Understanding the Economic Impact of an Essential Service: Applying Time-Driven Activity-Based Costing to the Hospital Airway Response Team.

BACKGROUND: As the United States moves toward value-based care metrics, it will become essential for anesthesia groups nationwide to understand the costs of their services. Time-driven activity-based costing (TDABC) estimates the amount of time it takes to perform a clinical activity by dividing complex tasks into process steps and mapping each step and has historically been used to estimate the costs of various health care services. TDABC is a tool that can be adapted for variable staffing models and the volume of service provided. Anesthesia departments often provide staffing for airway response teams (ART). The economic implications of staffing ART have not been well described. We present a TDABC model for ART activation in a tertiary-care center to estimate the cost incurred by an anesthesiology department to staff an ART. METHODS: Pages received by the Brigham and Women's Hospital ART over a 24-month time period (January 2019 to December 2020) were analyzed and categorized. The local administrative database was queried for the Current Procedural Terminology (CPT) code used to bill for emergency airway placements. Sessions were held by multiple members of the ART to create process maps for the different types of ART activations. We estimated the staffing costs using the estimated time it took for each type of ART activation as well as the data collected for local ART activations. RESULTS: From the paging records, we analyzed 3368 activations of the ART. During the study period, 1044 airways were billed for with emergency airway CPT code. The average revenue collected per airway was $198.45 (95% CI, $190-$207). For STAT/Emergency airway team activations, process maps and non-STAT airway team activations were created, and third subprocess map was created for performing endotracheal intubation. Using the TDABC, the total staffing costs are estimated to be $218,601 for the 2-year study period. The ART generated $207,181 in revenue during the study period. CONCLUSIONS: Our analysis of ART-activation pages suggests that while the revenue generated may cover the cost of staffing the team during ART activations, it does not cover consumable equipment costs. Additionally, the current fee-for-service model relies on the team being able to perform other clinical duties in addition to covering the airway pager and would be impossible to capture using traditional top-down costing methods. By using TDABC, anesthesia groups can demonstrate how certain services, such as ART, are not fully covered by current reimbursement models and how to negotiate for subsidy agreements.As the transition from traditional fee-for-service payments to value-based care models continues in the United States, improving the understanding and communication of medical care costs will be essential. In the United States, it is common for anesthesia groups to receive direct revenue from hospitals to preserve financial viability, and therefore, knowledge of true cost is essential regardless of payer model.1 With traditional payment models, what is billable and nonbillable may not reflect either the need for or the cost of providing the service. As anesthesia departments navigate the transition of care from volume to value, actual costs will be essential to understand for negotiations with hospitals for support when services are nonbillable, when revenue from payers does not cover anesthesia costs, and when calculating the appropriate share for anesthesia departments when bundled payments are distributed.

Adaptation of an Obstetric Anesthesia Service for the Severe Acute Respiratory Syndrome Coronavirus-2 Pandemic: Description of Checklists, Workflows, and Development Tools.

BACKGROUND: Care of the pregnant patient during the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic presents many challenges, including creating parallel workflows for infected and noninfected patients, minimizing waste of materials, and ensuring that clinicians can seamlessly transition between types of anesthesia. The exponential community spread of disease limited the time for development and training. METHODS: The goals of our workflow and process development were to maximize safety for staff and patients, minimize the risk of contamination, and reduce the waste of unused supplies and materials. We used a cyclical improvement system and the plus/delta debriefing method to rapidly develop workflows consisting of sequential checklists and procedure-specific packs. RESULTS: We designed independent workflows for labor analgesia, neuraxial anesthesia for cesarean delivery, conversion of labor analgesia to cesarean anesthesia, and general anesthesia. In addition, we created procedure-specific material packs to optimize supplies and prevent wastage. Finally, we generated sequential checklists to allow staff to perform standard operating procedures without extensive training. CONCLUSIONS: Collectively, these workflows and tools allowed our staff to urgently care for patients in high-risk situations without prior experience. Over time, we refined the workflows using a cyclical improvement system. We present our checklists and workflows as well as the system we used for their development, so that others may use them to their benefit.

Organizational aspects of pediatric anesthesia and surgery between two waves of Covid-19.

BACKGROUND: The initial wave of the Covid-19 pandemic has hit Italy, and Lombardy in particular, with violence, forcing to reshape all hospitals' activities; this happened even in pediatric hospitals, although the young population seemed initially spared from the disease. "Vittore Buzzi" Children's Hospital, which is a pediatric/maternal hospital located in Milan (Lombardy Region), had to stop elective procedures-with the exception of urgent/emergent ones-between February and May 2020 to leave space and resources to adults' care. We describe the challenges of reshaping the hospital's identity and structure, and restarting pediatric surgery and anesthesia, from May on, in the most hit area of the world, with the purpose to avoid and contain infections. Both patients and caregivers admitted to hospital have been tested for Sars-CoV-2 in every case. METHODS: Observational cohort study via review of clinical charts of patients undergoing surgery between 16th May and 30th September 2020, together with SARS-CoV -2 RT-PCR testing outcomes, and comparison to same period surgeries in 2019. RESULTS: An increase of approximately 70% in pediatric surgeries (OR 1.68 [1.33-2.13], P < .001) and a higher increase in the number of surgeries were reported (OR 1.75 (1.43-2.15), P < .001). Considering only urgent procedures, a significant difference in the distribution of the type of surgery was observed (Chi-squared P-value < .001). Sars-CoV-2-positive patients have been 0.8% of total number; 14% of these was discovered through caregiver's positivity. CONCLUSION: We describe our pathway for safe pediatric surgery and anesthesia and the importance of testing both patient and caregiver.

Workplace well-being in pediatric anesthesia: How to design and implement a bespoke evidence-based framework in your department.

BACKGROUND: All anesthetists are at risk of mental ill health and pediatric anesthetists face additional stressors that may impact upon well-being, particularly after an adverse outcome. The SARS COV-2 pandemic has resulted in a plethora of resources to support the well-being of frontline workers. Developing a well-being system for an anesthesia department using these resources may be complex to implement. AIMS: In this article we outline how an anesthesia department can design and implement a framework for wellbeing, regardless of resources and financial constraints. We use the example of a free online toolkit developed in Australia for anesthetists. METHODS: The "Long lives, Healthy Workplaces toolkit" is a framework which has been specifically developed by mental health experts for anesthetists, and does not require departments to pay for external experts.1 Departments can design a long-term model of evidence-based mental health strategies to meet their unique needs using five steps outlined in the toolkit and detailed in this article. The framework uses cycles of assessment and review to create an adaptable approach to incorporate emerging evidence. We explain how culture can impact the implementation of a well-being framework and we outline how departments can set goals and priorities. CONCLUSION: Departments have different constraints which will alter how they approach supporting anaesthetists' wellbeing. Regardless of location or funding all departments should explicitly address anesthetists well-being. Long term sustainable well-being programs require a strategic and coordinated approach.

Roadmap: one anesthesiology department's strategic approach to COVID-19.

PURPOSE OF REVIEW: The COVID-19 pandemic has driven transformation in every aspect of the healthcare delivery system. The unpredictable onset and magnitude of COVID-19 infections resulted in wide gaps in preparedness for healthcare systems. The development of protocols to address both scarcity of resources and staff protection continues to be essential for risk mitigation. RECENT FINDINGS: The northeast region of the United States had a rapid early surge of COVID-19 infections leading to the exhaustion of critical care capacity. In addition, northeastern hospitals experienced decrease in elective surgical interventions, including organ transplantation. Limited availability of COVID-19 testing and personal protective equipment further fueled the pandemic. This commentary highlights a comprehensive innovative approach to addressing the operating room and hospital demands, as well as the shortages in resources and staffing during the pandemic. SUMMARY: The VCU Department of Anesthesiology operated at 40% of its regular operating room volume throughout the COVID-19 pandemic because of the increased demand from emergency cases. The delay in the peak surge allowed Virginia Commonwealth University, Department of Anesthesiology to develop a comprehensive infrastructure resulting in resulting is maximal workforce risk mitigation.

Anesthesia Infrastructure and Resources in Bangladesh.

BACKGROUND: Monitoring improvements in nationwide anesthesia capacity over time is critical to ensuring that population anesthesia needs are being met and identifying areas for targeted health systems interventions. Anesthesia resources in Bangladesh were previously measured using a cross-sectional nationwide hospital-based survey in 2012. No follow-up studies have been conducted since then. METHODS: A follow-up cross-sectional study was performed in 16 public hospitals; 8 of which are public district hospitals, and 8 are medical college (tertiary) hospitals in Bangladesh. A survey tool assessing hospital anesthesia capacity, developed by Vanderbilt University Medical Center, was utilized. Nationwide data were obtained from the Ministry of Health and Family Welfare and from the Bangladesh Society of Anaesthesiologists. Institutional Review Board approvals were obtained in the United States and Bangladesh, and informed consent was waived. RESULTS: Bangladesh has 952 anesthesiologists (0.58 anesthesiologists per 100,000 people), which represents a modest increase from 850 anesthesiologists in 2012. Significant improvements in electricity and clean water availability have occurred since the 2012 survey. Severe deficiencies in patient safety and monitoring equipment (eg, pulse oximetry, electrocardiography, blood pressure, anesthesia machines, and intubation materials) were noted, primarily at the district hospital level. CONCLUSIONS: Despite modest improvements in certain anesthesia metrics over the past several years, the public health care system in Bangladesh still suffers from substantial deficiencies in anesthesia care.

COVID-Activated Emergency Scaling of Anesthesiology Responsibilities Intensive Care Unit.

In response to the rapidly evolving coronavirus disease 2019 (COVID-19) pandemic and the potential need for physicians to provide critical care services, the American Society of Anesthesiologists (ASA) has collaborated with the Society of Critical Care Anesthesiologists (SOCCA), the Society of Critical Care Medicine (SCCM), and the Anesthesia Patient Safety Foundation (APSF) to develop the COVID-Activated Emergency Scaling of Anesthesiology Responsibilities (CAESAR) Intensive Care Unit (ICU) workgroup. CAESAR-ICU is designed and written for the practicing general anesthesiologist and should serve as a primer to enable an anesthesiologist to provide limited bedside critical care services.

Anesthesia departments' readiness for the COVID-19 pandemic; a nationwide cross-sectional study in Israel.

BACKGROUND: The Coronavirus infectious disease 2019 (COVID-19) brings anesthesiologists and intensive care physicians to the mainstay of clinical workload and healthcare managements' focus. There are approximately 900 anesthesiologists in Israel, working in non-private hospitals. This nationwide cross-sectional study evaluated the readiness and involvement of anesthesia departments in Israel in management of the COVID-19 pandemic. The impact on anesthesiologists' health, workload, and clinical practices were also evaluated. METHODS: An online questionnaire was distributed to all of anesthesia department chairs in Israel on April 14th. Each response was identifiable on the hospital level only. Informed consent was waived since no patient data were collected. RESULTS: Response rate was 100%. A decrease of at least 40% in operating-room activity was reported by two-thirds of the departments. Anesthesiologists are leading the treatment of COVID-19 patients in 19/28 (68%) Israeli hospitals. Israel Society of Anesthesiologists' recommendations regarding intubation of COVID-19 patients were strictly followed (intubations performed by the most experienced available physician, by rapid-sequence induction utilizing video-laryngoscopy, while minimizing the number of people in the room - about 90% compliance for each). Anesthesiologists in most departments use standard personal protective equipment when caring for COVID-19 patients, including N95 masks, face shields, and water-proof gowns. Only one anesthesiologist across Israel was diagnosed with COVID-19 (unknown source of transmission). All department chairs reported emerging opportunities that advance the anesthesia profession: implementation of new technologies and improvement in caregivers' clinical capabilities (68% each), purchase of new equipment (96%), and increase in research activity (36%). CONCLUSIONS: This nationwide cross-sectional study had a complete response rate and therefore well-represents the anesthesia practice in Israel. We found that Israeli anesthesia departments are generally highly involved in the health system efforts to cope with the COVID-19 pandemic. Anesthesia and airway management are performed in a remarkably comparable manner and with proper protection of caregivers. Ambulatory anesthesia activity has dramatically decreased, but many departments find opportunities for improvement even in these challenging times.

In-House Anesthesia and Interventional Radiology Technologist Support Optimize Mechanical Thrombectomy Workflow after Hours.

BACKGROUND AND PURPOSE: Prior literature suggests after-hours delay leads to poor functional outcomes in stroke patients undergoing thrombectomy. We aimed to evaluate the impact of time of presentation on mechanical thrombectomy (MT) metrics and its association with long-term functional outcome in an Interventional Radiology (IR) suite equipped operating room (OR) setting. METHODS: Retrospective review of prospectively maintained database on all stroke patients undergoing mechanical thrombectomy between January 2015 and December 2018 at our CSC. Work hours were defined by official OR work hours (Monday-Friday 7 AM and 5 PM) and after-hours as between 5 PM and 7 AM during weekdays and weekends as well as official hospital holidays. Primary outcome was 90-day modified Rankin Scale (mRS). Secondary outcomes included door to groin puncture time and procedural complications. RESULTS: A total of 315 patients were included in the analyses. 209 (66.4%) received mechanical thrombectomy after hours and 106 (33.6%) during work hours. There was no difference in the shift distribution of functional outcome on the mRS at 90 days (OR: 1.14, CI: 0.72-1.78, p=0.58) and the percentage of patients achieving functional independence (mRS 0-2) at 90 days (43.1% vs. 41.3%; p=0.83) between the after hour and work hour groups respectively. Similarly, there was no difference in median door to groin times and procedural complications among both groups, with significant year on year improvement in overall time metrics. CONCLUSIONS: Our study showed that undergoing MT during off-hours had similar functional outcomes when compared to MT during working hours in an OR setting. The after-hours deleterious effect might disappear when MT is performed in a system with 24-hours in-house Anesthesia and IR tech services.

Measuring Clinical Productivity of Anesthesiology Groups: Surgical Anesthesia at the Facility Level.

Benchmarking and comparing group productivity is an essential activity of data-driven management. For clinical anesthesiology, accomplishing this task is a daunting effort if meaningful conclusions are to be made. For anesthesiology groups, productivity must be done at the facility level in order to reduce some of the confounding factors. When industry or external comparisons are done, then the use of total ASA units per anesthetizing sites allows for overall productivity comparisons. Additional productivity components (total ASA units/h, h/case, h/operating room/d) allow for leaders to develop productivity dashboards. With the emergence of large groups that provide care in multiple facilities, these large groups can choose to invest more effort in collecting data and comparing facility productivity internally with group-defined measurements including total ASA units per full time equivalent.

ECONOMIC EFFECTIVENESS OF DIFFERENT METHODS OF ANESTHESIA OF CURETTAGE OF UTERINE CAVITY.

Anesthesia of curettage of uterine cavity (CUC) at postoperative period causes additional expenses. Preventive intraoperative anesthesia makes it possible to reduce these expenses and provide significant positive economic effect on state budget. The objective of this research is determination of influence of different methods of anesthesia of CUC on cash value of anesthetic maintenance of CUC and the possibility of saving of budgetary funds. 128 women took part in the research. They underwent the procedure of CUC. Anesthetic maintenance was performed using different medicamental combinations and their dosages. Mathematical calculation of the cost of each CUC stage was done considering the cost of consumables, medical preparations and value of labor of medical staff. In the course of this research, it was proven that a combination of additional use of dexketoprofen (at the stage of premedication of CUC) and performing preventive intraoperative applicational anesthesia with bupivacaine solution can save 130 452,26UAH of wage fund per year and general budget savings within the confines of a state can each 9 954 617,67UAH per year.

Universal videolaryngoscopy: a structured approach to conversion to videolaryngoscopy for all intubations in an anaesthetic and intensive care department.

BACKGROUND: Videolaryngoscopy (VL) is increasingly used, but not yet routine practice, for tracheal intubation. Few departments formally trial equipment before adopting it into practice. We describe the decision-making and implementation processes that our department used when introducing universal VL, with the C-MAC© (Karl Storz, Germany), throughout our anaesthesia and intensive care departments. METHODS: We used a structured process to assess the feasibility of a change to universal VL. After departmental training, we undertook a 2 month trial period of mandating VL for all adult in-theatre intubations. Thereafter, VL remained widely available, but not mandated. We regularly surveyed anaesthetists and anaesthetic assistants to evaluate departmental opinion regarding the introduction of universal VL. RESULTS: Before the trial period, one-third of anaesthetists judged that universal VL would be of overall benefit to patient safety, team dynamics, and quality of care. Reservations from both junior and senior anaesthetists focused on training concerns. Support for a changeover to VL, amongst both anaesthetists and anaesthetic assistants, increased throughout the trial period. Six months after the 2 month trial, support had grown further and was almost unanimous. Anaesthetists reported significant benefits in clinical performance, teaching, and human factors, especially teamwork and situation awareness. CONCLUSIONS: Performing a formal and prolonged trial of mandatory VL in theatre led to changes in perceptions and departmental consensus. As a result of the trial, the department agreed to the use of C-MAC© videolaryngoscopy as the default intubation technique throughout theatres and intensive care, with removal of standard Macintosh laryngoscopes from routine use.

Solving the negative impact of congestion in the postanesthesia care unit: a cost of opportunity analysis.

BACKGROUND: Congestion in the postanesthesia care unit (PACU) leads to the formation of waiting queues for patients being transferred after surgery, negatively affecting hospital resources. As patients recover in the operating room, incoming surgeries are delayed. The purpose of this study was to establish the impact of this phenomenon in multiple settings. METHODS: An operational mathematical study based on the queuing theory was performed. Average queue length, average queue waiting time, and daily queue waiting time were evaluated. Calculations were based on the mean patient daily flow, PACU length of stay, occupation, and current number of beds. Data was prospectively collected during a period of 2 months, and the entry and exit time was recorded for each patient taken to the PACU. Data was imputed in a computational model made with MS Excel. To account for data uncertainty, deterministic and probabilistic sensitivity analyses for all dependent variables were performed. RESULTS: With a mean patient daily flow of 40.3 and an average PACU length of stay of 4 hours, average total lost surgical opportunity time was estimated at 2.36 hours (95% CI: 0.36-4.74 hours). Cost of opportunity was calculated at $1592 per lost hour. Sensitivity analysis showed that an increase of two beds is required to solve the queue formation. CONCLUSIONS: When congestion has a negative impact on cost of opportunity in the surgical setting, queuing analysis grants definitive actions to solve the problem, improving quality of service and resource utilization.

Creation and Execution of a Novel Anesthesia Perioperative Care Service at a Veterans Affairs Hospital.

Physician-led perioperative surgical home models are developing as a method for improving the American health care system. These models are novel, team-based approaches that help to provide continuity of care throughout the perioperative period. Another avenue for improving care for surgical patients is the use of enhanced recovery after surgery pathways. These are well-described methods that have shown to improve perioperative outcomes. An established perioperative surgical home model can help implementation, efficiency, and adherence to enhanced recovery after surgery pathways. For these reasons, the Tennessee Valley Healthcare System, Nashville Veterans Affairs Medical Center created an Anesthesiology Perioperative Care Service that provides comprehensive care to surgical patients from their preoperative period through the continuum of their hospital course and postdischarge follow-up. In this brief report, we describe the development, implementation, and preliminary outcomes of the service.

Effect of Individual Surgeons and Anesthesiologists on Operating Room Time.

BACKGROUND: Variability in operating room (OR) time causes overutilization and underutilization of the available ORs. There is evidence that for a given type of procedure, the surgeon is the major source of variability in OR time. The primary aim was to quantify the variability between surgeons and anesthesiologists. As illustration, the value of modeling the individual surgeons and anesthesiologist for OR time prediction was estimated. METHODS: OR data containing 16,480 cases were obtained from a general surgery department. The total amount of variability in OR time accounted for by the type of procedure, first and second surgeon, and the anesthesiologist was determined with the use of linear mixed models. The effect on OR time prediction was evaluated as reduction in overtime and idle time per case. RESULTS: Differences between first surgeons can account for only 2.9% (2.0%-4.2%) of the variability in OR time. Differences between anesthesiologists can account for 0.1% (0.0%-0.3%) of the variability in OR time. Incorporating the individual surgeons and anesthesiologists led to an average reduction of overtime and idle time of 1.8 (95% confidence interval, 1.7-2.0, 10.5% reduction) minutes and 3.0 (95% confidence interval, 2.8%-3.2, 17.0% reduction) minutes, respectively. CONCLUSIONS: In comparison with the type of procedure, differences between surgeons account for a small part of OR time variability. The impact of differences between anesthesiologists on OR time is negligible. A prediction model incorporating the individual surgeons and anesthesiologists has an increased precision, but improvements are likely too marginal to have practical consequences for OR scheduling.

[Organization of an anaesthesia preoperative evaluation clinic - The Anaesthesia/Patient Blood Management Clinic: one Model]. / Organisation der Prämedikationsambulanz - Die Anästhesie-†/†Patient Blood Management-Sprechstunde: ein Modell.

The anesthesia preoperative evaluation has been developed in recent years in a centralized clinic, that can be visited by the majority of patients, in order to evaluate and obtain patient's consent for anesthesia. In the current article, the organization and structure of such a central anesthesia preoperative evaluation clinic in the Department of Anesthesia, Intensive Care and Pain Medicine at the University Hospital of Muenster, is described. Besides the central preoperative evaluation clinic, 3 clinics are localized in separate buildings and preoperative visits have to be completed in special scenarios on the wards, too. A pharmaceutical evaluation for patient's medication and the patient blood management have been integrated into the anesthesia preoperative evaluation clinic. Processes are explained and current numbers of patients are mentioned.

A single consent for serial anesthetics in burn surgery.

Obtaining anesthesia informed consent for a series of repetitive debridements in burn-injured patients requires a significant time investment for anesthesiologists and patient families. A single consent form was introduced that covered multiple related anesthetics in burn patients. The number of consents per patient before and after implementation was analyzed using Welch ANOVA; Tukey-Kramer post hoc test, with 99% confidence intervals for mean differences was used to examine pairwise comparisons. The mean number of consents per patient was 4.5 ± 2.8 and 1.6 ± 0.51 (P < 0.001) before (2010) and after implementation (2013), respectively. The Multiple Related Anesthetics Consent Form in this population resulted in less time spent by anesthesia providers in obtaining consent for patients undergoing multiple related procedures while providing patient- and family-centric care.

Management implications for the perioperative surgical home related to inpatient case cancellations and add-on case scheduling on the day of surgery.

BACKGROUND: The American Society of Anesthesiologists has embraced the concept of the Perioperative Surgical Home as a means through which anesthesiologists can add value to the health systems in which they practice. One key listed element of the Perioperative Surgical Home is to support "scheduling initiatives to reduce cancellations and increase efficiency." In this study, we explored the potential benefits of the Perioperative Surgical Home with respect to inpatient cancellations and add-on case scheduling. We evaluated 6 hypotheses related to the timing of inpatient cancellations and preoperative anesthesia evaluations. METHODS: Inpatient cancellations were studied during 26 consecutive 4-week intervals between July 2012 and June 2014 at a tertiary care academic hospital. All timestamps related to scheduling, rescheduling, and cancellation activities were retrieved from the operating room (OR) case scheduling system. Timestamps when patients were seen by anesthesia residents were obtained from the preoperative evaluation system database. Batch mean methods were used to calculate means and SE. For cases cancelled, we determined whether, for "most" (>50%) cancellations, a subsequent procedure (of any type) was performed on the patient within 7 days of the cancellation. Comparisons with most and other fractions were assessed using the 1 group, 1-sided Student t test. We evaluated whether a few procedures were highly represented among the cancelled cases via the Herfindahl (Simpson's) index, comparing it with <0.15. The rate of scheduling activity was assessed by computing the number of OR scheduling office decisions in each 1-hour bin between 6:00 AM and 3:59 PM. These values were compared with ≥1 decision per hour at the study hospital. RESULTS: Data from 24,735 scheduled inpatient cases were assessed. Cases cancelled after 7 AM on the day before or at any time on the scheduled day of surgery accounted for 22.6% ± 0.5% (SE) of the scheduled minutes all scheduled cases, and 26.8% ± 0.4% of the case volume (i.e., number of cases). Most (83.1% ± 0.6%, P < 10) cases performed were evaluated on the day before surgery. Most (67.6% ± 1.6%, P < 10) minutes of cancelled cases were evaluated on the day before surgery. Most (62.3% ± 1.5%, P < 10) cases were seen earlier than 6:00 PM of the day before surgery. The Herfindahl index among cancelled procedures was 0.021 ± 0.001 (P < 10 compared not only to <0.15 but also to <0.05), showing large heterogeneity among the cancelled procedures. A subsequent procedure was not performed for most cancelled cases (50.6% ± 0.9% compared with >50%, P = 0.12), implying that the indication for the cancelled procedure no longer existed or the patient/family decided not to proceed with surgery. When only cancellations on the scheduled day of surgery were considered, the cancellation rate was 14.0% ± 0.3% of scheduled inpatient minutes and 11.8% ± 0.2% of scheduled inpatient cases. There were 0.59 ± 0.02 OR schedule decisions per hour per 10 ORs between 6:00 AM and 3:59 PM (P < 10, corresponding to ≥1 decision per hour at the 36 OR study hospital). CONCLUSIONS: The study hospital had a high inpatient cancellation rate, despite the fact that most patients whose cases were cancelled were seen by an anesthesia resident by 6:00 PM of the day before surgery. This finding suggests that further efforts to reduce the cancellations by seeing patients sooner on the day before surgery, or seeing even more patients the day before surgery, would not be an economically useful focus of the Perioperative Surgical Home. The wide heterogeneity among cancelled cases indicates that focusing on a few procedures would not materially affect the overall cancellation rate. The relatively low rate of subsequent performance of a procedure on patients whose cases had been cancelled suggests that trying to decrease the cancellation rate might be medically counterproductive. The hourly rate of decisions in the scheduling office during regular work hours on the day of surgery highlights the importance of decisions made at the OR control desk and scheduling office throughout the day to reduce the hours of overused OR time. These data suggest that efforts of the Perioperative Surgical Home related to inpatient cancellations should focus on management decision-making to mitigate the disruptions to the planned OR schedule caused by inpatient case cancellations and add-on cases, more so than on efforts to reduce inpatient cancellation rates.