An economic evaluation of a systems-based strategy to expedite surgical treatment of hip fractures.

BACKGROUND: A recent systematic review has indicated that mortality within the first year after hip fracture repair increases significantly if the time from hospital admission to surgery exceeds forty-eight hours. Further investigation has shown that avoidable, systems-based factors contribute substantially to delay in surgery. In this study, an economic evaluation was conducted to determine the cost-effectiveness of a hypothetical scenario in which resources are allocated to expedite surgery so that it is performed within forty-eight hours after admission. METHODS: We created a decision tree to tabulate incremental cost and quality-adjusted life years in order to evaluate the cost-effectiveness of two potential strategies. Several factors, including personnel cost, patient volume, percentage of patients receiving surgical treatment within forty-eight hours, and mortality associated with delayed surgery, were considered. One strategy focused solely on expediting preoperative evaluation by employing personnel to conduct the necessary diagnostic tests and a hospitalist physician to conduct the medical evaluation outside of regular hours. The second strategy added an on-call team (nurse, surgical technologist, and anesthesiologist) to staff an operating room outside of regular hours. RESULTS: The evaluation-focused strategy was cost-effective, with an incremental cost-effectiveness ratio of $2318 per quality-adjusted life year, and became cost-saving (a dominant therapeutic approach) if =93% of patients underwent expedited surgery, the hourly cost of retaining a diagnostic technologist on call was <$20.80, or <15% of the hospitalist's salary was funded by the strategy. The second strategy, which added an on-call surgical team, was also cost-effective, with an incremental cost-effectiveness ratio of $43,153 per quality-adjusted life year. Sensitivity analysis revealed that this strategy remained cost-effective if the odds ratio of one-year mortality associated with delayed surgery was >1.28, =88% of patients underwent early surgery, or =339.9 patients with a hip fracture were treated annually. CONCLUSIONS: The results of our study suggest that systems-based solutions to minimize operative delay, such as a dedicated on-call support team, can be cost-effective. Additionally, an evaluation-focused intervention can be cost-saving, depending on its success rate and associated personnel cost.

Health economics: what value to the theatre practitioner?

Clinical effectiveness has become embedded into healthcare in the last decade. In juxtaposition with this philosophy lies health economics with its mantra of resources being finite, whilst the need for healthcare remains infinite. An outline of a provocative cost-benefit analysis is provided to increase the knowledge of health economics for those working in the operating department. This paper argues that cost effectiveness must be embedded within clinical effectiveness.

Operating room nursing directors' influence on anesthesia group operating room productivity.

BACKGROUND: Implementation of initiatives to increase anesthesia group productivity depends not just on anesthesia groups, but on operating room (OR) nursing administration. OR nursing directors may encourage organizational change based on the needs of their hospitals and nurses. These changes may differ from those that would increase the anesthesia group's productivity. We assessed reward structures using (A) letters of nomination for the "OR Manager of the Year" award offered annually by the publication OR Manager, and (B) data from a salary/career survey of OR directors by the same publication. METHODS: (A) There were 164 nomination letters submitted from 2004 through 2007 for 45 nominees. The letters contained n = 2659 full sentences and n = 50,821 words. We systematically created a list of 36 terms related to finance, profit, and productivity. We also analyzed the frequency of use of these terms relative to the use of the 15 most common relationship-oriented terms (e.g., compassion, encourage, mentor, and respect). (B) The salary/career survey's questions relevant to anesthesia group productivity had responses from 303 US OR directors, 97% of whom were nurses. We tested the strength of the relationship between the budget responsibility of the OR nursing director and his or her annual salary. RESULTS: (A) 2.6% of sentences in the nomination letters included at least one term related to profit and productivity (95% confidence interval 2.0%-3.2%). Relationship-oriented terms were 9.0 times more prevalent (95% confidence interval 7.1-11.4). (B) There was statistically significant positive proportionality between the OR nursing director's operational budget (including personnel) and his or her salary (Pearson r = 0.64, P < 0.001). The 10th percentile of the operational budget was $1 million and the 90th percentile was $36 million. The budget of $1 million was associated with a salary 22% less than the median and the budget of $36 million was associated with a salary 22% larger than the median. CONCLUSION: Through (A) organizational constituencies, and (B) compensation, many US OR nursing directors likely are encouraged to enhance relations with nursing staff, not to champion organizational initiatives that would reduce under-utilized OR time and OR nursing labor costs. Resulting decisions can differ from those that would increase the productivity (profit) of the anesthesia group. Anesthesia groups need to champion initiatives to increase anesthesia productivity, while being sensitive to institutional expectations of nursing directors.

Unraveling surgical assistant modifiers.

This article aims to answer frequently asked questions regarding accurate reporting of assistant surgeons versus assistant at surgery modifiers.

Show me the money! Factors to consider when looking to finance a RNFA position.

Increasingly hospitals are looking to the Registered Nurse First Assistant (RNFA) position as a means to ensure readily available, qualified assistance for a patient's surgical intervention. Each year, in Canada, the number of RNFAs grows. As more individuals learn about the benefits of the position, through either direct experience or published reports, interest in the role increases. This, coupled with the reality of physician shortages, is bringing the RNFA role to the forefront in numerous hospitals across the country. Funding the position is one of the largest challenges that hospitals, and RNFAs, face in converting a recognized need into the reality of a paid RNFA position.

Use of linear programming to estimate impact of changes in a hospital's operating room time allocation on perioperative variable costs.

BACKGROUND: Administrators at hospitals with a fixed annual budget may want to focus surgical services on priority areas to ensure its community receives the best health services possible. However, many hospitals lack the detailed managerial accounting data needed to ensure that such a change does not increase operating costs. The authors used a detailed hospital cost database to investigate by how much a change in allocations of operating room (OR) time among surgeons can increase perioperative variable costs. METHODS: The authors obtained financial data for all patients who underwent outpatient or same-day admit surgery during a year. Linear programming was used to determine by how much changing the mix of surgeons can increase total variable costs while maintaining the same total hours of OR time for elective cases. RESULTS: Changing OR allocations among surgeons without changing total OR hours allocated will likely increase perioperative variable costs by less than 34%. If, in addition, intensive care unit hours for elective surgical cases are not increased, hospital ward occupancy is capped, and implant use is tracked and capped, perioperative costs will likely increase by less than 10%. These four variables predict 97% of the variance in total variable costs. CONCLUSIONS: The authors showed that changing OR allocations among surgeons without changing total OR hours allocated can increase hospital perioperative variable costs by up to approximately one third. Thus, at hospitals with fixed or nearly fixed annual budgets, allocating OR time based on an OR-based statistic such as utilization can adversely affect the hospital financially. The OR manager can reduce the potential increase in costs by considering not just OR time, but also the resulting use of hospital beds and implants.

Determining the cost-effectiveness of the Registered Nurse First Assistant: the research link.

As monetary constraints in health care increase, stakeholders search for avenues to ensure cost-effective care provision. In the perioperative environment one such avenue involves the group of health care providers supporting surgeons and patients during surgery--the surgical assistant. In Canada, general practice physicians predominantly fill this role. Another viable option promoted as a cost-effective alternative to the physician assistant is the Registered Nurse First Assistant (RNFA). The relationship between RNFA cost-effectiveness and role implementation and reimbursement is explored in this article. The importance of formally determining the cost-effectiveness of the RNFA through the utilization and development of research is presented.

Speaking the language of finance.

Nursing leadership skills have changed dramatically in a short period of time. Just being able to cover the schedule and ensure adequate orientation for new employees are not enough in today's health care environment. This article outlines steps to ensure adequate staffing levels, assess productivity, and justify the operational supplies and capital equipment necessary for effective patient care. It also outlines steps nursing leaders can take to market their programs and services.

A strategy to decide whether to move the last case of the day in an operating room to another empty operating room to decrease overtime labor costs.

UNLABELLED: We examined how to program an operating room (OR) information system to assist the OR manager in deciding whether to move the last case of the day in one OR to another OR that is empty to decrease overtime labor costs. We first developed a statistical strategy to predict whether moving the case would decrease overtime labor costs for first shift nurses and anesthesia providers. The strategy was based on using historical case duration data stored in a surgical services information system. Second, we estimated the incremental overtime labor costs achieved if our strategy was used for moving cases versus movement of cases by an OR manager who knew in advance exactly how long each case would last. We found that if our strategy was used to decide whether to move cases, then depending on parameter values, only 2.0 to 4.3 more min of overtime would be required per case than if the OR manager had perfect retrospective knowledge of case durations. The use of other information technologies to assist in the decision of whether to move a case, such as real-time patient tracking information systems, closed-circuit cameras, or graphical airport-style displays can, on average, reduce overtime by no more than only 2 to 4 min per case that can be moved. IMPLICATIONS: The use of other information technologies to assist in the decision of whether to move a case, such as real-time patient tracking information systems, closed-circuit cameras, or graphical airport-style displays, can, on average, reduce overtime by no more than only 2 to 4 min per case that can be moved.

Marketing the RN first assistant role.

Nurses who are educated and certified for the RN first assistant (RNFA) role must look for ways to introduce the RNFA role into their health care setting while also marketing their services over another assistant's services. This article offers information on the RNFA role, including practice requirements, a job description, and strategies to help institute the first assistant role into a health care facility.