Streamlining variability in hospital charges for standard thyroidectomy: Developing a strategy to decrease waste.

BACKGROUND: We assessed the efficiency, consistency, and appropriateness of perioperative processes for standard (total) thyroidectomy and devised a valuable strategy to decrease variability and waste. METHODS: Our multidisciplinary team evaluated <23-hour stay standard thyroidectomy performed by 3 surgical endocrinologists. We used the nominal group technique, process flowcharts, and root cause analysis to evaluate 6 perioperative processes. Anticipated decreases in costs, charges, and resources from improvements were calculated. RESULTS: Median total charge for standard thyroidectomy was $27,363 (n = 80; $48,727 variation). Perioperative coordination between surgery and anesthesia clinics could eliminate unnecessary testing (potential decrease in charges of $1,505). Nonoperating room time was less in the outpatient operating room (43 vs 52 minutes; P < .001). Consistent scheduling could decrease charges by $585.49 per case. By decreasing 20% of nondisposable instruments on the surgical tray, we could decrease sterile processing costs by $13.30 per case. Modification of postoperative orders could decrease charges by $643 per patient. Overall, this comprehensive analysis identified an anticipated decrease in cost/charge of >$200,000 annually. CONCLUSION: Perioperative process analyses revealed wide variability for a single, presumed uniform procedure. Systematic assessment helped to identify opportunities to improve efficiency, decrease unnecessary waste and procedures/instrument usage, and focus on patient-centered, quality care. This multidisciplinary strategy could substantially decrease costs/charges for common operative procedures.

A case series of thoracic paravertebral blocks using a combination of ropivacaine, clonidine, epinephrine, and dexamethasone.

Five patients who underwent surgery for breast cancer were followed for 6 days after placement of a multiple-injection, one-time paravertebral block. Data were collected on patient satisfaction, analgesic consumption, side effects, and complications. Ropivacaine as a sole agent in paravertebral blocks has a clinical duration of up to 6 hours. The addition of epinephrine, clonidine, and dexamethasone prolonged the clinical duration considerably.

Adaptation of the OODA Loop to reduce postoperative nausea and vomiting in a high-risk outpatient oncology population.

Postoperative nausea and vomiting (PONV) remains a ubiquitous concern for surgical outpatients with published rates ranging from 14% to 80%. An evidence-based approach was used to reduce PONV in a high-risk adult outpatient oncology population. The Observe, Orient, Decide, and Act (OODA) Loop, a rapid cycle management strategy, was adapted for use in an outpatient surgery center with six ORs. A PONV prophylaxis protocol was developed and adapted until a stable PONV rate was achieved. A combination of dexamethasone, promethazine, and ondansetron was used in patients with one to three PONV risk factors. Patients with four major risk factors received an additional intervention. The PONV rate for the final protocol stabilized below 4% by 46 weeks and remained stable through 79 weeks. The OODA paradigm provides an effective technique for interfacing health care research with clinical practice. In this case, an effective PONV prophylaxis plan was developed from within a collaborative nursing and medical setting.