ACT model should be used to meet the staffing

requirements identified in the DAL model 3. The ACT model described in this report, including the assumptions, should be tested at

demonstration sites:

The choice of demonstration sites should be based on confirmed commitment to the process

The choice of demonstration sites should be made by a committee representative of the stake holders

The contracts for the demonstration sites should have clearly defined reporting requirements based on the accountability measures outlined in this report

The demonstration sites should be activated at the earliest possible time and have short timelines for implementation and reporting

4. Roll-out of the ACT model across the AHSCs should not proceed before full evaluation of

the demonstration sites 5. Ideally, roll-out of the ACT model should occur as part of a full AFP implementation 6. No Anesthesiology AFP should be instituted without an undertaking to proceed with the

appropriate elements of the ACT model, at the earliest possible opportunity, being included in the plan. Further, existing AFP agreements should be modified at the earliest opportunity to include these elements


Appendix 1 – Questionnaires


Questionnaire for the Chief of Anesthesia

Daily Anaesthetic Locations HospitalOperating RoomsICU/CVICUTEEAcute Pain ServiceChronic Pain ClinicPre-Anaesthetic ClinicD&T/Labs (ex-ray, CV lab, etc)Cath LabBurns/HaemoONc/GI/Virtual DCSOR On CallTotal

Staffing HospitalPhysician StaffingAnesthesiologistsFellows (clinical time 0.4)Non-physician staffingAnesthetic assistants

Technical Role OnlyTechnical & Clinical Role

Registered nurses supporting anesthesiapre-operative services

intra-operative servicespost-operative services

Source of Funding HospitalAnesthesiologistsAnesthetic Assistants - TechnicalAnesthetic Assistants - Technical & ClinicalRNs - pre-operativeRNs - intra-operatiaveRNs - post-operatiave

Earnings HospitalAverage Anesthesiologist Earnings

Practice Plan Support HospitalAnnual Practice Plan Support $$$ (excluding OHIP and AFP payments) from hospital and other sources

Overview of Anesthesia Services


Pre-Operative Services HospitalTotal number of patients reviewed in any way by pre-surgical screening

Chart review onlyChart & telephone review only

Seen in clinic by nurseSeen in clinic by anesthesiologist

Pre-Operative Staffing HospitalNumber of clerical FTEsNumber of nursing FTEsAvg FTE anesthesiologist commitment per week

Source of Funding (e.g. hospital, practice plan, etc.) HospitalClericalNursing

Post-Operative Pain Management Services Hospital# of patients receiving anesthesiology supervised pain management services annually

PCAEpidural

SpinalOther

Average # of anesthesiologist visits per day for pain servicePCA

EpiduralSpinalOther

Average # of nurse visits per day for pain servicePCA

EpiduralSpinalOther

Post-Operative Pain Management Related Staffing HospitalNumber of nursing FTEsAvg FTE anesthesiologist commitment per week

Source of Funding (e.g. hospital, practice plan, etc.) HospitalNursing

Pre-Operative Services

Post-Operative Services


Questionnaire for Manager of Peri-Operative Services

Intra-Operative Services Hospital

Total Number of Operative Cases per year

HospitalTotal operative hours per yearAverage operative hours per caseTotal surgical hours per year Average surgical hours per caseAverage clean up time between cases

Hospital

Hospital

HospitalORs regularily running past 4:00pm

scheduledunscheduled (excluding ER)

Number of ORS running past 6:00pmscheduledunscheduled (excluding ER)

OR closures in Marchnumber of weeksnumber of Ors

OR closures in Summernumber of weeksnumber of Ors

OR closures in Decembernumber of weeksnumber of Ors

HospitalFrequency of 2nd ER room 6pm to midnight Mon-FriFrequency of 2nd ER room weekends

Anesthia Related Staffing HospitalNumber of anesthesia assistants with technical roleNumber of anesthesia assistants wit technical & clinical role

Source of Funding (e.g. hospital, practice plan, etc.) HospitalAnesthesia assistants with technical roleAnesthesia assistants with clinical role

Patient no longer requires surgeryPatient did not show

Volume

Total Inpatient Caseswith anesthesia involvement

no anesthesia involvement% of cases admitted on day of surgery

Total Outpatient Caseswith anesthesia involvement

no anesthesia involvement

Capacity Utilization

Anesthesiologist unavailablePatient bumped by emergency

Patient not medically fit for surgeryPatient permanently no longer fit for surgery

Patient inadequately prepared

Total number of ORs and procedure rooms on siteORs & procedure rooms currently in operationORs & procedure rooms currently budgeted

Patient delined surgery

Summary of Intra-Operative Services

Patient illness

Total number of cancellations per year

Emergency Room

Cancellations

Insufficient OR time allotted (room ran late)Lack of elective time

% of unscheduled admissions of outpatient casesHours

Physical Capacity


Appendix 2 – Individuals Interviewed

Children’s Hospital of Eastern Ontario Dr. William Splinter – Chief of the Department of Anesthesia Ms. Elizabeth Winters – Operations Director, Surgery Hamilton Health Sciences Ms. Charlotte Daniels – Vice President of Patient Services Dr. Richard McLean – Chief of the Department of Anesthesia Hospital for Sick Children Dr. Lawrence Roy – Anaesthetist in Chief Ms. Cathy Seguin – Vice President, Child Health Services Kingston Hospitals Dr. John Cain – Head, Department of Anesthesiology Ms. Tracy Kent-Hillis – Program Operational Director, Surgery, Peri-Operative and Anesthesia Program (KGH) Ms. Theresa Markowski – Project Coordinator, Peri-Operative Services (HDH) London Health Sciences Centre Dr. Davy Cheng – Professor and Chair/Chief Dept. of Anesthesia and Perioperative Medicine Ms. Bernadette MacDonald – Vice President, Surgery Clinical Business Unit St. Joseph’s Health Care – Hamilton Dr. Fred Baxter – Chief, Department of Anesthesia Mr. Derek McNally – Administrative Director, Clinical Programs St. Joseph’s Health Care – London Ms. Sandra Letton – Vice President, Chief Nursing Executive St. Michael’s Hospital Dr. Patricia Houston – Anesthetist-in-Chief & Medical Director, Perioperative Services Ms. Valerie Zellermeyer – Program Director, Perioperative Services Sunnybrook & Women’s College Health Sciences Centre Ms. Jane Delacy – Director of Operations Dr. Gil Faclier – Department Chief The Ottawa Hospital Ms. Pam Bush – Clinical Director Perioperative Services Dr. Homer Yang – Professor & Chair of University Dept. and Chief, Department of Anesthesiology University Health Network & Mount Sinai Hospital Dr. David Bevan – Professor and Chair of University Dept. and Anesthesiologist-in-Chief Ms. Christina Copplestone – Program Director Nursing, Surgery & Oncology (MSH) Mr. Scott McIntaggart – Executive Director, Integrated Surgical Programs (UHN) University of Ottawa Heart Institute Dr. James Robblee – Chief, Division of Cardiac Anesthesiology


Appendix 3 – DAL Calculation

The basic assumption is that to estimate the required number of anesthesiologists, for any given hospital site, you must first identify the number of clinical locations that must be staffed on a daily basis (five day work week) by anesthesiologists or other suitably trained professionals (anesthetic assistants or other allied health professionals) provide the required services for that hospital site. Such a location has been called a Daily Anesthetic Location (DAL). Each DAL represents the need, to the exclusion of other activity for an anesthesiologist or alternative, five days per week. A fairly comprehensive list of DALs that will be found at most teaching hospitals is outlined below.

OR Providing general, local, regional and/or neuroleptic anaesthesia and monitoring in an operating room. Either inpatient or day surgery

TEE Trans-esophageal echocardiography carried out for cardiac assessment in the perioperative period mainly for cardiac surgery

ICU Provision of critical care services to patients in intensive care

Obstetrics Coverage of obstetrical services for epidural anaesthesia and caesarian sections

Pre-Anesthetic Clinic Review and consultation on pre-operative cases Chronic Pain Clinic Anaesthetic services in the diagnosis and

management of chronic pain Acute Pain Service The supply of pain management services to post-

operative and other in-hospital patients Lab Support/Diagnostic/Therapeutic Anaesthetic support for diagnostic locations such as

interventional radiology, cardiac cath labs, paediatric CT and MRI, etc.

On Call Involves day off before night call and, in some circumstances, the day off after night call. May have extra on call for special programs such as Obstetrics.

Having identified the number of DALs, allowance must be made for vacation and study leave for these professional staff. However, in taking account of vacation time, it is recognized that at times during the year (e.g. Christmas, March Break and the summer) there are often reductions in the required DALs to be staffed and such reductions can be subtracted from the required leave time. In addition there is a requirement to provide professional staff at Academic Institutions with academic time to fulfill their academic obligations.


The steps to achieve an estimate of required FTEs can be summarized as 1. Identify the DALs, OR and non-OR 2. Identify staff required to cover for vacation time by determining the total weeks of vacation

for existing staff and subtracting the weeks saved through regularly scheduled OR closures

3. Identify staff required to cover for academic time by adding a 10% multiplier to existing

staff and staff required to cover for vacation.


Appendix 4 – Overview of Anesthesia Services at AHSCs by Site

Staffing Formula Components Feb.2003 Nov.2005 Difference

DALs 32.6 40.9 8.3Required Anesthesia FTE 41.1 50.4 9.3Actual Anesthesiologist FTE 35.6 40.9 5.3Shortfall FTE 5.5 9.5 4.0

DALs 16 17.6 1.6Required Anesthesia FTE 20.2 21.3 1.1Actual Anesthesiologist FTE 19 19.4 0.4Shortfall FTE 1.2 1.9 0.7

DALs 22.0 25.4 3.4Required Anesthesia FTE 28.0 31.9 3.9Actual Anesthesiologist FTE 28.3 26.2 -2.1Shortfall FTE -0.4 5.7 6.0

DALs 57.3 64.5 7.2Required Anesthesia FTE 67.5 79.0 11.5Actual Anesthesiologist FTE 49.4 68.1 18.8Shortfall FTE 18.2 10.9 -7.3

DALs 7.0 8.2 1.2Required Anesthesia FTE 9.6 11.2 1.5Actual Anesthesiologist FTE 9.9 10.2 0.3Shortfall FTE -0.3 1.0 1.2



DALs 56.1 60.3 4.2Required Anesthesia FTE 69.4 72.9 3.5Actual Anesthesiologist FTE 58.7 54.4 -4.3Shortfall FTE 10.8 18.5 7.8


Hamilton Health Sciences

Hamilton St. Joseph's Health Care

Kingston Health Sciences Centre

London Health Sciences Centre

University Health Network/Mount Sinai Hospital

Ottawa Heart Institute

St. Michael's Hospital

Sunnybrook and Women's College Health Sciences Centre

The Ottawa Hospital


Appendix 5 – Overview of Anesthesia Services at AHSCs by Site (including other allied health professionals)

Staffing Formula Components Feb.2003 Nov.2005 Difference

DALs 32.6 40.9 8.3Required Anesthesia FTE 41.1 51.0 9.9Actual Anesthesiologist FTE 35.6 40.9 5.3Actual Assistant/RN Anesthesia FTEs 0.0 1.5 1.5Shortfall FTE 5.5 8.6 3.1

DALs 16 17.6 1.6Required Anesthesia FTE 20.2 21.4 1.2Actual Anesthesiologist FTE 19 19.4 0.4Actual Assistant/RN Anesthesia FTEs 0 0.3 0.3Shortfall FTE 1.2 1.8 0.6

DALs 22.0 25.4 3.4Required Anesthesia FTE 28.0 32.2 4.2Actual Anesthesiologist FTE 28.3 26.2 -2.1Actual Assistant/RN Anesthesia FTEs 0.4 1.9 1.5Shortfall FTE -0.8 4.1 4.8

DALs 57.3 64.5 7.2Required Anesthesia FTE 67.5 79.5 12.0Actual Anesthesiologist FTE 49.4 68.1 18.8Actual Assistant/RN Anesthesia FTEs 0.0 1.4 1.4Shortfall FTE 18.2 10.0 -8.1

DALs 7.0 8.2 1.2Required Anesthesia FTE 9.6 11.2 1.5Actual Anesthesiologist FTE 9.9 10.2 0.3Actual Assistant/RN Anesthesia FTEs 0.0 0.0 0.0Shortfall FTE -0.3 1.0 1.2



DALs 56.1 60.3 4.2Required Anesthesia FTE 69.4 73.3 3.9Actual Anesthesiologist FTE 58.7 54.4 -4.3Actual Assistant/RN Anesthesia FTEs 1.5 1.3 -0.2Shortfall FTE 9.3 17.6 8.4



Hamilton St. Joseph's Health Care



University Health Network/Mount Sinai Hospital

Ottawa Heart Institute

St. Michael's Hospital

Sunnybrook and Women's College Health Sciences Centre

The Ottawa Hospital


Appendix 6 – Hospital Specific Information


Children’s Hospital of Eastern Ontario


Daily Anaesthetic Locations (DALs) CHEOOperating Rooms 6ICU/CVICU 0.8TEEAcute Pain Service 1Chronic Pain Clinic 0.4Pre-Anaesthetic Clinic 1D&T/Labs (ex-ray, CV lab, etc) 1.4Other (oncology/radiation) 0.6Other ( procedure room) 0.4OR On Call 1Obstetrics on-call coverageTotal 12.6

Staffing CHEOPhysician StaffingAnesthesiologists 16.1Fellows (clinical time 0.6) 1.2Non-physician staffingAnesthesia assistants

Technical Role OnlyTechnical & Clinical Role 2.6

Registered nurses supporting anesthesiapre-operative services 1*

intra-operative services 2post-operative services

*RPN

Position # of FTE total weeks vacationAnesthesiologists 16.1 128.8Fellows 1.2 6.0Anesthesia Assistants & RNs 5.6 22.4

157.2

Month weeks closed total weeks savedMarch 0 0Summer 1.6 9.6December 1 6.0

15.6141.6

3.21.9

**Total weeks vacation requiring staff coverage/44 weeks***FTE anesthesiologists and FTE vacation replacement x 10%

12.63.21.9

17.8

16.11.21.8

19.1-1.4

****equivalent anesthesiologist FTE

AnesthesiologistsFellows

TotalNon-physicians****

Overview of Anesthesia Services at the Children's Hospital of Eastern Ontario - 2004/05

Total Weeks of OR Closures

Total Weeks of Vacation

Current DALsVacation Replacement

Required Anesthesiologist FTE

Current Anesthesiologist FTE

ORs closed

TotalTotal Weeks of Vacation Requiring Staff Coverage (vacation - OR closures)FTE required for vacation replacement**FTE required for academic replacement***

Academic ReplacementTotal

Shortfall FTE

Summary Table for CHEO

weeks of vacation854

Total

066


Pre-Operative Services CHEOTotal number of patients reviewed in any way by pre-surgical screening 6,122

Chart review onlyChart & telephone review only

Seen in clinic by nurseSeen in clinic by anesthesiologist 6,122

Pre-Operative Staffing CHEONumber of clerical FTEs 0.5Number of nursing FTEs* 1Avg FTE anesthesiologist commitment per week 1*RPN

Post-Operative Pain Management Services CHEO# of patients receiving anesthesiology supervised pain management s 745

PCA 482Epidural 241

SpinalOther 22

Average # of anesthesiologist visits per day for pain servicePCA 2

Epidural 2SpinalOther 3

Average # of nurse visits per day for pain servicePCA 0


Post-Operative Pain Management Related Staffing CHEONumber of nursing FTEs 0Avg FTE anesthesiologist commitment per week 0.6

Summary of Pre-Operative Services at CHEO - 2004/05

Summary of Post-Operative Services at CHEO - 2004/05


CHEO

Total Number of Operative Cases per year 7170Total satelite cases (outside OR) 10624

23132313

0

48664866

CHEOTotal operative hours per year not trackedTotal satelite hours (outside OR) not trackedAverage operative hours per caseTotal surgical hours per year Average surgical hours per caseAverage clean up time between cases 15 minutes

CHEO1394

CHEO8 + 16 + 1 6 + 1

CHEOORs regularily running past 4:00pm 2-3

scheduled 1unscheduled (excluding ER)

Number of ORS running past 6:00pm 1scheduledunscheduled (excluding ER)

OR closures in Marchnumber of weeks 0number of Ors 0

OR closures in Summernumber of weeks 1.6number of Ors 6

OR closures in Decembernumber of weeks 1number of Ors 6

CHEOFrequency of 2nd ER room 6pm to midnight Mon-FriFrequency of 2nd ER room weekendsAnesthia Related Staffing CHEONumber of anesthesia assistants with technical role 0Number of anesthesia assistants with technical & clinical role 4.6

TOTAL Intra-Operative Services (scheduled & emergent)


Volume


Emergency Room

Total number of ORs and procedure rooms on siteORs & procedure rooms currently in operationORs & procedure rooms currently budgetedCapacity Utilization

Summary of Intra-Operative Services at CHEO - 2004/05

Physical Capacity


Cancellations



% of cases admitted on day of surgeryTotal Outpatient Cases

with anesthesia involvement




Daily Anaesthetic Locations McMaster General Henderson TotalOperating Rooms 7.8 12.2 6.8 26.8ICU/CVICU 0 0.75 0 0.75TEE 1 1Acute Pain ServiceChronic Pain Clinic 2.6 2.6Pre-Anaesthetic Clinic 1 0.8 1 2.8D&T/Labs (ex-ray, CV lab, etc) 0.3 0.3Obstetrics (daytime coverage) 1 1Other (Pediatric Sedation ) 0.6 0.6Other ( ) 0OR On Call (includes obstetrics) 2 2 1 5Obstetrics on-call coverage see above 0Total 12.4 19.65 8.8 40.85

Staffing McMaster General Henderson TotalPhysician StaffingAnesthesiologists 38.7Fellows (clinical time) 0.2 cardiac & 0.6 pain) 2.2Non-physician staffingAnesthetic assistants

Technical Role Only 1 1 1 3Technical & Clinical Role

Registered nurses supporting anesthesiapre-operative services 2.9 1.8 1.9 6.6

intra-operative services 1.2 1.2post-operative services 1 0.5 0.5 2


341.4

Month weeks closed total weeks savedMarch 1 18Summer 2 36December 2 38

92249.45.74.4

*Total weeks vacation requiring staff coverage/44 weeks**FTE anesthesiologists and FTE vacation replacement x 10%

40.95.74.4

51.0

38.72.21.5

42.48.6

***equivalent anesthesiologist FTE

Overview of Anesthesia Services at Hamilton Health Sciences - 2004/05


TotalNon-physicians***



Current DALs

covered by Pre-Anesthetic Clinic

19

Vacation Replacement



ORs closed

TotalTotal Weeks of Vacation Requiring Staff Coverage (vacation - OR closures)FTE required for vacation replacement*FTE required for academic replacement**


Shortfall FTE

Summary Table for Hamilton Health Sciences


Total

1818


Pre-Operative Services McMaster General Henderson TotalTotal number of patients reviewed in any way by pre-surgical screening 8,944 4368 7199 20511

Chart review only n/a n/a n/a 0Chart & telephone review only 287 n/a n/a 287

Seen in clinic by nurse 2,068 1340 479 3887Seen in clinic by anesthesiologist 6,589 3018 6720 16327

Pre-Operative Staffing McMaster General Henderson TotalNumber of clerical FTEs 3 2.4 2.3 7.7Number of nursing FTEs - RN's 2.9 1.8 1.9 6.6Avg FTE anesthesiologist commitment per week 1 0.8 1 2.8Number of Lab Staff - RPN McMaster (Gen & Hen staffed by lab serv) 0.7

Post-Operative Pain Management Services McMaster General Henderson Total# of patients receiving anesthesiology supervised pain management services annually

PCA 856 761 1258 2875Epidural 530 412 744 1686

Spinal 0Other 0

Average # of anesthesiologist visits per day for pain service 0PCA 12* 7* 9* 0

Epidural 8* 5* 7* 0Spinal 0Other 0

Average # of nurse visits per day for pain service 0PCA 12* 7* 9* 0

Epidural 8* 5* 7* 0Spinal 0Other 0

Post-Operative Pain Management Related Staffing McMaster General Henderson TotalNumber of nursing FTEs 1 0.5 0.5 2Avg FTE anesthesiologist commitment per week (Linked to Clinic) 0*Estimated

Summary of Pre-Operative Services at Hamilton Health Sciences - 2004/05

Summary of Post-Operative Services at Hamilton Health Sciences - 2004/05


McMaster General Henderson Total

Total Number of Operative Cases per year - Scheduled 8100.0 5054.0 7041.0 20195.0Total Number of Operative Cases per year - Emergent 1948.0 2225.0 1076.0 5249.0Total Number of Operative Cases per year 10048.0 7279.0 8117.0 25444.0Total Satellite Operative Cases (booked outside OR) 3420.0 193.0 64.0 3677.0

4137.0 5505.0 3384.0 13026.04137.0 5505.0 3384.0 13026.0

0.0 0.0 0.0 0.052.0 43.0 69.0 54.7

5911.0 1774.0 4733.0 12418.05900.0 1763.0 4721.0 12384.0

11.0 11.0 12.0 34.00.2 0.2 0.2 0.2

McMaster General Henderson TotalTotal Number of Operative Hours per year - Scheduled 10864.1 14757.0 8197.7 33818.8Total Number of Operative Hours per year - Emergent 3107.6 6037.5 1660.8 10806.0Total operative hours per year 13971.7 20794.5 9858.5 44624.8Total satellite operative hours (booked outside OR) 4313.3 403.3 37.0 4753.6Average operative hours per case 1.4 2.9 1.2 1.8Total surgical hours per year 9257.0 15221.0 6546.0 31024.0Average surgical hours per case 0.9 2.1 0.8 1.3Average clean up time between cases 0.3 0.3 0.3 0.3

McMaster General Henderson Total467 1154 569 2190

McMaster General Henderson Total8 10 78 10 6.68 10 6.6

McMaster General Henderson TotalORs regularly running past 4:00pm

scheduled 4 6 2 12unscheduled (excluding ER) 1 2 0 3

Number of ORS running past 6:00pmscheduled 0 3 0 3unscheduled (excluding ER) 1 2 0 3

OR closures in Marchnumber of weeks 1 1 1 1number of Ors 6 6 6 18

OR closures in Summernumber of weeks 2 2 2 2number of Ors 6 6 6 18

OR closures in Decembernumber of weeks 2 2 2 2number of Ors 7 6 6 19

McMaster General Henderson TotalFrequency of 2nd ER room 6pm to midnight Mon-Fri 0 100% 0 1Frequency of 2nd ER room weekends 0 100% 0 1Anesthesia Related Staffin

2524.624.6

g McMaster General Henderson TotalNumber of anesthesia assistants with technical role 0 0 0 0Number of anesthesia assistants with technical & clinical role 0 0 1.2 1.2

Volume



Total Outpatient Cases

Physical Capacity

CancellationsTotal number of cancellations per year

with anesthesia involvementno anesthesia involvement

Emergency Room

Summary of Intra-Operative Services at Hamilton Health Sciences - 2004/05

TOTAL Intra-Operative Services (scheduled & emergency)




Hamilton St. Joseph’s Health Care


Daily Anaesthetic Locations St. Joseph'sOperating Rooms 11.6ICU/CVICU 0.4TEEAcute Pain Service 0.5Chronic Pain Clinic 0.6Pre-Anaesthetic Clinic 2D&T/Labs (ex-ray, CV lab, etc)Obstetrics (daytime coverage) 0.5OR On Call 2Obstetics on-call coverage - covered by 1rstTotal 17.6

Staffing Hamilton St. Joe'sPhysician StaffingAnesthesiologists 19.4Fellows Non-physician staffingAnesthesia assistants

Technical Role Only 1Technical & Clinical Role

Registered nurses supporting anesthesiapre-operative services 2

intra-operative servicespost-operative services 1

Position # of FTE total weeks vacationAnesthesiologists 19.4 118.146Fellows 0 0.0Anesthesia Assistants & RNs 1 4

122.146

Month weeks closed total weeks savedMarch 1 4Summer 8 32December 2 10.0

4676.146

1.72.1


17.61.72.121.4

19.40.00.319.71.8




Overview of Anesthesia Services at Hamilton St. Joseph's Health Care - 2004/05






ORs closed



Shortfall FTE

Summary Table for Hamilton St. Joseph's Health Care

weeks of vacation6.09

54

Total

445


Pre-Operative Services St. Joseph'sTotal number of patients reviewed in any way by pre-surgical screening 12,474

Chart review only NAChart & telephone review only NA

Seen in clinic by nurse 12,474Seen in clinic by anesthesiologist 12,474

Pre-Operative Staffing St. Joseph'sNumber of clerical FTEs 3Number of nursing FTEs 2Avg FTE anesthesiologist commitment per week 2

Post-Operative Pain Management Services St. Joseph's# of patients receiving anesthesiology supervised pain management services annually

PCAEpidural

SpinalOther

Average # of anesthesiologist visits per day for pain service 30PCA

EpiduralSpinalOther

Average # of nurse visits per day for pain service 30PCA 15

Epidural 10Spinal 5Other

Post-Operative Pain Management Related Staffing St. Joseph'sNumber of nursing FTEs 1Avg FTE anesthesiologist commitment per week 1

Summary of Post-Operative Services at Hamilton St. Joe's - 2004/05

Summary of Pre-Operative Services at Hamilton St. Joe's - 2004/05


TOTAL Intra-Operative Services (Scheduled and Emergency) Charlton Minor Proc CAHS Total

Total Number of Operative Cases per year 11575 4063 2978 18616Total Number of Scheduled Cases 9185Total Number of Emergent Cases 2390 NATotal Satelite Operative Cases (outside OR) see CAHS NA

6333 NA6303 NA

30 2978not available 2637

8220 3418152 NA

68 4063NA

Charlton Minor Proc CAHS TotalTotal operative hours per year 19669 1756.45 1433.32 22858.77Total elective hours 15549.58Total emergent hours 4119.42Total satelite operative hours (outside OR) see CAHS Average operative hours per case 1.5 0.28Total surgical hours per year 13954 926.28Average surgical hours per case 1 0.18Average clean up time between cases 16 min 0.02

Charlton Minor Proc CAHS Total1138

Charlton Minor Proc CAHS Total14 3 214 2 1.5 17.511 2 1.5 14.5

Charlton Minor Proc CAHS TotalORs regularily running past 4:00pm

scheduled 3unscheduled (excluding ER) 2 - 3

Number of ORS running past 6:00pmscheduled øunscheduled (excluding ER) seldom

OR closures in Marchnumber of weeks 1 1 1 1number of Ors 4 2 1.5 7.5

OR closures in Summernumber of weeks 8 8 2number of Ors 4 1 1.5

OR closures in Decembernumber of weeks 2 2 2 2number of Ors 5 2 1.5 8.5

Charlton Minor Proc CAHS TotalFrequency of 2nd ER room 6pm to midnight Mon-Fri occasionallyFrequency of 2nd ER room weekends no second rm bookedAnesthia Related Staffin

19

g Charlton Minor Proc CAHS TotalNumber of anesthesia assistants with technical role 1 0 1 2Number of anesthesia assistants with technical & clinical role 0 0 0 0


Volume

Total Inpatient Cases

Summary of Intra-Operative Services at Hamilton St. Joseph's Health Care - 2004/05



Physical Capacity

Cancellations

no anesthesia involvement% of unscheduled admissions of outpatient cases

Hours


Emergency Room



TOTAL Intra-Operative Services (Scheduled and Emergency) Charlton Minor Proc CAHS Total

Total Number of Operative Cases per year 11575 4063 2978 18616Total Number of Scheduled Cases 9185Total Number of Emergent Cases 2390 NATotal Satelite Operative Cases (outside OR) see CAHS NA

6333 NA6303 NA

30 2978not available 2637

8220 3418152 NA

68 4063NA

Charlton Minor Proc CAHS TotalTotal operative hours per year 19669 1756.45 1433.32 22858.77Total elective hours 15549.58Total emergent hours 4119.42Total satelite operative hours (outside OR) see CAHS Average operative hours per case 1.5 0.28Total surgical hours per year 13954 926.28Average surgical hours per case 1 0.18Average clean up time between cases 16 min 0.02

Charlton Minor Proc CAHS Total1138

Charlton Minor Proc CAHS Total14 3 214 2 1.5 17.511 2 1.5 14.5

Charlton Minor Proc CAHS TotalORs regularily running past 4:00pm

scheduled 3unscheduled (excluding ER) 2 - 3

Number of ORS running past 6:00pmscheduled øunscheduled (excluding ER) seldom

OR closures in Marchnumber of weeks 1 1 1 1number of Ors 4 2 1.5 7.5

OR closures in Summernumber of weeks 8 8 2number of Ors 4 1 1.5

OR closures in Decembernumber of weeks 2 2 2 2number of Ors 5 2 1.5 8.5

Charlton Minor Proc CAHS TotalFrequency of 2nd ER room 6pm to midnight Mon-Fri occasionallyFrequency of 2nd ER room weekends no second rm bookedAnesthia Related Staffin

19

g Charlton Minor Proc CAHS TotalNumber of anesthesia assistants with technical role 1 0 1 2Number of anesthesia assistants with technical & clinical role 0 0 0 0


Volume


Summary of Intra-Operative Services at Hamilton St. Joseph's Health Care - 2004/05



Physical Capacity

Cancellations


Hours


Emergency Room



Hospital for Sick Children


Daily Anaesthetic Locations Sick KidsOperating Rooms 14ICU/CVICUTEEAcute Pain Service 1Chronic Pain Clinic 1Pre-Anaesthetic Clinic 1D&T/Labs (ex-ray, CV lab, etc) 3Cath Lab 2Burns/HaemoONc/GI/ 1Virtual DCS 1OR On Call 2Total 26

Staffing Sick KidsPhysician StaffingAnesthesiologists 25.4Fellows (clinical time 0.4) 4Non-physician staffingAnesthetic assistants


Registered nurses supporting anesthesiapre-operative services 1

intra-operative servicespost-operative services 1.5

Position # of FTE total weeks vacationAnesthesiologists 25.4 203.2Fellows 4 20Anesthesia Assistants & RNs 2.5 10

233.2

Month weeks closed total weeks savedMarch 2 9Summer 11 38.5December 2 25.4

72.9160.3

3.62.9


26.03.62.9

32.6

25.44.00.6

30.02.5




Overview of Anesthesia Services at the Hospital for Sick Children - 2004/05






ORs closed



Shortfall FTE

Summary Table for Sick Kids


Total

4.53.512.7


Pre-Operative Services Sick KidsTotal number of patients reviewed in any way by pre-surgical screening 8,435

Chart review only 8,435Chart & telephone review only

Seen in clinic by nurse 8,435Seen in clinic by anesthesiologist 354

Pre-Operative Staffing Sick KidsNumber of clerical FTEs 0.5Number of nursing FTEs 1Avg FTE anesthesiologist commitment per week 1The preop numbers are confusing - a significant number of ambulatory patients are assessed by nursing just prior to coming to the OR whereas preop anesthesia clinic has been established to assess the problematic patients in advance of the day of surgery. This is currently undersupported here.

Post-Operative Pain Management Services Sick Kids# of patients receiving anesthesiology supervised pain management services annually 750

PCA 600Epidural 130

Spinal 20Other

Average # of anesthesiologist visits per day for pain service 6PCA 2




Post-Operative Pain Management Related Staffing Sick KidsNumber of nursing FTEs 1.5Avg FTE anesthesiologist commitment per week 1.5

Summary of Pre-Operative Services at the Hospital for Sick Children - 2004/05

Summary of Post-Operative Services at the Hospital for Sick Children - 2004/05


TOTAL Intra-Operative Services (Scheduled & Emergency) Sick Kids

Total Number of Operative Cases per year 11811Total Satelite Cases 5990

60586058

075%55455545

02.50%

Sick KidsTotal operative hours per year 28900Total satelite hours 10288Average operative hours per case 2.02Total surgical hours per year 16912Average surgical hours per case 1.45Average clean up time between cases 15 minutes

Sick Kids2755

Sick Kids18 + 815 + 815 + 8

Sick KidsORs regularily running past 4:00pm

scheduled 9unscheduled (excluding ER) 0

Number of ORS running past 6:00pmscheduled 0.5unscheduled (excluding ER) 2


OR closures in Summernumber of weeks 11number of Ors 3.8/wk

OR closures in Decembernumber of weeks 2number of Ors 12.7

Sick KidsFrequency of 2nd ER room 6pm to midnight Mon-Fri almost alwaysFrequency of 2nd ER room weekends almost alwaysAnesthia Related Staffing Sick KidsNumber of anesthesia assistants with technical role 2Number of anesthesia assistants with technical & clinical role 0

Summary of Intra-Operative Services at the Hospital for Sick Children - 2004/05

% of unscheduled admissions of outpatient cases

Volume





Hours


Physical Capacity

Emergency Room

Total number of ORs and procedure rooms on siteORs & procedure rooms currently in operationORs & procedure rooms currently budgeted




Daily Anaesthetic Locations General Hotel Dieu TotalOperating Rooms 10 4.6 14.6ICU/CVICU 2 2TEE 1 1Acute Pain Service 1 1Chronic Pain Clinic 0.1 0.7 0.8Pre-Anaesthetic Clinic 0.7 0.7D&T/Labs (ex-ray, CV lab, etc) not coveredObstetrics (daytime coverage) 1 1Other ( Dental Clinic/ECTs ) 1.3 1.3OR On Call 2 2Obstetrics on-call coverage 1 1Total 19.4 6 25.4

Staffing General Hotel Dieu TotalPhysician Staffing GFTs 23 23Associates 2.6 2.6Fellows (clinical time 0.3) 0.6 0.6Non-physician staffingAnesthetic assistants

Technical Role Only 0.5 0.5Technical & Clinical Role 1 1

Registered nurses supporting anesthesiapre-operative services 6 6

intra-operative services 0.6 2 2.6post-operative services 1 1

Position # of FTE total weeks vacationAnaesthetist 23 184Associates 2.6 20.8Fellows 0.6 3.0Anesthesia Assistants 3.6 14.4

222.2

Month weeks closed total weeks savedMarch HDH 1 2March KGH 1 3Summer HDH 1 9Summer KGH 2 10December HDH 1 5.5December KGH 2 12

41.5180.74.12.7


25.44.12.732.2

23.02.60.61.928.14.1


Overview of Anesthesia Services of Kingston AHSC - 2004/05

weeks of vacation88


39

5.56

5

Total Weeks of OR ClosuresORs closed

2

54

Total

Current DALsVacation ReplacementAcademic Replacement


Non-physicians***TotalShortfall FTE

Summary Table for Kingston AHSC

Associates

TotalCurrent Anesthesiologist FTEAnesthesiologists

Fellows




Pre-Operative Services General Hotel Dieu TotalTotal number of patients reviewed in any way by pre-surgical screening 11426 11426

Chart review only n/a 0Chart & telephone review only 2746 2746

Seen in clinic by nurse 8680 8680Seen in clinic by anesthesiologist 1903 1903

Pre-Operative Staffing General Hotel Dieu TotalNumber of clerical FTEs 3.6 3.6Number of nursing FTEs 6 6Avg FTE anesthesiologist commitment per week 0.7 0.7All patients have either telephone or on-site visitAll patients having a procedure with an anesthesiologist are assessed by PSS

Post-Operative Pain Management Services General Hotel Dieu Total# of patients receiving anesthesiology supervised pain management services annually 3124

PCA 1208 1208Epidural 1498 1498

Spinal 212 212Last 12 mths - 206 blocks in database but #s included with PCA-IV Other 206 206

Average # of patients on pain service per day 37 37Length of stay 2.28 days PCA 11 11Length of stay 3.87 days Epidural 23 23Length of stay 0.9 days Spinal 1 1Length of stay 2.28 days Other 2 2

Post-Operative Pain Management Related Staffing General Hotel Dieu TotalNumber of nursing FTEs 1 0 1Avg FTE anesthesiologist commitment per week 1 0 1* only 11.27% of blocks did not have PCA - IV as well

Summary of Pre-Operative Services at the Kingston AHSC - 2004/05

Summary of Post-Operative Services at Kingston AHSC - 2004/05


Total Intra-Operative Services (Scheduled & Emergency) General Hotel Dieu Total

Total Number of Operative Cases per year 8309 6684 14993Total Satelite Cases (outside OR) n/a

6339 0 6339100%

80%1970 6684 8654

Total Satelite Cases (outside OR) 02% 5578 5578

1106 11060.50%

General Hotel Dieu TotalTotal operative hours per year 17721 6503 24224Total satelite hours (outside OR) n/aAverage operative hours per case 2.1 0.97Total surgical hours per year 13399 4609 18008Average surgical hours per case 1.61 0.69Average clean up time between cases (minutes) 15 15

General Hotel Dieu Total774 463 1237

General Hotel Dieu Total10 8 1810 5.5 15.510 5.5 15.5

General Hotel Dieu TotalORs regularily running past 4:00pm

scheduled 3 0 3unscheduled (excluding ER) 1.3 0 1.3

Number of ORS running past 6:00pmscheduled 1 0 1unscheduled (excluding ER) 0 0

OR closures in Marchnumber of weeks 1 1number of Ors 3 2

OR closures in Summernumber of weeks 2 9number of Ors 5 1

OR closures in Decembernumber of weeks 2 1number of Ors 6 5.5

General Hotel Dieu TotalFrequency of 2nd ER room 6pm to midnight Mon-Fri rare n/aFrequency of 2nd ER room weekends rare n/aAnesthia Related Staffing General Hotel Dieu TotalNumber of anesthesia assistants with technical role 2 0 2Number of anesthesia assistants with technical & clinical role 1 2.5 3.5

Summary of Intra-Operative Services at the Kingston AHSC - 2004/05

Volume






Emergency Room


Physical Capacity


Cancellations



Daily Anaesthetic Locations University Victoria St. Joseph's TotalOperating Rooms 14 13 12 39ICU/CVICU/step-up unit 2 0 1 3TEE 1 0 0 1Acute Pain Service 1 1 0 2Chronic Pain Clinic 0 0.5 1.5 2Pre-Anaesthetic Clinic 1 1 0.5 2.5D&T/Labs (ex-ray, CV lab, PACU, etc) 2 1 0 3Obstetrics (daytime coverage) 0 0 1 1Other ( Regional nerve block ) 1 1Other ( )OR On Call (on/off, Liver Tx, cardiac call) 4 2 2 8Obstetrics on-call coverage 0 2 0 2Total 25 20.5 19 64.5

Staffing University Victoria St. Joseph's TotalPhysician StaffingAnesthesiologists 23.6 21.7 15 60.3Fellows (0.6 clinical time) 5.4 0 2.4 7.8Non-physician staffingAnesthetic assistants

Technical Role Only 4 7 1 12Technical & Clinical Role

Registered nurses supporting anesthesiapre-operative services 6 7 3 16

intra-operative servicespost-operative services 1 1 0.5 2.5


543.4


184359.48.26.8


64.58.26.879.5

60.37.81.469.510.0


Overview of Anesthesia Services at London AHSC - 2004/05

Total

Shortfall FTE

Summary Table for London AHSC


Total

2012




ORs closed


Academic Replacement



Current DALs

28




Pre-Operative Services University Victoria St. Joseph's TotalTotal number of patients reviewed in any way by pre-surgical screening 5,638 8,372 14718 28728

Chart review only 1,878 8,372 0 10250Chart & telephone review only 256 249 1400 1905

Seen in clinic by nurse 3,504 8,123 8100 19727Seen in clinic by anesthesiologist 2,014 2,930 3718 8662

Pre-Operative Staffing University Victoria St. Joseph's TotalNumber of clerical FTEs 4 4 4.5 12.5Number of technicians (conduct ecg and collect bloodwork) 2 2Number of nursing FTEs 6 7 3 16Avg FTE anesthesiologist commitment per week 1 1 0.5 2.5*seen by internal medicine

Post-Operative Pain Management Services University Victoria St. Joseph's Total# of patients receiving anesthesiology supervised pain management 2920 3550 2120 8590

PCA 1700 2000 110 3810Epidural 240 1500 1800 3540

Spinal 800 0 100 900Other: regional nerve block 180 50 110 340

Average # of anesthesiologist visits per day for pain service 77.5PCA 16 15 9 40

Epidural 8 10 4 22Spinal 5 5

Other: Consult and regional block 0.5 1 9 10.5Average # of nurse visits per day for pain service 114

PCA 20 30 8 58Epidural 10 20 30

Spinal 6 6Other: regional block 10 2 8 20

Post-Operative Pain Management Related Staffing University Victoria St. Joseph's TotalNumber of nursing FTEs 1 1 0.5 2.5Avg FTE anesthesiologist commitment per week 1 1 0.5 2.5

Summary of Pre-Operative Services at London AHSC - 2004/05

Summary of Post-Operative Services at London AHSC - 2004/05



TOTAL Intra-Operative Services (scheduled & emergency) University Victoria St. Joseph's Total

Total Number of Operative Cases per year 7,813 15,611 17593 41,017 6,605 12,965 1,208 2,646

Total Satelite Operative Cases (outside OR) 640 774 13647 15,061 5,085 9,218 4736 19,039 5,061 9,218 4683 18,962

24 - 52 76 56% 33% 61.3 62

2,683 6,238 12857 21,778 2,299 6,232 12070 20,601

384 6 788 1,178 <1.0% <1.0% <1.0% <1.0%

University Victoria St. Joseph's TotalTotal operative hours per year 21,791 29,242 22339 73,372

18,389 24,634 3,402 4,608

Total Satelite Operative Hours (outside OR) 1,785 216 0 2,001 Average operative hours per case 2.8 1.9 1.3 Total surgical hours per year 16,756 20,371 16369 53,496 Average surgical hours per case 2.1 1.3 0.9Average clean up time between cases (minutes) 10 10 9

University Victoria St. Joseph's Total455 907 1568 2930

University Victoria St. Joseph's Total17 19 14 5014 13 12 2614 13 12 39

University Victoria St. Joseph's TotalORs regularly running past 4:00pm




OR closures in Summernumber of weeks 9 9 9 9number of Ors 3.5 4.5 4 12

OR closures in Decembernumber of weeks 2 2 2 2number of Ors 11 9 8 28

University Victoria St. Joseph's TotalFrequency of 2nd ER room 6pm to midnight Mon-Fri 50% 80% n/aFrequency of 2nd ER room weekends 25% 100% n/aAnesthia Related Staffing University Victoria St. Joseph's TotalNumber of anesthesia assistants with technical role 2 6 1 9Number of anesthesia assistants with technical & clinical role 0 0 0 0


Summary of Intra-Operative Services at London AHSC - 2004/05





Volume



Emergency Room

ElectiveEmergency

ElectiveEmergency

Physical CapacityTotal number of ORs and procedure rooms on siteORs & procedure rooms currently in operationORs & procedure rooms currently budgeted

% of cases admitted on day of surgery


St. Michael’s Hospital


Daily Anaesthetic Locations St. Mike'sOperating Rooms 21ICU/CVICU 3TEE 1Acute Pain Service 1Chronic Pain Clinic 0.4Pre-Anaesthetic Clinic 2D&T/Labs (ex-ray, CV lab, etc) 0.8Obstetrics (daytime coverage) 1Other ( Cysto ) 1Other ( Litho ) 1OR On Call 2Obstetrics on-call coverage 1Total 35.2

Staffing St. Mike'sPhysician StaffingAnesthesiologists 34.3Fellows* 4.2Non-physician staffingAnesthetic assistants


Registered nurses supporting anesthesiapre-operative services 9.7

intra-operative services 2post-operative services 3

*fellows = 0.3 FTE - time makes allowance for 0.4 academic time and supervision of clinical time

Position # of FTE total weeks vacationAnesthesiologists 34.3 274.4Fellows 4.2 21Anesthesia Assistants & RNs 5 20

315.4

Month weeks closed total weeks savedMarch 1 3Summer 12 36Summer 6 30December 1 7December 1 18

94221.4

5.03.9


35.25.03.9

44.2

34.34.21.6

40.14.1




Overview of Anesthesia Services at St. Michael's Hospital - 2004/05



Current DALs

3

18




ORs closed



Shortfall FTE

Summary Table for St. Michael's Hospital


Total

3

57


Pre-Operative Services St. Mike'sTotal number of patients reviewed in any way by pre-surgical screening 13,900

Chart review only 3,400Chart & telephone review only

Seen in clinic by nurse 10,500Seen in clinic by anesthesiologist 4,530

Pre-Operative Staffing St. Mike'sNumber of clerical FTEs 6Number of nursing FTEs 9.7Number of pharmacists FTEs 1Avg FTE anesthesiologist commitment per week 2

Post-Operative Pain Management Services St. Mike's# of patients receiving anesthesiology supervised pain management services annually 4450

PCA 3229Epidural 213

Spinal 700Other 262

Average # of anesthesiologist visits per day for pain service 40PCA 30

Epidural 5Spinal 3Other 2



Post-Operative Pain Management Related Staffing St. Mike'sNumber of nursing FTEs 3Avg FTE anesthesiologist commitment per week 1

Summary of Pre-Operative Services at St. Michael's Hospital - 2004/05

Summary of Post-Operative Services at St. Michael's Hospital - 2004/05



Intra-Operative Services (Scheduled and Emergency) St. Mike's

Total Number of Operative Cases per year 14932Total Scheduled Cases per year 12204Total ER cases per year 2728Total satelite cases (outside OR) 3333

868814932

072%62446244

00.0035%

St. Mike'sTotal operative hours per year 32160Total scheduled operative hours 25736Total ER operative hours 6428Total satelite hours (outside OR) 3507Average operative hours per case IP 195 min/ OP 89 minTotal surgical hours per year 21283Average surgical hours per case IP 117 min/ OP 44 minAverage clean up time between cases IP 23 min/ OP 13 min

St. Mike's817/ 5.0%108/ .7%

included above1

49/ .3%119/ .8%

025/ .2%70/ .5%36/ .2%56/ .4%

2St. Mike's

2220/21

20St. Mike's

ORs regularily running past 4:00pmscheduled 2unscheduled (excluding ER) 3

Number of ORS running past 6:00pmscheduled 0unscheduled (excluding ER) 1


OR closures in Summernumber of weeks Stage 1 - 12 wks, Stage 2 - 6 wksnumber of Ors Stage 1 - 3 ORs, Stage 2 - + 2 Ors

OR closures in Decembernumber of weeks Stage 1 - 1 wk, Stage 2 - 1 wknumber of Ors Stage 1 - 4-14 ORs, Stage 2 - 17-18 ORs

St. Mike'sFrequency of 2nd ER room 6pm to midnight Mon-Fri 90%Frequency of 2nd ER room weekends 77%Anesthesia Related Staffing St. Mike'sNumber of anesthesia assistants with technical role N/ANumber of anesthesia assistants with technical & clinical role 2+2** 2 RNs provide CS to cataract/other like patients 2-3 RRT OR positions provide a mix of administrative, clinical and technical support

Summary of Intra-Operative Services at St. Michael's Hospital - 2004/05

ORs & procedure rooms currently budgetedCapacity Utilization

Emergency Room

Patient illnessPhysical CapacityTotal number of ORs and procedure rooms on siteORs & procedure rooms currently in operation

Patient inadequately preparedPatient declined surgery



Volume





Hours

Cancellations

Patient bumped by emergencyPatient not medically fit for surgery

Patient permanently no longer fit for surgery

Total number of cancellations per yearInsufficient OR time allotted (room ran late)

Lack of elective timeAnesthesiologist unavailable

Intra-Operative Services (Scheduled and Emergency) St. Mike's

Total Number of Operative Cases per year 14932Total Scheduled Cases per year 12204Total ER cases per year 2728Total satelite cases (outside OR) 3333

868814932

072%62446244

00.0035%

St. Mike'sTotal operative hours per year 32160Total scheduled operative hours 25736Total ER operative hours 6428Total satelite hours (outside OR) 3507Average operative hours per case IP 195 min/ OP 89 minTotal surgical hours per year 21283Average surgical hours per case IP 117 min/ OP 44 minAverage clean up time between cases IP 23 min/ OP 13 min

St. Mike's817/ 5.0%108/ .7%

included above1

49/ .3%119/ .8%

025/ .2%70/ .5%36/ .2%56/ .4%

2St. Mike's

2220/21

20St. Mike's

ORs regularily running past 4:00pmscheduled 2unscheduled (excluding ER) 3

Number of ORS running past 6:00pmscheduled 0unscheduled (excluding ER) 1


OR closures in Summernumber of weeks Stage 1 - 12 wks, Stage 2 - 6 wksnumber of Ors Stage 1 - 3 ORs, Stage 2 - + 2 Ors

OR closures in Decembernumber of weeks Stage 1 - 1 wk, Stage 2 - 1 wknumber of Ors Stage 1 - 4-14 ORs, Stage 2 - 17-18 ORs

St. Mike'sFrequency of 2nd ER room 6pm to midnight Mon-Fri 90%Frequency of 2nd ER room weekends 77%Anesthesia Related Staffing St. Mike'sNumber of anesthesia assistants with technical role N/ANumber of anesthesia assistants with technical & clinical role 2+2** 2 RNs provide CS to cataract/other like patients 2-3 RRT OR positions provide a mix of administrative, clinical and technical support

Summary of Intra-Operative Services at St. Michael's Hospital - 2004/05

ORs & procedure rooms currently budgetedCapacity Utilization

Emergency Room

Patient illnessPhysical CapacityTotal number of ORs and procedure rooms on siteORs & procedure rooms currently in operation

Patient inadequately preparedPatient declined surgery



Volume





Hours

Cancellations

Patient bumped by emergencyPatient not medically fit for surgery

Patient permanently no longer fit for surgery

Total number of cancellations per yearInsufficient OR time allotted (room ran late)

Lack of elective timeAnesthesiologist unavailable


Sunnybrook & Women’s College Health Sciences Centre

Daily Anaesthetic Locations Sunnbrook Women's OAI TotalOperating Rooms 16 4.4 4 24.4ICU/CVICUTEE 0.8 0.8Acute Pain Service 1 0.2 1 2.2Chronic Pain Clinic 1 0.2 1.2Pre-Anaesthetic Clinic 1 0.8 1 2.8D&T/Labs (ex-ray, CV lab, etc) 1.2 1.2Obstetrics (daytime coverage) 2 2OR On Call 2 2Obstetrics on-call coverage 2 2Total 23 9.6 6 38.6

Staffing Sunnbrook Women's OAI Total

Anesthesiologists 25.2 9.2 0.4 34.8Fellows (clinical time 0.8 @ Sunnybrook & 0.5 @ W 4.8 1 5.8

Anesthetic assistantsTechnical Role Only 1 1 2

Technical & Clinical Role 4 2 6Registered nurses supporting anesthesia 0

pre-operative services 5 3.5 2.2 10.7intra-operative services 0post-operative services 2 1 3


343.4


115228.45.2


38.65.24.047.8

34.85.83.243.84.0


Overview of Anesthesia Services at Sunnybrook & Women's College HSC - 2004/05

Physician staffing

Non-physician staffing

AnesthesiologistsFellowsNon-physicians***



Current DALs

18

Total




ORs closed



Shortfall FTE

Summary Table for Sunnybrook & Women's


Total

46.25

Total

Daily Anaesthetic Locations Sunnbrook Women's OAI TotalOperating Rooms 16 4.4 4 24.4ICU/CVICUTEE 0.8 0.8Acute Pain Service 1 0.2 1 2.2Chronic Pain Clinic 1 0.2 1.2Pre-Anaesthetic Clinic 1 0.8 1 2.8D&T/Labs (ex-ray, CV lab, etc) 1.2 1.2Obstetrics (daytime coverage) 2 2OR On Call 2 2Obstetrics on-call coverage 2 2Total 23 9.6 6 38.6

Staffing Sunnbrook Women's OAI Total

Anesthesiologists 25.2 9.2 0.4 34.8Fellows (clinical time 0.8 @ Sunnybrook & 0.5 @ W 4.8 1 5.8

Anesthetic assistantsTechnical Role Only 1 1 2

Technical & Clinical Role 4 2 6Registered nurses supporting anesthesia 0

pre-operative services 5 3.5 2.2 10.7intra-operative services 0post-operative services 2 1 3


343.4


115228.45.2


38.65.24.047.8

34.85.83.243.84.0


Overview of Anesthesia Services at Sunnybrook & Women's College HSC - 2004/05

Physician staffing

Non-physician staffing

AnesthesiologistsFellowsNon-physicians***



Current DALs

18

Total




ORs closed



Shortfall FTE

Summary Table for Sunnybrook & Women's


Total

46.25

Total



Pre-Operative Services Sunnbrook Women's OAI TotalTotal number of patients reviewed in any way by pre-surgical screening 4869 6472 3265 14606

Chart review only 0 3143 3143Chart & telephone review only 0 1410 404 1814

Seen in clinic by nurse 4869 1917 6786Seen in clinic by anesthesiologist 60 1106 1166

Pre-Operative Staffing Sunnbrook Women's OAI TotalNumber of clerical FTEs 2.4 1.1 3.5Number of nursing FTEs 5.1 3.4 2.2 10.7

Avg FTE anesthesiologist commitment per week 1 0.8 1 2.8

Post-Operative Pain Management Services Sunnbrook Women's OAI Total# of patients receiving anesthesiology supervised pain management services annually 6104

PCA 3300 3300Epidural 1970 1970

Spinal 0 0oral 834 834

Average # of anesthesiologist visits per day for pain service 37PCA 1to2 1to2 20

Epidural 1to2 12Spinal 0 0

oral 1to2 5Average # of nurse visits per day for pain service 37

PCA 1to2 20Epidural 1to2 12

Spinal 0 0oral 1to2 5

Post-Operative Pain Management Related Staffing Sunnbrook Women's OAI TotalNumber of nursing FTEs 2 1 3Avg FTE anesthesiologist commitment per week 1 1

Summary of Pre-Operative Services at Sunnybrook & Women's College HSC - 2004/05

Summary of Post-Operative Services at Sunnybrook & Women's College HSC - 2004/05

Pre-Operative Services Sunnbrook Women's OAI TotalTotal number of patients reviewed in any way by pre-surgical screening 4869 6472 3265 14606


Seen in clinic by nurse 4869 1917 6786Seen in clinic by anesthesiologist 60 1106 1166

Pre-Operative Staffing Sunnbrook Women's OAI TotalNumber of clerical FTEs 2.4 1.1 3.5Number of nursing FTEs 5.1 3.4 2.2 10.7

Avg FTE anesthesiologist commitment per week 1 0.8 1 2.8

Post-Operative Pain Management Services Sunnbrook Women's OAI Total# of patients receiving anesthesiology supervised pain management services annually 6104

PCA 3300 3300Epidural 1970 1970

Spinal 0 0oral 834 834

Average # of anesthesiologist visits per day for pain service 37PCA 1to2 1to2 20

Epidural 1to2 12Spinal 0 0

oral 1to2 5Average # of nurse visits per day for pain service 37

PCA 1to2 20Epidural 1to2 12

Spinal 0 0oral 1to2 5

Post-Operative Pain Management Related Staffing Sunnbrook Women's OAI TotalNumber of nursing FTEs 2 1 3Avg FTE anesthesiologist commitment per week 1 1

Summary of Pre-Operative Services at Sunnybrook & Women's College HSC - 2004/05

Summary of Post-Operative Services at Sunnybrook & Women's College HSC - 2004/05




TOTAL Intra-Operative Services (scheduled & emergency) Sunnybrook Women's OAI Total

Total Number of Operative Cases per year 10573 4486 3438 18497Total satelite cases (outside OR)

7615 1563 2303 114817615 1563 2303 11481

0 0 0 083.9

2958 2923 1135 70162958 2923 1135 7016

0 0 0 00

Sunnybrook Women's OAI TotalTotal operative hours per year 24797.75 6498.80 7313.80 38610.35Total satelite hours (outside OR)Average operative hours per case 2.35 2.32 2.13 2.26Total surgical hours per year 21447.32 5972.80 7201.75 34621.87Average surgical hours per case 2.03 2.09 1.37* Average clean up time between cases (inpatient) 30 20 26 25.33

Sunnybrook Women's OAI Total1443 100 159 1702

Sunnybrook Women's OAI Total17 8 4 2915 5+ 2 4 1915 4.5 + 2 4 19

Sunnybrook Women's OAI TotalORs regularily running past 4:00pm




OR closures in Summernumber of weeks 12 12 12 12number of Ors 4 1.25 1 6.25

OR closures in Decembernumber of weeks 2 2 2 2number of Ors 10 emerg only 4 14

Sunnybrook Women's OAI TotalFrequency of 2nd ER room 6pm to midnight Mon-Fri 2 0 0 2Frequency of 2nd ER room weekends 2 0 0 2Anesthia Related Staffing Sunnybrook Women's OAI TotalNumber of anesthesia assistants with technical role 0 0 0 0Number of anesthesia assistants with technical & clinical role 6 0 2 8

Summary of Intra-Operative Services at Sunnybrook & Women's College HSC - 2004/05


Volume


data not availableTotal Inpatient Cases


Physical Capacity



Total number of ORs and procedure rooms on site

data not available


ORs & procedure rooms currently in operationORs & procedure rooms currently budgetedCapacity Utilization

Emergency Room


The Ottawa Hospital

Daily Anaesthetic Locations General Civic Riverside TotalOperating Rooms 14 15 9 38ICU/CVICU 0.75 1.5 0 2.25TEE 0 1 0 1Acute Pain Service 1 1 0 2Chronic Pain Clinic 0.6 0.6 0 1.2Pre-Anaesthetic Clinic 1 1.4 0.6 3D&T/Labs (ex-ray, CV lab, etc) 1 2 0 3Obstetrics (daytime coverage) 1 1 0 2Other (Lithotripsy) 0 0 0.8 0.8Other (Hyperbaric Unit) 1 0 0 1OR On Call (includes obstetrics) 2 4 0 6Total 22.35 27.5 10.4 60.25

Staffing General Civic Riverside TotalPhysician StaffingAnesthesiologists 19.6 52.9Fellows (clinical time 0.5) 1.5Non-physician staffingAnesthetic assistants

Technical Role Only 1 1Technical & Clinical Role

Registered nurses supporting anesthesiapre-operative services 3.8 5 6.9 15.7

intra-operative services (Technical Role Only) 1 1 2intra-operative services (Clinical Role Only) 2 2

post-operative services 1 1 2

Position # of FTE total weeks vacationAnesthesiologists 52.9 423.2Fellows 1.5 7.5Anesthesia Assistants & RNs 4 16

446.7

Month weeks closed total weeks savedMarch 1 13Summer 9 75.6December 2 12December 2 35

135.6311.1

7.16.0


60.37.16.0

73.3

52.91.51.3

55.717.6


Overview of Anesthesia Services at The Ottawa Hospital - 2004/05

33.3

6

Shortfall FTE

Summary Table for The Ottawa Hospital


Total

13




ORs closed





Current DALs

17.5

8.4

Total





Pre-Operative Services General Civic Riverside Eye Centre TotalTotal number of patients reviewed in any way by pre-surgical screening 7085 4251 7226 18562

Chart review only 0Chart & telephone review only 3030 3030

Seen in clinic by nurse 8799 5821 5180 5966 25766Seen in clinic by anesthesiologist 3146 5202 1320 962 10630

Pre-Operative Staffing General Civic Riverside Eye Centre TotalNumber of clerical FTEs 2 1 1.3 2Number of nursing FTEs 3.8 5 3 3.9 15.7Avg FTE anesthesiologist commitment per week 1 1.4 0.4 0.2 3

Post-O

6.3

perative Pain Management Services General Civic Riverside Total# of patients receiving anesthesiology supervised pain management services annually 3500 3483 6983

PCA 0Epidural 710 1143 1853

Spinal 1748 1575 3323Other 0

Average # of anesthesiologist visits per day for pain service 20.5 25.1 45.6PCA 0


Average # of nurse visits per day for pain service 28.6 35.2 63.8PCA 0


Post-Operative Pain Management Related Staffing General Civic Riverside TotalNumber of nursing FTEs 1 1 0 2Avg FTE anesthesiologist commitment per week 1 1.2 0 2.2

Summary of Pre-Operative Services at The Ottawa Hospital - 2004/05

Summary of Post-Operative Services at The Ottawa Hospital - 2004/05


Intra-Operative Services (Scheduled & Emergency) General Civic Riverside Eye Centre Eye Institute Total

Total Scheduled Operative Cases per year 7085 8501 7226 8695 2517 34024Total ER Operative Cases per year 2461 3170 6 194 18 5831Total Satellite Operative Cases (outside OR) * * *

4475 4312 n/a n/a n/a 87874472 4288 n/a n/a n/a 8760

3 24 n/a n/a n/a 2788% 87% 87.5%2610 4189 7226 8695 2517 252372605 4158 6785 8695 2517 24760

5 31 441 0 0 4770.47 0.01 0

General Civic Riverside Eye Centre Eye Institute TotalTotal Scheduled operative hours per year 14178:55 18332:18 6025:41 3702:44 1294:20 43531Total ER operative hours per year 5129 7470 6.25 267.5 15.5 12888.25Total satelite operative hours (outside OR)Average operative hours per case 2:00 2:09 0:50 0:25 0:30Total surgical hours per year 9740:09 12745:36 3746:15 2341:08 1050:56 29,624.04Average surgical hours per case 1:22 1:29 0:31 0:16 0:25 0.87Average clean up time between cases 0:17 0:15 0:13 0:10 0:15

General Civic Riverside Eye Centre Eye Institute Total357 574 300 84 128 1443

General Civic Riverside Eye Centre Eye Institute Total13 16 6 4 2 41

12+1 14.5 6 4 2 39.513 14.5 6 4 2 39.5

General Civic Riverside Eye Centre Eye Institute TotalORs regularily running past 4:00pm - - 0

scheduled 1 2 0 0 0unscheduled (excluding ER) 2 1 0 0 0

Number of ORS running past 6:00pm - - 0scheduled 0 0 0 0 0unscheduled (excluding ER) 0 0 0 0 0

OR closures in March

33

00

- - 0number of weeks 1 1 1 1 1 5number of Ors 25 25 15 10 5 80

OR closures in Summer - - 0number of weeks 9 9 2 2 2 24number of Ors 179 199 60 40 20 498

OR closures in December - - 0number of weeks 2 2 2 2 2 10number of Ors 63 70 42 28 14 217

General Civic Riverside Eye Centre Eye Institute TotalFrequency of 2nd ER room 6pm to midnight Mon-Fri Wed - Fri always n/a n/a n/a 0Frequency of 2nd ER room weekends rare always n/a n/a n/a 0

General Civic Riverside Eye Centre Eye Institute5129 7470 6.25 267.5 15.5 12888.252461 3170 6 194 18 5831

Anesthia Related Staffin

(2005)

(2004)

(2004)

g General Civic Riverside Eye Centre Eye Institute TotalNumber of anesthesia assistants with technical role 0Number of anesthesia assistants with technical & clinical role 0 0 0 0 0 0

* Total satellite operative cases outside of the O.R.Civic - Dental Clinic - approximately 290 patients Cancer Clinic Special Procedures - exceeded 411 proceduresRadiology Support - 6 days per monthCase Room - one anesthesiologist per day Monday - Friday 0800 - 1800General CampusRadiology Support - 2 days per monthCase Room - one anesthesiologist per dayMonday to Friday 0800 - 1530



Summary of Intra-Operative Services at The Ottawa Hospital - 2004/05

Volume

with anesthesia involvementTotal Inpatient Cases



Physical CapacityTotal number of cancellations per year

Hours

Cancellations

Total number of ORs and procedure rooms on siteORs & procedure rooms n operationORs & procedure rooms udgeted

Cases


Emergency Room

Emergency ActivityHours

currently i currently b


University Health Network & Mount Sinai Hospital


Daily Anaesthetic Locations TGH TWH Mt.Sinai TotalOperating Rooms 15 15 10 40ICU/CVICU 3 0 0 3TEE 1 0 1 2Acute Pain Service 0.5 0.5 0 1Chronic Pain Clinic 0 1 2 3Pre-Anaesthetic Clinic 1.5 1.5 0.6 3.6D&T/Labs (ex-ray, CV lab, etc) 1 1 2 4Obstetrics (daytime coverage) 0 0 1 1OR On Call 3 3 2 8Obstetrics on-call coverage 0 0 2 2Total 25 22 20.6 67.6

Staffing TGH TWH Mt.Sinai TotalPhysician StaffingAnesthesiologists 25.5 19 21.7 66.2Fellows (clinical time 0.3) 5 3 3 11Non-physician staffingAnesthetic assistants

Technical Role Only 4 3 2 9Technical & Clinical Role 3 2 5

Registered nurses supporting anesthesiapre-operative services 3 4 4 11

intra-operative servicespost-operative services 3 3 1 7

Position # of FTE total weeks vacationAnesthesiologists 66.2 529.6Fellows 11 54.5Anesthesia Assistants & RNs 20 80

664.1

Hospital total weeks savedMount Sinai Hospital 36Toronto General Hospital 71Toronto Western Hospital 98.5

205.5458.610.47.7


67.610.47.785.7

66.211.04.581.74.1


Overview of Anesthesia Services at the UHN & MSH - 2004/05

Fellows


Total







Shortfall FTE

Summary Table for UHN and MSH


TotalTotal Weeks of OR Closures

Anesthesiologists


Pre-Operative Services TGH TWH Mt.Sinai TotalTotal number of patients reviewed in any way by pre-surgical screening 4754 7535 7737 20026


Seen in clinic by nurse 4294 5200 6484 15978Seen in clinic by anesthesiologist 2513 5541 1790 9844

Pre-Operative Staffing TGH TWH Mt.Sinai TotalNumber of clerical FTEs 4 2 2Number of nursing FTEs 6 2 4Avg FTE anesthesiologist commitment per week 1.5 1.5 0.6 3.6

Post-O

812

perative Pain Management Services TGH TWH Mt.Sinai Total# of patients receiving anesthesiology supervised pain management services annually 4326 2107 2394 8827

PCA 2849 2849Epidural 1129 1129

Spinal 0Other 348 348

Average # of anesthesiologist visits per day for pain service 3-4MD, 1RN 0PCA 0




Post-Operative Pain Management Related Staffing TGH TWH Mt.Sinai TotalNumber of nursing FTEs 3 3 1Avg FTE anesthesiologist commitment per week 0.5 0.5 0 1

Summary of Pre-Operative Services at UHN and MSH - 2004/05

Summary of Post-Operative Services at UHN & MSH - 2004/05

7


Intra-Operative SCHEDULED Services General Western PMH MSH Total

Total Number of Operative Cases per year 6751 10966 1667 12583 319675906 2970 1004 3444 133245906 2970 1004 3437 13317

0 0 0 7 757% 21% N/A 85.30%845 7996 663 3846 13350845 7996 663 2877 12381

0 0 0 969 9691% 0% N/A 3.70%

Intra-Operative EMERGENCY Services General Western PMH MSH Total

Total Number of Operative Cases per year 1568 1932 0 1210 4710General Western PMH MSH Total

Total operative hours per year 34022 25347 4653 17814.97 81837Average operative hours per case 4 2 1.7 1.49Total surgical hours per year 21159.67 14381.28 1573.55 11647.65 48762Average surgical hours per case 3 1 1 1.02Average clean up time between cases n/a n/a n/a 0

General Western PMH MSH TotalTotal operative hours per year 29267.75 19719.27 4653 16976.9 70617Total surgical hours per year 17945.55 11242.45 1573.55 30762

General Western PMH MSH TotalTotal operative hours per year 4754.25 5627.73 0 838.07 11220Total surgical hours per year 7866.7 3138.83 0 11006

General Western PMH MSH Total1281 935 69 398

General Western PMH MSH Total19 19 2 12 & 2 & 2 5619 16 10 & 2 & 2 4915 13 10 & 2 & 2 42

General Western PMH MSH TotalORs regularily running past 15:30pm 4 or 5

scheduled 11/day 1 or 2unscheduled (excluding ER) 2/day 3

Number of ORS running past 17:30pm(TGH & PMH) and 17:00 (TWH)scheduled 3/day 1unscheduled (excluding ER)

General Western PMH MSH TotalFrequency of 2nd ER room 6pm to midnight Mon-Fri occFrequency of 2nd ER room weekends occAnesthia Related Staffing General Western PMH MSH TotalNumber of anesthesia assistants with technical roleNumber of anesthesia assistants with technical & clinical role 5


Hours - All Cases

Hours - Elective Cases


% of unscheduled admissions of same day patients cases

Volume

Physical CapacityTotal number of ORs and procedure rooms on siteORs & procedure rooms currently in operationORs & procedure rooms currently budgeted

Summary of Intra-Operative Services at UHN and MSH - 2004/05

Emergency Room

Volume

% of cases admitted on day of surgeryno anesthesia involvement

Total Same Day Patients Cases



Hours - Emergency Cases (includes Add-Ons)

Cancellations


University of Ottawa Heart Institute



Overview of Anesthesia Services at the University of Ottawa Heart Institute - 2004/05

Daily Anaesthetic Locations (DALs) Heart InstituteOperating Rooms 4.4ICU/CVICU 1.4TEE 1Acute Pain ServiceChronic Pain ClinicPre-Anaesthetic Clinic 0.4D&T/Labs (ex-ray, CV lab, etc)Obstetrics (daytime coverage)Other ( )OR On Call 1Obstetrics on-call coverageTotal 8.2

Staffing Heart InstitutePhysician StaffingAnesthesiologists 10.2Fellows (2 fellows 100% supervision) 0.0Non-physician staffingAnesthetic assistants

Technical Role Only 5.0Technical & Clinical Role



Position # of FTE total weeks vacationAnesthesiologists 10.2 81.6Fellows 0 0Anesthesia Assistants & RNs 5 20

101.6


497.62.21.2


8.22.21.211.6

10.20.00.010.21.4






Current DALs

1



ORs closed



Shortfall FTE

Summary Table for the Heart Institute


Total

0

0


Overview of Anesthesia Services at the University of Ottawa Heart Institute - 2004/05

Daily Anaesthetic Locations (DALs) Heart InstituteOperating Rooms 4.4ICU/CVICU 1.4TEE 1Acute Pain ServiceChronic Pain ClinicPre-Anaesthetic Clinic 0.4D&T/Labs (ex-ray, CV lab, etc)Obstetrics (daytime coverage)Other ( )OR On Call 1Obstetrics on-call coverageTotal 8.2

Staffing Heart InstitutePhysician StaffingAnesthesiologists 10.2Fellows (2 fellows 100% supervision) 0.0Non-physician staffingAnesthetic assistants

Technical Role Only 5.0Technical & Clinical Role



Position # of FTE total weeks vacationAnesthesiologists 10.2 81.6Fellows 0 0Anesthesia Assistants & RNs 5 20

101.6


497.62.21.2


8.22.21.211.6

10.20.00.010.21.4






Current DALs

1



ORs closed



Shortfall FTE

Summary Table for the Heart Institute


Total

0

0



Pre-Operative Services Heart InstituteTotal number of patients reviewed in any way by pre-surgical screening 1800

Chart review only 0Chart & telephone review only 0

Seen in clinic by nurse 700Seen in clinic by anesthesiologist 1800

Telehealth program developing with increasing numbers 50Pre-Operative Staffing Heart InstituteNumber of clerical FTEs 1Number of nursing FTEs 3Avg FTE anesthesiologist commitment per week 0.6Note: this does not include pre-op assessment of in-patients (over 50% of the practice)

Summary of Pre-Operative Services at the Heart Institute - 2004/05


Intra-Operative Services (Scheduled & Emergency) Heart Institute

Total Number of Operative Cases per year* 13361850

100%

35%350

100%

0Heart Institute

Total operative hours per year 8917Average operative hours per caseTotal surgical hours per year Average surgical hours per case - major 5.5

23.5

Average surgical hours per case - cardioversions 0.75Average clean up time between cases 0.5

Heart Institute382

Heart Institute666

Heart InstituteORs regularily running past 4:00pm

scheduled 5unscheduled (excluding ER)

Number of ORS running past 6:00pmscheduledunscheduled (excluding ER) 2

OR closures in Marchnumber of weeksnumber of Ors

OR closures in Summernumber of weeks 4number of Ors 1

OR closures in Decembernumber of weeksnumber of Ors

Heart InstituteFrequency of 2nd ER room 6pm to midnight Mon-Fri 0Frequency of 2nd ER room weekends 0Anesthia Related Staffing Heart InstituteNumber of anesthesia assistants with technical role 5Number of anesthesia assistants with technical & clinical role 0

*1000 minor (reopenings, sternal wires, tracheostomies, ICD, debridement, cardioversion)

Emergency Room

Average surgical hours per case - reopeningsAverage surgical hours per case - EP labs


Physical Capacity

Hours

Volume


with anesthesia involvementTotal Inpatient Cases

Total Outpatient Caseswith anesthesia involvement


Summary of Intra-Operative Services at the Heart Institute - 2004/05



Documents

Transforming the Delivery of Operative Anesthesia Services in Ontario