Ambulatory Surgery Facility and Nursing Considerations in M.I.S.S. (Minimally Invasive Spine Surgery)

Goal: Deliver quality of care with optimal outcome.

M.I.S.S. procedures have evolved to a point now that it is commonly performed in either office based or free standing ambulatory surgery center. Many M.I.S.S. providers find themselves owning or taking part ownership in such ventures. Successful delivery of quality care is a measurable outcome that can be influenced by the following five factors:

• M.I.S.S. provider
• facility
• surgery team
• equipment
• patient

1. The M.I.S.S. provider

There is some university training, but more rather peer to peer, preceptor ship, fellowship, conferences and courses offered. There are now also board exams such given by AAMISMS and FRCP and FRCS in Minimally Invasive Spine Medicine and Surgery.   

Credentials and certifications are essentials for M.I.S.S. providers as well as for the team.

2. Facility

Know the standards and guidelines so well that you all times can meet and set the standards with practical adaptations for M.I.S.S. needs. Be a mode setter. Seek excellence and show it through Medicare, JCAHO, AAAHC and other certifications.

The size of the room may be a small enough to fit a c-arm, a gurney, a tech and the M.I.S.S. provider for simple injections, while it may need to be as much as 30% bigger than a regular OR in order to fit all equipment and personnel for the Endoscopic discectomies. Especially if utilized for conferences, and or preceptor ships.

The environment and the air flow can be quite a problem if not dealt with correctly. In less than 10 minutes the room goes from low energy load to high load, as all equipment are turned on and 8-12 people enters the OR. The Engineers or technician of HVAC company must many times witness the OR environment with all its equipment and people to understand the needs. Sharing a HVAC unit between OR and recovery is greatly discouraged as it many times creates a too hot OR or too cold recovery area.

Electricity and enough circuits is another factor to take in consideration.

The max out voltage on the units many time does not take in consideration the surge of energy that the unit takes as one turns it on an off, thus one can blow fuses without understanding why. As the set up changes and equipment is moved from side to side depending on the patient’s pathology and symptoms; a minimum of two 15 amp/110V (Video tower, computers, equipments), one 30 amp/110V (C-arm) and one 50 amp/220V (Laser) should be available from either side of the room. Ceiling booms and equipment towers can assist in keeping all the electrical cords to a minimum on the floor. 

A center is very dependent on being able to sterilize instruments in between surgeries in order to keep room turn over time down and perform surgeries. The sterilizer becomes a hot commodity when it is down.  Having an extra set of instruments and endoscopes is optimal but is not realistic many times. Preventive maintenance agreements and good relationship with service providers can avoid delayed and or cancelled cases.

The combination of a Steris System 1 and an autoclave will keep the procedure flow going. Verify that the water to the sterilizer is hot and softened, with backflow preventions.

Emergency generator is a must. A second floor facility must have emergency power to the elevator. When planning a facility, considering the first floor if at all possible can contain some costs by the size of Emergency generator needed. The propane generator is the preferable to a diesel generator. A diesel generator requires more maintenance and generates more noise.

When establishing the vacuum pump size it according to maximum use. A three phase double pump is usually the minimal need.

Med gas system is essential as well. Review carefully which gases you really need it can reduce cost substantially is it is decided that there is only need for Oxygen versus if there a need for oxygen, air and nitrous. For optimal cleaning of the small lumen instruments, power water and nitrogen needs to be brought into the decontamination room. Utilizing these tools together with an ultrasonic washer shortens the instrument turn over time. Nitrogen is used instead of air due to the difference in humidity as well as cost.

On site laundry facility is a small investment up front in comparison to the high cost of having a long term contract with a linen company.

3. Personnel

As technology moves forward we are pace setters and we set the standards in this field.

When choosing staff remember that you will have to train them as there are no formal schools teaching M.I.S.S techniques. Look for people that are able to “think on their feet”. Build a TEAM. The team can break or make the M.I.S.S. surgeon.

This high tech on-the-edge field of medicine has only one constant, change.

It is imperative to have policy and procedures in place. Have a routine but be adaptable and have educated flexibility as new situations arise. Review all tasks that are needed for the facility to run, encourage and ensure cross training of all staff. BCLS and ACLS certifications are a must. Any RN performing IV Sedation must be certified.  Encourage staff to get other certifications such as, Laser safety, Ambulatory Surgery Certification, CNOR, CRNFA and PACU.

This is a quest for research and development. The right staff will thrive on being on the edge and know the quest for M.I.S.S.  to be known as the golden standard of care for cervical, thoracic and lumbar disc pathologies.

The surgeon may perform the operative procedure but it takes the whole team to make the M.I.S.S. surgery possible. The anesthesia provider maintains the patient pain free, comfortable and awake enough to respond to the surgeon during the surgery or gives general aesthesia when indicated. The C-arm technician ensures MRI films are in the OR, ensures radiation safety standards compliance, assists the anesthesia provider and the circulator to position the patient, and knows how to get the view needed to confirm instrument and needle placement. There is a log maintained of all used contrast media and fluoro times. The intra operative EMG monitor tech, assist in placing the needles and monitors the nerves before, during and shortly after the surgery and documents on the intra operative EMG record. The scrub tech is well familiar with the use of all instruments, keeps them organized, troubleshoots and is many times the “McGuire of surgery”. The first assistant assists the surgeon with an extra pair of hands, keeping track of 10-14 cords. The circulator keeps an eye on the whole operating suite, ensures maintenance of sterile field, maintains the irrigation fluids, mixed with antibiotics and empties and strains suction canisters for disc materials. The Medical Records Documentation specialist, obtains room pictures, C-arm images, endoscopic images, and attaches them to the Surgery report. The laser officer keeps the laser log, ensures adherence to laser safety standards, operates the laser, and does quality controls on the fibers following each surgery. The Bio-medical equipment tech operates all equipment and can trouble shoot. The Materials manager keeps all supplies at par levels. When supplies are on back order and are needed he finds other means of obtaining supplies. The Instrument tech knows how to care for the instruments so they last longer.  The Admission and discharge nurse knows the ‘red flag” and is able to teach and assess patients perception of the surgery and understanding of instructions given. One nurse is delegated to order medications, and will continuously look for back up options as various medications used daily in the surgical facility suddenly goes on “national back order”. The charge nurse maintains daily staffing and patient flow. The facility manager serves as the team leader, backup staff and appoints a safety officer, compliance officer, HIPAA officer, and JCAHO point person and so on. The facility manager oversees contracts, vendors, accounts payable and receivable, month end close, facility statistics, credentialing, staff and acts as a lesion as needed.

Looking at all the staff above it is obvious that in M.I.S.S surgeries it is essential that the staff knows how to multitask, and can preform more than one roll of the ones listed above.

Knowing your vendors and looking out for the economic interest for the surgery center, decreases the up-cost of doing the M.I.S.S. surgery. 

3. Equipment

There is a high start up cost to obtain all equipment, instruments and endoscopes for M.I.S.S.  Having an extra set of instruments and endoscopes is optimal but is not realistic many times. The instruments are delicate and they need very detailed oriented care. The narrow and long lumens make them a challenge to decontaminate and sterilize. Ultrasonic washer becomes essential as well as pressurized water and nitrogen in processing these instruments. Careful inspection of each screw and joint is necessary as well as speedy processing as the disc tissue quickly dries up.

Many surgeons are struggling with the current inapt instruments and scopes on the market, many of them are collaborating with various engineers within the bio-medical instrument industry in research and development of new instruments and endoscopes.

There needs to be procedure, protocol and diligent documentation by the various players of all the processes in the development of improved tools.

4. Patients

There are few “red flags” to consider after the patient has become a surgical candidate. The preoperative nursing interview screens for any “red flags” such as;

·       The need for and lack of support system and adequate care taker following procedures and surgeries.

·       Stairs in the house.

·       Psychologic disorders.

·       Patient not emotionally “ready” for surgery and has “cold feet’.

·       Over the counter medicine, Herbal medicines and anti inflammatories that prolongs bleeding.

·       Patient’s awareness and understanding of informed consent, the risk and benefits of the proposed operation.

·       Possible pregnancy

If any questions or “red flags” are identified during the preoperative assessment, the M.I.S.S. surgeon is notified and the issues are dealt with prior to surgery.

Anna Maj-Lis Aasa, RN, CNOR

M.I.S.S. Consultants