Why can't we improve turnover time? A systematic review.

BACKGROUND: Despite substantial efforts to reduce operating room (OR) turnover time (TOT), delays remain a frustration to physicians, staff, and hospital leadership. These efforts have employed many systems and human factor-based approaches with variable results. A deeper dive into methodologies and their applicability could lead to successful and sustained change. The aim of this study was to conduct a systematic review to evaluate relevant research focused on improving OR TOT and clearly defining measures of successful intervention. MATERIAL AND METHODS: A systematic review of OR TOT interventions implemented between 1980 through October 2022 was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Research databases included: 1) PubMed; 2) Web of Science; and 3) OVID Medline. RESULTS: A total of 38 articles were appropriate for analysis. Most employed a pre/post intervention approach (29, 76.3%), the remaining utilized a control/intervention approach. Nine intervention methods were identified: the majority included a process redesign bundle (24, 63%), followed by overlapping induction, dedicated unit/team/space feedback, financial incentives, team training, education, practice guidelines, and redefinition of roles/responsibilities. Studies were further categorized into one of two groups: (1) those that utilized predetermined interventions based on anecdotal experience or prior literature (18, 47.4%) and (2) those that conducted a prospective analysis on baseline data to inform intervention development (20, 52.6%). DISCUSSION: There are significant variability in the methodologies utilized to improve OR TOT; however, the most effective solutions involved process redesign bundles developed from a prospective investigation of the clinical work-system.

The Application of Human Factors Engineering to Reduce Operating Room Turnover in Robotic Surgery.

BACKGROUND: Challenges associated with turnover time are magnified in robotic surgery. The introduction of advanced technology increases the complexity of an already intricate perioperative environment. We applied a human factors approach to develop systematic, data-driven interventions to reduce robotic surgery turnover time. METHODS: Researchers observed 40 robotic surgery turnovers at a tertiary hospital [20 pre-intervention (Jan 2018 to Apr 2018), 20 post-intervention (Jan 2019 to Jun 2019)]. Components of turnover time, including cleaning, instrument and room set-up, robot preparation, flow disruptions, and major delays, were documented and analyzed. Surveys and focus groups were used to investigate staff perceptions of robotic surgery turnover time. A multidisciplinary team of human factors experts and physicians developed targeted interventions. Pre- and post-intervention turnovers were compared. RESULTS: Median turnover time was 67 min (mean: 72, SD: 24) and 22 major delays were noted (1.1/case). The largest contributors were instrument setup (25.5 min) and cleaning (25 min). Interventions included an electronic dashboard for turnover time reporting, clear designation of roles and simultaneous completion of tasks, process standardization of operating room cleaning, and data transparency through monthly reporting. Post-intervention turnovers were significantly shorter (U = 57.5, p = .000) and ten major delays were noted. CONCLUSIONS: Human factors analysis generated interventions to improve turnover time. Significant improvements were seen post-intervention with a reduction in turnover time by a 26 min and decrease in major delays by over 50%. Future opportunities to intervene and further improve turnover time include targeting pre- and post-operative care phases.

How Hospitals Can Save Lives and Themselves: Lessons on Patient Flow From the COVID-19 Pandemic.

COVID-19 has strained hospital capacity, detracted from patient care, and reduced hospital income. This article lays out a tested strategy that surgical and hospital leaders can use to overcome clinical and financial strain, emphasizing the experience at 2 leading North American medical centers. By classifying the time and resource needs of surgical patients and smoothing the flow of surgical admissions over all days of the week, hospitals can dramatically improve hospital efficiency, the quality of care and timely access to care for emergent and urgent surgeries. Through and beyond the time of COVID, smoothing the flow of surgical patients is a key means to restore hospital vitality and improve the care of all patients.

Beyond the Do-not-resuscitate Order: An Expanded Approach to Decision-making Regarding Cardiopulmonary Resuscitation in Older Surgical Patients.

American Society of Anesthesiologists guidelines recommend that anesthesiologists revisit do-not-resuscitate orders preoperatively and revise them if necessary based on patient preferences. In patients without do-not-resuscitate orders or other directives limiting treatment however, "full code" is the default option irrespective of clinical circumstances and patient preferences. It is time to revisit this approach based on (1) increasing understanding of the power of default options in healthcare settings, (2) changing demographics and growing evidence suggesting that an expanding subset of patients is vulnerable to poor outcomes after perioperative cardiopulmonary resuscitation (CPR), and (3) recommendations from multiple societies promoting risk assessment and goal-concordant care in older surgical patients. The authors reconsider current guidelines in the context of these developments and advocate for an expanded approach to decision-making regarding CPR, which involves identifying high-risk elderly patients and eliciting their preferences regarding CPR irrespective of existing or presumed code status.

A Systems-based Approach to Reduce Deep Venous Thrombosis and Pulmonary Embolism in Trauma Patients.

BACKGROUND: Venous thromboembolism (VTE) in trauma patients carries significant morbidity and mortality. We previously described how titrating enoxaparin dosing by anti-Xa trough levels was associated with a lower VTE rate. We combined this strategy with a higher initial enoxaparin dose for a majority of patients and modified the electronic medical record (EMR) to encourage immediate dosing. We sought to determine if this systems-based approach was associated with a decrease in VTE rate. STUDY DESIGN: A retrospective review was conducted of all trauma patients on prophylactic enoxaparin at an academic, Level I Trauma Center from 01/2013 to 05/2014 (PRE) and 06/2015 to 02/2018 (POST). The patients in PRE were prescribed enoxaparin 30 mg twice daily without dose adjustments. The patients in POST received 40 mg twice daily unless exclusion criteria applied, with doses titrated to maintain anti-Xa trough levels between 0.1 and 0.2 IU/mL. RESULTS: There were 478 patients in the PRE and 1306 in the POST. Compared to PRE, POST patients were of similar age and were as likely to present after blunt trauma, although POST patients had lower injury severity scores (10 vs. 9, p < 0.01). The overall VTE rate was lower in POST (6.9% vs. 3.6%, p < 0.01). The adjusted risk of VTE (AOR 0.61, adjusted p = 0.04) was lower in POST and POST was independently protective for VTE (AOR 0.54; p = 0.01). CONCLUSION: By implementing system changes to improve enoxaparin dosing after trauma, a significant reduction in VTE rate was observed. Wider application of this strategy should be considered.

Thoracic Endovascular Aortic Repair in Octogenarians and Nonagenarians.

BACKGROUND: The oldest segments of the population are expanding rapidly, and the number of thoracic endovascular aortic repairs (TEVARs) performed in the elderly parallels this trend. We describe our institutional TEVAR experience in octogenarians and nonagenarians. METHODS: All patients 80 years and older undergoing TEVAR at a single institution were reviewed using a prospectively maintained database. Baselines demographics, operative details, and outcomes were retrospectively analyzed. RESULTS: Twenty-five octogenarians and nonagenarians (age, 84.8 ± 3.7 years; 64% male) underwent TEVAR between January 2014 and January 2019. The most common preoperative comorbidities were hypertension (n = 24; 96%) and tobacco use (n = 18; 72%), and the mean modified frailty index was 0.32 ± 0.17. Degenerative aneurysms constituted the majority of aortic pathologies (60%), and most patients were symptomatic (64%), with a mean maximal aortic diameter of 62.7 ± 15.6 mm. Endoleaks were noted in 3 (12%) patients. Intensive care unit length of stay was 2.0 (1.5, 3.0) days, and the total length of stay was 5.0 (3.0, 7.0) days. In-hospital mortality was 12% (n = 3), while the overall 30-day mortality was 16% (n = 4). The median follow-up was 469.0 (76.0, 586.0) days. On univariate analysis, the presence of a postoperative complication was associated with a significantly increased risk of 30-day mortality (P < 0.01). CONCLUSIONS: Despite the inherently elevated operative risk among the elderly, this study demonstrates reasonable success rates for TEVAR in octogenarian and nonagenarian patients. In properly selected patients, advanced age alone should not be a prohibitive factor for TEVAR.

Timing of Chemical Thromboprophylaxis and Deep Vein Thrombosis in Major Colorectal Surgery: A Randomized Clinical Trial.

OBJECTIVE: To identify the optimal timing of perioperative chemical thromboprophylaxis (CTP) and incidence of occult preoperative deep vein thrombosis (OP-DVT) in patients undergoing major colorectal surgery. BACKGROUND: There is limited Level 1 data regarding the optimal timing of CTP in major colorectal surgery and the incidence of OP-DVT remains unclear. Both issues influence the occurrence of venous thromboembolism (VTE) and may impact Medicare reimbursement because of penalties for hospital-acquired conditions. METHODS: Patients undergoing major colorectal surgery underwent preoperative lower extremity venous duplex (LEVD) immediately before surgery. Those without OP-DVT were randomized to preoperative or postoperative CTP with 5000 units of subcutaneous heparin. Patients underwent repeat LEVD in the recovery room and on postoperative day 2. Outcome measures included early (48-hrs) and overall (30-days) postoperative VTE, bleeding complications, and OP-DVT. RESULTS: Eighteen patients (4.2%) had OP-DVT and were excluded. The randomized group included 376 patients (51.6% female) with mean age of 52.7 ±â€Š17.6 years. No pulmonary embolism occurred. There was no significant difference in preoperative versus postoperative CTP with respect to early postoperative DVT [3/184 (1.6%) vs 5/192 (2.6%); P = 0.72], DVT at 30 days (1.6% vs 3.6%; P = 0.34) or bleeding complications requiring reoperation (0.5% vs 1.6%; P = 0.62). CONCLUSIONS: The risk of OP-DVT is higher than that of perioperative DVT after colorectal surgery and preoperative screening LEVD should be considered to identify and treat patients at risk for pulmonary embolism. Preoperative and postoperative CTP are equally safe in protecting against VTE. CMS should account for these factors when assigning financial disincentives for perioperative VTE. TRIAL REGISTRATION: Clinicaltrials.gov #NCT01976988.

Barriers to efficiency in robotic surgery: the resident effect.

BACKGROUND: Robotic surgery offers advantages over conventional operative approaches but may also be associated with higher costs and additional risks. Analyzing surgical flow disruptions (FDs), defined as "deviations from the natural progression of an operation," can help target training techniques and identify opportunities for improvement. MATERIALS AND METHODS: Thirty-two robotic surgery operations were observed over a 6-wk period at one 900-bed surgical center. FDs were recorded in detail and classified into one of 11 different categories. Procedure type, robot model, and resident involvement were also recorded. Linear regression analyses were used to evaluate the effects of these parameters on FDs and operative duration. RESULTS: Twenty-one prostatectomies, eight sacrocolpopexies, and three nephrectomies were observed. The mean number of FDs was 48.2 (95% confidence interval [CI] 38.6-54.8 FDs), and mean operative duration was 163 min (95% CI 148-179 min). Each FD added 2.4 min (P = 0.025) to a case's total operative duration. The number and rate of FDs were significantly affected by resident involvement (P = 0.008 and P = 0.006, respectively). Resident cases demonstrated mostly training, equipment, and robot switch FDs, whereas nonresident cases demonstrated mostly equipment, instrument changes, and external factor FDs. CONCLUSIONS: Although the FDs encountered in resident training are more frequent, they may not significantly increase operative duration. Other FDs, such as equipment or external factors, may be more impactful. Limiting these specific FDs should be the focus of performance improvement efforts.

Flow disruptions during trauma care.

BACKGROUND: Flow disruptions (FDs) are deviations from the progression of care that compromise safety or efficiency. The frequency and specific causes of FDs remain poorly documented in trauma care. We undertook this study to identify and quantify the rate of FDs during various phases of trauma care. METHODS: Seven trained observers studied a Level I trauma center over 2 months. Observers recorded details on FDs using a validated Tablet-PC data collection tool during various phases of care-trauma bay, imaging, operating room (OR)-and recorded work-system variables including breakdowns in communication and coordination, environmental distractions, equipment issues, and patient factors. RESULTS: Researchers observed 86 trauma cases including 72 low-level and 14 high-level activations. Altogether, 1,759 FDs were recorded (20.4/case). High-level trauma comprised a significantly higher number (p = 0.0003) and rate of FDs (p = 0.0158) than low-level trauma. Across the three phases of trauma care, there was a significant effect on FD number (p < 0.0001) and FD rate (p = 0.0005), with the highest in the OR, followed by computed tomography. The highest rates of FD per case and per hour were related to breakdowns in coordination. CONCLUSIONS: This study is the largest direct observational study of the trauma process conducted to date. Complexities associated with the critical patient who arrives in the trauma bay lead to a high prevalence of disruptions related to breakdowns in coordination, communication, equipment issues, and environmental factors. Prospective observation allows individual hospitals to identify and analyze these systemic deficiencies. Appropriate interventions can then be evaluated to streamline the care provided to trauma patients.

Flow disruptions in trauma care handoffs.

BACKGROUND: Effective handoffs of care are critical for maintaining patient safety and avoiding communication problems. Using the flow disruption observation technique, we examined transitions of care along the trauma pathway. We hypothesized that more transitions would lead to more disruptions, and that different pathways would have different numbers of disruptions. METHODS: We trained observers to identify flow disruptions, and then followed 181 patients from arrival in the emergency department (ED) to the completion of care using a specially formatted PC tablet. We mapped each patient's journey and recorded and classified flow disruptions during transition periods into seven categories. RESULTS: Mapping the transitions of care shows that approximately four of five patients were assessed in the ED, transferred to imaging for further diagnostics, and then returned to the ED. There was a mean of 2.2 ± 0.09 transitions per patient, a mean of 0.66 ± 0.15 flow disruptions per patient, and 0.31 ± 0.07 flow disruptions per transition. Most of these (53%) were related to coordination problems. Although disruptions did not rise with more transitions, patients who went directly to the operating room or needed direct admission to intensive care unit were significantly more likely (P=0.0028) to experience flow disruptions than those who took other, less expedited pathways. CONCLUSIONS: Transitions in trauma care are vulnerable to systems problems and human errors. Coordination problems predominate as the cause. Sicker, time-pressured, and more at-risk patients are more likely to experience problems. Safety practices used in motor racing and other industries might be applied to address these problems.

Initial experience with a modified "candy-plug" technique for false lumen embolization in chronic type B aortic dissection.

Background: Persistent distal false lumen (FL) perfusion after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) can lead to aneurysmal degeneration and an increased risk of rupture. We have presented our initial experience using a modified "candy-plug" (CP) technique for FL embolization. Methods: From February 2021 to July 2022, we treated six patients using the modified CP technique. All the patients had undergone prior or simultaneous TEVAR for chronic TBAD with persistent FL perfusion and aneurysm expansion. Bilateral common femoral artery access was obtained, and intravascular ultrasound was used to confirm wire access in the true lumen (TL) and FL. A conformable TAG device (W.L. Gore & Associates, Flagstaff, AZ) was used in four cases and an Excluder aortic cuff (W.L. Gore & Associates) in two cases. The device was modified by placing a constraining "napkin-ring" suture through the middle segment of the device. Femoral sheaths were placed in the TL and FL. A standard TL TEVAR extension was performed at the level of the celiac artery (zone 5). Next, the CP device was advanced and deployed in the FL, distally aligning it with the TL device. An appropriately sized Amplatzer II plug (Abbot Vascular, Santa Clara, CA) was then deployed in the constrained segment of the modified stent graft. Completion angiography was performed to confirm successful FL embolization. Results: Technical success was defined as successful deployment of the CP device in the FL. The technical success rate was 100% (six of six patients). Clinical success was defined as the cessation of aneurysm growth on follow-up computed tomography angiography. No 30-day mortality, myocardial infarction, stroke, spinal cord ischemia, access site complications, or aortic-related reinterventions occurred. Surveillance imaging at a mean follow-up of 10 months confirmed clinical success (stable aneurysm size or shrinkage) for all five patients with follow-up data available. Conclusions: The modified CP embolization technique is a promising solution for persistent distal FL perfusion after TEVAR for TBAD. Further investigation is required to determine the long-term durability of this technique as an adjunct to TEVAR to promote aortic remodeling.

Understanding ultrarare adverse events - Lessons learned from a twelve-year review of intraoperative deaths at an academic medical center.

BACKGROUND: Intraoperative death (ID) is rare, the incidence remains challenging to quantify and learning opportunities are limited. We aimed to better define the demographics of ID by reviewing the longest single-site series. METHODS: Retrospective chart reviews, including a review of contemporaneous incident reports, were performed on all ID between March 2010 to August 2022 at an academic medical center. RESULTS: Over 12 years, 154 IDs occurred (∼13/year, average age: 54.3 years, male: 60%). Most occurred during emergency procedures (n = 115, 74.7%), 39 (25.3%) during elective procedures. Incident reports were submitted in 129 cases (84%). 21 (16.3%) reports cited 28 contributing factors including challenges with coordination (n = 8, 28.6%), skill-based errors (n = 7, 25.0%), and environmental factors (n = 3, 10.7%). CONCLUSIONS: Most deaths occurred in patients admitted from the ER with general surgical problems. Despite expectations for incident reporting, few provided actionable information on ergonomic factors which might help identify improvement opportunities.

Eagle syndrome revisited: cerebrovascular complications.

Cervical pain caused by the elongation of the styloid process (Eagle syndrome) is well known to otolaryngologists but is rarely considered by vascular surgeons. We report two patients with cerebrovascular symptoms of Eagle syndrome treated in our medical center in the past year. Case 1: an 80-year-old man with acromegaly presented with dizziness and syncope with neck rotation. The patient was noted to have bilateral elongated styloid processes impinging on the internal carotid arteries. After staged resections of the styloid processes through cervical approaches, the symptoms resolved completely. Case 2: a 57-year-old man presented with acute-onset left-sided neck pain radiating to his head immediately after a vigorous neck massage. Hospital course was complicated by a 15-minute transient ischemic attack resulting in aphasia. Angiography revealed bilateral dissections of his internal carotid arteries, with a dissecting aneurysm on the right. Both injuries were immediately adjacent to the bilateral elongated styloid processes. Despite immediate anticoagulation therapy, he experienced aphasia and right hemiparesis associated with an occlusion of his left carotid artery. He underwent emergent catheter thrombectomy and carotid stent placement, with near-complete resolution of his symptoms. Elongated styloid processes characteristic of Eagle syndrome can result in both temporary impingement and permanent injury to the extracranial carotid arteries. Although rare, Eagle syndrome should be considered in the differential diagnosis in patients with cerebrovascular symptoms, especially those induced by positional change.

A Human Factors Approach to Surgical Patient Safety.

This article explores the role of human factors engineering in patient safety in surgery. The authors discuss the history and evolution of human factors and the role of human factors in patient safety and provide a description of human factors methods used to study and improve patient safety.