Case Start Times Research Articles

Su1271 Nonanesthesiologist Administration of Propofol Boluses vs. Continuous Infusion Plus Boluses for Outpatient Colonoscopy: A Randomized Study

used to optimize manufacturing processes for several decades. Our aim for this pilot study was to demonstrate the value of discrete event simulation in optimizing endoscopy unit efficiency. Methods: Through a series of site visits and web conferences, we built an animated discrete event simulation model of a six-room gastrointestinal endoscopy unit at a single academic health care facility in Washington, DC. Procedures performed in the unit include colonoscopy, upper endoscopy, single balloon enteroscopy, endoscopic ultrasound and ERCP. Endoscopy unit staff electronically captured time data for the model using a commercially available software suite between January and June 2011. Simulation software was used for model creation. After validating the baseline model, we simulated a series of scenario analyses to compare the performance measures of the baseline model with the results from alternative configurations of unit flow and operational characteristics. Key outcome measures included: patient flow time from arrival to discharge; first case start time; and procedure room utilization Results: The animated simulation model is represented below in figure 1. Average patient flow time was 170 minutes. Average procedure room utilization ranged from 51%-77% and pre-op utilization averaged 44%. The first procedure of the day, scheduled to begin at 8am, began between 8:18am and 8:28am. The bathrooms in the pre-op area were identified as a bottleneck for the first cases of the day as patients waited to change prior to being prepped for their procedure. The model suggested that an 8am start time could be achieved with minor changes in unit flow, including prepping one patient in the procedure room in place of pre-op and shifting the prep time 15 minutes earlier in the morning. Conclusions: Discrete event simulation modeling is an effective tool for studying the capacity and operational efficiency of endoscopy units, which in turn may have a direct impact on improving patient experience and reducing the cost of providing endoscopic services. Further modeling efforts are underway to understand how alternative appointment schedules, staffing arrangements and patient flow patterns can optimize unit efficiency.

Abstract 30: Real-Time Review of AF Ablation Quality Metrics Improves Patient Outcomes and Resource Utilization

Background: Atrial fibrillation is an extremely prevalent condition with a high level of associated morbidity, mortality and healthcare resource utilization. Catheter-based ablation is an effective tool for the management of symptomatic AF patients, however the procedure is technically and logistically complex. Data describing process improvement within the context of an AF ablation program are limited. Methods: We developed an AF Treatment Registry to track patients undergoing AF ablation. Our primary purpose was to conduct real-time review of pre-specified quality and resource utilization outcomes, thereby facilitating process improvement. Patient characteristics and procedural details were collected at the time of ablation and at regular intervals thereafter. Members of a multidisciplinary AF treatment team reviewed registry data on a weekly basis. Operational deficiencies were identified and changes implemented. In this study, we evaluated the impact of our intervention on AF ablation case start time, case duration and procedural adverse outcomes. Results: In the six months prior to our intervention, mean AF ablation case start time was 8:31 AM (n=12), mean case duration was 203 minutes (n=24), mean procedural transseptal time was 228 minutes (n=24) and the rate of adverse outcomes was 16.7% (n=24). Over a 20-month period post-intervention, concurrent with process improvement efforts, 104 patients presented for AF ablation. During the last six months of the study period, the rate of adverse outcomes decreased to 0% (n=35, p=0.13), average case start time improved by 52 minutes (n=21, p<0.01), mean case duration decreased by 34 minutes (n=35, p<0.01) and mean procedural transseptal time decreased by 46 minutes (n=35, p=0.05). Conclusion: Use of a registry to facilitate real-time review of AF ablation outcomes and quality metrics was associated with a decrease in adverse events and an increase in the efficiency of hospital resource utilization. Although the non-randomized nature of this study precludes an assumption of causality, we hypothesize that real-time review and feedback was the primary driver of performance improvement.

Turnover time in arthroscopic shoulder surgery: A reduction of 18% by three simple strategies

Purpose: The aim of the study was to determine whether 3 strategies such as parallel anesthetic induction, improving first case start times, and dedicating porters to surgical theatres could reduce turnover times. Methods: A prospective interventional clinical study of operating room processes was conducted in a day surgery facility during arthroscopic shoulder surgery. The study included a 10-week observation period, then a 2-week education period, followed by a 10-week intervention period. Three intervention strategies were used as (1) parallel anesthetic induction, defined as performing the anesthetic induction on the next patient during the intraoperative period of the currently anesthetized patient; (2) a dedicated porter system, in which the porter completed his duties of room clean up and next patient prep before leaving the room; and (3) starting the first case within 10 minutes of scheduled start time. The major outcome was turnover time—the time between end of skin closure of the first patient to knife to skin of the next patient in the same theater. Minor outcomes included porter time (wheel out to wheel in), first case start times, and cost savings. Results: Intervention of the 3 strategies reduced turnover time by 9 minutes (18%), from 51±10 minutes (mean±SD) to 42±9 minutes. Porter times were reduced by 6 minutes (27%). First case start times improved by 12 minutes, although this did not affect turnover time per se. Total time savings per day was 61 minutes. The reduction in turnover time and improvement in first case start times resulted in a minimum net financial benefit of $430 per day to the day surgery facility.

Review of the 23rd Annual Meeting of the Society for Pediatric Anesthesia

Review of the 23rd Annual Meeting of the Society for Pediatric Anesthesia

Arterial access and door‐to‐balloon times for primary percutaneous coronary intervention in patients presenting with acute ST‐elevation myocardial infarction

This study compares the transradial versus the transfemoral approach for time to intervention for patients presenting with ST elevation myocardial infarction (STEMI). Survival following STEMI is associated with reperfusion times (door-to-balloon; D2B). For patients undergoing primary PCI for acute STEMI, potential effects of transradial approach (r-PCI) as compared with the femoral artery approach (f-PCI) on D2B times have not been extensively studied. Consecutive patients presenting with STEMI at a tertiary care medical center were enrolled in a comprehensive-Heart Alert program (HA) and included in this analysis. Time parameters measured included: door-to-ECG, ECG-to-HA activation, HA activation-to-cath lab team arrival, patient arrival in cath lab to arterial access, and arterial access-to-balloon inflation. Of 240 total patients, 205 underwent successful PCI (n = 124 r-PCI; n = 116 f-PCI). No significant difference was observed in the pre-cath lab times. Mean case start times for r-PCI took significantly longer (12.5 +/- 5.4 min vs. 10.5 +/- 5.7 min, P = 0.005) due to patient preparation. Once arterial access was obtained, balloon inflation occurred faster in the r-PCI group (18.3 vs. 24.1 min; P < 0.001). Total time from patient arrival to the cardiac cath lab to PCI was reduced in the r-PCI as compared to the f-PCI group (28.4 vs. 32.7 min, P = 0.01). There was a small but statistical difference in D2B time (r-PCI 76.4 min vs. f-PCI 86.5 min P = 0.008). Patients presenting with STEMI can undergo successful PCI via radial artery approach without compromise in D2B times as compared to femoral artery approach.

Setting Performance Standards for an Anesthesia Department

The Stanford University Department of Anesthesia established performance standards by identifying aspects of their service that were related to an important “customer’s” perception of quality. A “quality grid” targeted service attributes that surgeons scored high for importance and low for performance. Control charts and flow charts helped establish reasonable performance levels for “timely first case starts” and “turnaround time.” Control charts indicated that a reasonable performance standard for timely first case starts was “less than 20% of first case delays will be related to anesthesia activities.” For turnaround time, the standard was set at “less than 10% of all turnaround times will be greater than 15 minutes, because of anesthesia-related activities.” After instituting performance standards, the performance for first case start times improved from a 36% defective rate to a 9% defective rate. Anesthesia-related delays in turnaround times stabilized at a 16% defective rate. Using appropriate service standards can improve performance.