Contributors to Operating Room Underutilization and Implications for Hospital Administrators.

Operating rooms (ORs) are an important source of hospital revenue, and utilization rate is a key determinant of OR efficiency. Multiple factors contribute to OR underutilization, and OR managers may have biased views about which factors contribute most to OR underutilization. We examined various factors leading to OR underutilization at one academic tertriary care center.Data were collected retrospectively from over a 12-month period. Contribution to OR underutilization was measured in terms of hours of OR underutilization. Statistical significance between categories and days was calculated using an unpaired t test.By comparing means of the various contributors to OR underutilization (patient in the room, turnover time, scheduling gaps, OR holds, closed rooms), we determined that mid/end-of-day gaps and closed rooms contributed the most hours (9.7% and 4.6%, respectively; P < .0001) to OR underutilization, whereas turnover time and "patient in the room" contributed the least (2.0% and 0.8%, respectively; P < .0001).The contributors to OR underutilization are complex, and many OR staff from physicians to nurses and OR administrators may have biased views about which factors contribute most predominantly to inefficiency. Awareness of how various factors contribute to OR underutilization can pave the way for goal-directed changes on a systems-based level to improve efficiency in the OR by decreasing underutilization.

Introduction of a new electronic medical record system has mixed effects on first surgical case efficiency metrics.

To evaluate the effect of deploying a new electronic medical record (EMR) system on first case starts in the operating room. Data on first case start times were collected after implementation of a new EMR (Epic) from June 2015 to May 2016, which replaced a legacy system of both paper and electronic records. These were compared to data from the same months in the three proceeding years. First patient in room (FPIR) on time was true if the patient was in operating room before 7:35 AM (or 9:35 AM on Wednesdays) and first case on time start (FCOTS) was true if completion of anesthetic induction was less than 20 min after the patient entered the operating room (or 35 min for cardiac and neurosurgery). Times beyond these cutoffs were quantified as FPIR and FCOTS delays in minutes. Average delays were compared by month with two-sample t tests and 95 % confidence intervals. There was a significant increase in FPIR delays in the first month (11.07 vs. 3.47 min, p < 0.0001), which abated by the fifth month. Post-implementation FCOTS delays improved by the third month (4.53 vs. 7.10 min, p < 0.0001). Both results persisted throughout the study. First month FPIR delays were not limited to any one specialty. EMRs have the potential to improve hospital workflows, but are not without learning curves. FPIR and FCOTS delays return to baseline after a few months, and in the case of FCOTS, can improve beyond baseline.

Qualitative analysis of barriers to efficient operating room turnovers in a tertiary care academic medical center.

BACKGROUND: The operating room (OR) turnover is a critical period in patient care and OR management. Turnover time (TOT) is a traditional quantitative measure of OR efficiency but is lacking when used to describe the TOT process. METHODS: Frontline staff members involved with OR turnover were interviewed regarding turnover duties, barriers to performing these duties, ways to facilitate these duties, and satisfaction with the turnover process. A grounded theory approach was used to identify common themes, which were then tabulated. RESULTS: Interviews were completed for 38 frontline staff, including anesthesiologists, surgeons, nurses, and OR assistants. We identified the following common themes among barriers to successful OR turnover: communications, patient transport, preoperative preparations, staffing, workflow, and workload. CONCLUSIONS: Interview data of OR staff can supplement quantitative efficiency measures and identify areas of opportunity in OR management and patient safety.

Successful strategies for the reduction of operating room turnover times in a tertiary care academic medical center.

BACKGROUND: Turnover time (TOT) is one of the classic measures of operating room (OR) efficiency. There have been numerous efforts to reduce TOTs, sometimes through the employment of a process improvement framework. However, most examples of process improvement in the TOT focus primarily on operational changes to workflows and statistical significance. These examples of process improvement do not detail the complex organizational challenges associated with implementing, expanding, and sustaining change. METHODS: TOT data for general and gastrointestinal surgery were collected retrospectively over a 26-mo period at a large multispecialty academic institution. We calculated mean and median TOTs. TOTs were excluded if the sequence of cases was changed or cases were canceled. Data were retrieved from the perioperative nursing data entry system. RESULTS: Using performance improvement strategies, we determined how various events and organizational factors created an environment that was receptive to change. This ultimately led to a sustained decrease in the OR TOT both in the general and gastrointestinal surgery ORs that were the focus of the study (44.8 min versus 48.6 min; P < 0.0001) and other subspecialties (49.3 min versus 53.0 min; P < 0.0001), demonstrating that the effect traveled outside the study area. CONCLUSIONS: There are obstacles, such as organizational culture and institutional inertia, that OR leaders, managers, and change agents commonly face. Awareness of the numerous variables that may support or impede a particular change effort can inform effective change implementation strategies that are "organizationally compatible."

Variability of subspecialty-specific anesthesia-controlled times at two academic institutions.

Realistic scheduling of operating room cases decreases costs, optimizes utilization and improves staff and patient satisfaction. Currently limited data exists to establish anesthesia-controlled time benchmarks based on specific subspecialty service. In this multicenter retrospective analysis of cases performed during a 53 month period at two large multispecialty academic institutions, data were retrieved from the perioperative information systems at each center. Both induction and emergence times were calculated. We then determined mean and median anesthesia controlled times based on each subspecialty service and compared them to previously published anesthesia-controlled time data. We obtained data on 104,184 cases at hospital A, and 122,560 cases at Hospital B. For all specialties at hospital A and hospital B, median induction time was 16.0 min and 17.0 min, emergence time was 14.0 and 8.0 min, and total anesthesia controlled time was 31.0 min and 27.0 min respectively. There was considerable variability among different surgical specialties deviating from the previously established 30 min benchmark. Subspecialties with lower total anesthesia controlled times in both centers were pain, general surgery, gynecology, plastic surgery and urology. Subspecialties with higher total anesthesia controlled times in both centers included cardiac surgery, neurosurgery, transplant and vascular. Cardiac surgery had the highest total time of 60 min and 50 min at Hospital A and B respectively. Individual specialty-specific anesthesia controlled times should be used for case scheduling and to benchmark anesthesia performance.

The addition of a regional block team to the orthopedic operating rooms does not improve anesthesia-controlled times and turnover time in the setting of long turnover times.

STUDY OBJECTIVE: To determine whether a regional block team with a dedicated space for performance of regional anesthetics would decrease turnover time and shorten the working day in a busy orthopedic practice with lengthy turnover times. DESIGN: Prospective, randomized study. SETTING: Tertiary-care teaching hospital. PATIENTS: 927 orthopedic procedures over a three-month period. INTERVENTIONS: The randomized placement of a regional block team to the orthopedic operating room (OR) suite. MEASUREMENTS: We evaluated the differences in anesthesia-controlled times, first-case start times, turnover times, and OR end times using a computerized OR information system. We also surveyed the surgeons regarding their perceptions of changes in turnover time and anesthesia-controlled times during the study period. Standard descriptive statistics were computed. RESULTS: Of a total of 927 cases, 398 cases were cared for by a regional block team and 529 cases received care in the usual manner, with the OR team providing the regional block. There was no difference between the study and control groups for on-time, first-case starts (57.73% vs 42.27%), induction time (13.2 vs 14.2 min), emergence time (8.1 vs 9.0 min), turnover time (70.3 vs 77.8 min), and OR end times. Most of the surgeons surveyed felt that the regional block team reduced turnover time significantly. CONCLUSION: A regional block team in this environment does not reduce anesthesia-controlled times and turnover times in an orthopedic OR suite with long turnover times, and it would be virtually impossible to recover the associated extra cost. The surgeons' perspective of turnover time is inaccurate.

Creating safer health systems: Lessons from other sectors and an account of an application in the Safer Clinical Systems programme.

Despite well meaning initiatives over decades, the percentage of inpatients suffering adverse events remains constant in most advanced health systems. The notion of incident reporting as used in other safety critical industries has proved far less effective in healthcare. This article describes a new patient safety paradigm in the search for improved patient safety in healthcare. Underpinned by a holistic use of human factors the Safer Clinical Systems programme involves a proactive, risk-based approach seeking to eliminate or control risk before it is converted to patient harm. The tools and techniques applied by healthcare professional in real-life settings are described along with the outcomes of a significant reduction in risk and improvement in safety culture as measured by the Safety Culture Index. The challenges of applying the approach are discussed but it is argued that important progress could be made if a critical mass of healthcare staff were helped to acquire skills in human factors.

Process redesign to improve first case surgical starts in an academic institution.

PURPOSE: On time start of the first surgical case improves operating room (OR) utilization, physician, and patient satisfaction and decreases delays in subsequent cases. The goal of our study was to evaluate the effect of a multidisciplinary initiative to improve first patient in the room (FPIR) and first case on time start (FCOTS) metrics in a tertiary care setting. MATERIALS AND METHODS: A multidisciplinary committee focused on first case start data collection. Reasons for both anesthesia and surgical delays were analyzed. Improvement efforts focused on the timely completion of surgical consent, a requirement of a surgical, anesthesia, and nurse team member presence at the patient's bedside by specific time, and parallel processing in the OR. RESULTS: Over 65,100 OR cases were analyzed between 2007 and 2014. There was a statistically significant improvement in FPIR (82.80% versus 69.60%, p < .0001) and FCOTS (66.60% versus 55.90%, p < .0001). Surgical consent completion rate increased from 35% baseline to 68%-100%, depending on the surgical subspecialty. Improvements appeared sustainable several years following process implementation for both FPIR (84.60% versus 69.60%, p < .0001) and FCOTS (67.60% versus 55.90%, p < .0001). CONCLUSIONS: Our study demonstrates a successful targeted, multidisciplinary initiative to improve first case surgical starts in an academic setting. Our approach was organizational rather than punitive or rewarding on an individual basis. Strategies included establishing concrete, time-specific goals and posting them visibly, empowering individuals to fulfill them, and ensuring no compromise in patient safety. In the complex environment of academic medicine including research protocols and teaching in the ORs, our organizational approach proved sustainable over several years.

Strategies to maintain operating room functionality following the complete loss of the recovery room due to an internal disaster.

The post-anesthesia care unit (PACU) is a major contributor to the operating room (OR) process flow and efficiency. A sudden failure of hospital facility infrastructure due to a burst pipe resulted in the complete loss of a 66-bed combined preoperative and PACU facility of a major academic medical center. The OR suites were undamaged. The clinical and administrative challenges of caring for surgical patients without the usual preoperative and postoperative care areas are discussed. Our strategy for maintaining OR functions and management of patient flow, OR personnel, case prioritization, and equipment needs are detailed from the time of initial crisis until restoration of these clinical care areas. Utilization of the hospital disaster Incident Command Structure and the activation and decision support provided by the hospital Emergency Operations Center (EOC) for the week immediately following the crisis, helped maintain OR functionality.

Improvement of intraoperative antibiotic prophylaxis in prolonged cardiac surgery by automated alerts in the operating room.

OBJECTIVE: To assess the impact of an automated intraoperative alert to redose prophylactic antibiotics in prolonged cardiac operations. DESIGN: Randomized, controlled, evaluator-blinded trial. SETTING: University-affiliated hospital. PATIENTS: Patients undergoing cardiac surgery that lasted more than 4 hours after the preoperative administration of cefazolin, unless they were receiving therapeutic antibiotics at the time of surgery. INTERVENTION: Randomization to an audible and visual reminder on the operating room computer console at 225 minutes after the administration of preoperative antibiotics (reminder group, n = 137) or control (n = 136). After another 30 minutes, the circulating nurse was required to indicate whether a follow-up dose of antibiotics had been administered. RESULTS: Intraoperative redosing was significantly more frequent in the reminder group (93 of 137; 68%) than in the control group (55 of 136; 40%) (adjusted odds ratio, 3.31; 95% confidence interval, 1.97 to 5.56; P < .0001). The impact of the reminder was even greater when compared with the 6 months preceding the study period (129 of 480; 27%; P < .001), suggesting some spillover effect on the control group. Redosing was formally declined for 19 of the 44 patients in the reminder group without redosing. The rate of surgical-site infection in the reminder group (5 of 137; 4%) was similar to that in the control group (8 of 136; 6%; P = .42), but significantly lower than that in the pre-study period (48 of 480; 10%; P = .02). CONCLUSION: The use of an automatic reminder system in the operating room improved compliance with guidelines on perioperative antibiotic prophylaxis.

Emotional intelligence in the operating room: analysis from the Boston Marathon bombing.

INTRODUCTION: The Boston Marathon terrorist bombing that occurred on April 15, 2013 illustrates the importance of a cohesive, efficient management for the operating room and perioperative services. Conceptually, emotional intelligence (EI) is a form of social intelligence used by individuals in leadership positions to monitor the feelings and emotions of their team while implementing a strategic plan. OBJECTIVE: To describe the experience of caring for victims of the bombing at a large tertiary care center and provide examples demonstrating the importance of EI and its role in the management of patient flow and overall care. METHODS: A retrospective review of trauma data was performed. Data regarding patient flow, treatment types, treatment times, and outcomes were gathered from the hospital's electronic tracking system and subsequently analyzed. Analyses were performed to aggregate the data, identify trends, and describe the medical care. RESULTS: Immediately following the bombing, a total of 35 patients were brought to the emergency department (ED) with injuries requiring immediate medical attention. 10 of these patients went directly to the operating room on arrival to the hospital. The first victim was in an operating room within 21 minutes after arrival to the ED. CONCLUSION: The application of EI in managerial decisions helped to ensure smooth transitions for victims throughout all stages of their perioperative care. EI provided the fundamental groundwork that allowed the operating room manager and nurse leaders to establish the calm and coordinated leadership that facilitated patient care and teamwork.

Brachial plexus injury from CT-guided RF ablation under general anesthesia.

Brachial plexus injury in a patient under general anesthesia (GA) is not uncommon, despite careful positioning and, particularly, awareness of the possibility. The mechanism of injury is stretching and compression of the brachial plexus over a prolonged period. Positioning the patient within the computed tomography (CT) gantry for abdominal or chest procedures can simulate a surgical procedure, particularly when GA is used. The potential for brachial plexus injury is increased if the case is prolonged and the patient's arms are raised above the head to avoid CT image degradation from streak artifacts. We report a case of profound brachial plexus palsy following a CT-guided radiofrequency ablation procedure under GA. Fortunately, the patient recovered completely. We emphasize the mechanism of injury and detail measures to combat this problem, such that radiologists are aware of this potentially serious complication.

Introduction of anesthesia resident trainees to the operating room does not lead to changes in anesthesia-controlled times for efficiency measures.

BACKGROUND: Operating room efficiency is an important concern in most hospitals today. Little work has been reported to evaluate the contribution of anesthesia residents to changes in anesthesia-controlled time-related efficiencies in the operating room. The goal of this study was to measure the impact of the initiation of new residents to the operating room on anesthesia-related time measures of operating room efficiency. METHODS: Using the computerized operating room information systems, specific data regarding anesthesia-controlled times were extracted over three distinct 2-week periods over the course of 1 academic year. These included the first 2 weeks of July, when most of the operating rooms were staffed by attending physicians working alone; 2 weeks in September when new anesthesia residents were working in a 2:1 ratio with staff; and 2 weeks in May. The induction times, emergence times, and room turnover times were compared over these three periods for first-year anesthesia residents. Standard descriptive statistics were computed. Analysis of variance testing was then conducted comparing each of these time periods. Significance was set at P < 0.05. RESULTS: A total of 3,004 surgical procedures were performed during the 2-week study periods in July, September, and May, respectively. For the July, September, and May groups, the mean anesthesia induction times were 17.3, 19.0, and 20.8 min (P = 0.047); the emergence times were 8.7, 9.7, and 10.0 min, (P = 0.024); and the corresponding mean room turnover times were 47.6, 48.5, and 48.6 min (P = 0.907), respectively. CONCLUSION: Although statistically significant time differences were found, these data strongly suggest that the initiation of anesthesia trainees to the operating room has no clinically or economically meaningful adverse effect on the anesthesia-controlled time component of operating room efficiency.