Room Turnover Time Research Articles

Anesthesia Preoperative Medicine Clinic: Beyond Surgery Cancellations

We read with great interest the article of Dr. Ferschl et al. 1titled “Preoperative Clinic Visits Reduce Operating Room Cancellations and Delays,” in which the authors reported a decrease in same-day surgery cancellation rate from 16.2% to 8.4% using an anesthesia preoperative medicine clinic (APMC). The value of an APMC, besides the physical and psychological preparation for surgery, was clearly demonstrated by their study. We applaud their excellent work and would like to present our own data to support their conclusion: An evaluation in the APMC can significantly reduce case cancellations and delays on the day of surgery.In 1998, Kaiser Permanente Baldwin Park Medical Center (Baldwin Park, California) was built to provide a full spectrum of medical and surgical service to a large and diversified population 225,000. We set up an AMPC lead by board-certified anesthesiologists from the beginning, in which all patients were evaluated 1–30 days before their scheduled surgery. Our objectives were (1) to complete preoperative anesthesia evaluation at one time in one hospital visit, (2) to reduce same day surgery cancellations, (3) to minimize operative room delays, and (4) to improve patient’s safety and patient’s satisfaction. As of the end of September 2005, we had a total of 66,424 scheduled surgical procedures (46,959 ambulatory surgeries and 19,465 inpatient surgeries). With respect to the 66,424 scheduled surgeries, we had a total of 1462 same-day case cancellations due to various reasons, with a surgery cancellation rate of 2.2% (medically related, administrative related, and patient related), the lowest same-day cancellation rate reported so far in the literature. We attribute our low same-day surgery cancellation to our successful implementation of APMC.Despite the various benefits of APMC, such as decreased perioperative morbidity and mortality,2–4the value of a full-service APMC for all preoperative patients is increasingly under scrutiny because of the cost of APMCs.5There are growing number of facilities and ambulatory surgical centers replacing APMCs with “cost-effective” alternatives such as phone preanesthesia evaluations, reviews of health surveys, and computer-assisted information gathering.6It is also increasingly common that preoperative anesthesia evaluation is conducted in preoperative holding hours even minutes before scheduled surgery and anesthesia. The study of Dr. Ferschl et al. clearly raises questions about the practice and calls for more studies to evaluate the safety, efficiency, cost, and patient and staff satisfaction of this practice.Operating room efficiency is a major determinant of hospital cost. Reengineering the perioperative process, rather than focusing on operating room turnover time, has recently shown promising result for improving overall operating room productivity.7It was estimated that the cost of operating room time was between $1,430 and $1,700/h plus the variable setup cost of the individual case.8–10However, the negative impact of case cancellations goes far beyond its financial consequence to the hospital; it also impacts patients, family members, and society.10Furthermore, frequent case cancellations can decrease both patient and staff satisfaction. In a health industry that is more frequently pay-for-performance oriented, quality, efficiency, and patient satisfaction are increasingly used as indicators for consumers as well as insurers for selecting healthcare providers. In the cost-driven environment, only hospitals that deliver high-quality care and high patient satisfaction at an affordable price can maintain their financial viability. The study of Dr. Ferschl et al. , along with others, clearly demonstrates that streamlining the perioperative practice, including APMCs, can be more rewarding.We will share our full APMC experience, in addition to our decreased surgery cancellation rate, in our following report.*Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, California. chunyuan.x.qiu@kp.orgThe authors thank Rosie Rivera, R.H.I.T. (System Administrator, Kaiser Permanente Baldwin Park Medical Center, Baldwin Park, California), for her effort in collecting perioperative data.

Assessing Operating Room Efficiency and Parallel Processing

Assessing Operating Room Efficiency and Parallel Processing

Interdisciplinary Work Flow Assessment and Redesign Decreases Operating Room Turnover Time and Allows for Additional Caseload

Operating room turnover time (TOT) and daily caseload can be improved by analyzing the routine tasks of the operating team and minimizing inefficiencies. In this prospective study, the assigned tasks and work flow patterns of the anesthesiologist, circulating nurse, and surgical technologist during operations and operating room turnover were studied and changes were implemented where inefficiencies were observed. A brief pilot followed by a broader-scale study was conducted. Tertiary care center. Circulating nurses and surgical technicians were routinely assigned to work with one anesthesiologist and one surgeon during the pilot study; 4 surgeons and 32 anesthesiologists participated in the follow-up study. The work flow diagram of each individual was redrawn, and changes were implemented. Critical moments were identified, in which brief assistance from other personnel was needed to improve efficiency. Operative TOT and number of daily operations were the main outcomes. A 2-tailed t test was used to compare the TOTs; chi(2) analysis was used to compare the number of cases completed. Significance was defined as P<.05. A total of 401 operations and 253 turnovers were evaluated. Redesign decreased operating room TOT from 43.7 to 27.7 minutes (P<.001). The mean number of cases completed per day increased from 1.78 to 2.34 (P<.001). Interdisciplinary work flow assessment and redesign resulted in decreased operating room TOTs and additional cases being completed each day for 4 different surgeons.

Interdisciplinary Work Flow Assessment and Redesign Decreases Operating Room Turnover Time and Allows for Additional Caseload—Invited Critique

Interdisciplinary Work Flow Assessment and Redesign Decreases Operating Room Turnover Time and Allows for Additional Caseload—Invited Critique

Introduction of Anesthesia Resident Trainees to the Operating Room Does Not Lead to Changes in Anesthesia-controlled Times for Efficiency Measures

Operating room efficiency is an important concern in most hospitals today. Little work has been reported to evaluate the contribution of anesthesia residents to changes in anesthesia-controlled time-related efficiencies in the operating room. The goal of this study was to measure the impact of the initiation of new residents to the operating room on anesthesia-related time measures of operating room efficiency. Using the computerized operating room information systems, specific data regarding anesthesia-controlled times were extracted over three distinct 2-week periods over the course of 1 academic year. These included the first 2 weeks of July, when most of the operating rooms were staffed by attending physicians working alone; 2 weeks in September when new anesthesia residents were working in a 2:1 ratio with staff; and 2 weeks in May. The induction times, emergence times, and room turnover times were compared over these three periods for first-year anesthesia residents. Standard descriptive statistics were computed. Analysis of variance testing was then conducted comparing each of these time periods. Significance was set at P < 0.05. A total of 3,004 surgical procedures were performed during the 2-week study periods in July, September, and May, respectively. For the July, September, and May groups, the mean anesthesia induction times were 17.3, 19.0, and 20.8 min (P = 0.047); the emergence times were 8.7, 9.7, and 10.0 min, (P = 0.024); and the corresponding mean room turnover times were 47.6, 48.5, and 48.6 min (P = 0.907), respectively. Although statistically significant time differences were found, these data strongly suggest that the initiation of anesthesia trainees to the operating room has no clinically or economically meaningful adverse effect on the anesthesia-controlled time component of operating room efficiency.

P0731 UTILIZATION OF NASAL AIRWAY FOR EGD IN CHILDREN

Introduction: In a patient population undergoing EGD, general anesthesia is commonly required to provide an optimal working environment for successful completion of endoscopic examination. We have revisited an old technique utilizing nasal airways to deliver oxygen and inhaled anesthetics for EGD and evaluated its effectiveness and safety profile. Methods: Two hundred charts of pediatric patients who have undergone EGD in our institution between 2001–2003 were identified. For our retrospective review, we selected 112 charts where EGD alone or in combination with another procedure (e.g, colonoscopy) were performed. Patients were anesthetized by either inhaled anesthetics alone, total intravenous anesthetics (TIVA), or a combination of both. The emphasis of our data collection was to compare the safety profile and efficiency of the nasal airway technique to other techniques by looking at the peri-procedure complication rates and operating room (OR) turnover times. Results: The age of patients ranged from 7 months to 20 years (mean, 9.8 years). Fifty-four were female (48%). The average time to leaving the OR was significantly lower in the nasal airway group compared to endotracheal intubation (p value <.001). Discharge times between our 3 comparison groups did not significantly differ. There were a total of 11 peri-operative adverse events among the three groups. No aspiration episodes occured and no event had long-lasting sequelae.Table 1Conclusion: In our study, nasal airway provided us with a satisfactory means of maintaining patent airway during EGD. The complication rate in the nasal airway group was lower than in other evaluated groups. The nasal airway group exhibited no increased risk of aspiration. Our findings suggest that a nasal airway method is a safe, non-invasive alternative to endotracheal intubation when used for EGD. OR turnover times were superior in the nasal airway group in comparison to patients being intubated. We also postulate that by providing oxygenation only via a nasal airway in combination with TIVA, one can minimize atmospheric pollution with inhaled anesthetics in the high volume endoscopy suite.

Introducing Manufacturing Efficiency Tools to the Endoscopy Suite: How the Toyota Model Helps Drive Endoscopes

Background: Processes in medicine evolve slowly. The manufacturing industry has for many years employed a variety of tools to assess and enhance efficiency. Adaptation of manufacturing tools to the endoscopy suite may improve efficiency. Methods: The rapid processes improvement workshop (RPIW) is a manufacturing industry tool designed to break down production processes into individual parts in order to identify and correct inefficiencies in motion and material use. We applied this technique to routine outpatient procedures performed in our endoscopy unit in an effort to decrease patient waiting times and improve patient flow. Two week-long workshops examined patient travel patterns, nurse and patient walking distances, resource allocation and equipment standardization. Patient travel times, patient cycle times, nurse walking distances, and number of procedures performed per room per day were measured before and after RPIW recommendations were implemented. No new technologies were incorporated during the study interval and the physician portion of the procedures was not changed. Follow-up measurements were made at 60 days to determine if gains were maintained. Results: See Table 1. Incorporation of RPIW recommendations reduced patient waiting and admission times, patient stays, room turn-over times and nursing travel times to the degree that two additional procedures could be added to each room per day. Improvements were largely sustained at 60 days. Conclusion: Industry productivity tools can help improve efficiencies, reduce patient waiting times and potentially increase endoscopy revenue.

An initial investigation of efficiency in endoscopy delivery

The demand for endoscopic services is increasing rapidly. Of the several potential mechanisms to improve the supply of endoscopic procedures, improved efficiency in the endoscopy unit has received little attention. We invited 20 experienced endoscopists to participate in an initial evaluation of endoscopy efficiency, in which they were observed performing procedures in their own unit. Procedure volume per unit time was used as the measure of efficiency. Medical directors and head nurses at each endoscopy unit were interviewed regarding factors they perceived as most important in limiting procedure volume. There was a greater than 3-fold variation in procedure volume score between the least efficient and most efficient endoscopists. The clearest trend predicting procedure volume score was short room turnover time (p = 0.0004). There was a trend toward improved procedure volume among endoscopists using another professional to sedate their patients and using two procedure rooms. The surveys of medical directors and head nurses suggested that multiple factors contribute to limiting procedure volume, but on average each perceived number of available doctors is the least important factor in limiting volume. Improving the efficiency of some endoscopists appears to be an important potential mechanism to meet the rising demand for endoscopic services. Increasing the resources that provide the opportunity for efficiency may be an important mechanism for increasing the availability of endoscopic services. Specific measures associated with improved efficiency include reduced room turnover times, and possibly use of two rooms per endoscopist and sedation by persons other than the endoscopist.

An initial investigation of efficiency in endoscopy delivery

OBJECTIVE: The demand for endoscopic services is increasing rapidly. Of the several potential mechanisms to improve the supply of endoscopic procedures, improved efficiency in the endoscopy unit has received little attention. METHODS: We invited 20 experienced endoscopists to participate in an initial evaluation of endoscopy efficiency, in which they were observed performing procedures in their own unit. Procedure volume per unit time was used as the measure of efficiency. Medical directors and head nurses at each endoscopy unit were interviewed regarding factors they perceived as most important in limiting procedure volume. RESULTS: There was a greater than 3-fold variation in procedure volume score between the least efficient and most efficient endoscopists. The clearest trend predicting procedure volume score was short room turnover time ( p = 0.0004). There was a trend toward improved procedure volume among endoscopists using another professional to sedate their patients and using two procedure rooms. The surveys of medical directors and head nurses suggested that multiple factors contribute to limiting procedure volume, but on average each perceived number of available doctors is the least important factor in limiting volume. CONCLUSIONS: Improving the efficiency of some endoscopists appears to be an important potential mechanism to meet the rising demand for endoscopic services. Increasing the resources that provide the opportunity for efficiency may be an important mechanism for increasing the availability of endoscopic services. Specific measures associated with improved efficiency include reduced room turnover times, and possibly use of two rooms per endoscopist and sedation by persons other than the endoscopist.

Tracheal extubation of adult surgical patients while deeply anesthetized: a survey of United States anesthesiologists

Study Objective: To examine current practice regarding the performance of tracheal extubation of adult surgical patients while deeply anesthetized (deep extubation). Design and Setting: Survey comprised of an anonymous written questionnaire mailed to 1,000 randomly selected active American Society of Anesthesiologists members. Measurements and Main Results: Questionnaires were mailed between February and April 1998. Five hundred eighty-three completed forms were returned, 538 of which were suitable for data analysis. Responses from anesthesiologists who infrequently or never administer general anesthetics to adult surgical patients were excluded. The overall frequency of deep extubation of adults was “never” for 106 respondents (19.7%), “rarely” for 87 (16.2%), and “more frequently” for 345 (64.1%). The most common reasons for never performing deep extubations were lack of necessity and concern regarding potential laryngospasm and aspiration. The most frequent indications for deep extubations were unclipped intracranial aneurysm, reactive airway disease, and open-globe eye surgery. The most frequent contraindications to deep extubations for those who otherwise perform the technique were difficult airway, aspiration risk, and obesity. After performing a deep extubation, 44.0% of respondents remain with the patient in the operating room until he or she is awake. Deep extubations were perceived to have no consistent effect on operating room turnover time by 61.6% of anesthesiologists who perform them. Conclusions: Most anesthesiologists in this survey perform deep extubations in adult surgical patients. Lack of necessity and potential respiratory complications were the main reasons cited by those who do not use the technique. Future investigations are necessary to examine the risk-to-benefit ratio of the technique in adults. Our results may be used to determine which potential indications should be examined in such studies and to help delineate the standard of care followed in this country.

Continuous quality improvement analysis of operating room turnover time.

The continuous quality improvement process reminds us how recognizing opportunity for growth enhances the provision of quality patient care.

The effects of an outpatient practice guideline at a teaching hospital: A prospective pilot study

Practice guidelines (PGs) are becoming increasingly important in modern medicine. To study the effects of a PG, we performed a pilot study at a large, urban, public teaching hospital according to a prospective, observational research design with both concurrent and historic controls. Specifically, we studied the effects of a multidisciplinary PG for pediatric outpatient tonsillectomy and adenoidectomy on the process of health-care delivery. Variables in the health-care process included patient compliance with clinic and surgery appointments, surgery time, operating room turnover, time in recovery room, unplanned admission rate, patient compliance with postoperative follow-up, provider compliance with guidelines, and hospital charges. Patients in the PG were found to have fewer preoperative laboratory tests, decreased duplication of services, and shorter operating room turnover times. Provider compliance with the PG varied by service and was intermittent at first but improved gradually. There was a trend toward improved compliance with postoperative follow-up in patients in the PG. Provider opinions concerning the guideline were positive. This pilot study demonstrates several advantages and disadvantages of the use of PGs in the outpatient setting and in a teaching hospital. (Otolaryngol Head Neck Surg 1997;117:388-93.)

Operating room start times and turnover times in a university hospital

To measure the start time for the first case of the day and the turnover times for subsequent cases in the operating rooms (ORs) at an academic hospital. Prospective study. ORs at a university medical center. All patients undergoing an operative procedure that started between 7 A.M. and 5 P.M. weekdays for the period January 1, 1989, through June 30, 1989. For each patient, the following times were recorded: OR ready, patient enters OR, anesthesia induction complete, surgery start, surgery end, patient leaves OR. Patients were brought into the OR just before the scheduled start time. Surgical incision was made 21 to 49 minutes after the patient was brought into the OR. Room turnover time (time from patient in to patient out) was almost uniformly 36 minutes. Patient turnover time (time from end of surgery in one patient to end of induction of next patient) was generally 1 hour. Turnover times were shorter for those ORs in which primarily monitored anesthesia care was provided and longer in ORs in which patients routinely required invasive monitoring. The scheduled start time for the first case of the day was generally the time the patient was brought into the OR. Because of the variable amount of time required for anesthesia induction and surgical preparation and draping, incision occurred 21 to 49 minutes later. The time between cases when no surgery was occurring was significantly longer than room turnover time because of the need to wake up one patient and induce the following patient. Because of a lack of standardized definitions, there is probably a strong perceptual difference among anesthesiologists, OR nurses, and surgeons when viewing start and turnover times. At our own teaching institution, shortening turnover times would increase the amount of elective OR time available, but the impact would not be significant because the number of procedures done per OR each day is low.