Total Room Time Research Articles

The Impact of Pediatric Laparoscopic Inguinal Hernia Repair in a Community Based Children's Ambulatory Surgery Center – It's Safe and Effective

PurposePediatric surgery in a free-standing children's ambulatory surgery center (C-ASC) is a common practice. The implementation of minimally invasive surgery in this setting may be associated with unique challenges. The purpose of this study was to compare a cohort of children who underwent laparoscopic (LHR) and open inguinal hernia repairs (OHR) at the C-ASC as part of a quality assurance initiative to assess safety and efficacy. MethodsFrom January 2021 to December 2021, the records of all children who underwent LHR or OHR at our C-ASC were analyzed. The following data was retrieved and compared with the Student's t-test: age, weight, gender, procedure type, total room time (RT), total operative time (OT), and outcomes. ResultsEighty-eight (n = 88) children underwent LHR or OHR during this period. There was no difference between the two groups regarding their age or weight. Both groups had equal outcomes, specifically, no wound infections or recurrent hernias. (2.5 year follow-up). There was a significant reduction in RT and OT in those children who underwent unilateral LHR compared to unilateral OHR (15% and 17% respectively, p < 0.05). In those children who underwent bilateral LHR and bilateral OHR, there was a reduction in RT and OT in the LHR group compared to OHR, but it was not significant (10% and 12% respectively, p > 0.05). ConclusionsPediatric LHR is safe and effective in the C-ASC. The unilateral LHR technique is associated with a significant reduction in total room time and operative time compared to the unilateral OHR technique. Additional analyses would be important to examine the relationship of time and outcomes in this setting. Type of studyOriginal Research Retrospective Case-control study.

Are Orthopaedic Trauma Surgeons Appropriately Compensated for Treating Acetabular Fractures? An Analysis of Operative Times and Relative Value Units.

To evaluate the work relative value units (RVUs) attributed per minute of operative time (wRVU/min) in fixation of acetabular fractures, evaluate surgical factors that influence wRVU/min, and compare wRVU/min with other procedures. Retrospective. Level 1 academic center. Two hundred fifty-one operative acetabular fractures (62 A, B, C) from 2015 to 2021. Work relative value unit per minute of operative time for each acetabular current procedural terminology (CPT) code. Surgical approach, patient positioning, total room time, and surgeon experience were collected. Comparison wRVU/min were collected from the literature. The mean wRVU per surgical minute for each CPT code was (1) CPT 27226 (isolated wall fracture): 0.091 wRVU/min, (2) CPT 27227 (isolated column or transverse fracture): 0.120 wRVU/min, and (3) CPT 27228 (associated fracture types): 0.120 wRVU/min. Of fractures with single approaches, anterior approaches generated the least wRVU/min (0.091 wRVU/min, P = 0.0001). Average nonsurgical room time was 82.1 minutes. Surgeon experience ranged from 3 to 26 years with operative time decreasing as surgeon experience increased ( P = 0.03). As a comparison, the wRVU/min for primary and revision hip arthroplasty have been reported as 0.26 and 0.249 wRVU/min, respectively. The wRVUs allocated per minute of operative time for acetabular fractures is less than half of other reported hip procedures and lowest for isolated wall fractures. There was a significant amount of nonsurgical room time that should be accounted for in compensation models. This information should be used to ensure that orthopaedic trauma surgeons are being appropriately supported for managing these fractures. Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Designing Clinical MRI for Enhanced Workflow and Value.

MRI is an expensive and traditionally time-intensive modality in imaging. With the paradigm shift toward value-based healthcare, radiology departments must examine the entire MRI process cycle to identify opportunities to optimize efficiency and enhance value for patients. Digital tools such as "frictionless scheduling" prioritize patient preference and convenience, thereby delivering patient-centered care. Recent advances in conventional and deep learning-based accelerated image reconstruction methods have reduced image acquisition time to such a degree that so-called nongradient time now constitutes a major percentage of total room time. For this reason, architectural design strategies that reconfigure patient preparation processes and decrease the turnaround time between scans can substantially impact overall throughput while also improving patient comfort and privacy. Real-time informatics tools that provide an enterprise-wide overview of MRI workflow and Picture Archiving and Communication System (PACS)-integrated instant messaging can complement these efforts by offering transparent, situational data and facilitating communication between radiology team members. Finally, long-term investment in training, recruiting, and retaining a highly skilled technologist workforce is essential for building a pipeline and team of technologists committed to excellence. Here, we highlight various opportunities for optimizing MRI workflow and enhancing value by offering many of our own on-the-ground experiences and conclude by anticipating some of the future directions for process improvement and innovation in clinical MR imaging. EVIDENCE LEVEL: N/A TECHNICAL EFFICACY: Stage 1.

Poster 253: Is the Use of Pretreatment Magnetic Resonance Imaging Necessary Prior to Surgery in Pediatric Tibial Spine Fractures

Objectives: Injuries to the tibial spine occur as a result of an anterior cruciate ligament (ACL) avulsion fracture from the intercondylar eminence of the proximal tibia. Similar to anterior cruciate ligament ruptures, tibial spine injuries are associated with damage to other intraarticular structures. These associated injuries are often visualized with Magnetic Resonance Imaging (MRI) obtained prior to surgery. The purpose of the study is to describe concomitant injuries visualized by a pretreatment MRI, to examine how this correlates to what is seen at the time of surgery, and to determine how a pretreatment MRI affects the time between injury and surgery as well the length of the surgical procedure itself. Our hypothesis is that a pretreatment MRI results in a longer time between injury and surgery without any affect on operating time or amount of concomitant pathology identified. Methods: Utilizing an institutional review board approved retrospective study, we identified patients under 18 years of age who underwent arthroscopic management of a tibial spine fracture over a 13 year period. Our exclusion criteria were patients with a concomitant ipsilateral lower extremity fracture or posterior cruciate ligament injury, patients with poor imaging quality, and patients with incomplete medical records. Patients were then categorized based on whether they obtained a pretreatment MRI. We then evaluated for concomitant injuries, time from injury to surgery, total room time, and tourniquet time between the groups. Results: A total of 85 patients met this inclusion criteria, of which 44 (51.7%) had a pretreatment MRI. There were no significant differences in age, gender, or Myers and McKeever grade between groups. All were treated with arthroscopic reduction and fixation. In the MRI group, there were 30 patients (68.2%) that were identified to have additional meniscal or chondral pathology. The three most common pathologies seen on MRI were lateral meniscus tears (13 patients), medial meniscus tears (6 patients), and intermeniscal ligament entrapment (6 patients). In addition, 28 patients (63.6%) were found to have a bone contusion pattern similar to that seen in ACL injuries and 17 patients (38.6%) showed signs of damage to the ACL fibers themselves. Of those 30 patients with meniscal pathology or entrapment seen on MRI, 17 patients (56.7%) were confirmed to have that pathology at the time of arthroscopy. The percentage of patients with meniscal or chondral pathology seen on arthroscopy was not significantly different between those who received a pretreatment MRI and those who did not (38.6% MRI group vs 41.5% No-MRI group p =0.79). The time from injury to surgery was significantly longer in the MRI group (19.3 days vs 10.1 days p=0.01). Both the tourniquet time (72 min vs 76 min) and operative time (83.5 min vs 90.5 min) were not significantly different(p=0.49 for tourniquet time and p=0.32 for room time). Conclusions: Over two-thirds of patients who sustained a tibial spine fracture were noted to have concomitant pathology on MRI, with 56.7% of injuries seen on MRI correlating to what was seen at the time of surgery. The use of pretreatment MRI was shown to delay surgery without any significant change in operative time, tourniquet time, or percentage of pathology identified at time of surgery. Previous studies have suggested that a pre-treatment MRI may be helpful in identifying pathology, however we believe this is the first study to determine if obtaining a pretreatment MRI influences operative time, tourniquet time, and pathology identified at time of surgery.

Clinical outcomes and learning curve for ERCP during advanced endoscopy training: a comparison of supine versus prone positioning

No studies have evaluated trainees' outcomes when learning ERCP with patients in the supine and prone positions simultaneously. We aimed to assess whether patient position impacts procedural outcomes and learning curve. We prospectively evaluated patients undergoing ERCP by a supervised advanced endoscopy trainee (AET) at a tertiary care center. Adult patients with native papillae were included. The AET was universally given 5 attempts per cannulation. Outcomes were evaluated quarterly. Successful cannulation was achieved in 44 supine (69%) and 17 prone (68%) patients (P= .95). Although mean time to reach the papilla was shorter in the supine patient position, time to biliary cannulation (7.8 vs 9.4 minutes, P= .53) and number of attempts were similar. A stepwise increase was seen in cannulation rates throughout the academic year (P< .01) and increased more in supine patients (P= .01). Procedure and total room times were shorter in supine patients. Shorter procedure and room turnover times and a comparable cannulation rate were found for supine versus prone ERCP.

PO-02-220 IMPROVED EFFICIENCY OF COMBINED CRYOBALLOON PVI AND WATCHMAN COMPARED TO SEPARATE PROCEDURES

There is a significant amount of pressure in EP labs across the country to maximize lab efficiency. Elective pulmonary vein isolation (PVI) and left atrial appendage occlusion (LAAO) devices such as Watchman are being scheduled out several months at most centers. To that end, we have sought to reduce the amount of repeat procedures in select patients by combining cryo PVI ablation with LAAO device implant. This is also beneficial from a patient satisfaction perspective and a safety perspective (e.g. one time groin access, transseptal puncture, and general anesthesia). The goal of this study was to look at total room and procedure times for isolated PVI and LAAO implant cases versus combining the two procedures. We retrospectively analyzed patients from our institution who had a combined PVI and Watchman FLX device placement in the last two years. Forty-two patients underwent the combined procedure. To allow a more direct comparison, patients who received additional lesions beyond PVI were excluded from our analysis. These 18 patients were compared to the last 50 patients who had an isolated PVI and the last 50 patients who had an isolated Watchman implant. Patients were selected for the combined procedure based on clinical criteria and operator preference. For each patient we reviewed the total room time (patient entering the EP lab until exit), procedural time (venous access to sheath removal), patient characteristics, and adverse events. All cases were done under general anesthesia with TEE. The average room time for isolated PVI was 180 minutes, isolated Watchman 114, and combined procedure 209. Procedure time for PVI was 91 minutes, Watchman 35, and the combined procedure 103. Adding 30 minute room turnover, the separate procedures would require 324 min, compared to 209 min for the combined procedure. The time savings of 115 min is the same room time required for an additional standalone Watchman. Patient characteristics are listed in the table below. There were no major adverse events in any of the groups. The implantation of Watchman device in addition to PVI increased room time by 30 minutes and added 12 minutes to the procedural time, without any adverse events. Combining these procedures in a select group of patients may safely and efficiently improve time resources. Any potential reduction in reimbursement for the combined procedures can be offset by the ability to perform one or more additional procedures in the room within the same time period.Tabled 1PVIWatchmanPVI + WatchmanAge63.376.773.4% Male747869CHADS2 VASc (mean)2.14.03.8% LVEF555653Room time (min)179114209Procedure time (min)9034102 Open table in a new tab

Outcomes of Dexmedetomidine with Local Regional Anesthesia in Carotid Endarterectomy

Adequate sedation to complement regional techniques in carotid endarterectomy (CEA) can be challenging. Dexmedetomidine has both analgesic and amnesic properties and is reported to be a safe and acceptable alternative to conventional general endotracheal anesthesia (GETA). Outcomes observing dexmedetomidine in conjunction with regional anesthesia in CEA are not well described or known. Compare the immediate (during hospitalization) and short-term (within 30days of hospitalization) postoperative outcomes in patients who underwent CEA using GETA versus local regional anesthesia (LRA) alone versus dexmedetomidine with LRA at a single institution to determine whether dexmedetomidine is a safe adjunct and if there are anesthesia advantages over LRA alone. A retrospective cohort study from January 2015 to December 2019 at Saint Joseph Mercy Ann Arbor. Patients were stratified into three groups based on anesthesia type: GETA, LRA, and dexmedetomidine (D) + LRA. Primary outcomes included stroke, myocardial infarction (MI), and death. Patient demographics were characterized and adjusted using propensity score weighting. Three hundred seventy nine patients met inclusion criteria; 182 patients in the GETA group, 66 in the D+LRA, and 131 in LRA. There were no significant differences across anesthesia groups in primary outcomes of stroke, MI, and death during the admission. The GETA group had significantly longer length of stay (LOS) compared to the D+LRA group (LOS=1.51days versus 0.85days; P=0.011) and the LRA group (LOS=1.08days; P=0.003). However, there was no significant difference in hospital LOS between the D+LRA group and LRA only groups (P=0.952). There was no significant difference between stroke (LRA 0.87%, GETA 0.85%, and LRA+Dex 3.52%), MI (LRA 0%, GETA 0.49%, LRA+Dex 0%), or death (LRA 5.24%, GETA 1.16%, LRA+Dex 0%), within 30days between all three of the anesthesia groups. There was no significant difference in postoperative pain scores when comparing the GETA group (mean 1.3, standard deviation [SD] 2.5) to LRA (mean 1.2, SD 2.1) and between LRA and D+LRA (mean 0.9, SD 2.1). Procedure time (time of skin incision to closure) and total room time were comparable among all three anesthesia groups (LRA 2.2hr, SD 2.2; GETA 2.1hr, SD 0.5; LRA+Dex 2.1hr, SD 0.5). The use of dexmedetomidine in addition to LRA is a safe and acceptable alternative to conventional GETA or LRA alone in CEA with shorter length of hospital stay when compared with GETA, improved patient tolerance based on physician observation, and similar rates of immediate and short-term complications and postoperative pain scores.

Improved Resource Utilization Using WALANT Hand Surgery in Adolescents.

Cost, efficiency, patient preference, and safety have driven utilization of wide awake, local anesthesia, no tourniquet (WALANT) in hand surgery. This is not well documented in adolescents. We hypothesize that the use of WALANT with adolescents reduced time spent in the operating room (OR) and in the hospital when compared with patients who underwent surgery with traditional anesthesia (TA). After institutional review board approval, we performed a retrospective review of patients aged 10 to 17 who underwent surgery at a regional hospital system including the level 1 pediatric trauma hospital. Operative notes were assessed for use of WALANT. We excluded those operations not traditionally amenable to WALANT. Using a propensity matched cohort, hospital time, OR time, and perioperative complications were recorded and compared to evaluate efficiency and perioperative safety. There were 28 cases in the WALANT group and 28 cases in the TA group after excluding cases not amenable to WALANT, and cases were propensity matched. Although the operative time (incision to closure) was similar, for WALANT patients, the in-room to procedure time (15 vs 22 minutes), procedure end to out-room time (5 vs 10 minutes), total room time (52.81 vs 63.68), and length of hospital stay (222 vs 342 minutes) were shorter than patients in the TA group. Our case series demonstrates time-savings both in the OR and in the hospital overall. Avoiding TA when WALANT is feasible may result in significant savings to hospital systems, patients, and payers while also freeing up anesthesia staff and perioperative nurses.

The Off-Table Technique Increases Operating Room Efficiency in Direct Anterior Hip Replacement

BackgroundWhen performing a total hip arthroplasty via the direct anterior approach (DAA), many orthopedic surgeons utilize an orthopedic traction table. This technique requires an expensive table, time for positioning, staff to operate the table, and time-consuming transitions when preparing the femur. Some surgeons advocate for an “off-table” technique to avoid these difficulties. In this paper, we compare operating room efficiency between on-table and off-table techniques.Material and methodsWe retrospectively reviewed patients undergoing total hip arthroplasty by a single surgeon across the transition from on-table to off-table DAA technique. Three cohorts were defined; the last 40 on-table hips, the first 40 off-table hips, followed by the second 40 hips. Timestamps from the operative record were recorded to calculate setup, surgical, takedown, and total room time. Implant fixation, patient demographic data, comorbidities, and complications were recorded.ResultsFrom cohort 1 to 2, there was a 7-minute (14.44%, P = .0002) improvement in setup time but no change in total room time. From cohort 2 to 3, there was an additional 7-minute (15.47%, P < .0001) improvement in setup time, 32-minute (25.88%, P < .0001) improvement in surgical time, and 40-minute (21.96%, P < .0001) improvement in total room time yielding cumulative changes from cohort 1 to 3 of 15 minutes (27.68%, P < .0001), 28 minutes (23.11%, P < .0001), and 43 minutes (23.37%, P < .0001), respectively. There was no correlation between height, weight, or body mass index and time at any interval.ConclusionConversion to an off-table DAA technique offers an improvement in operating room efficiency. This is seen in setup, operative, and total room time. Implementation could allow for an additional case each day.

Variation in Advanced Diagnostic Imaging Practice Patterns and Associated Risks Prior to Superior Cavopulmonary Connection: A Multicenter Analysis.

Single ventricle patients typically undergo some form of advanced diagnostic imaging prior to superior cavopulmonary connection (SCPC). We sought to evaluate variability of diagnostic practice and associated comprehensive risk. A retrospective evaluation across 4 institutions was performed (1/1/2010-9/30/2016) comparing the primary modalities of cardiac catheterization (CC), cardiac magnetic resonance (CMR), and cardiac computed tomography (CT). Associated risks included anesthesia/sedation, vascular access, total room time, contrast agent usage, radiation exposure, and adverse events (AEs). Of 617 patients undergoing SCPC, 409 (66%) underwent at least one advanced diagnostic imaging study in the 60days prior to surgery. Seventy-eight of these patients (13%) were analyzed separately because of a concomitant cardiac intervention during CC. Of 331 (54%) with advanced imaging and without catheterization intervention, diagnostic CC was most common (59%), followed by CT (27%) and CMR (14%). Primary modality varied significantly by institution (p < 0.001). Median time between imaging and SCPC was 13days (IQR 3-33). Anesthesia/sedation varied significantly (p < 0.001). Pre-procedural vascular access did not vary significantly across modalities (p = 0.111); procedural access varied between CMR/CT and CC, in which central access was used in all procedures. Effective radiation dose was significantly higher for CC than CT (p < 0.001). AE rate varied significantly, with 12% CC, 6% CMR, and 1% CT (p = 0.004). There is significant practice variability in the use of advanced diagnostic imaging prior to SCPC, with important differences in associated procedural risk. Future studies to identify differences in diagnostic accuracy and long-term outcomes are warranted to optimize diagnostic protocols.

Impact of Rapid Medical Evaluation on Patient Flow in an Urban Emergency Department.

Rapid Medical Evaluation (RME) is a new Emergency Department (ED) process that initiates testing while patients are in the Waiting Room. Primary goal of this study is to assess the effectiveness of RME pathway on the patient flow through the ED.This was a retrospective, single site, cohort study of patients presenting to the ED 12months before (PRE group) and 12months after (POST group) RME implementation. The POST group was divided into those that underwent RME and those managed using standard care pathway (SCP). Data was collected from Electronic Health Record (EHR) database using SQL and consisted of time stamp data for discrete ED patient events. The following metrics were calculated for all ED encounters: Active ED Room Time, Boarding Time, Total ED Room Time, Total ED Time, and Door-to-Provider Time.Patients undergoing RME on average spent 90-min less in ED Treatment Room compared to SCP group and were evaluated by a provider 151min earlier than if they had waited for an available ED Treatment Room.Implementation of RME helped reduce time patients spend in ED Treatment Room, improved patient throughput, and decreased Door-to-Provider time during the busiest times in the ED.

Single-Port robot assisted partial nephrectomy: initial experience and technique with the da Vinci Single-Port platform (IDEAL Phase 1).

The aim of this paper was to evaluate the safety and feasibility of robotic-assisted laparoscopic partial nephrectomy (RAPN) performed using the da Vinci Single-Port (SP) platform. A retrospective review was conducted from December 2018 to December 2019 of 14 consecutive patients with localized renal cancer who underwent SP robot-assisted partial nephrectomy at a single institution. The procedures were performed by 2 experienced robotic surgeons, reproducing the steps of the standard multiport robotic approach to partial nephrectomy. A transperitoneal approach was utilized with a 2.5 cm para-rectus incision with one assistant 12 mm laparoscopic port. No conversions to open or laparoscopic surgery occurred and no additional laparoscopic assistant ports were required. The median total operative time was 202 (162-231) minutes and the median total room time was 258 (215-295) minutes. The warm ischemia time averaged 20±8 minutes. 2 patients required angioembolization due to postoperative acute bleeding (Clavien-Dindo Grade 3a complication). Trifecta outcome (<25 min warm ischemia, no perioperative complications and negative margins) was achieved in 79% of patients. In one case, a positive margin was present. The median length of stay was of 1 day (Interquartile Range 1-2) with a median pain score on post-operative day 1 of 3.5 (Interquartile Range 2.4-5); 1/14 (7%) patient needed narcotic use at one week from discharge. At a median follow up of 5.0 (4.0-8.0) months, no patients have had evidence of disease recurrence. In this initial cohort, considering the introduction of a new technology, we observed satisfactory outcomes for several key perioperative variables including operative time, warm ischemia time, surgical margins, hospital stay, pain requirements in patients undergoing RAPN with the SP platform. For experienced robotic surgeons, RAPN with the SP platform is a safe and feasible approach for single site partial nephrectomy.

The Planning Fallacy in the Orthopedic Operating Room.

The planning fallacy posits that humans tend to underestimate the amount of time needed to complete a project and that greater complexity results in a larger difference in that estimation. If this phenomenon is present in the orthopedic operating room, it could lead to negative impacts on patients, their families, and physicians themselves. Nine fellowship-trained orthopedic surgeons at one institution were asked to give an estimate of their operative and total room times over the course of three months. Over 759 cases, the surgeons underestimated the total room times by 17.3% (p = 0.034) but did not underestimate their operative times (p = 0.590). The surgeons improved estimation of their operative time for all cases from 13.6 to 10.9 minutes of their actual time (p = 0.031) by comparing the absolute difference for the surgeons’ first 25% to the last 25% of cases. Procedures performed at the hospital underestimated operative and total room times by 8.9% and 7.4% compared to the ambulatory center, which overestimated operative times by 6.0% and underestimated total room times by 3.8% (p < 0.001). We found that the planning fallacy does exist in certain situations within the orthopedic operating room.

The Learning Curve in Hip Arthroscopy: Effect on Surgical Times in a Single-Surgeon Cohort

To quantify the effect of the learning curve in performing hip arthroscopy for femoroacetabular impingement (FAI) and labral tears on total operating room time, including times for setup, surgery, and wake up, during a single surgeon's initial hip arthroscopy procedures. A single surgeon's case list was retrospectively reviewed to identify all primary hip arthroscopy surgeries between November 1, 2018, and February 28, 2018, for the treatment of FAI and labral tears. Surgical times were recorded, including total room time; surgical time; setup time; and wake-up time. Linear regression was used to evaluate the relationship of these times relative to case number in the series. In addition, the series was divided into 3 sequential groups to further compare these times. In total, 225 patients were included in the study. The mean total room time for all cases was 155.4 minutes, 95% confidence interval ([CI] 150.9-160.0); mean surgical time was 115.6 minutes (95% CI 111.5-119.8), and mean setup time was 32.6 minutes (95% CI 31.8-33.4). Decreasing surgical time was associated with advancing number in the case series (P < .001, R2= 0.36). Decreasing total room time was accordingly associated with advancing number in the case series (P < .001, R2= 0.34). There were no significant differences in setup time and wake-up time as the case series advanced. When groups of 75 sequential cases were compared, significant decreases in surgical and total room time were noted between the first and second groups (P < .001) but not between the second and third groups (P= .52). Increasing complexity of surgeries was noted as the series advanced, including capsular closure and subspine decompression. This study supports the existence of a substantial learning curve for hip arthroscopy in the treatment of FAI and labral tears. Our findings suggest decreasing surgical time as the surgeon advances through the learning curve, with the initial 75 procedures requiring longer time to perform than subsequent cases. Hip arthroscopy is a technically demanding procedure. Understanding the long duration of the hip arthroscopy learning curve is helpful for surgeons considering the addition of hip arthroscopy to their practice.

Operating Room Personnel Determine Efficiency of Pediatric Spinal Fusions for Scoliosis

Study DesignRetrospective chart review. ObjectivesTo investigate the effect of different surgeons, anesthesiologists, and cRNAs individually and in teams on various perioperative and operative time intervals in a large, high-volume children's hospital. Summary of Background DataAlong with individual factors, studies have indicated that team factors play a role in efficiency, with larger teams leading to increased procedure times. An operating room (OR) staff dedicated to orthopedics has been reported to decrease turnover time; however, the characteristics and behaviors of surgical team members, to our knowledge, have not been analyzed as possible factors contributing to pediatric OR efficiency, and limited research has been conducted in the field of orthopedic personnel. MethodsChart review identified consecutive pediatric and adolescent patients who had primary posterior spinal fusion (PSF) of ≥7 levels for correction of spinal deformity. Time intervals and delays were recorded based on previous studies looking at OR efficiency and adjusted to the specific time points available in our perioperative nursing records. ResultsAdjusted for etiology, osteotomy, fusion levels, distance from hospital, staff switch, and body mass index, there was a significant difference in patient wait time among anesthesiologists, surgeon-anesthesiologist, and anesthesiologist-certified registered nurse anesthetist (cRNA) teams; in surgery prep time and total prep among surgeons and SA teams; and in surgery time and total room time among surgeons. There were no significant differences among cRNAs, individually, in any time interval. ConclusionsAnesthesiologists have a significant effect before and surgeons have a significant effect after entry into the OR. Identification of this variability provides an opportunity to study the differences in habits and processes of high- and low-efficiency teams, which can then be applied to all teams with the goal of improving performance of all surgical teams. Level of EvidenceLevel IV, case series.

The effect of suprainguinal fascia iliaca block on the recovery of patients after arthroscopic hip surgery.

Adolescent and young adult patients undergoing arthroscopic hip surgery experience significant pain in the immediate postoperative period. There is a small body of evidence that indicates suprainguinal fascia iliaca blocks can improve comfort during recovery from this intervention. Our hypothesis was that patients undergoing hip surgery would consume fewer opioids and have less pain in the perioperative time frame if they received the block as part of their analgesic regimen. In this study, we evaluated the outcomes of 716 patients, including 275 who received a suprainguinal fascia iliaca block, and 441 who did not have a block. Inclusion criteria included all age groups and American Society of Anesthesiologists, functional classes 1-2. Patients who received other concurrent procedures or those with incomplete data sets were excluded. We utilized a regional anesthesia database that combined data from various repositories into one web-based relational system. The primary outcomes were total opioid consumption and pain scores in the recovery room. Secondary outcomes included opioid side effects, block-related complications, and total recovery room time. Multivariable logistic regression analysis was used to evaluate opioid consumption, side effects, and total recovery times. Pearson chi-square was applied to assess the level of pain between the two groups. Total opioid consumption was significantly less in the block group compared to those not receiving a block (0.28mg/kg vs 0.35mg/kg, P<0.001, 95% CI of difference in medians 0.04-0.10mg/kg), but there was no statistical difference in pain scores. Patients with the regional block had a lower frequency of emesis in the PACU (0.7% vs 4.3%; P<0.005, 95% CI of difference: 2-25) and shorter PACU times (93 vs 108minutes, P<0.001, 95% CI of difference: 8-23minutes). Our study supports the clinical effectiveness of suprainguinal fascia iliaca blocks in young patients undergoing arthroscopic hip surgery.

Operator-Directed Procedural Sedation in the Congenital Cardiac Catheterization Laboratory

ObjectivesThe purpose of this study was to evaluate the association between the method of procedural sedation and outcomes for congenital cardiac catheterization procedures. BackgroundThe safety of operator-directed sedation (ODS) in the pediatric/congenital cardiac catheterization laboratory has been questioned. To our knowledge, the relative safety of ODS versus general anesthesia (GA) in these cases has not to date been critically evaluated. MethodsA single-center retrospective cohort study was performed to compare the relative safety, cost, and times of catheterization procedures performed with ODS and those performed with GA from a cardiac anesthesiologist. The risk of adverse outcomes was compared using propensity-score-adjusted models. Using the same propensity score, procedure times and relative charges were also compared. ResultsOver the study period, 4,424 procedures in 2,547 patients were studied. Of these, 27% of cases were performed with ODS. ODS procedures were 70% diagnostic procedures, 17% device closure of patent ductus arteriosus, 5% balloon pulmonary valvuloplasty, and 3% pulmonary artery angioplasty. The risk of adverse event in adjusted models for ODS cases was significantly lower than in GA cases (odds ratio: 0.66; 95% confidence interval: 0.45 to 0.95; p = 0.03). Total room time and case time were also significantly shorter (p < 0.001). Professional (charge ratio: 0.88; p < 0.001) and hospital (charge ratio: 0.84; p < 0.001) charges for ODS cases were also lower than those for GA cases. ConclusionsThis study demonstrates that clinical judgment can identify subjects in whom ODS is not associated with increased risk of adverse events. The use of ODS was associated with reduced case times and charges. In combination, these findings suggest that the selective use of ODS can allow for greater efficiency and higher value care without sacrificing safety.

The Surgical Experience aboard USNS COMFORT (T-AH-20) during Operation Continuing Promise 2015

In 2015, the United States Navy hospital ship (USNS) COMFORT, deployed to 11 Caribbean and Latin American countries over a six-month period to provide humanitarian civic assistance. Personnel from the United States Navy and multiple nongovernmental organizations collaborated to offer surgical and medical care. Data from past deployments aid in planning for future missions by prioritizing finite resources and maximizing care. The data analyzed included all patients evaluated and treated by the Directorate of Surgical Services of the USNS COMFORT between April and September 2015. Comparative and descriptive statistics were performed to analyze patient demographics, surgical subspecialty performing the procedures, types of general and pediatric surgical procedures performed, operative times, and complication rates. Of the 1256 surgical cases performed aboard USNS COMFORT during CP15, 24.8 per cent were general surgery cases, followed by 16 per cent ophthalmology, 10.6 per cent pediatric surgery, 10 per cent plastic surgery, and eight additional specialties with <10 per cent of the cases each. Total operative time was 1253 hours with a total room time of 1896.5 hours. The identified complication rate was 1.99 per cent across all specialties. The USNS COMFORT platform offers the unique capability to provide humanitarian surgical assistance. Reporting these data demonstrate that there is a need for humanitarian assistance and this can be provided safely through the Continuing Promise mission. Future deployments may target resources toward the surgical services with higher volumes, which were general surgery, ophthalmology, pediatric surgery, and plastic surgery.

Duration time of vacuum-assisted biopsy for nonpalpable breast masses: comparison between stereotactic and ultrasound-guided procedure.

Minimally invasive biopsy should be a standard practice in the non-operative diagnosis of breast lesions that are suspicious for or highly suggestive of malignancy. The aim of this study was to compare the procedure duration time for different methods of minimally invasive image-guided vacuum-assisted breast biopsy (VABB). Six hundred and ninety-one women with nonpalpable breast masses classified as BI-RADS IV or V were studied. All of them underwent minimally invasive percutaneous VABB with an 11-gauge needle. In 402 patients an ultrasound-guided procedure with a hand-held device was performed while in 289 women stereotactic biopsy was carried out using a dedicated prone table unit with digital imaging. In each case the duration of biopsy was measured in terms of the total procedure time, room time and physician time. There were no significant differences between the stereotactic and ultrasound-guided groups with regard to patient age, body mass index, menopausal status, history of parity, hormone replacement therapy, breast parenchymal pattern (according to Wolfe's classification), family history of breast cancer, mass size and number of samples. Ultrasound-guided biopsy was found to take significantly less time than prone stereotactic biopsy in every aspect of procedure duration. Mean total procedure time, room time, and physician time in minutes were 26.7 ± 8.2 vs 47.5 ± 9.4 (P <0.01), 23.1 ± 8.5 vs 36.5 ± 9.2 (P <0.05), and 12.3 ± 5.6 vs 18.6 ± 5.9 (P <0.05), respectively. Ultrasound-guided breast biopsy is less time-consuming than the stereotactic procedure for both the patient and the physician. Because of the shorter procedure time (as well as other well-known advantages: real-time imaging, lower cost), ultrasound-guided biopsy should be considered the method of choice for sampling suspicious nonpalpable breast masses.

Impact of Hospital-Employed Physician Assistants on a Level II Community-Based Orthopaedic Trauma System.

The American Academy of Orthopedic Surgeons and the Orthopedic Trauma Association have released guidelines for the provision of orthopedic trauma services such as adequate stipends, designated operating rooms, ancillary staff, and guaranteed reimbursement for indigent care. One recommendation included a provision for hospital-based physician assistants (PAs). Given current reimbursement arrangements, PA collections for billable services may not meet their salary and benefit expenses. However, their actions may indirectly affect emergency room, operating room, and hospital reimbursement and patient care itself. The purpose of our study is to define the true impact of hospitalbased PAs on orthopaedic trauma care at a level II community hospital. Retrospective case series. Level II trauma center. One thousand one hundred four trauma patients with orthopaedic injuries. PA involvement. Emergency room data such as triage time, time until seen by the orthopedic service, and total emergency room time was recorded. Operating room data such as time to surgery, set-up time, total operating time, and out of room time was entered as well. Charts were reviewed to determine if patients were given postoperative antibiotics and Deep Venous Thrombosis (DVT) prophylaxis. Intraoperative and postoperative complications were noted, and lengths of stay were calculated for all patients. At our institution, PA collections from patient care cover only 50% of their costs for salary and benefits. However, with PA involvement, trauma patients with orthopedic injuries were seen 205 minutes faster (P = 0.006), total Emergency Room (ER) time decreased 175 minutes (P = 0.0001), and time to surgery improved 360 minutes (P . 0.03). Operating room parameters were minimally improved, but postoperative DVT prophylaxis increased by a mean of 6.73% (P = 0.0084), postoperative antibiotic administration increased by 2.88% (P = 0.0302), and there was a 4.67% decrease in postoperative complications (P = 0.0034). Average length of stay decreased by 0.61 days (P = 0.27). Although the PA's collections do not cover their costs, the indirect economic and patient care impacts are clear. By increasing emergency room pull through and decreasing times to Operating Room (OR), operative times, lengths of stay, and complications, their existence is clearly beneficial to hospitals, physicians, and patients as well. Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.