Improving On-Time First Case Starts: An Integrative Review and Quality Improvement Project Plan.

PURPOSE: Surgeon late arrival is the major cause of delays in first case starts. The estimated cost of these delays can reach $800,000 a year. The purpose of this integrative review and proposed quality improvement (QI) project plan was to increase the first case on-time starts through surgeon behavior modification. DESIGN: An integrative literature review and creation of a QI project plan. METHODS: The literature review included an independent electronic literature search between the years of 2011 and 2020 through CINAHL PLUS, PubMed, and Medline OVID databases. The search was limited to scholarly peer-reviewed journal articles in the English language, and search terms included: "operating rooms," "delay first cases start," "first case tardiness," and "operating room efficiency." The QI project plan was a three-phase process based on surgeon behavioral modification using educational material, visual reminders, and individualized e-mail notifications of habitually late surgeons. FINDINGS: A synthesis of articles reported proper site marking and surgical consent 15 to 30 minutes before surgery increased first case on-time starts from 55.90% to 66.60% and a mean delay decrease of 9.67 minutes to 7.17 minutes. Visual cues significantly enhanced memory, 64% versus 50%, and e-mail reminders increased compliance, 77% to 86.1%. CONCLUSION: As the need for hospital revenue dependency grows, so will the need for more efficient operating rooms. The evidence shows a positive correlation between early arrival by surgeons to the preoperative area and increased on-time first case starts.

Intrathecal Opioid Dosing During Spinal Anesthesia for Cesarean Section: An Integrative Review.

Approximately one in three women in the United States deliver via Cesarean section (CS), making it one of the most common surgical procedures in the country. Neuraxial (spinal or epidural) anesthesia is the most effective and common anesthetic approach for pain relief during a CS in the United States and often associated with adverse effects such as nausea, vomiting, and pruritus. While recommended dose ranges exist to protect patient safety, there are a lack of guidelines for opioid doses that both optimize postoperative pain management and minimize side effects. This integrative review synthesizes the evidence regarding best practice of opioid dosing in neuraxial anesthesia for planned CS. Evidence supports the use of lower doses of intrathecal (IT) opioids, specifically 0.1 morphine, to achieve optimal pain management with minimal nausea, vomiting, and pruritus. Lower IT doses have potential to achieve pain management and to alleviate preventable side effects in women delivering via CS.

Cardiovascular Collapse During Transurethral Resection of Bladder Tumor: A Case Report.

Despite innovative modalities, transurethral resection (TUR) procedures are the primary surgical intervention for bladder tumor and enlarged prostate. TUR syndrome, a major complication of TUR procedures, leads to derangement in electrolytes, hemodynamic compromise, and possible cardiac arrest. This case report describes cardiovascular collapse in a 60-year-old male during TUR of a bladder tumor under general anesthesia. The patient developed hypoxia, which progressed to cardiovascular collapse. Electrolyte analysis revealed acute hyponatremia. The patient was resuscitated successfully, transferred to intensive care unit, and discharged from the hospital without any complications. This case report of a cardiovascular collapse during transurethral resection of bladder tumor offers insight of the risks in urologic procedures and highlights the importance of clear communication as well as early recognition and successful management of complications.