The Impact of a Real-Time Locating System within the Perioperative Environment on Physicians and Patients' Families.

BACKGROUND: Humber River Hospital has implemented a real-time location system (RTLS) within the operating room in order to provide real-time information about patients' status and manage the many components involved during the perioperative journey. OBJECTIVE: The aim of this study was to explore both physicians' and family members' perceptions of the functionality and efficiency of the RTLS within the perioperative environment. METHODS: Semi-structured interviews were conducted with physicians and patients' family members to elicit various perspectives regarding the use of RTLSs throughout the perioperative process. Interviews were recorded and transcribed to extract key themes. RESULTS: Three themes gleaned from physician interviews were system weaknesses, perceptions of potential benefit, and benefits to family members. Three themes uncovered from family member interviews included convenience, ameliorating anxiety, and reducing interruptions. CONCLUSION: Overall, physicians reported that the RTLS had potential to enhance workflow but that significant improvement regarding its implementation and use was needed to reach its full benefit. Family members were unanimous that it provides them with all the tracking information they desire.

Descripción de las herramientas de comunicación utilizadas en el área quirúrgica y la perspectiva de los instrumentadores quirúrgicos / Description of communication tools practices in the surgical area and the perspective of surgical instrumenters

La comunicación efectiva dentro de las organizaciones es uno de los factores más importantes para lograr un trabajo positivo y eficaz. Se realizó una investigación cuyo objetivo fue identificar y describir las herramientas de comunicación en el área de Quirófano Central del Hospital Italiano de Buenos Aires y las distintas perspectivas de los instrumentadores quirúrgicos respecto de su utilización. Métodos: se realizó un estudio de corte transversal con un componente de observación participativa de los medios de comunicación y una encuesta a los instrumentadores quirúrgicos de la institución. Resultados: se identificaron ocho tipos de herramientas de comunicación en el área quirúrgica. El correo electrónico (e-mail) como herramienta de comunicación es muy utilizado según los instrumentadores quirúrgicos, pero estos sugirieron otras herramientas más directas, como reuniones y capacitaciones solas o en combinación para determinados tipos de información. Conclusiones: los instrumentadores quirúrgicos utilizan una amplia gama de medios de comunicación en el área quirúrgica. La distribución de preferencias según el tipo de información indica que la elección de estos medios debería ser personalizada. (AU)

Effective communication within organizations is one of the most important factors to achieve a positive and effective work. An investigation was carried out and its objective was to identify and describe the communication tools in the surgical area of the Hospital Italiano de Buenos Aires and the different perspectives of the surgical nurses regarding its use. Methods: a cross-sectional study was carried out with a component of participative observation of the communication tools and a survey of the surgical nurses of the institution. Results: eight types of communication tools were identified in the surgical area. The implementation of email as a communication tool is widely used by surgical nurses, but they suggested other more direct tools such as meetings and training sessions alone or in combination for certain types of information. Conclusions: Surgical nurses use a wide range of communication tools in the surgical area. The distribution of preferences according to the type of information indicates that the choice of these tools should be personalized. (AU)

An evaluation of perioperative communication in the operating room.

Communication failures can lead to sentinel events in the operating room. Knowledge of basic surgical steps is important for all team members to ensure work flow efficiency. Surgeons and non-surgeons were surveyed to determine perceived and actual quality of communication between team members, using knowledge of surgical steps as a marker of communication quality. Participants agreed that communication was important, but non-surgeons were unable to name the four key steps of a laparoscopic cholecystectomy (p = 5.0E-07), indicating poor communication between surgeons and non-surgeons.

Patient Survey of Referral From One Surgeon to Another to Reduce Maximum Waiting Time for Elective Surgery and Hours of Overutilized Operating Room Time.

BACKGROUND: Studies of shared (patient-provider) decision making for elective surgical care have examined both the decision whether to have surgery and patients' understanding of treatment options. We consider shared decision making applied to case scheduling, since implementation would reduce labor costs. METHODS: Study questions were presented in sequence of waiting times, starting with 4 workdays. "Assume the consultant surgeon (ie, the surgeon in charge) you met in clinic did not have time available to do your surgery within the next 4 workdays, but his/her colleague would have had time to do your surgery within the next 4 workdays. Would you have wanted to discuss with a member of the surgical team (eg, the scheduler or the surgeon) the availability of surgery with a different, equally qualified surgeon at Mayo Clinic who had time available within the next 4 workdays, on a date of your choosing?" There were 980 invited patients who underwent lung resection or cholecystectomy between 2011 and 2016; 135 respondents completed the study and 6 respondents dropped out after the study questions were displayed. RESULTS: The percentages of patients whose response to the study questions was "4 days" were 58.8% (40/68) among lung resection patients and 58.2% (39/67) among cholecystectomy patients. The 97.5% 2-sided confidence interval for the median maximum wait was 4 days to 4 days. Patients' choices for the waiting time sufficient to discuss having another surgeon perform the procedure did not differ between procedures (P = .91). Results were insensitive to patients' sex, age, travel time to hospital, or number of office visits before surgery (all P ≥ .20). CONCLUSIONS: Our results indicate that bringing up the option with the patient of changing surgeons when a colleague is available and has the operating room time to perform the procedure sooner is being respectful of most patients' individual preferences (ie, patient-centered).

La calidad en el Bloque Quirúrgico del Hospital Clínico San Cecilio. La perspectiva del cliente interno / Quality in the anesthesia department of San Cecilio Hospital from the professionals' perspective

Objetivo. Evaluar la calidad de los servicios prestados por el Bloque Quirúrgico (BQ) del Hospital Clínico Universitario San Cecilio (HUSC), desde el punto de vista del personal sanitario del hospital. Material y métodos. Emplazamiento: Andalucía. Participantes: 134 profesionales con contacto con el BQ del HUSC. Instrumento: cuestionario de elaboración propia, con las siguientes dimensiones: accesibilidad, trato personal, confortabilidad, calidad científico-técnica (escala 1-5 puntos), satisfacción global (escala 0-10) y propuestas de mejora. El análisis incluyó estudio descriptivo, correlación, diferencia de medias (según sexo, frecuencia de la relación y unidad de gestión clínica [UGC]) y modelo de regresión lineal. Resultados. La calidad del trato tuvo una media de 4,2 puntos (DT 0,5), la calidad científico-técnica de 4,0 (DT 0,5), la accesibilidad de 3,3 (DT 0,7), el confort del personal sanitario de 3,3 puntos (DT 0,9) y de los pacientes de 2,6 (DT 1,0). La satisfacción total con las prestaciones del BQ fue de 7,1 (escala 0-10). La evaluación del BQ es mejor entre las mujeres y las UGC con menos de 10 profesionales. Peor valoración se recibe por parte de las UGC con contacto diario con el BQ. Entre las propuestas de mejora se recogieron: reducir listas de espera, crear espacios de información a familiares, mejorar las condiciones laborales, la formación y la satisfacción del personal del BQ, la comunicación y colaboración interprofesional. Conclusiones. La evaluación realizada por profesionales sanitarios de otras UGC muestra la necesidad de formación del personal del BQ, así como de intervenciones en la organización e infraestructuras, con el objetivo de mejorar la calidad asistencial y la satisfacción general de profesionales y ciudadanía (AU)

Objective. To evaluate the quality of the services provided by the anaesthesia department of the San Cecilio Clinical University Hospital, from the health professionals’ point of view. Material and methods. Location: Andalusia. Participants: 134 health professionals in contact with the hospital anaesthesia department. Tool: self-administered questionnaire, measuring: accessibility, personal treatment, comfort, scientific and technical quality (scale 1 to 5), overall satisfaction (scale 0 to 10), and suggestions for improvement. A descriptive statistical and correlation analysis were performed, including mean differences (by sex, frequency of contact with the anaesthesia department, and unit), as well as a regression model. Results. The quality of personal treatment received a mean of 4.2 points (SD 0.651), the scientific and technical quality 4.00 points (SD 0.532), accessibility 3.3 (SD 0.795), professional comfort 3.30 (SD 0.988), and patient comfort 2.62 points (SD 1.051). Overall satisfaction obtained a mean of 7.1 points (0 to 10 scale). Women and professionals working in units with less than 10 people had a better general evaluation of the anaesthesia department. The worse perspective was that of staff with daily contact with the anaesthesia department. Among the suggestions for improvement there were: Reducing waiting lists, creating special rooms to give information to families, improving working conditions, training and work satisfaction for staff, and achieving better communication and collaboration between health professionals. Conclusions. The internal evaluation shows the need for training strategies and organisational interventions in the anaesthesia department, in order to achieve a better quality and satisfaction for both professionals and patients (AU)

Implications of Perioperative Team Setups for Operating Room Management Decisions.

BACKGROUND: Team performance has been studied extensively in the perioperative setting, but the managerial impact of interprofessional team performance remains unclear. We hypothesized that the interplay between anesthesiologists and surgeons would affect operating room turnaround times, and teams that worked together over time would become more efficient. METHODS: We analyzed 13,632 surgical cases at our hospital that involved 64 surgeons and 48 anesthesiologists. We detrended and adjusted the data for potential confounders including age, American Society of Anesthesiologists physical status, and surgical list (scheduled cases of specific surgical specialties). The surgical lists were categorized as ear, nose, and throat surgery; trauma surgery; general surgery; and gynecology. We assessed the relationship between turnaround times and assignment of different anesthesiologists to specific surgeons using a Monte Carlo simulation. RESULTS: We found significant differences in team performances among the different surgical lists but no team learning. We constructed managerial decision tables for the assignment of anesthesiologists to specific surgeons at our hospital. We defined a decision algorithm based on these tables. Our analysis indicated that had this algorithm been used in staffing the operating room for the surgical cases represented in our data, median turnaround times would have a reduction potential of 6.8% (95% confidence interval 6.3% to 7.1%). CONCLUSIONS: A surgeon is usually predefined for scheduled surgeries (surgical list). Allocation of the right anesthesiologist to a list and to a surgeon can affect the team performance; thus, this assignment has managerial implications regarding the operating room efficiency affecting turnaround times and thus potentially overutilized time of a list at our hospital.

Resident Physicians Improve Nontechnical Skills When on Operating Room Management and Leadership Rotation.

BACKGROUND: Anesthesiology residency primarily emphasizes the development of medical knowledge and technical skills. Yet, nontechnical skills (NTS) are also vital to successful clinical practice. Elements of NTS are communication, teamwork, situational awareness, and decision making. METHODS: The first 10 consecutive senior residents who chose to participate in this 2-week elective rotation of operating room (OR) management and leadership training were enrolled in this study, which spanned from March 2013 to March 2015. Each resident served as the anesthesiology officer of the day (AOD) and was tasked with coordinating OR assignments, managing care for 2 to 4 ORs, and being on call for the trauma OR; all residents were supervised by an attending AOD. Leadership and NTS techniques were taught via a standardized curriculum consisting of leadership and team training articles, crisis management text, and daily debriefings. Resident self-ratings and attending AOD and charge nurse raters used the Anaesthetists' Non-Technical Skills (ANTS) scoring system, which involved task management, situational awareness, teamwork, and decision making. For each of the 10 residents in their third year of clinical anesthesiology training (CA-3) who participated in this elective rotation, there were 14 items that required feedback from resident self-assessment and OR raters, including the daily attending AOD and charge nurse. Results for each of the items on the questionnaire were compared between the beginning and the end of the rotation with the Wilcoxon signed-rank test for matched samples. Comparisons were run separately for attending AOD and charge nurse assessments and resident self-assessments. Scaled rankings were analyzed for the Kendall coefficient of concordance (ω) for rater agreement with associated χ and P value. RESULTS: Common themes identified by the residents during debriefings were recurrence of challenging situations and the skills residents needed to instruct and manage clinical teams. For attending AOD and charge nurse assessments, resident performance of NTS improved from the beginning to the end of the rotation on 12 of the 14 NTS items (P < .05), whereas resident self-assessment improved on 3 NTS items (P < .05). Interrater reliability (across the charge nurse, resident, and AOD raters) ranged from ω = .36 to .61 at the beginning of the rotation and ω = .27 to .70 at the end of the rotation. CONCLUSIONS: This rotation allowed for teaching and resident assessment to occur in a way that facilitated resident education in several of the skills required to meet specific milestones. Resident physicians are able to foster NTS and build a framework for clinical leadership when completing a 2-week senior elective as an OR manager.

[Intelligent operating room suite : From passive medical devices to the self-thinking cognitive surgical assistant]. / Der intelligente Operationssaal : Vom passiven Gerätepark zum mitdenkenden, kognitiven Assistenten.

Modern operating room (OR) suites are mostly digitally connected but until now the primary focus was on the presentation, transfer and distribution of images. Device information and processes within the operating theaters are barely considered. Cognitive assistance systems have triggered a fundamental rethinking in the automotive industry as well as in logistics. In principle, tasks in the OR, some of which are highly repetitive, also have great potential to be supported by automated cognitive assistance via a self-thinking system. This includes the coordination of the entire workflow in the perioperative process in both the operating theater and the whole hospital. With corresponding data from hospital information systems, medical devices and appropriate models of the surgical process, intelligent systems could optimize the workflow in the operating theater in the near future and support the surgeon. Preliminary results on the use of device information and automatically controlled OR suites are already available. Such systems include, for example the guidance of laparoscopic camera systems. Nevertheless, cognitive assistance systems that make use of knowledge about patients, processes and other pieces of information to improve surgical treatment are not yet available in the clinical routine but are urgently needed in order to automatically assist the surgeon in situation-related activities and thus substantially improve patient care.

A Study on the Effect on Scheduling and Management of Surgeries with the Introduction of Excellent Medical Information.

The services of OR play an important role in the medical business for department of surgery. The most important issue for OR is about the scheduling and management of surgeries. Good surgery schedule could elevate the utilization efficiency of OR. Therefore, the introduction of excellent medical information can both dramatically elevate the work efficiency of health care employees and reduce workload to reach win-win benefits in both management and performance.

Management implications for the perioperative surgical home related to inpatient case cancellations and add-on case scheduling on the day of surgery.

BACKGROUND: The American Society of Anesthesiologists has embraced the concept of the Perioperative Surgical Home as a means through which anesthesiologists can add value to the health systems in which they practice. One key listed element of the Perioperative Surgical Home is to support "scheduling initiatives to reduce cancellations and increase efficiency." In this study, we explored the potential benefits of the Perioperative Surgical Home with respect to inpatient cancellations and add-on case scheduling. We evaluated 6 hypotheses related to the timing of inpatient cancellations and preoperative anesthesia evaluations. METHODS: Inpatient cancellations were studied during 26 consecutive 4-week intervals between July 2012 and June 2014 at a tertiary care academic hospital. All timestamps related to scheduling, rescheduling, and cancellation activities were retrieved from the operating room (OR) case scheduling system. Timestamps when patients were seen by anesthesia residents were obtained from the preoperative evaluation system database. Batch mean methods were used to calculate means and SE. For cases cancelled, we determined whether, for "most" (>50%) cancellations, a subsequent procedure (of any type) was performed on the patient within 7 days of the cancellation. Comparisons with most and other fractions were assessed using the 1 group, 1-sided Student t test. We evaluated whether a few procedures were highly represented among the cancelled cases via the Herfindahl (Simpson's) index, comparing it with <0.15. The rate of scheduling activity was assessed by computing the number of OR scheduling office decisions in each 1-hour bin between 6:00 AM and 3:59 PM. These values were compared with ≥1 decision per hour at the study hospital. RESULTS: Data from 24,735 scheduled inpatient cases were assessed. Cases cancelled after 7 AM on the day before or at any time on the scheduled day of surgery accounted for 22.6% ± 0.5% (SE) of the scheduled minutes all scheduled cases, and 26.8% ± 0.4% of the case volume (i.e., number of cases). Most (83.1% ± 0.6%, P < 10) cases performed were evaluated on the day before surgery. Most (67.6% ± 1.6%, P < 10) minutes of cancelled cases were evaluated on the day before surgery. Most (62.3% ± 1.5%, P < 10) cases were seen earlier than 6:00 PM of the day before surgery. The Herfindahl index among cancelled procedures was 0.021 ± 0.001 (P < 10 compared not only to <0.15 but also to <0.05), showing large heterogeneity among the cancelled procedures. A subsequent procedure was not performed for most cancelled cases (50.6% ± 0.9% compared with >50%, P = 0.12), implying that the indication for the cancelled procedure no longer existed or the patient/family decided not to proceed with surgery. When only cancellations on the scheduled day of surgery were considered, the cancellation rate was 14.0% ± 0.3% of scheduled inpatient minutes and 11.8% ± 0.2% of scheduled inpatient cases. There were 0.59 ± 0.02 OR schedule decisions per hour per 10 ORs between 6:00 AM and 3:59 PM (P < 10, corresponding to ≥1 decision per hour at the 36 OR study hospital). CONCLUSIONS: The study hospital had a high inpatient cancellation rate, despite the fact that most patients whose cases were cancelled were seen by an anesthesia resident by 6:00 PM of the day before surgery. This finding suggests that further efforts to reduce the cancellations by seeing patients sooner on the day before surgery, or seeing even more patients the day before surgery, would not be an economically useful focus of the Perioperative Surgical Home. The wide heterogeneity among cancelled cases indicates that focusing on a few procedures would not materially affect the overall cancellation rate. The relatively low rate of subsequent performance of a procedure on patients whose cases had been cancelled suggests that trying to decrease the cancellation rate might be medically counterproductive. The hourly rate of decisions in the scheduling office during regular work hours on the day of surgery highlights the importance of decisions made at the OR control desk and scheduling office throughout the day to reduce the hours of overused OR time. These data suggest that efforts of the Perioperative Surgical Home related to inpatient cancellations should focus on management decision-making to mitigate the disruptions to the planned OR schedule caused by inpatient case cancellations and add-on cases, more so than on efforts to reduce inpatient cancellation rates.

Managing uncertainties in the surgical scheduling.

Current surgical scheduling system has difficulties to handle unpredictable events or uncertainties. Source of uncertainties may come from the patient or the surgery itself, where several cases require immediate changes in data, such as when surgery delays or cancellation occurs on the same day. The study aimed to model the uncertainties for managing identified uncertainties during the continuous scheduling, framed by resilience concept to cope with the system fragility. In order to be able to control and adjust any changes which may affect the surgery schedule of the day, we provide alternatives of solution rather than strictly decide the best valued options. We identified dimensions of uncertainties and categorized them based on the resilience concept, computed the impact value of potentially conflicted resources as a result of schedule change. With the model applied, we would provide a list of most acceptable and less vulnerable alternatives for anesthesiologist as a scheduler to build resilience in the surgical scheduling.

Positioning patient status monitors in a family waiting room.

OBJECTIVE: To determine where to place patient status displays for family members in the operating room family waiting room at The Children's Hospital of Philadelphia. METHODS: We calculated the percentage of seats from which wall monitors placed in hypothetical positions would be usable. We validated the usability of the new monitors by observing nonemployees' use of monitors in the waiting room 1 week before and 1 week after implementation. RESULTS: Compared to the legacy monitor, the new monitors were observed to be used from more locations within the waiting room and more people were observed to use the new monitors soon after entering the waiting room. CONCLUSIONS: Seemingly trivial decisions like where in a waiting room to place monitors can be informed by careful data collection and the consequences can observably impact communication between hospital staff and family members waiting for loved ones in surgery.

Information needs for the OR and PACU electronic medical record.

OBJECTIVE: The amount of clinical information that anesthesia providers encounter creates an environment for information overload and medical error. In an effort to create more efficient OR and PACU EMR viewer platforms, we aimed to better understand the intraoperative and post-anesthesia clinical information needs among anesthesia providers. MATERIALS AND METHODS: A web-based survey to evaluate 75 clinical data items was created and distributed to all anesthesia providers at our institution. Participants were asked to rate the importance of each data item in helping them make routine clinical decisions in the OR and PACU settings. RESULTS: There were 107 survey responses with distribution throughout all clinical roles. 84% of the data items fell within the top 2 proportional quarters in the OR setting compared to only 65% in the PACU. Thirty of the 75 items (40%) received an absolutely necessary rating by more than half of the respondents for the OR setting as opposed to only 19 of the 75 items (25%) in the PACU. Only 1 item was rated by more than 20% of respondents as not needed in the OR compared to 20 data items (27%) in the PACU. CONCLUSION: Anesthesia providers demonstrate a larger need for EMR data to help guide clinical decision making in the OR as compared to the PACU. When creating EMR platforms for these settings it is important to understand and include data items providers deem the most clinically useful. Minimizing the less relevant data items helps prevent information overload and reduces the risk for medical error.

Applications for radio-frequency identification technology in the perioperative setting.

We implemented a two-year project to develop a security-gated management system for the perioperative setting using radio-frequency identification (RFID) technology to enhance the management efficiency of the OR. We installed RFID readers beside the entrances to the OR and changing areas to receive and process signals from the RFID tags that we sewed into surgical scrub attire and shoes. The system also required integrating automatic access control panels, computerized lockers, light-emitting diode (LED) information screens, wireless networks, and an information system. By doing this, we are able to control the flow of personnel and materials more effectively, reduce OR costs, optimize the registration and attire-changing process for personnel, and improve management efficiency. We also anticipate this system will improve patient safety by reducing the risk of surgical site infection. Application of security-gated management systems is an important and effective way to help ensure a clean, convenient, and safe management process to manage costs in the perioperative area and promote patient safety.

Explanation for the near-constant mean time remaining in surgical cases exceeding their estimated duration, necessary for appropriate display on electronic white boards.

BACKGROUND: Consider a case that has been ongoing for longer than the scheduled duration. The anesthesiologist estimates that there is 1 hour remaining. Forty-five minutes later the case has not yet finished, and closure has not yet started. We showed previously that the mean (expected) time remaining is approximately 1 hour, not 15 minutes. The relationship is a direct mathematical consequence of the log-normal probability distributions of operating room (OR) case durations. We test the hypothesis that, with an accurate probabilistic model, until closure begins the estimated mean time remaining would be the mean time from the start of closure to OR exit. METHODS: Among the 311,940 OR cases in a 7-year time series from 1 hospital, there were 3962 cases for which (1) there had been previously at least 30 cases of the same combination of scheduled procedure(s), surgeon, and type of anesthetic and (2) the actual OR time exceeded the 0.9 quantile of case duration before the case started. A Bayesian statistical method was used to calculate the mean (expected) minutes remaining in the case at the 0.9 quantile. The estimate was compared with the actual minutes from the time of the start of closure until the patient exited the OR. RESULTS: The mean ± standard error of the pairwise difference was 0.2 ± 0.4 minutes. The Bayesian estimate for the 0.9 quantile was exceeded by 10.2% ± 0.01% of cases (i.e., very close to the desired 10.0% rate). CONCLUSIONS: If a case is taking longer than the expected (scheduled) duration, closure has not yet started, and someone in the OR is asked how much time the case likely has remaining, the value recorded on a clipboard for viewing later should be the estimated time remaining (e.g., "1 hour") not an end time (e.g., "5:15 pm"). Electronic whiteboard displays should not show that the estimated time remaining in the case is less than the mean time from start of closure to OR exit. Similarly, if closure has started, the expected time remaining that is displayed should not be longer than the mean time from closure to OR exit. Finally, our results match previous reports that, before a case starts, statistical methods can reliably be used to assist in decisions involving the longest amount of time that cases may take (e.g., conflict checking for resources, filling holes in the OR schedule, and preventing holes in the schedule).