Improving and Maintaining On-Time Start Times for Nonelective Cases in a Major Academic Medical Center.

BACKGROUND: As health care expenditures continue to increase, thoughtful use of perioperative resources is important. Efforts to improve operating room (OR) efficiency often focus on increasing on-time first case starts to improve OR utilization, reduce subsequent delays, and reduce adverse events. One institution, with severely limited inpatient hospital capacity and an extensive daily add-on list of surgical cases, focused efforts to improve OR efficiency by improving on-time first case starts for unscheduled, nonemergent surgeries. METHODS: A multidisciplinary team was assembled to work together for this quality improvement (QI) initiative. The primary outcome measure was the percentage of cases starting on time. The team identified six key steps thought to contribute to on-time start performance. Data were collected for each of these process measures, and feedback was shared with stakeholders. RESULTS: By measuring adherence to and giving feedback about critical steps in the preoperative process, on-time starts improved from a baseline of 65% to 85% (p = 0.041). Sustained improvement was seen even after daily measurement ceased and the QI project was completed. CONCLUSION: Establishing a multidisciplinary team to improve timely care of unscheduled, nonelective surgical patients; identifying key elements necessary for on-time surgical case starts; and providing feedback to clinicians were associated with a sustained improvement in OR efficiency for a traditionally difficult-to-schedule patient population.

Improving surgical efficiency of immediate implant-based breast reconstruction following mastectomy.

PURPOSE: Traditionally, during a mastectomy with implant-based reconstruction, the surgical oncologist completes their operative procedure prior to the reconstructive surgeon entering the room. In this scenario, two separate instruments kits and tables are utilized. In our institution, we created a combined instrument kit for use by both surgical teams. We compared set-up and operative times for each process and the subsequent savings associated with this novel approach. METHODS: Sixty-eight patients undergoing mastectomy with implant-based reconstruction were divided into two groups-those who underwent the procedure with separate oncology and reconstructive kits and those who underwent the procedure with combined instrumentation. Set-up time, procedure time, and clinical outcome endpoints were compared. Costs associated with each process were estimated. RESULTS: Surgical set-up time was lower using the combined kit versus separate kits [mean for unilateral cases, 25.1 ± 9.6 min vs. 35.7 ± 10.4 min (p < 0.01) and mean for bilateral cases, 33.1 ± 10.3 min vs. 43.5 ± 9.9 min (p = 0.31)]. Procedure time was significantly lower using the combined kit versus separate kits [mean for unilateral cases, 156.2 ± 31.7 min vs. 172.1 ± 33.0 min (p < 0.05) and mean for bilateral cases, 207.3 ± 39.3 min vs. 228. 8 ± 42.7 min (p = 0.03)]. Post-operative outcomes were not significantly different between the two groups at 6 months post-surgery (p = 0.72). Due to a decrease in operating room utilization and costs associated with instrumentation, we estimated $134,396 to $206,621 with unilateral cases and a $289,167 to $465,967 in yearly savings with bilateral cases by using the combined process. CONCLUSION: Mastectomy with implant-based reconstruction utilizing combined instrumentation, with surgeons working simultaneously, led to decreased operating room utilization and costs without impacting clinical outcomes. Level of evidence II.