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To learn 13 00:00:30,649 --> 00:00:33,009 more, visit carecredit.com 14 00:00:33,009 --> 00:00:34,229 forward slash beckerspodcast. 15 00:00:35,809 --> 00:00:37,969 This is Gracelyn Keller with the Becker's Healthcare 16 00:00:37,969 --> 00:00:40,129 Podcast, and we are recording live at the 17 00:00:40,129 --> 00:00:43,030 twenty second annual Spine Orthopedic and Pain Management 18 00:00:43,090 --> 00:00:43,590 Conference. 19 00:00:44,129 --> 00:00:46,864 I'm currently joined by doctor Doctor. Leanne Carlisle, 20 00:00:47,004 --> 00:00:49,824 who is the medical director of UMA anesthesia 21 00:00:50,364 --> 00:00:53,164 at University Health Systems. So Doctor. Carlisle, thank 22 00:00:53,164 --> 00:00:55,004 you for being here. Let's start off by 23 00:00:55,004 --> 00:00:56,604 having you introduce yourself and tell us a 24 00:00:56,604 --> 00:00:58,384 little bit more about your role in organization. 25 00:00:59,030 --> 00:01:01,369 Absolutely. Yes. And good morning to you, Grace. 26 00:01:01,750 --> 00:01:03,270 My name is doctor Lee Carlisle. I am 27 00:01:03,270 --> 00:01:06,010 the medical director of UMA Anesthesia Services. 28 00:01:06,709 --> 00:01:10,069 UMA is University Medical Associates, which is a 29 00:01:10,069 --> 00:01:10,569 nonprofit 30 00:01:11,545 --> 00:01:12,045 multispecialty 31 00:01:12,504 --> 00:01:13,484 group practice 32 00:01:13,784 --> 00:01:17,405 that provides health care services to University Health. 33 00:01:17,864 --> 00:01:19,564 Now University Health 34 00:01:20,104 --> 00:01:20,924 is the 35 00:01:21,224 --> 00:01:24,420 public health and hospital system for Bexar County. 36 00:01:24,579 --> 00:01:25,879 And how good are you 37 00:01:26,259 --> 00:01:28,579 with Texas geography? Do you know where Bexar 38 00:01:28,579 --> 00:01:30,659 County is? I do not. I've only been 39 00:01:30,659 --> 00:01:33,859 to Texas once. Okay. So Bexar County actually 40 00:01:33,859 --> 00:01:35,079 houses San Antonio. 41 00:01:35,700 --> 00:01:37,859 And San Antonio, if you didn't know, is 42 00:01:37,859 --> 00:01:40,004 one of the seven it's the seventh largest 43 00:01:40,064 --> 00:01:41,924 city in The United States. 44 00:01:42,384 --> 00:01:42,884 So 45 00:01:43,185 --> 00:01:45,045 lots of people in the county, 46 00:01:45,424 --> 00:01:48,384 lots of opportunity for patient care. So that's 47 00:01:48,384 --> 00:01:49,685 where I work and live. 48 00:01:50,384 --> 00:01:50,884 Wonderful. 49 00:01:51,344 --> 00:01:53,344 Well, thank you for joining me. And, 50 00:01:53,744 --> 00:01:55,640 I'd love to start off with what trends 51 00:01:55,640 --> 00:01:57,719 or shifts that you're currently seeing in the 52 00:01:57,719 --> 00:01:58,219 industry, 53 00:01:58,840 --> 00:02:01,079 that you specifically think are important for leaders 54 00:02:01,079 --> 00:02:02,459 to be paying attention to. 55 00:02:02,840 --> 00:02:03,340 Absolutely. 56 00:02:03,640 --> 00:02:04,140 So 57 00:02:04,599 --> 00:02:05,899 I've been in the field 58 00:02:06,200 --> 00:02:07,340 of anesthesia, 59 00:02:07,719 --> 00:02:08,219 primarily 60 00:02:09,314 --> 00:02:10,215 in ambulatory 61 00:02:10,514 --> 00:02:11,414 surgery centers, 62 00:02:12,275 --> 00:02:13,955 that one of the major shifts that I've 63 00:02:13,955 --> 00:02:15,974 seen in a change of patient population, 64 00:02:17,235 --> 00:02:18,694 patients are much sicker 65 00:02:18,995 --> 00:02:21,974 in being cared for in an ambulatory outpatient 66 00:02:22,034 --> 00:02:22,534 setting. 67 00:02:23,069 --> 00:02:24,830 Variety of reasons for that. 68 00:02:25,310 --> 00:02:25,810 Certainly, 69 00:02:26,590 --> 00:02:28,989 the insurance companies have a vested interest in 70 00:02:28,989 --> 00:02:32,030 finding a low cost center, which ambulatory surgery 71 00:02:32,030 --> 00:02:35,084 centers are. The challenge of that all we 72 00:02:35,324 --> 00:02:38,125 always is to make sure that we assess 73 00:02:38,125 --> 00:02:39,185 the patient adequately 74 00:02:39,724 --> 00:02:41,644 and provide the same level of care we 75 00:02:41,644 --> 00:02:42,944 would within the hospital. 76 00:02:43,884 --> 00:02:45,905 In San Antonio, like I mentioned, 77 00:02:46,444 --> 00:02:49,344 patient population is growing by leaps and bounds. 78 00:02:49,644 --> 00:02:50,144 So 79 00:02:50,709 --> 00:02:51,209 increased 80 00:02:51,509 --> 00:02:53,849 patient volumes is what we're seeing. 81 00:02:54,150 --> 00:02:55,129 And, again, 82 00:02:55,509 --> 00:02:55,909 being 83 00:02:56,310 --> 00:02:58,169 the challenges that come with that 84 00:02:58,550 --> 00:02:59,050 staffing 85 00:02:59,669 --> 00:03:00,169 throughput, 86 00:03:01,669 --> 00:03:02,169 resources, 87 00:03:03,594 --> 00:03:05,275 Those are some of the challenges that we 88 00:03:05,275 --> 00:03:07,455 see with the increasing patient population. 89 00:03:08,074 --> 00:03:10,074 And the other one is a the third 90 00:03:10,074 --> 00:03:12,155 one is one that's near and dear to 91 00:03:12,155 --> 00:03:14,655 my heart that I pay great attention to 92 00:03:14,875 --> 00:03:15,775 is the challenges 93 00:03:16,074 --> 00:03:17,775 within the world of anesthesia, 94 00:03:18,259 --> 00:03:19,479 the anesthesia shortages. 95 00:03:20,019 --> 00:03:22,340 This has been growing for the last several 96 00:03:22,340 --> 00:03:24,680 years and is projected to last 97 00:03:25,620 --> 00:03:28,599 years into the future. Becker's does a wonderful 98 00:03:28,659 --> 00:03:29,639 job of highlighting 99 00:03:30,500 --> 00:03:32,120 the challenges in anesthesia, 100 00:03:33,114 --> 00:03:34,634 and certainly, I see it on the front 101 00:03:34,634 --> 00:03:35,134 line. 102 00:03:36,394 --> 00:03:36,894 Absolutely. 103 00:03:37,675 --> 00:03:40,074 And let's touch on staffing and workforce challenges 104 00:03:40,074 --> 00:03:41,995 too as these continue to be a concern 105 00:03:41,995 --> 00:03:45,034 across health care. So how's your organization navigating 106 00:03:45,034 --> 00:03:47,034 these pressures, and what strategies have you seen 107 00:03:47,034 --> 00:03:47,775 work well? 108 00:03:48,919 --> 00:03:49,819 Back in 109 00:03:50,439 --> 00:03:51,409 February 110 00:03:51,409 --> 00:03:52,379 2023, 111 00:03:53,159 --> 00:03:55,980 the Bexar County Hospital District Board of Managers 112 00:03:57,000 --> 00:03:59,400 tasked Ed Banas, who is the president and 113 00:03:59,400 --> 00:04:01,180 CEO of University Health, 114 00:04:01,694 --> 00:04:02,354 to address 115 00:04:02,735 --> 00:04:03,715 these ongoing 116 00:04:04,735 --> 00:04:05,955 anesthesia shortages. 117 00:04:06,655 --> 00:04:08,495 What he came up with was a really 118 00:04:08,495 --> 00:04:09,555 innovative plan 119 00:04:09,854 --> 00:04:10,834 of a delegated 120 00:04:11,134 --> 00:04:11,634 delegation 121 00:04:12,014 --> 00:04:12,754 of privileges 122 00:04:13,055 --> 00:04:13,794 for CRNAs. 123 00:04:15,140 --> 00:04:15,960 This has 124 00:04:16,980 --> 00:04:20,100 flipped our staffing model, our team model that 125 00:04:20,100 --> 00:04:22,279 we practice at the surgery center, 126 00:04:22,819 --> 00:04:25,779 and has allowed the CRNAs to practice to 127 00:04:25,779 --> 00:04:28,120 the fullest extent of their license. 128 00:04:29,345 --> 00:04:31,524 We implemented this in 129 00:04:31,904 --> 00:04:33,444 June, 130 00:04:34,064 --> 00:04:35,274 so June 131 00:04:35,274 --> 00:04:36,084 2024, 132 00:04:36,544 --> 00:04:38,324 and it has been 133 00:04:39,504 --> 00:04:41,685 a wonderful experience for me 134 00:04:42,339 --> 00:04:44,680 to work within a team of 135 00:04:44,980 --> 00:04:46,600 highly trained CRNAs. 136 00:04:48,019 --> 00:04:48,920 We've realized 137 00:04:50,100 --> 00:04:51,560 increased patient throughput 138 00:04:51,939 --> 00:04:53,959 when you compare at our institution. 139 00:04:55,254 --> 00:04:57,574 The patient population that we cared for in 140 00:04:57,574 --> 00:04:59,915 the last two quarters of twenty twenty three 141 00:05:00,615 --> 00:05:02,935 compared to the last two quarters of twenty 142 00:05:02,935 --> 00:05:05,675 twenty four, we saw a 13% 143 00:05:06,454 --> 00:05:09,379 increase in patients that we cared for. And 144 00:05:09,379 --> 00:05:10,680 I attribute this 145 00:05:11,060 --> 00:05:12,040 to the 146 00:05:12,660 --> 00:05:13,160 experienced 147 00:05:13,540 --> 00:05:14,040 team, 148 00:05:14,899 --> 00:05:15,800 to the process 149 00:05:16,100 --> 00:05:19,560 that allows me to act as a consulting 150 00:05:19,779 --> 00:05:21,480 physician on the team. 151 00:05:21,964 --> 00:05:25,105 I am no longer doing direct patient care. 152 00:05:25,964 --> 00:05:26,705 My responsibility 153 00:05:27,085 --> 00:05:29,805 as the medical director of the surgery centers 154 00:05:29,805 --> 00:05:32,705 under University Health is to focus on strategic 155 00:05:32,764 --> 00:05:33,264 goals 156 00:05:33,805 --> 00:05:34,785 for the facilities 157 00:05:35,370 --> 00:05:36,589 as well as prescreening 158 00:05:36,970 --> 00:05:39,370 all patients before they show up for the 159 00:05:39,370 --> 00:05:40,270 date of surgery. 160 00:05:40,889 --> 00:05:42,029 This has decreased 161 00:05:42,490 --> 00:05:43,790 our same day cancellation 162 00:05:44,170 --> 00:05:46,410 rate. So when the patients do make it 163 00:05:46,410 --> 00:05:48,970 on the schedule, they stick and we get 164 00:05:48,970 --> 00:05:50,110 to care for them. 165 00:05:50,474 --> 00:05:51,854 So a multifold 166 00:05:52,235 --> 00:05:52,735 benefit 167 00:05:53,115 --> 00:05:53,935 of this 168 00:05:54,875 --> 00:05:55,854 staffing model, 169 00:05:56,154 --> 00:05:58,974 delegation of CRNAs, delegation of privileges, 170 00:06:00,074 --> 00:06:02,254 the cost savings for the institution 171 00:06:02,714 --> 00:06:03,774 is also something 172 00:06:04,370 --> 00:06:06,550 We used to practice medical direction 173 00:06:07,170 --> 00:06:09,589 at the surgery center, which required 174 00:06:09,970 --> 00:06:10,790 two MDs 175 00:06:11,330 --> 00:06:12,470 and six CRNAs. 176 00:06:13,250 --> 00:06:15,029 We now have one MD, 177 00:06:15,330 --> 00:06:18,050 myself, at the surgery center where I'm based 178 00:06:18,050 --> 00:06:18,710 out of 179 00:06:19,014 --> 00:06:20,235 and seven CRNAs. 180 00:06:20,694 --> 00:06:23,675 So we have a reduction in salary costs. 181 00:06:24,134 --> 00:06:24,634 So 182 00:06:25,095 --> 00:06:26,314 a great combination 183 00:06:27,095 --> 00:06:27,595 of 184 00:06:28,375 --> 00:06:28,875 factors 185 00:06:29,654 --> 00:06:31,595 have increased the efficiency 186 00:06:32,230 --> 00:06:34,730 and maximized the revenue per institution. 187 00:06:35,990 --> 00:06:38,550 And as outpatient care continues to grow, how 188 00:06:38,550 --> 00:06:40,250 do you see the role of orthopedics, 189 00:06:41,029 --> 00:06:44,250 and ASCs evolving within the broader healthcare ecosystem? 190 00:06:45,714 --> 00:06:48,535 I think it's a really exciting time, again, 191 00:06:48,595 --> 00:06:51,634 to see these cases being outsourced from the 192 00:06:51,634 --> 00:06:52,134 hospitals 193 00:06:52,514 --> 00:06:53,574 into the ASCs. 194 00:06:54,354 --> 00:06:55,014 The challenge 195 00:06:55,474 --> 00:06:56,774 always is to 196 00:06:57,310 --> 00:06:58,990 make sure that they are able to go 197 00:06:58,990 --> 00:07:00,610 home at the end of the day. 198 00:07:01,310 --> 00:07:02,290 Regional anesthesia 199 00:07:03,470 --> 00:07:04,529 or a multimodal 200 00:07:05,069 --> 00:07:05,569 approach 201 00:07:06,110 --> 00:07:07,970 for pain care management 202 00:07:08,350 --> 00:07:08,850 postoperatively 203 00:07:09,550 --> 00:07:11,089 is an absolute necessity. 204 00:07:12,095 --> 00:07:14,495 This is also something that I'm really excited 205 00:07:14,495 --> 00:07:17,155 about at the institution where I am. 206 00:07:17,615 --> 00:07:20,095 The MARC, which is where the surgery center 207 00:07:20,095 --> 00:07:21,875 where I am, and downtown, 208 00:07:22,175 --> 00:07:25,455 the other ambulatory surgery center of U H, 209 00:07:25,455 --> 00:07:29,120 the Robert b Green Ambulatory Surgery Center, have 210 00:07:29,120 --> 00:07:31,779 a robust regional anesthesia service. 211 00:07:32,319 --> 00:07:33,540 We started this 212 00:07:33,920 --> 00:07:35,209 in February 213 00:07:35,209 --> 00:07:36,180 2025. 214 00:07:36,720 --> 00:07:38,740 This is all run by the CRNAs 215 00:07:39,375 --> 00:07:42,194 who are completely adept in regional anesthesia 216 00:07:42,895 --> 00:07:46,035 and have created a great working network 217 00:07:46,415 --> 00:07:47,955 with the orthopedic surgeons, 218 00:07:48,415 --> 00:07:50,754 as well as other physicians who are interested 219 00:07:50,975 --> 00:07:53,875 in post op pain blocks, but primarily ortho, 220 00:07:54,569 --> 00:07:56,669 to provide their patients with 221 00:07:57,050 --> 00:07:57,550 aftercare 222 00:07:58,089 --> 00:08:00,169 that enables them to go home at the 223 00:08:00,169 --> 00:08:01,069 end of the day. 224 00:08:02,009 --> 00:08:03,709 What we've seen since February 225 00:08:04,329 --> 00:08:04,829 is 226 00:08:05,370 --> 00:08:07,949 patients who arrive in the Recovery Room 227 00:08:08,875 --> 00:08:11,754 and less than ten percent are receiving pain 228 00:08:11,754 --> 00:08:13,055 medications there. 229 00:08:13,915 --> 00:08:14,735 The impact 230 00:08:15,274 --> 00:08:16,895 on PACU stays, 231 00:08:17,514 --> 00:08:19,055 the post anesthesia 232 00:08:19,514 --> 00:08:20,254 care unit, 233 00:08:20,795 --> 00:08:22,334 has been tremendous. 234 00:08:23,129 --> 00:08:25,790 It shortens the amount of time that patients 235 00:08:26,090 --> 00:08:26,830 are recovering. 236 00:08:27,449 --> 00:08:28,189 It doesn't 237 00:08:28,810 --> 00:08:29,310 create 238 00:08:30,410 --> 00:08:31,150 a stop 239 00:08:31,770 --> 00:08:34,410 for OR cases coming out of the Operating 240 00:08:34,410 --> 00:08:37,455 Rooms. But quite the contrary, it frees up 241 00:08:37,615 --> 00:08:38,115 PACU 242 00:08:38,654 --> 00:08:41,535 space to allow more patients to flow through 243 00:08:41,535 --> 00:08:42,274 our facility. 244 00:08:43,134 --> 00:08:45,295 So less than ten percent are receiving pain 245 00:08:45,295 --> 00:08:45,795 meds. 246 00:08:46,335 --> 00:08:48,115 The average block lasts 247 00:08:48,575 --> 00:08:49,795 two to three days. 248 00:08:50,519 --> 00:08:53,820 So the reliance on narcotics is dramatic. 249 00:08:55,160 --> 00:08:57,500 It has changed how we manage 250 00:08:57,879 --> 00:08:58,379 pain. 251 00:08:58,920 --> 00:09:00,379 We don't use narcotics 252 00:09:00,759 --> 00:09:03,500 like we used to. And in fact, CMS 253 00:09:03,800 --> 00:09:04,300 introduced 254 00:09:04,774 --> 00:09:06,315 a no pain act 255 00:09:07,095 --> 00:09:08,075 that is reimbursing 256 00:09:09,174 --> 00:09:09,674 for 257 00:09:10,455 --> 00:09:10,955 modalities 258 00:09:11,815 --> 00:09:14,554 that help to reduce the reliance on narcotics. 259 00:09:14,774 --> 00:09:16,315 These are for Medicare patients. 260 00:09:17,000 --> 00:09:20,379 So, for example, they're reimbursing for EXPAREL, 261 00:09:21,240 --> 00:09:23,799 reimbursing for the cost of the vial, as 262 00:09:23,799 --> 00:09:25,659 well as a 6% 263 00:09:26,759 --> 00:09:28,459 bonus added to that 264 00:09:29,000 --> 00:09:30,860 to try to focus on 265 00:09:32,565 --> 00:09:33,065 multimodal 266 00:09:33,365 --> 00:09:33,865 approaches 267 00:09:34,404 --> 00:09:37,144 instead of our traditional reliance on narcotics. 268 00:09:38,004 --> 00:09:40,184 Patient satisfaction, as you can imagine, 269 00:09:40,725 --> 00:09:42,024 is wonderful. 270 00:09:42,804 --> 00:09:44,825 Imagine having an ankle reconstruction 271 00:09:45,285 --> 00:09:48,549 and going home and never needing any pain 272 00:09:48,549 --> 00:09:49,049 medication, 273 00:09:49,830 --> 00:09:51,929 and your block lasts for 274 00:09:52,789 --> 00:09:54,090 three, four days, 275 00:09:55,029 --> 00:09:58,389 again, the CRNA regional anesthesia program that we've 276 00:09:58,389 --> 00:09:59,370 developed there 277 00:09:59,845 --> 00:10:01,945 has been a wonderful source of revenue 278 00:10:02,404 --> 00:10:02,904 for 279 00:10:04,085 --> 00:10:04,904 The EXPAREL 280 00:10:05,445 --> 00:10:05,945 reimbursement, 281 00:10:06,884 --> 00:10:08,504 where it pays for the vial 282 00:10:08,884 --> 00:10:10,664 as well as a 6% 283 00:10:11,044 --> 00:10:11,544 increase 284 00:10:12,200 --> 00:10:12,940 of revenue 285 00:10:13,399 --> 00:10:14,539 of that cost. 286 00:10:15,399 --> 00:10:18,600 The patients are happy. The surgeons are very 287 00:10:18,600 --> 00:10:20,919 happy. They don't get calls in the middle 288 00:10:20,919 --> 00:10:22,519 of the night for pain meds. And when 289 00:10:22,519 --> 00:10:24,360 they show up back in clinic for their 290 00:10:24,360 --> 00:10:25,419 post op visit, 291 00:10:26,534 --> 00:10:27,274 they usually, 292 00:10:27,575 --> 00:10:30,054 I can't say always, they usually hear good 293 00:10:30,054 --> 00:10:30,554 news. 294 00:10:31,575 --> 00:10:33,735 Well, doctor Carlisle, thank you so much for 295 00:10:33,735 --> 00:10:35,975 sharing these thoughts today. Is there anything else 296 00:10:35,975 --> 00:10:37,414 you'd like to share that we didn't touch 297 00:10:37,414 --> 00:10:37,914 on? 298 00:10:38,534 --> 00:10:40,980 I would like to. Like I mentioned before, 299 00:10:40,980 --> 00:10:42,360 I'm from San Antonio 300 00:10:42,820 --> 00:10:43,320 and, 301 00:10:43,700 --> 00:10:45,000 live and work there. 302 00:10:45,540 --> 00:10:48,360 The team that I work with is primary 303 00:10:48,660 --> 00:10:50,759 primarily retired CRNAs. 304 00:10:51,700 --> 00:10:53,399 We talked about this 305 00:10:54,625 --> 00:10:56,245 innovative staffing model, 306 00:10:57,024 --> 00:10:58,404 delegation of privileges 307 00:10:58,784 --> 00:10:59,284 within 308 00:11:00,304 --> 00:11:03,345 the medical staff for CRNAs to practice to 309 00:11:03,345 --> 00:11:05,664 the fullest extent of their license. This requires 310 00:11:05,664 --> 00:11:06,565 that the CRNA 311 00:11:07,190 --> 00:11:09,929 understands and is comfortable in working autonomously. 312 00:11:11,509 --> 00:11:12,730 Military CRNAs 313 00:11:13,830 --> 00:11:16,089 are the ones who are comfortable practicing 314 00:11:16,470 --> 00:11:16,970 autonomously 315 00:11:17,750 --> 00:11:20,009 as well as other experienced CRNAs. 316 00:11:20,995 --> 00:11:23,634 Another fun fact about San Antonio, it's known 317 00:11:23,634 --> 00:11:25,334 as Military City USA. 318 00:11:26,115 --> 00:11:27,975 We have a large military presence. 319 00:11:28,434 --> 00:11:31,814 We have a large population of retired military. 320 00:11:32,274 --> 00:11:34,534 So my current team is probably 321 00:11:34,914 --> 00:11:35,894 90% 322 00:11:36,360 --> 00:11:37,980 retired military CRNAs, 323 00:11:38,919 --> 00:11:39,899 highly skilled. 324 00:11:40,279 --> 00:11:42,620 They also promote a team culture. 325 00:11:43,159 --> 00:11:45,799 I think a strong team culture on an 326 00:11:45,799 --> 00:11:47,580 anesthesia team is vital. 327 00:11:48,615 --> 00:11:49,995 Looking out for each other, 328 00:11:50,455 --> 00:11:53,014 not just focusing on your own OR and 329 00:11:53,014 --> 00:11:54,154 your own cases, 330 00:11:54,535 --> 00:11:56,794 but looking out for your teammates 331 00:11:57,975 --> 00:12:01,195 so we can create a very stable staffing 332 00:12:01,254 --> 00:12:03,355 model for university health 333 00:12:04,509 --> 00:12:06,769 currently and for years to come. 334 00:12:07,789 --> 00:12:09,709 Wonderful. Well, thank you so much for joining 335 00:12:09,709 --> 00:12:12,110 me today on the Becker's Healthcare Podcast. Again, 336 00:12:12,110 --> 00:12:14,589 we're recording live at the twenty second annual 337 00:12:14,589 --> 00:12:17,169 Spine Orthopedic and Pain Management Conference.