Optimal Operating Room Research Articles

Ergonomic Considerations in Urologic Surgery

This paper aims to discuss the various work-related musculoskeletal disorders (WRMDs) among urologists and provide an overview of the latest recommendations to improve awareness of ergonomic principles that can be applied in the operating room, with special consideration of challenges faced during pregnancy. Urologists suffer from a large burden of WRMDs. The main drivers of pain associated with the various surgical approaches include repetitive movements, static and awkward body positions, and the use of burdensome equipment. Pregnant surgeons are at an even greater risk of WRMDs and face high rates of pregnancy complications. Laparoscopy, endoscopy, robot-assisted surgeries, and open surgeries present unique ergonomic challenges for the practicing urologist. Proper posture and equipment use, optimal operating room setup, intraoperative stretching breaks, and an emphasis on teaching ergonomic principles can reduce the risk of WRMDs. Surgeons are also at increased risk of WRMDs during pregnancy but may continue to operate while taking measures to limit physical exertion and fatigue. Improving awareness of and incorporating ergonomic principles early in a urologist's career may reduce the risk of injury and improve operative performance and longevity.

Assessing Root Causes of First Case On-time Start (FCOTS) Delay in the Orthopedic Department at a Busy Level II Community Teaching Hospital.

INTRODUCTIONDue to the high cost of operating room time, hospitals have been under increasing pressure to optimize operating room (OR) efficiency. One parameter that has been used to predict OR efficiency is First Case On-Time Start (FCOTS). In this brief report, the authors describe results from a quality improvement project designed to identify the rates and primary causes of first case delay for elective procedures within the orthopedic department at their suburban community hospital.METHODSThis was a retrospective, quality improvement project. The authors reviewed information from their anesthesia group to identify the rate and causes for delayed FCOTS, as well as observations and employee interviews to map contributing factors of delay.RESULTSSurgery data on 159 days reviewed indicated that 107 (67.3%) days had first case delays. Of the 398 total first cases during this period, 156 (39.2%) were found to be delayed. The authors identified surgeon practices, with 74 (56.5%) as the main contributor to delay, followed by pre-operative processes, with 24 (18.3%), and room-related causes, 17 (13.0%). The anesthesia department and the patient were minor causes of delay, with 9 (6.9%) and 7 (5.3%) of case delays respectively.DISCUSSIONResults were similar to other studies, indicating surgeons and pre-operative as main cause for delay. A fishbone diagram revealed patient factors, inefficiency in the pre-operative process, and staff tardiness as some of the causes.CONCLUSIONSDuring this project, surgeon practices and preoperative processes were the main factors contributing to OR inefficiency within the community-based hospital. Future strategies to improve daily OR flow within similar institutions should target surgeon on-time arrival and streamlining of the pre-operative process to effectively reduce FCOTS delays.

Optimizing the robotic surgery team: an operations management perspective.

To assess the critical threshold to optimize operating room (OR) time for each surgical team member in robotically assisted sacrocolpopexy (RASCP) and to evaluate the most efficient team compositions. All women who underwent RASCP for pelvic organ prolapse (POP) were prospectively entered in a database. Patients having unrelated concomitant surgery were excluded. Our primary outcome measure was total OR time. We utilized factor analysis, regression analysis, and analysis of variance, OR time mapping, and stochastic optimization to identify 'optimal' surgical team configuration. The database included 359 consecutive RASCPs, all performed for stage III-IV POP: 156 (43%) were with total and 44 (12%) supracervical hysterectomies and 159 (44%) post-hysterectomy. Mean age was 58.6 ± 9.3years. Mean parity was 2.8 ± 1.4, and mean body mass index was 28 ± 4.7kg/m2. A total of 4 surgeons, 34 first assistants, 20 circulating nurses, 15 surgical technologists, and 59 anesthesiologist/nurse anesthetists were involved. Optimal experience levels for each team member were achieved at the following number of robotic procedures: surgeon 44; first assistant 13; surgical technologist 66; circulating nurse 56; anesthesia provider 46. Our analysis revealed that the surgical technologist and first assistant played the most significant roles within the team. The surgeon was ranked third followed by the circulating nurse and anesthesia provider, respectively. Operating time in robotic surgery is multifactorial. Experience of each member of a robotic surgery team is critical. An optimal team can be composed of a variety of combinations of experience levels among the robotic team members.

Utilizing Lean Methodology to Optimize Operating Room Efficiency: A Multidisciplinary Process Mapping Exercise.

Utilizing Lean Methodology to Optimize Operating Room Efficiency: A Multidisciplinary Process Mapping Exercise.

1187 Utilizing Lean Methodology to Optimize Operating Room Efficiency: A Multidisciplinary Process-Mapping Exercise

Study Objective Optimizing surgical capacity while maintaining high quality patient care is an ongoing challenge in the operating room, particularly for complex procedures requiring significant resources, such as robotic hysterectomy. Process Mapping is a Quality Improvement (QI) strategy which can identify common barriers to surgical efficiency and quality of care by dividing a process into its individual components and analyzing each step separately. Our aim was to design an ideal-state intraoperative pathway for robotic hysterectomy in order to improve operating room efficiency and minimize case cancellation. Design Surgical care team members were invited to a meeting where process steps were evaluated and suggestions for improvements were identified. Various QI/LEAN methodologies were utilized including affinity diagrams with multi-voting, parallel processing strategies and checklist development. Setting Canadian tertiary-care academic hospital Patients or Participants A “current-state” process map for robotic hysterectomy was developed with input from the intraoperative care team consisting of gynecologists, anesthesiologists and nursing staff Interventions Output from the exercise included the design of a “future-state/ideal-state” process map incorporating proposed multidisciplinary strategies for improved efficiency and plans for subsequent implementation. Measurements and Main Results In the 5 months following introduction of the ideal-state process map, mean surgical case time for robotic hysterectomy decreased by 28 mins (11%) and case cancellation rate decreased by 70%. Mean case time, case cancellation rates and the acceptability of proposed interventions will be analyzed in a recurring fashion as part of a Plan-Do-Study-Act (PDSA) cycle. Conclusion A multi-disciplinary approach to improving operating room efficiency allowed for sharing of responsibility and improved communication between team members. Engagement of all stakeholders is fundamental to ensuring accurate analysis of current process flow and successful deployment of QI strategies. This process mapping exercise can be easily applied to other surgical procedures and expanded for use in surgical teaching and education.

A random forest and simulation approach for scheduling operation rooms: Elective surgery cancelation in a Chinese hospital urology department.

Many hospitals encounter surgery cancelations for various reasons. We present a methodology applying data mining and simulation to optimize operating room (OR) scheduling in a urology department in West China Hospital. To the best of our knowledge, this is 1 of the first efforts to seek an optimal schedule solution based on cancelation risk of elective surgeries as well as OR allocation between elective and nonelective surgeries. First, chi-square test and random forest prediction modeling were used to predict potential elective surgeries with high cancelation risk, and the factors, including surgeon, number of days since admission of patient, first surgery or not, etc., that influence elective surgery cancelation were identified. Second, a simulation technology was designed to compare 7 different scheduling strategies. The results demonstrated that for elective surgery, cancelation rate low surgery first outperformed the others and increased the productivity of the ORs from 72% to 83%, while for nonelective surgery performed in a separate OR, there was no improvement because the supply was greater than necessary at present. However, in total, the selected strategies led to 7% higher productivity.

ISQUA16-2984COMPUTER AIDED QUALITY ASSURANCE IN THE PLANNING OF THE SURGICAL PATHWAY

The surgical pathway is a complex, cost-intensive activity within a hospital that should be managed efficiently. The aim of this study is to automatically manage the scheduling of the operating theatre through real-time monitoring of all critical steps in the perioperative process and to present this information in a structured and understandable fashion to the personnel. We optimize operating room (OR) planning and scheduling by predicting OR time using the information that is available in the preoperative and perioperative phase. …

Optimal operating room scheduling for normal and unexpected events in a smart hospital

A smart hospital can react to emergencies and unexpected events in real time. Emergencies occur frequently in hospitals, and the number of lives saved should be maximized. Because emergency patients disrupt established schedules of hospital operating room, proactive techniques should be employed to save as many lives as possible. In this study, three optimization models were developed for optimizing operating room scheduling during unexpected events and accommodating emergency patient surgeries in the established schedule. The first model (Model I) schedules emergency patients in newly opened rooms, whereas the second model (Model II) aims to assign emergency patients to untapped ranges; the third model (Model III) resequences elective and emergency patients in the room with the greatest free margin. This paper presents a real-life case study for illustration; the three models are adopted and the results are subsequently compared. In conclusion, the proposed models are expected to provide proactive plans for hospitals as well as enhance the performance and efficiency of operating rooms.

Process Simulation during the Design Process Makes the Difference: Process Simulations Applied to a Traditional Design

The objective is evaluation of a traditionally designed operating room using simulation of various surgical workflows. A literature search showed that there is no evidence for an optimal operating room layout regarding the position and size of an ultraclean ventilation (UCV) canopy with a separate preparation room for laying out instruments and in which patients are induced in the operating room itself. Neither was literature found reporting on process simulation being used for this application. Many technical guidelines and designs have mainly evolved over time, and there is no evidence on whether the proposed measures are also effective for the optimization of the layout for workflows. The study was conducted by applying observational techniques to simulated typical surgical procedures. Process simulations which included complete surgical teams and equipment required for the intervention were carried out for four typical interventions. Four observers used a form to record conflicts with the clean area boundaries and the height of the supply bridge. Preferences for particular layouts were discussed with the surgical team after each simulated procedure. We established that a clean area measuring 3 × 3 m and a supply bridge height of 2.05 m was satisfactory for most situations, provided a movable operation table is used. The only cases in which conflicts with the supply bridge were observed were during the use of a surgical robot (Da Vinci) and a surgical microscope. During multiple trauma interventions, bottlenecks regarding the dimensions of the clean area will probably arise. The process simulation of four typical interventions has led to significantly different operating room layouts than were arrived at through the traditional design process. Evidence-based design, human factors, work environment, operating room, traditional design, process simulation, surgical workflowsPreferred Citation: Traversari, R., Goedhart, R., & Schraagen, J. M. (2013). Process simulation during the design process makes the difference: Process simulations applied to a traditional design. Health Environments Research & Design Journal 6(2), pp 58-76.

Rapid Intraoperative Zygoma Fracture Imaging

A fractured zygoma frequently results in an aesthetically displeasing facial asymmetry. Open reduction and internal fixation may accurately realign the facial skeleton but often with undesirable sequelae. The authors' objective was to develop a precise technique of intraoperative zygoma fracture imaging using a C-arm to permit anatomical fracture realignment while reducing the extent of skeletal exposure required. The simplicity and accessibility of this method should allow its widespread clinical application. First, using a model skull, the relative positions of the C-arm required to adequately depict zygoma projection, width, arch contour, and zygoma rotation were defined. Second, diverse zygoma fracture types were created in six cadaver heads with a Mini Bionix machine and were repaired using C-arm guidance; accuracy was confirmed with postoperative computed tomography. Third, after defining optimal operating room setup, the accuracy in a clinical case was assessed. Two C-arm views were defined. The zygoma projection view (C-arm at 70 to 90 degrees to the skull's coronal plane) allows visualization of projection, width, and contour. The rotation view (C-arm at 70 to 90 degrees to the skull's sagittal plane) allows visualization of zygoma rotation. Postoperative computed tomographic imaging confirmed anatomical repair in all cases. Average operating room duration was less than 30 minutes, with operating room times decreasing progressively. The authors have developed an accurate technique of intraoperative zygoma fracture imaging and reduction guidance. This technique may decrease the risks of open access by potentially limiting direct skeletal exposure to buttresses where skeletal stabilization is required. In addition, this method is simple, can be learned and used rapidly, and is readily accessible.

A Simulation Model for Determining the Optimal Size of Emergency Teams on Call in the Operating Room at Night

Hospitals that perform emergency surgery during the night (e.g., from 11:00 pm to 7:30 am) face decisions on optimal operating room (OR) staffing. Emergency patients need to be operated on within a predefined safety window to decrease morbidity and improve their chances of full recovery. We developed a process to determine the optimal OR team composition during the night, such that staffing costs are minimized, while providing adequate resources to start surgery within the safety interval. A discrete event simulation in combination with modeling of safety intervals was applied. Emergency surgery was allowed to be postponed safely. The model was tested using data from the main OR of Erasmus University Medical Center (Erasmus MC). Two outcome measures were calculated: violation of safety intervals and frequency with which OR and anesthesia nurses were called in from home. We used the following input data from Erasmus MC to estimate distributions of all relevant parameters in our model: arrival times of emergency patients, durations of surgical cases, length of stay in the postanesthesia care unit, and transportation times. In addition, surgeons and OR staff of Erasmus MC specified safety intervals. Reducing in-house team members from 9 to 5 increased the fraction of patients treated too late by 2.5% as compared to the baseline scenario. Substantially more OR and anesthesia nurses were called in from home when needed. The use of safety intervals benefits OR management during nights. Modeling of safety intervals substantially influences the number of emergency patients treated on time. Our case study showed that by modeling safety intervals and applying computer simulation, an OR can reduce its staff on call without jeopardizing patient safety.

Predicting Patient Nonappearance for Surgery as a Scheduling Strategy to Optimize Operating Room Utilization in a Veterans' Administration Hospital

Predicting Patient Nonappearance for Surgery as a Scheduling Strategy to Optimize Operating Room Utilization in a Veterans' Administration Hospital

Predicting Patient Nonappearance for Surgery as a Scheduling Strategy to Optimize Operating Room Utilization in a Veterans' Administration Hospital

Previous attempts at improving operating room utilization have generally emphasized more accurate scheduling, starting the first case on time, and reducing turnover time. Surgical case cancellations have largely been ignored except for recommendations for preoperative screening and good physician-patient communication to improve patient compliance. A retrospective review of operating room records was initially used to identify reasons for surgical cancellations. This was followed by a retrospective stratified case-control study of patient records to identify preexisting factors that predict the failure of patients to appear for surgical procedures as scheduled. Factors assessed included demographics, type of surgical procedure, compliance with previous healthcare visits, substance abuse, mental illness, travel distance, and neurologic problems. The authors reviewed their operating room utilization and found patient nonappearance rates to be a substantial source of surgical cancellations. Furthermore, multivariate analysis demonstrated that patient nonappearance could be strongly predicted from patient noncompliance with clinic visits and other clinical procedures without reference to the other variables assessed. Further analysis of data from an independent sample of patients confirmed this observation. Noncompliance with hospital visits for surgical procedures can be predicted from noncompliance with other healthcare encounters. Surgical procedures for previously noncompliant patients should be booked at the end of the operating room day, when the cancellation is least likely to interfere with operating room flow.

Creating an Optimal Operating Room Schedule

SCHEDULING IN THE OR suite is a particularly daunting task for many surgical services managers. CREATING AN OPTIMAL OR schedule requires looking at constraining factors as well as historical data. THIS ARTICLE presents one solution to creating an OR schedule that results in increased use of the OR suite and better profitability.

Operating room utilization: information management systems

Advances during the past year in operational decision making using information management systems data have been predominantly in better understanding of how to allocate operating room time based on operating room efficiency, not just operating room utilization. Each quarter, operating room allocations based on maximizing operating room efficiency can be calculated with 6-10 months of data. Analysis can be performed using operating room or anesthesia information management system data. Uncertainty in knowing the operating rooms in which cases were performed (i.e. in knowing turnover times) has little effect on operating room allocations or efficiency. It is important, however, that when a service has filled its allocated operating room time and has a new case to schedule, the case be scheduled into the operating room time of another service. The service whose operating room time is released can be the service with the largest difference between allocated and scheduled operating room time at the time when the new case is scheduled. If optimal operating room allocations and case scheduling based on maximizing operating room efficiency are not implemented, the resulting increase in anesthesia group labor costs can be used in negotiations as a statistically sound estimate for the increased labor cost to the group. During the last couple of years there has been continual advancement in our understanding of how to analyze operating room information system data based on operating room efficiency. Work has expanded from operating room allocations to case scheduling, releasing allocated operating room time, and addressing implementation challenges including poor data quality or lack of interest in change.

Mobile zoned/exponential LAF screen: a new concept in ultra-clean air technology for additional operating room ventilation

A mobile screen (0.5×0.4m) producing ultra-clean exponential LAF (air-flow central zone 0.6m/s and peripheral zone 0.4m/s) was investigated as an addition to conventional turbulent/mixing operating room ventilation. The evaluation was performed during strictly standardized sham operations reflecting conditions during major surgery. The study consisted of a pilot experiment designed to give high counts of sedimenting aerobic colony forming units (cfu). In a second main study, recording dust particles, air-borne and sedimenting aerobic cfu, the screen was associated with optimal operating room clothing.In the pilot experiment the use of the screen resulted in a substantial reduction of sedimenting bacteria from 3835–4940 to 0–390cfu/m2/h. In the main study, the use of the additional LAF reduced the surface contamination from 416–329 to 7–78cfu/m2/h up to 1.6m from the screen (P=0.001–0.0001). Measured in the wound area the screen reduced the air counts of bacteria from 9–14 to 0.2–0.4cfu/m3 (P=0.008–0.0001) and a marked reduction of air-borne dust particles was recorded (P=0.007–0.009).In conclusion, the additional mobile LAF screen reduced the counts of aerobic air-borne and sedimenting bacteria-carrying particles as well as dust particles to the levels gained with complete ultra-clean LAF room ventilation. Thus, the screen might prove a valuable addition to operating room ventilation as well as in other areas where asepsis is essential.

Statistical power analysis to estimate how many months of data are required to identify operating room staffing solutions to reduce labor costs and increase productivity.

We performed a statistical power analysis to determine how many historical data are needed for optimal operating room (OR) management decision making. The work applies to hospitals that provide service for all of its surgeons' elective cases on whatever workday the surgeons and patients choose. The hospital and anesthesia group adjust OR staffing and patient scheduling to care for the patients while minimizing OR staffing costs and maximizing labor productivity. Two years of data were obtained from a seven-OR surgical suite. The data were repeatedly split into training and testing datasets. The optimal staffing solution was calculated for each training dataset to maximize the efficiency of OR time usage and was then applied to the corresponding testing dataset. Training datasets ranged in size from 30 to 270 consecutive workdays. With 30 workdays of data, the statistical method identified staffing solutions that had an average of 35% decreased costs and 27% increased productivity as compared to the existing staffing plan. There was no significant improvement in performance with more than 210 workdays (10 mo) of data. With 30 workdays of OR or anesthesia group data, the optimization method can significantly reduce staffing costs and increase productivity compared with existing staffing. When applied routinely for adjusting staffing (e.g., on a quarterly basis), 9 to 12 mo of data should be used. With 30 workdays of operating room or anesthesia group data, the optimization method can propose staffing solutions that significantly decrease costs and increase productivity compared with existing staffing solutions. We recommend that, when the statistical method is applied routinely for adjusting staffing (e.g., on a quarterly basis), 9 to 12 mo of data be used.