Orientation

This orientation booklet provides a detailed yet practical overview of our administrative processes, clinical workflows, documentation expectations, and day-to-day operations. Please take time to review the physical copies of important policies posted in the anesthesia office (preoperative screening grid, BMI policy, blood bank inventory, etc.), and do not hesitate to ask questions of your colleagues, Spencer Soffe, or Kelly Smith. We look forward to working with you!

Sincerely,

Evergreen Anesthesia Associates

1. Administrative & Payroll Information

Office Manager

Kelly Smith is our office manager. Her primary responsibility is collaborating and interfacing with our billing company, Park Medical Management. She also handles general administrative and secretary duties.

Email: kmsmith2@outlook.com

Phone: 360-561-3012

Payroll & Accounting — Solvent Financial

Payroll, accounting, and bookkeeping are managed by Solvent Financial. Your point of contact is:

Haylie DeVine, Accountant

Phone: 509-940-7572 (call or text)

Email: haylie@solventfc.com

Payroll is processed monthly, no later than the 26th of each month.

Staff Calendar (Google Sheets)

Your scheduled workdays are tracked on a shared Google Sheets calendar. This calendar is the official record used to generate payroll.

It is your responsibility to ensure your scheduled days are entered accurately. If you trade days or weeks with another full-time staff CRNA, please send an email to both Spencer Soffe and Kelly Smith so the calendar can be updated promptly. Trading your shifts with a locum or per diem CRNA requires prior approval from Aaron Eastman or Spencer Soffe.

Requesting Time Off

Planned days off — Submit requests to Spencer Soffe and Kelly Smith as far in advance as possible. While we strive to accommodate requests whenever feasible, last-minute requests are rarely approved due to staffing constraints. Collaborating with colleagues to find coverage is strongly encouraged and greatly appreciated.

Sick or emergency days off — We understand that these cannot be planned. In the event you are unable to work your scheduled shift due to illness or emergency, please notify the group owners and Kelly Smith as soon as possible.

Cafeteria Meals

All meals in the KVH cafeteria (including grab-and-go items available 24/7) are covered by our employer group, EAA. Your employee badge should already be linked to the department account. If your badge is not working, please notify Spencer Soffe immediately. Backup account number (if needed): 704000.

2. Billing & Documentation

Accurate and complete documentation is critical for timely and successful insurance reimbursement. Incomplete records delay collections and create additional work for our billing team.

Required Elements for Every Anesthesia Record

The following must be present in every finalized anesthesia record:

Anesthesia start and stop times
ASA Physical Status classification (PS 1–4)
Any performed blocks must be documented using the Macros built into the anesthesia record. If a block is documented in free text or a separate note, you must print the documentation and place it in the designated bin in the anesthesia office.

Required Documentation Set per Encounter

Preoperative note
Finalized intraoperative anesthesia record
Post-anesthesia note

For anesthesia procedures outside of OR/OB (central lines, a-lines), a procedure note will suffice. Please obtain a face sheet and handwrite the physical status, procedure performed, and start/stop times, then place the face sheet in the filing bin in our office.

Billing Follow-up

If any required element is missing, Laurie Reeder from our billing department will send you a direct message in Cerner. Please complete the outstanding documentation as quickly as possible and reply to Laurie's message to confirm completion.

3. Cerner Workflow

Preoperative Order Placement (Night Before Cases)

It is standard practice to place preoperative orders the evening before scheduled procedures. Common orders include:

Zofran 4 mg IV + Pepcid 20 mg IV
IV start with subcutaneous lidocaine
Fluids: Lactated Ringer’s 1000 mL bag (most adult patients); Normal Saline micro drip for renal patients, select pediatric cases, etc.
Local anesthetics for peripheral nerve blocks. If ordered through the preoperative order set, preoperative RNs will pull medications and have them at the bedside. Exparel requires an active order in Cerner to pull from the Pyxis.

You may add or modify orders (additional labs, type & screen, etc.) based on patient needs. This is also an excellent time for a thorough chart review.

Preoperative orders are not needed for: cataracts, GI scopes with anesthesia, cardioversions/TEEs.

Room Assignments

The Call CRNA will send room assignments via group text message during the afternoon or evening prior to the surgical day.

Preoperative Screening & Communication

Our preop clinic is in a separate building on campus. Most communication occurs through Cerner messaging. Respond to preop messages within 24 hours whenever possible. For urgent last-minute requests from surgeon clinics, preop staff has been instructed to call the on-call CRNA directly.

Preoperative Screening Booklet (Developed by EAA): A detailed preoperative testing grid is posted in the anesthesia office. This grid guides preop nurses on which labs, tests, and medication instructions to provide based on patient history and surgical risk.

When Further Evaluation or Delay Is Needed

If you determine a patient requires additional optimization, testing, or cannot safely proceed on the scheduled date, call the surgeon directly to discuss your concerns and proposed plan. Surgeons greatly prefer this direct communication over receiving a message from the preop clinic stating “Anesthesia has cancelled the case.” After discussion, reply to the Cerner message with the agreed-upon plan.

In-Person Anesthesia Consults

Contact the preop clinic (message or call) to request scheduling. The appointment will appear in your Cerner calendar view. Preop staff will attempt to schedule during times a CRNA is available and are very accommodating with rescheduling if needed.

BMI Policy (posted in anesthesia office)

General surgical procedures: Maximum BMI 55

Obstetric elective procedures: Maximum BMI 50

Patients with BMI >45 (especially OB) are typically flagged to anesthesia in advance. Procedures with BMI >55 are considered on a case-by-case basis, primarily limited to colonoscopies, and require mutual agreement between anesthesia and the proceduralist.

4. Daily Roles & Scheduling

Call CRNA (Anesthesia in Charge – AIC)

The Call CRNA serves as the leader for the day with responsibilities including:

Facilitating overall OR efficiency — true room flips if surgeon requests
Providing breaks and performing regional blocks as needed
Managing OB requests
Covering remote anesthesia locations (GI suites, cardioversions, central lines, arterial lines, etc.)
Responding to preop screening messages

Post-Call CRNA

Typically works an 8-hour shift. We make every effort to release the post-call provider by 3:00 pm.

Day Shift CRNA

Standard 10-hour shift. On many days, cases conclude early enough to finish by 3:30 pm. Occasionally, we run two rooms until 5:00–5:30 pm.

GI / Endoscopy Cases

Two GI suites are located near (but outside) the main OR. Most routine screening colonoscopies are performed with RN-administered conscious sedation.

Anesthesia is requested for:

Patients with high BMI
Significant comorbidities
Cases previously aborted due to inadequate sedation

Complex cases (GI bleeds, food impactions, high-risk patients) are almost always moved to the main OR for safety and better access to equipment and supplies. We typically limit scheduling to 2–3 GI cases per day to preserve OR efficiency.

5. Obstetrical Anesthesia (Family Birthing Center)

Epidural Request Process

When an epidural is requested, the OB RN will provide:

Gravida/Para
Current dilation
Significant medical history
BMI
Recent labs
Delivering provider
Rate of labor progress

OB nurses follow their protocol to:

Administer a 500 mL fluid bolus at least 20 minutes prior
Ensure labs (including CBC/platelets) are resulted
Schedule the epidural in Cerner
Prepare the patient (bathroom, epidural positioning device, sitting position)

Your Preparation & Procedure

Order the “Epidural Order Set” in advance.

Default infusion: 250 mL bag of 0.125% bupivacaine + fentanyl 2 mcg/mL
Standard settings: 10 mL/hr continuous, 5 mL patient bolus, 30-minute lockout (adjustable as clinically indicated)
Alternative: 0.2% plain ropivacaine is also available

The epidural cart is located next to the C-section suite foyer (B. Braun epidural/CSE kits). Infusion bags are stored in the OB medication room (code: 534). Epidural pump code when starting “New Program”: 94629.

After placement, co-sign the epidural bag(s) into the patient’s MAR so nurses can track volume. Open a full anesthesia record for all labor epidurals (visible in Cerner preoperative tracking). Chart only test dose and supplemental boluses; the continuous infusion is tracked in the MAR. Suspend the record after placement so the next Call CRNA can finalize if needed.

Finalization: End time = delivery time (obtain from OB delivery note, I&O Labor and Delivery tab, or ask the RN).

Labor Epidural → Cesarean Section

These are documented as two separate records. Close the labor epidural record 1 minute before the anesthesia start time for the cesarean section. This is critical for accurate billing.

6. Pharmacy, Medications & Equipment

Medication Charting Accuracy

The medication selected in Cerner must exactly match the concentration and dose drawn from the Pyxis. Some quick-select options do not match stocked concentrations — search the full drug library when necessary.

C-Section Protocols

Initiate post-op order set: “24-Hour Post Intrathecal/Epidural Order Set.” Anesthesia manages post-op pain orders for 24 hours post duramorph administration, then OBGYN takes over.

Ensure pitocin (pre-mixed 30 units/500 mL) is running on a pump at 95 mL/hr when you leave the OR and roll to PACU/PP room.

Codonics Drug Labeling System

Every anesthesia workstation has a Codonics label printer. Create a personal account and attach the generated QR code to your badge. Scanning a medication vial prints a label with your initials, date/time, drug name, and concentration.

Not all medications are currently in the system — create blank labels and handwrite information as needed. Bring empty vials of missing medications to the pharmacy for addition to the system.

Emergency & Specialty Carts

All located in the OR hallway:

Difficult Airway Cart: Cook cricothyrotomy kit, intubating LMAs, jet ventilator setup
Malignant Hyperthermia Cart: Dantrolene (nearing expiration) + Ryanodex now available
Standard Crash Cart

Airway Equipment

Four Glidescopes (dedicated units in most ORs and OB suite)
New McGrath video laryngoscope

Stocking Responsibilities

You are responsible for stocking the block cart and epidural cart. Anesthesia machine towers are stocked by OR staff. Syringes, blunt needles, and laryngoscope blades (top drawer of anesthesia workstation) are typically maintained by SRNAs when present; during SRNA gaps, staff assistance may need to be requested.

7. Specialty Notes — Orthopedics

Dr. Longo — Total Knee Arthroplasty (TKA)

Dr. Longo strongly prefers an adductor canal block with Exparel. Many providers also perform IPACK and/or deep genicular blocks. Some patients may have received Iovera cryoneurolysis several weeks prior — continue with standard nerve blocks afterward.

Dr. Longo prefers general anesthesia with LMA due to previous concerns about spinal anesthesia delaying room turnover. He is willing to accommodate patient preference or medical indications for spinal anesthesia when appropriate.

8. PACU Responsibilities

Submit post-anesthesia orders in Cerner for surgical patients. Provide care and oversight until the patient is discharged from Phase 1 recovery. Post-anesthesia orders are typically not required for cataract procedures, routine GI cases, or any case that proceeds directly to Phase 2 recovery.

After the patient meets criteria to leave Phase 1 recovery and a post-op note is documented, the surgeon takes primary responsibility for the patient (including writing admission orders to the floor or ICU and consulting the hospitalist if necessary).

9. Blood Bank

Our blood bank inventory is limited (typical of critical access hospitals):

No platelets or cryoprecipitate stocked on-site (must be ordered from Yakima or Portland; several-hour delay)
Approximately 4–6 units each of O-negative and O-positive red cells available at all times
Additional units can be obtained with advance planning
Belmont rapid infuser is available in the Emergency Department

We are confident you will find our team supportive and collaborative. Please review all posted documents in the anesthesia office and feel free to reach out to any of us with questions. Welcome to KVH — we’re glad you’re here!

The KVH Anesthesia Team

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