The AAMC paradigm TACTICS may be a helpful framework.
(TACTICS – Teamwork, Advocacy, Coordination,
Technology, Improvement, Cost, Safety) Not all categories
apply to each solution but use these categories as a
framework for a comprehensive solution to the problem.
- Preoperative Clinic Resident for a Day
You were asked to evaluate a 68-year-old man with
presumed prinz metal angina for an elective hip
replacement. The cardiology consult "cleared"
the patient for surgery and recommended avoiding hypoxia
and hypotension in the OR.
How will this consult affect patient care? How do you
proceed with information supplied by the consult? What
is your role? If you require more information how will
this affect the patient, his family, his relationship
with his cardiologist, the OR schedule, the surgeon,
cost, the intended unit for admission and the hospital?
- Floor Runner for a Day
The OR is booked to full capacity. A patient with a
ruptured aortic aneurysm needs immediate repair.
What criteria will you use to choose the operating
room to interrupt for this case? What effect will your
decision have on the other patients, same day surgery
admissions, the waiting room, the holding area, the OR
team, the hospital’s revenue and the hospital’s
reputation? The emergency case will require a high
acuity in terms of equipment and support staff (Your OR
has only 1 Rapid Infusion Pump, 2 level one warmers, 1
working I-stat and three overloaded "resource
technicians", all already in use). How will you
allocate these limited resources?
- OR Attending for a Day
The SICU notifies you that there is no nurse
available to receive the patient you have just induced,
intubated and "lined-up" for a coronary bypass
graft. The surgeon wants to proceed stating, "they’ll
find a nurse by the time we’re done."
What criteria should you use to cancel the case? If
you cancel the case where does the patient go? What
criteria would you use to discharge the patient home
today? How will your decision impact the patient, the
patient’s safety, the surgeon, the OR team, the OR
schedule, the PACU, the SICU, the nursing administrator,
the hospital’s revenue and hospital’s standing in
the community?
- Surgeon for a Day
The first patient on your schedule has violated the
hospital’s NPO guidelines. The anesthesiologist
informs you will have to postpone the case for 4 hours
or wait to the end of your schedule to perform the
liposuction and abdominoplasty.
What do you do? How will your decision effect the
patient, the OR team, the surgeon scheduled to follow
your cases, the patient scheduled to be seen in your
office and your reputation in the community? You have no
patients ready for surgery and the OR wants to use
"your" room for a "quick" emergency?
What do you say?
- Circulating Nurse for a Day
After inserting the arthroscope into the patient’s
right knee, the orthopedic surgeon realizes that she
should be operating on the left knee. The H &P and
consent state left knee but the site was marked on the
right. You cannot recall if a "time out"
occurred to read the consent.
What do you do next? Who should be contacted? What is
the appropriate paper work to be completed? How will
this sentinal event affect the patient, you, the
surgeon, the anesthesiologist, the OR and the hospital?
- Bean Counter for a Day
A very nervous patient cannot decide if he wants
general or regional anesthesia for his bilateral hernia
repair.
Calculate the cost of the different anesthetic
techniques. How do cost and charges differ? How does
your anesthetic technique affect insurance and out of
pocket expenses? How are anesthesia charges divided
between equipment, medications, OR and professional
fees? What affect do these charges have on federal and
state budgets and taxes?
- Hospital Administrator for a Day
The hospital is over census. You do not know when and
how many beds will become available. The operating room
schedule has 25 elective cases, which will require
postoperative admissions. There are 15 in-patients
scheduled for procedures and 20 cases scheduled as same
day surgeries.
What criteria will you use to "direct
traffic" today? What are your options? How will
your decisions affect the patients, the admissions area,
the OR, the floor, hospital income and the community’s
perception of the hospital?
Infectious Control Officer for a Day
There is a potential contamination of an OR by a
patient not previously diagnosed with TB.
What measures will you take? How will this affect the
OR equipment, personnel and schedule? How will this
problem affect the PACU, the intended floor for
admission and the other patients? What will you tell
other patients and families?
- Safety Officer for a Day
A suspected hazardous spill has occurred on the
loading dock.
What measures will you take? How will this affect the
OR, the hospital and the community? What will you tell
patients and their families? What will you tell the
media?
- Billing Specialist for a Day
The surgeon performed a complicated procedure, which
does not have a CPT code. The anesthesia bill, the OR
bill and the surgical bill all describe the procedure
differently.
What is a CPT code? How do you resolve the different
descriptions on the paperwork? How will this affect
billing and reimbursement for the anesthesiologist, the
surgeon and the hospital? How will it affect the patient
and third party payer?
- Critical Care Nurse for a Day
Too late! You realize the anesthesia resident has
left the unit before giving you a full report on this
intubated 47-year-old man s/p a craniotomy for
glioblastoma. How are you going to find out about the
patient’s pre-surgical condition and intra-operative
course? His wife wants to come in to the unit "just
to see my husband for a minute." The surgeon left
orders for the patient to go immediately to CT scan. The
respiratory technician wants to know what you will need
for transport? Radiology wants to know how soon you will
be arriving.
How do you address all these concerns? How do you
prioritize them? What information do you need and how
will you obtain it?
- PACU Resident for a Day
You are called by the PACU nurse for a 84 kg
57-year-old Hispanic female who is having 10/10 pain.
When you arrive at the bedside the patient is crying.
She had a femoral nerve block preoperatively and then
had a general anesthetic for the ACL repair. The nurse
has administered 24mg of morphine intravenously over the
past 45 minutes.
What are your options for pain relief? Your attending
wants to do a fascia iliaca block. How will you consent
the patient? How do your decisions affect the patient
and patient’s family perception of the postoperative
care at your institution?
- Labor and Delivery Attending for a Day
You are called to operating room 3 where there is a
25-year-old female with a twin gestation pushing the
first baby. The patient has intravenous access.
What kind of care does this patient need? How
likely is it that the patient will deliver the second
baby vaginally? Which anesthetic techniques will you
choose for the cesarean section, if necessary? Who is
going to take care of this patient? What are your
options? How do your decisions affect the patient’s
and patient’s family’s perception of the
obstetrical care at your institution? What are the
legal and billings implications of you taking care of
the patient yourself?
