Resource evaluation framework for total knee arthroplasty.

PURPOSE: This article describes a framework for evaluating efficiency of OR procedures incorporating time measurement, personnel activity, and resource utilization using traditional industrial engineering tools of time study and work sampling. METHODS: The framework measures time using time studies of OR procedures and work sampling of personnel activities, ultimately classified as value-added or non-value-added. Statistical methods ensure that the collected samples meet adequate levels of confidence and accuracy. Resource utilization is captured through documentation of instrument trays used, defects in instruments, and trash weight and classification at the conclusion of surgeries. FINDINGS: A case study comprising 12 observations of total knee arthroplasty surgeries illustrates the use of the framework. The framework allows researchers to compare time, personnel, and resource utilization simultaneously within the OR setting. PRACTICAL IMPLICATIONS: The framework provides a holistic evaluation of methods, instrumentation and resources, and staffing levels and allows researchers to identify areas for efficiency improvement. ORIGINALITY/VALUE: The methods presented in this article are rooted in traditional industrial engineering work measurement methods but are applied to a healthcare setting in order to efficiently identify areas for improvement including time, personnel, and processes in operating rooms.

Avances en la gestión del bloque quirúrgico. El papel del coordinador de quirófano / Advances in operating room management. The role of operating room director

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Integrated Practice Improvement Solutions-Practical Steps to Operating Room Management.

UNLABELLED: Perioperative productivity is a vital concern for surgeons, anesthesiologists, and administrators as the OR is a major source of hospital elective admissions and revenue. Based on elements of existing Practice Improvement Methodologies (PIMs), "Integrated Practice Improvement Solutions" (IPIS) is a practical and simple solution incorporating aspects of multiple management approaches into a single open source framework to increase OR efficiency and productivity by better utilization of existing resources. MATERIALS AND METHODS: OR efficiency was measured both before and after IPIS implementation using the total number of cases versus room utilization, OR/anesthesia revenue and staff overtime (OT) costs. Other parameters of efficiency, such as the first case on-time start and the turnover time (TOT) were measured in parallel. RESULTS: IPIS implementation resulted in increased numbers of surgical procedures performed by an average of 10.7%, and OR and anesthesia revenue increases of 18.5% and 6.9%, respectively, with a simultaneous decrease in TOT (15%) and OT for anesthesia staff (26%). The number of perioperative adverse events was stable during the two-year study period which involved a total of 20,378 patients. CONCLUSION: IPIS, an effective and flexible practice improvement model, was designed to quickly, significantly, and sustainably improve OR efficiency by better utilization of existing resources. Success of its implementation directly correlates with the involvement of and acceptance by the entire OR team and hospital administration.

The Effect of an Interdisciplinary QI Project to Reduce OR Foot Traffic.

We instituted a multidisciplinary educational and operational quality improvement initiative to assess the effect of process interventions on reducing OR door openings and, by extension, surgical site infections. From 2009 to 2012, we conducted an initial trial to gather information and identify reasons for door openings followed by a three-phase investigation that evaluated a total of 102 orthopedic hip and knee procedures in which we counted door openings from the time of incision to the closing of the capsule. We analyzed the effectiveness of door opening deterrents (eg, a pull shade, magnetic yellow caution tape across the door frame) and changes in traffic processes (eg, clear-covered implant carts). The interventions and process changes showed a 50% reduction in door openings compared to the baseline.

[When the health care inspectorate closes the operating theatres: a case study]. / Als de Inspectie de operatiekamers sluit.

BACKGROUND: The topic of 'quality of care' is subject to intense interest from the media, the public and the government. One of the key roles of the Dutch Health Care Inspectorate (IGZ) is the supervision and monitoring of quality of care. When the IGZ pays a visit, this generally has many consequences for the hospital concerned. CASE STUDY: Following an unannounced inspection of a hospital, the IGZ closed the operating department due to shortcomings in the quality of care. The IGZ and the hospital proved to have different ideas concerning the norms of quality. Using a theoretical framework we have tried to provide some insight into the consequences of this situation. CONCLUSION: A hospital comprises a number of different domains each with its own value system (market, governmental and political, societal, medical profession). To prevent these differences standing in the way of good care, we advise all parties to look outside their own domain in order to overcome the boundaries and connect to other domains and value systems.

Choice of loco-regional anesthetic technique affects operating room efficiency for carpal tunnel release.

Intravenous regional anesthesia (Bier block) is indicated for minor procedures such as carpal tunnel release but must be performed in the operating room. We hypothesize that preoperative peripheral nerve blocks decrease anesthesia-controlled time compared to Bier block for carpal tunnel release. With IRB approval, we reviewed surgical case data from a tertiary care university hospital outpatient surgery center for 1 year. Unilateral carpal tunnel release cases were grouped by anesthetic technique: (1) preoperative nerve blocks, or (2) Bier block. The primary outcome was anesthesia-controlled time (minutes). Secondary outcomes included surgical time and time for nerve block performance in minutes, when applicable. Eighty-nine cases met criteria for analysis (40 nerve block and 49 Bier block). Anesthesia-controlled time [median (10th-90th percentiles)] was shorter for the nerve block group compared to Bier block [11 (6-18) vs. 13 (9-20) min, respectively; p = 0.02). Surgical time was also shorter for the nerve block group vs. the Bier block group [13 (8-21) and 17 (10-29) min, respectively; p < 0.01), but nerve blocks took 10 (5-28) min to perform. Ultrasound-guided nerve blocks performed preoperatively reduce anesthesia-controlled time compared to Bier block and may be a useful anesthetic modality in some practice environments.

Flammability of topical preparations and surgical dressings in cutaneous and laser surgery: a controlled simulation study.

BACKGROUND: Surgical fires are a rare, but serious complication of dermatologic procedures involving electrosurgical and laser devices. Given the lack of data regarding basic fire safety principles, many dermatologists remain unaware of this potential risk. OBJECTIVE: We evaluated the flammability of topical preparations and surgical drapes commonly encountered in the immediate operative field during cutaneous and laser surgery. METHODS: Surgical dressings, drapes, and pork belly skin were examined for fire risk upon exposure to isopropyl alcohol, chlorhexidine gluconate, and aluminum chloride under dry, saturated, and damp conditions. Both electrosurgery and a carbon-dioxide laser were used as ignition sources. RESULTS: At least some char was observed in 86 of 126 simulated conditions (68%). Flames occurred in 2 test conditions: dry underpad drapes and cotton balls exposed to the carbon-dioxide laser. In general, drapes and dressings dampened or saturated with isopropyl alcohol failed to ignite with electrofulguration or electrodessication, although sparks and moderate char developed on pork belly skin and the underpad drape. Materials dampened or saturated with chlorhexidine gluconate, which contains isopropyl alcohol, generated less smoke and char compared with materials exposed to aluminum chloride, which does not contain alcohol. LIMITATIONS: Future studies may assess the flammability of materials in the setting of oxygen supplementation. CONCLUSION: In common cutaneous surgical environments, electrosurgery or ablative laser may lead to char and rarely to fire. Char may be seen in up to two thirds of simulated conditions, and in a minute proportion of conditions, fire is observed.

Recuperador celular / No disponible

Los recuperadores de sangre son unos instrumentos usados cada vez más en los quirófanos. Resultan especialmente útiles en las intervenciones donde existe mucho riesgo de sangrado y las necesidades transfusionales son elevadas. En pediatría tienen una gran importancia en intervenciones complicadas con la finalidad de evitar transfusiones alogénicas (sangre obtenida de donantes). La aplicación del recuperador de sangre en el campo quirúrgico es muy simple y de fácil utilización. Se trata de una cánula de aspiración que recoge la sangre que queda libre, trasladándola a una centrifugadora donde se filtra y lava, almacenándola en una bolsa de recogida para su posterior infusión. La sangre es de gran calidad y contiene un hematocrito más elevado que la procedente de banco (AU)

The blood retrievers are instruments increasingly used in operating rooms. They are especially useful in operations where there is a high risk of bleeding and transfusion requirements are high. In paediatrics is of great importance in complex interventions in order to avoid allogeneic transfusion (blood collected from donors). The implementation of the recovery of blood in the surgical field is very simple and easy to use. This is a suction tube that collects the blood that is free, transferring it to a centrifuge where it is filtered and washed, stored in a blood collection bag for subsequent infusion. The blood is of high quality and contains a high hematocrit blood from the bank (AU)

Treating patients with smallpox in the operating room.

Recent events around the world have emphasized the need for health care facilities to prepare to deal with biological threats, including smallpox. At Walter Reed Army Medical Center, Washington, DC, administrators recognized the need for a policy on handling patients with smallpox in the OR and asked a group of students to create a template policy for care of patients with smallpox in need of surgery. This article provides a brief history of smallpox, concerns surrounding smallpox today, and smallpox characteristics with which perioperative personnel should be familiar, as well as a guideline for treating patients in the OR who have smallpox.

[Hygiene between tradition and implementation]. / Hygiene zwischenTradition und Erkenntnis.

The basis of evidence for hygiene rules implemented in hospitals is traditionally small. This is not only because there is little theoretical knowledge on the reciprocal influence between a single hygienic mistake/a single microbial input and the manifestation of a nosocomial infection. There are also not enough clinical studies, especially on complex hygiene questions, to determine whether special measures (e.g., septic rooms)can compensate for deficits in hygiene practice. Furthermore, it would be necessary to designate security buffers distinctly. In-house traditions are able to stabilize hygienic behavior in an excellent manner. They should be fostered and not disparaged as myths. Discussions of experts should not be conducted in public; that is disastrous for the everyday work of physicians in hospitals.

Consideraciones en torno al control ambiental de quirófanos / Considerations with regard to the environmental control of operating theatres

Partiendo de la situación existente en la industria farmacéutica por lo que se refiere a los ambientes controlados se revisa el estado de esta cuestión en quirófanos y se proponen procedimientos de diseño y control (AU)

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OR management.

Market forces throughout the US, especially in specific geographic areas, have brought about profound changes in health care delivery. One of the most significant is the move to managed and capitated care with the resulting impact on hospital reimbursement. As these forces gain momentum, continually moving further from fee for-service, the hospital portion of the healthcare dollar continues to contract. In response, healthcare delivery organizations are developing innovative strategies to ensure the continual provision of cost effective care. Emphasis is placed upon keeping resources close to the point-of-care delivery. Necessary savings, reductions, and efficiencies must come from structural change, reengineering, best practice development, and more cost effective care delivery with highly standardized use of resources. Healthcare is in a transitionary stage. The transition has been from providing acute inpatient care to managing the continuum of care, from treating illness in individuals to providing education and maintaining wellness in the defined population. Revenue centers are no longer recognized; rather, in this increasingly capitated market, all, including operating rooms, are cost centers. The focus is no longer on filling beds, ORs, radiology suites, etc. The challenge is to find effective methods to minimize the needed resources to deliver high quality, cost effective care while maintaining and increasing patient and physician satisfaction. This article focuses on surgery in a large integrated system, Sharp Health care (San Diego, CA), a network of organizations providing, or arranging to provide, a coordinated continuum of services to a defined population.

A methodology for QI in the coronary artery bypass grafting procedure involving comparative process analysis.

This report describes an example of applying comparative process analysis to improve surgical procedures. This approach to health care quality improvement relies on combining techniques from the technical disciplines of systems analysis and systems engineering with concepts embodied in the philosophies of total quality management. Coronary artery bypass grafting (CABG) has been examined in a cooperative observational study involving an engineer, cardiac surgeons, perfusionists, nurses, and an anesthesiologist. A baseline process flow for the CABG procedure was developed, against which interinstitutional variations among the five participating medical centers have been identified. On the basis of analysis of the variations, efforts are under way to develop a strategy for incremental continuous improvement in the CABG procedure in each of the five institutions. On the basis of the perceived success of the first phase of the activity, a second phase, wider in scope, has been undertaken.