Information and communication needs of healthcare workers in the perioperative domain.

Perioperative work requires the collaborative efforts of a multitude of actors. Coordinating such collaboration is challenging, and coordination breakdowns may be very expensive and jeopardize patient safety. We studied the needs for status information and projection of future status and events for key actors in the perioperative environment. We found that information and projection needs differed significantly between actors. While just-in-time notifications sufficed for some, others were dependent on projections to provide high quality and efficient care. Finally, information on current status and support in projecting the future unfolding of events could improve actors situated coordination capabilities.

Shaping the operating room and perioperative systems of the future: innovating for improved competitiveness.

PURPOSE OF REVIEW: To review the current state of anesthesiology for operative and invasive procedures, with an eye toward possible future states. RECENT FINDINGS: Anesthesiology is at once a mature specialty and in a crisis--requiring breakthrough to move forward. The cost of care now approaches reimbursement, and outcomes as commonly measured approach perfection. Thus, the cost of further improvements seems ready to topple the field, just as the specialty is realizing that seemingly innocuous anesthetic choices have long-term consequences, and better practice is required. SUMMARY: Anesthesiologists must create more headroom between costs and revenues in order to sustain the academic vigor and creativity required to create better clinical practice. We outline three areas in which technological and organizational innovation in anesthesiology can improve competitiveness and become a driving force in collaborative efforts to develop the operating rooms and perioperative systems of the future: increasing the profitability of operating rooms; increasing the efficiency of anesthesia; and technological and organizational innovation to foster improved patient flow, communication, coordination, and organizational learning.

Visualizing patient trajectories on wall-mounted boards - information security challenges.

Since operating room departments are among the costliest resources at a hospital, much attention is devoted to maximize their utilization. Operating room activities are however notoriously hard to plan in advance. This has to do with the unpredictable, problem-solving nature of the work and that the work is carried out by a multidisciplinary team of health personnel, members of which also have commitments outside the operating room department. We assume that operating room teams have the capacity to coordinate themselves and that coordination might be facilitated by visualizing relevant information on wall-mounted boards. To characterize clinical situations that require coordination and re-planning of the teams' work, we have developed a realistic scenario. We analyse and discuss the information security challenges that follow from displaying information on the whereabouts of other teams, actors and patients on wall-mounted boards in the operating rooms. Information security threats could be mitigated by de-identification techniques. Information demands could thereby be met without sacrificing the privacy of those whose information is displayed.

Automatic time-motion study of a multistep preoperative process.

BACKGROUND: Hospitals use time-motion studies to monitor process effectiveness and patient waiting. Manual tracking is labor-intensive and potentially influences system performance. New technology known as indoor positioning systems (IPS) may allow automatic monitoring of patient waiting and progress. The authors tested whether an IPS can track patients through a multistep preoperative process. METHODS: The authors used an IPS between October 14, 2005, and June 13, 2006, to track patients in a multistep ambulatory preoperative process: needle localization and excisional biopsy of a breast lesion. The process was distributed across the ambulatory surgery and radiology departments of a large academic hospital. Direct observation of the process was used to develop a workflow template. The authors then developed software to convert the IPS data into usable time-motion data suitable for monitoring process efficiency over time. RESULTS: The authors assigned tags to 306 patients during the study period. Eighty patients never underwent the procedure or never had their tag affixed. One hundred seventy-seven (78%) of the remaining 226 patients successfully matched the workflow template. Process time stamps were automatically extracted from the successful matches, measuring time before radiology (mean +/- SD, 77 +/- 35 min), time in radiology (105 +/- 35 min), and time between radiology and operating room (80 +/- 60 min), which summed to total preoperative time (261 +/- 67 min). CONCLUSIONS: The authors have demonstrated that it is possible to use a combination of IPS technology and sequence alignment pattern matching software to automate the time-motion study of patients in a multidepartment, multistep process with the only day-of-surgery intervention being the application of a tag when the patient arrives.

Real-time checking of electronic anesthesia records for documentation errors and automatically text messaging clinicians improves quality of documentation.

INTRODUCTION: The quality of electronic anesthesia documentation is important for downstream communication and to demonstrate appropriate diligence to care. Documentation quality will also impact the success of reimbursement contracts that require timely and complete documentation of specific interventions. We implemented a system to improve completeness of clinical documentation and evaluated the results over time. METHODS: We used custom software to continuously scan for missing clinical documentation during anesthesia. We used patient allergies as a test case, taking advantage of a unique requirement in our system that allergies be manually entered into the electronic record. If no allergy information was entered within 15 min of the "start of anesthesia care" event, a one-time prompt was sent via pager to the person performing the anesthetic. We tabulated the daily fraction of cases missing allergy data for the 6 mo before activating the alert system. We then obtained the same data for the subsequent 9 mo. We tested for systematic performance changes using statistical process control methodologies. RESULTS: Before initiating the alert system, the fraction of charts without an allergy comment was slightly more than 30%. This decreased to about 8% after initiating the alerts, and was significantly different from baseline within 5 days. Improvement lasted for the duration of the trial. Paging was suspended on nights, weekends, and holidays, yet weekend documentation performance also improved, indicating that weekday reminders had far-reaching effects. DISCUSSION: Electronic anesthesia documentation performance can be rapidly managed and improved by using an automatic process monitoring and alerting system.

Clinical processes in an innovative vascular surgeon community. Implications for workflow modeling.

OBJECTIVE: To identify factors influencing variations in clinical work in the care of patients with abdominal aortic aneurism. METHOD: Ethnographic observations of 26 meetings between surgeons and patients in two community hospitals and one university hospital. Observations data were abstracted into scenarios that describe the typical clinical workflow. Characterizations of features of the scenarios were performed. RESULTS: When comparing the university hospital and the community hospitals we find large variations in patient trajectories, and in the relation between actors' and roles. CONCLUSION: Given a clinical domain distinguished by an unrelenting search for new and improved surgical techniques, workflow system requirements should reflect that healthcare planning not only is conducted with the purpose of providing care but also with purpose of developing new or maintaining existing surgical skills.

Small changes in operative time can yield discrete increases in operating room throughput.

BACKGROUND AND PURPOSE: Operating room throughput is influenced by the efficiency of the perioperative process (for nonoperative time) and by the surgeon (for operative time). Operative time is thought not to be easily amenable to deliberate reductions. We tested the hypothesis that gradual improvements in operative time had allowed one surgeon to perform additional cases during scheduled hours. MATERIALS AND METHODS: The surgeon had been working in both a high-throughput and a conventional operating room for more than 1 year prior to the study. During the studied interval, we applied statistical process control analysis to time data for the surgeon performing full days of complex laparoscopic operations. Separate analyses were conducted for the conventional and high-throughput operating rooms. The average operative time for each day and the number of cases per day were plotted against sequential days for each environment. RESULTS: Midway through the studied interval, there was a discrete 17-minute drop in operative time in both the high-throughput and the conventional environment. Throughput increased from two cases per day to three per day in the high-throughput environment. The average end time for the three-case days was 17:15 (range 16:04-18:32). Longer average operative and nonoperative times in the conventional rooms precluded performing three complex cases during regular work hours. CONCLUSION: There was a sudden, rather than a gradual, reduction of operative time leading to extra cases being performed. This coincided with (1) the surgeon being assigned a new fellow and (2) administrative commitment to finish three cases per day. Our original hypothesis was negated, but other controllable causes for changes in surgical throughput were identified.

What is optimal timing for trauma team alerts? A retrospective observational study of alert timing effects on the initial management of trauma patients.

BACKGROUND: Trauma teams improve the initial management of trauma patients. Optimal timing of trauma alerts could improve team preparedness and performance while also limiting adverse ripple effects throughout the hospital. The purpose of this study was to evaluate how timing of trauma team activation and notification affects initial in-hospital management of trauma patients. METHODS: Data from a single hospital trauma care quality registry were matched with data from a trauma team alert log. The time from patient arrival to chest X-ray, and the emergency department length of stay were compared with the timing of trauma team activations and whether or not trauma team members received a preactivation notification. RESULTS: In 2009, the trauma team was activated 352 times; 269 times met the inclusion criteria. There were statistically significant differences in time to chest X-ray for differently timed trauma team activations (P = 0.003). Median time to chest X-ray for teams activated 15-20 minutes prearrival was 5 minutes, and 8 minutes for teams activated <5 minutes before patient arrival. Timing had no effect on length of stay in the emergency department (P = 0.694). We found no effect of preactivation notification on time to chest X-ray (P = 0.474) or length of stay (P = 0.684). CONCLUSION: Proactive trauma team activation improved the initial management of trauma patients. Trauma teams should be activated prior to patient arrival.

Process support for risk mitigation: a case study of variability and resilience in vascular surgery.

OBJECTIVE: To inform the design of IT support, the authors explored the characteristics and sources of process variability in a surgical care process that transcends multiple institutions and professional boundaries. SETTING: A case study of the care process in the Abdominal Aortic Aneurysm surveillance programme of three hospitals in Norway. DESIGN: Observational study of encounters between patients and surgeons accompanied by semistructured interviews of patients and key health personnel. RESULTS: Four process variety dimensions were identified. The captured process variations were further classified into intended and unintended variations according to the cause of the variations. Our main findings, however, suggest that the care process is best understood as systematised analysis and mitigation of risk. Even if major variations accommodated for the flexibility needed to achieve particular clinical aims and/or to satisfy patient preferences, other variations reflected healthcare actors' responses to risks arising from a lack of resilience in the existing system. On this basis, the authors outlined suggestions for a resilience-based approach by including awareness in workflow as well as feedback loops for adaptive learning. The authors suggest that IT process support should be designed to prevent process breakdowns with patient dropouts as well as to sustain risk-mitigating performance. CONCLUSION: Process variation was in part induced by systemised risk mitigation. IT-based process support for monitoring processes such as that studied here should aim to ensure resilience and further mitigate risk to enhance patient safety.

Implementation of a direct-from-recovery-room discharge pathway: a process improvement effort.

BACKGROUND: The authors describe a process improvement effort to achieve direct-from-recovery-room discharge for elective laparoscopic cholecystectomy patients--without prior patient selection. METHODS: The authors developed and implemented a new pathway, and then measured the learning curve (ie, success rate over time for direct discharge) and compared patients achieving direct discharge with patients admitted after surgery. RESULTS: The learning curve between the first patient and steady-state performance was 56 patients. A total of 80% of patients achieved direct discharge. Directly discharged patients were younger (P<.001), had lower ASA physical status classifications (P<.005), and left the recovery room earlier in the day (P<.0001). However, elderly patients and those with high ASA scores frequently could be directly discharged from the recovery room. CONCLUSIONS: Through small team based rapid cycle process improvement, direct-from-recovery-room discharge of laparoscopic cholecystectomy patients can be achieved in an unselected patient population with a short learning curve.

Causes of cancellations on the day of surgery at two major university hospitals.

Cancellations of elective cases on the day of surgery waste valuable operating-room time. The authors studied cancellations at an American hospital and a Norwegian university hospital to test (a) whether the quality of hospital administrative data on cancellations is sufficient for meaningful comparative analysis and (b) whether causes of cancellations at these 2 major academic hospitals are comparable. Large retrospective cause-of-cancellation data sets were obtained from each hospital. The authors then prospectively established root causes of cancellations by on-site investigation and interviews of the hospital personnel involved. The surgical department at the Norwegian hospital cancelled 14.58% of cases in 2003 and 16.07% in 2004. The American hospital cancelled 16.52% of all cases between May 1, 2003, and April 30, 2004. Administrative data may give a rough picture of causes of cancellations. However, most findings at either of the hospitals do not translate easily to the other.

Statistical process control as a tool for monitoring nonoperative time.

BACKGROUND: Administrators need simple tools to quickly identify even small changes in the performance of perioperative systems. This applies both to established systems and to impact assessments of deliberate perioperative system design changes. METHODS: Statistical process control was originally developed to detect nonrandom variation in manufacturing processes by continuous comparison to previous performance. The authors applied the technique to assess the nonoperative time performance between successive cases for same surgeon following themselves in a redesigned operating room. This operating room specifically implemented a new patient care pathway that improves throughput by reducing the nonoperative time. The authors tested how quickly statistical process control detected reductions in nonoperative time. They also tested the ability of statistical process control to detect successively smaller performance changes and investigated its utility for longitudinal process monitoring. RESULTS: Statistical process control detected a clear reduction in nonoperative time after the new operating room had been used for only 2 days. The method could detect nonoperative time changes of between 5 and 10 min per case for a single operating room within one fiscal quarter. Nonoperative time for the new process was globally stable over the 31 months analyzed, but late in the analysis period, the authors detected small performance decrements, mostly attributable to factors external to the new operating room. CONCLUSIONS: Statistical process control is useful for detecting changes in perioperative system performance, represented in this study by nonoperative time. The technique is able to detect changes quickly and to detect small changes over time.

The effect of direct-from-recovery room discharge of laparoscopic cholecystectomy patients on recovery room workload.

Ambulatory laparoscopic cholecystectomy pathways move patients through the hospital without encountering delays caused by congested inpatient bed units. However, redirecting patients to a direct discharge pathway might not be beneficial if recovery capacity is further taxed by additional workload. In this study, we attempt to assess the operational impact on recovery room workload of directly discharging laparoscopic cholecystectomy patients to home. We conducted a retrospective case-control review of recovery room flow sheets to determine recovery room time and effort required for laparoscopic cholecystectomy patients. The study was restricted to patients of a single surgeon to minimize confounds from surgical technique. Fifty-seven case patients (May 1, 2004, through November 30, 2004), all managed with intent to directly discharge from the recovery room, were compared with control patients (n = 81) from the corresponding 6 months in the year before the direct-discharge plan. The times (mean; 95% confidence interval) to meet objective criteria for adequate pain control (3.5 minutes [2.1 to 5.9] versus 4.0 minutes [2.6 to 6.1]) and readiness for discharge from phase 1 recovery (8.1 minutes [4.8 to 13.6] versus 6.1 minutes [4.0 to 9.5]) were not different between the groups. The number and distribution of interventions documented in the recovery process were not different between groups, nor was there a difference in recovery room length of stay (158 minutes [138 to 182] versus 149 minutes [132 to 167]). In our study, recovery room records reveal little if any increased workload associated with the direct-to-home discharge of laparoscopic cholecystectomy patients.

Does parallel workflow impact anesthesia quality?

Redesigns of workflow to allow parallel processing of OR tasks in the Operating Room of the Future at Massachusetts General Hospital have reduced non-operative time, increasing OR throughput. Automatically gathered anesthesia times were studied to address concerns that the new process constricted anesthesia work time. Upon close examination, it was found that 'Induction Time' was the only time interval not impacted by extraneous influences that invalidated other metrics based on the automatic data. 'Induction Time' increased in the Operating Room of the Future as compared to Standard Operating Rooms.