Orthopaedic surgery is a discipline of increasing importance as an avenue for health-care delivery in the United States. Americans of working age and older (sixty-five years and over) identify disorders of the musculoskeletal system as the foremost cause of limitation of activity1. The country's population is aging, as the proportion of individuals sixty-five years of age and older is growing at a faster rate than the total population. Furthermore, the number of orthopaedic procedures and the corresponding allocation of resources are expected to increase in coming years. For example, the annual demand for primary total knee arthroplasty has been projected to reach 3.48 million procedures by the year 2030, and the quantity of revision knee arthroplasties is estimated to increase 601% from 2005 levels by that same year2.
Increasing demands are being placed on the health-care system, as a result of the growing number of people in need of care and the continuing advances in costly technology3. The concurrent changes in reimbursements and rising costs have created pressures to increase clinical efficiency, specifically targeting the most resource-intensive unit in the hospital: the operating room4. As a consequence of increasing costs combined with diminishing health-care resources, interest in the economic examination and evaluation of health care is growing. Bozic et al. identified a paucity of economic studies of health care in the orthopaedic literature, providing evidence that most orthopaedic surgeons are not familiar with economic principles and their relation to the health-care system5. In consideration of the importance that is placed on operating-room efficiency as a necessity for the continued function of most health-care delivery institutions, we reviewed and assessed the state of the literature concerning this increasingly important issue, seeking to identify successful strategies that increase the throughput as well as the quality of operating rooms.
We found that a number of strategies have been devised with the goal of improving throughput in operating rooms, and they can be loosely categorized into general measures for improvement and strategies more specific to the preoperative (Table I), intraoperative (Table II), and postoperative (Table III) phases of operating-room processing flow. We collated our findings and organized them around important questions that should be addressed when considering operating-room efficiency.
While we believe that the concept of operating-room efficiency is an important one, and efficiency can be improved by making process changes, we also want to emphasize that no increase in efficiency can substitute for good, safe patient care.
What Are the Causes of Delays, and What Are Appropriate Solutions?
In a landmark study performed at the Medical University of South Carolina, Overdyk et al. demonstrated a number of successful strategies for improving operating-room efficiency6. Several of their findings addressed the preoperative phase of the operative day. Two strategies devised by the authors for increased operating-room throughput were the adoption of a standardized language of procedural times and time periods and an educational period for operating-room staff intended to provide guidelines for improving efficiency. The guidelines were devised from the findings of the preintervention, prospective data-collection period of the study. During the educational period, representatives from the various departments contributing to operating-room patient care informed their constituencies of the most common sources of delay specific to their task area, target times for improved efficiency, and strategies to attain those time goals. Analysis of the preintervention prospective data demonstrated that a disproportionate number of delays were occurring during the first procedure of the operative day. The most common causes of a delay in the first operation included delayed patient registration and transportation, personnel unavailability, and congestion in the staging area. Overdyk et al. implemented a number of changes to address these sources of delay.
In response to inefficient patient registration and transportation, for example, existing nursing and ancillary personnel were reassigned to registration and preoperative nursing functions6. The anesthesia providers were allowed to transport patients to the operating room and to prepare them for anesthesia in parallel with the preoperative preparation by the nurses, which replaced the preintervention practice of waiting until the nursing tasks were completed. No additional staff was recruited for patient preparatory functions. To address the unavailability of personnel, the chief of surgery was notified in writing of surgeons who were repeatedly unavailable to begin their cases on time and was informed that these surgeons were at risk of losing their operating-room time slots. To relieve congestion in the staging area prior to surgery, patients were rerouted to less crowded holding areas on the basis of their admission status. Furthermore, an important feature of the study by Overdyk et al. was the monthly recording of operating-room times and causes of operating-room delays by circulating nurses with use of a standardized data form, which was placed on display in the operating room. These data were compiled into monthly reports that were discussed at meetings of the operating-room efficiency committee and were submitted to the chiefs of surgery and anesthesia, as well as the director of nursing for the operating-room suites.
Overdyk et al. achieved a number of improvements with regard to patient flow in the operating room through initiating a program for operating-room efficiency awareness and implementing specific strategies. Timing data that documented when the patient was in the room, anesthesia was ready, surgical preparation had started, and the procedure had started were all substantially earlier for the first patient of the day. The start time for the first operation of the day was advanced an average of twenty-two minutes. Turnover time was decreased for all cases combined by an average of sixteen minutes. Also, the unavailability of surgeons, anesthesiologists, and residents was also reduced. Overall, Overdyk et al. estimated that their initiatives to increase operating-room efficiency resulted in forty-six minutes of time savings in each operating room on a daily basis6.
Similar approaches have been successful at other institutions as well7-11. In all instances, the need for efficiency was balanced with the need to maintain or improve both patient safety and staff satisfaction. At the University of Florida, work-flow assessment was completed by a team consisting of nurses, surgeons, anesthesiologists, and surgical technicians, and the results showed many instances of small inefficiencies that could be remedied by clearer role definition, the development of teams, and better communication strategies7. After implementing improvements, the mean turnaround time decreased from 43.7 minutes to 27.7 minutes, and the mean number of patients increased from 1.78 to 2.34 per room per day7. Heslin et al. reported on work done at the University of Alabama that included strategies of incentivizing employees for overtime work, policies surrounding release of unbooked rooms to a central pool for reassignment, multidisciplinary management teams, and strict adherence to the National Patient Safety Goals; their efforts increased the number of on-time starts and the number of operations done per day while decreasing adverse events, delays in patient admissions, and staff departures10. At Case Western Reserve University, a multidisciplinary team reduced nonoperative time (room turnover and anesthesia time) by 50% through the introduction of parallel processing, dedicated surgical teams, and minimizing nonoperative tasks done within the operating room9. Brigham and Women's Hospital in Boston used observational techniques to identify efficiency issues that could be directly related to patient safety. They determined that communication breakdown, information loss, high workload, and multiple competing tasks all contribute to the potential for adverse events, but they were all modifiable through better team coordination and communication8.
What Strategies Are Available to Improve First-Case Start Times and Turnover Times?
Two time periods of the orthopaedic operative day that have received study in the literature include first-case start times and turnover times. Since turnover time occurs between operations, it can be considered a component of both the preoperative and postoperative phases as is discussed in the present article. The St. Luke's Episcopal Hospital orthopaedic perioperative team implemented the Continuous Outcomes Measurement and Improvement Technique model to improve first-case actual start times at their institution12. Windle et al.12 noted that a delay in starting an operation has a multiplying and cumulative effect on the scheduled operations that follow. The orthopaedic team initiated a number of strategic changes regarding preoperative evaluation tests and processing in the preoperative holding area. The preintervention policy at St. Luke's for preoperative evaluation was to have patients arrive for testing on the day prior to the surgery. As a part of the new strategy, surgeons were asked to instruct their patients to arrive for their preoperative testing as well as the anesthesia and nursing evaluations two weeks prior to the scheduled surgery. The perioperative staff started checking patient records at seventy-two, forty-eight, and twenty-four hours prior to scheduled surgeries for completion of all necessary documentation, immediately notifying the physician's office staff if any documentation was missing. To improve processing in the preoperative holding area before surgery, nurses in the postanesthesia care unit were scheduled to arrive at 6:00 a.m. on the day of surgery in the preoperative area to assist with preparations for the first patient. An infusion therapy team nurse also reported daily to assist with intravenous infusion insertion and antibiotic administration. These changes allowed for early transport of patients to the operating room for the anesthesia staff to begin induction. By adopting these changes, the orthopaedic service enjoyed several gains in efficiency. The new two-week preadmission strategy resulted in an increase from 40% to 90% of all patients being preadmitted. Overall delays in orthopaedic operations decreased from a rate of 7.8% to 3.9%. The proportion of total orthopaedic operations starting on time increased to between 80% and 87%, and there was a 26% improvement in actual start times for the first patient12.
Much of the nonsurgical time between patients (turnover time) is under the direction of the anesthesiology service. Anesthesia-controlled time can be conceptualized as the combination of two intervals, the time from operating-room entry until surgical preparation begins and the time from the end of the surgical procedure until operating-room exit13. In a study examining the effect of reducing anesthesia turnover time on operating-room throughput, Sokolovic et al. found that increasing anesthesia staff by one physician and one nurse for induction of a surgical patient prior to the ending of the case of a previous patient substantially decreases turnover time14. By overlapping the anesthesia induction of the next patient with the case of the previous patient, the authors showed a decreased mean turnover time between patients from sixty-five minutes to fifty-two minutes, and they increased the patient occupancy time in the operating room from four hours and twenty-eight minutes per day to five hours and twenty-seven minutes14. Krieg et al. investigated adding a completely separate induction area without adding personnel and determined that the mean turnover time was reduced from twenty minutes to fourteen minutes without any increase in critical events15.
To determine the effect of a regional anesthesia induction room on anesthesia-controlled time, Williams et al. compared anesthesia-controlled time in anterior cruciate ligament reconstructions performed with use of regional anesthesia induced in a designated room with the anesthesia-controlled time for the same procedure performed with the patient placed under general anesthesia without use of an induction room. They found that anesthesia-controlled time was lowest for regional anesthesia induced in an induction room16. A Canadian study examined the effects of performing brachial plexus anesthetic blocks in an operating-room suite space designated for such blocks on the utilization of operating-room time for a combined orthopaedic and plastic surgery practice performing upper-extremity procedures17. Armstrong and Cherry found that utilizing a designated room to perform brachial plexus blocks reduced average preoperative anesthesia-controlled time to 11.4 minutes, compared with brachial plexus blocks performed in the operating room itself, which required 32.9 minutes17. In another study, Torkki et al. sought to determine the effects of concurrent induction of anesthesia in an induction room on the entire operative day for urgent orthopaedics cases, on operating-room throughput times, and on the number of completed cases performed between the hours of 7:45 a.m. and 3:00 p.m.13. They found that use of an induction room decreased nonoperative time by 45.6%. Furthermore, there was a reduction in the delays between phases of the operative day, which the authors attributed to the immediate proximity of the induction room to the operating room, as the next patient was already anesthetized and ready to be transported to the operating room when room cleaning was complete. An additional procedure was able to be added to the operating-room schedule between 7:45 a.m. and 3:00 p.m. Monthly overtime hours of the operating room decreased from 196 hours to 190 hours, and analysis of labor cost-efficiency demonstrated a 16% improvement13.
One strategy to improve first-case start times and turnover times involves incentivizing staff for good performance. Certainly, giving preference for first-case starts to teams that consistently meet expectations, allowing teams to leave early if all work is completed, giving flexibility to staff in scheduling, giving monetary bonuses for meeting specific targets, and similar strategies can have an impact on productivity and retention of staff, but it has not been proven that these are effective ways to increase overall efficiency18-20. In addition, care must be taken if incentives are used so that regulations of a governmental or other body are not violated. In some institutions, labor or union contracts prohibit giving direct monetary benefits, so special negotiations with these groups would need to occur before incentive programs could be launched.
Do Clinical Pathways Lead to Improvements in Operating-Room Efficiency?
Clinical pathways are the manifestation of applied industrial management science to health care. They represent an attempt by hospitals to reduce variable costs and variation in quality of care without affecting outcomes. The pathways are intended to address variability in the use of hospital support systems and resources for patients with similar conditions21. More specifically, they are defined as the optimal sequencing and timing of interventions by physicians, nurses, and staff for a given procedure22.
Macario et al. implemented a clinical pathway for total knee arthroplasty at their institution in order to determine the impact of the pathway on procedure costs21. They found that adopting a clinical pathway resulted in a 19% decrease in total hospital costs for each patient undergoing total knee arthroplasty. The point of focus of their pathway within the operating room was physician-managed utilization of resources. The authors observed that adopting a pathway resulted in simplification and standardization of the procedure, facilitated data collection and analysis, and resulted in reductions in waste and duplication of effort21. Clinical pathways have been implemented successfully in surgical disciplines other than orthopaedic surgery. Chalian et al. initiated intraoperative pathways for the treatment of head and neck cancers and concluded that clinical pathways are valuable, and improved time efficiencies are achievable through their implementation23.
What Are the Implications of Modified Staffing Models for Operating-Room Efficiency?
A study performed by Brenn et al., at their tertiary care institution, concerning staffing models for otolaryngologic surgical cases could have implications for other surgical specialties24. They determined the mean operative time intervals, anesthesia start times, surgical preparation times, and anesthesia end times for three relatively short head-and-neck procedures done in a traditionally staffed operating room, with both a circulating and a scrub nurse, and compared them with the same procedures done in a short procedure room staffed by one operating-room circulating nurse. They found that the total operative procedure times were shorter for two of the three procedures, with a similar time interval for the third procedure, despite the decrease in the number of staff assisting the surgeon. Brenn et al. concluded that, for specific short procedures, implementing the short-procedure-room setting within their facility resulted in decreased staffing costs and gains in efficiency24. Adopting a similar model for relatively short procedures in the other surgical services of a tertiary care center could possibly result in analogous gains in efficiency, although more work is necessary in this area.
Other staffing models, including the addition of a second shift Monday through Friday or the addition of weekend cases, could be considered, but these models have not been scientifically studied as to whether they would increase efficiency or improve patient access. In terms of adding volume, adding hours would seem to be an easy fix, but recent experience with the difficulty in recruiting a sufficient number of trained personnel, especially nurses and surgical technicians, has shown that this is not a viable solution for most hospitals18.
Should a Surgeon's Operating Margin Influence the Allocation of Operating-Room Time in Order to Improve Profitability?
In the environment of declining reimbursements, hospitals are forced to consider measures to maintain or increase revenues in order to remain viable. A major source of revenue for health-care institutions is surgical procedures. Macario et al. demonstrated that the profitability of individual surgical cases can be measured by contribution margin, and that this margin can vary among surgeons per hour of operating-room time25. In order to determine contribution margin for individual surgical cases, they subtracted variable costs from the total payment. The authors found that the contribution margin per hour of operating-room time varied among patients of individual surgeons as well as among surgeons. This degree of variability among surgeons was substantial enough that they determined operating-room managers can attempt to increase the profitability of an operating-room suite by allocating operating-room time according to contribution margin. Macario et al. concluded that, for institutions that have high operating-room utilization and fixed hours of operating-room time, the contribution margin for surgical services is best increased not by demanding an increased volume of cases from its surgeons, but by increasing the number of operating-room hours designated for lucrative procedures (essentially allocating operating-room time on the basis of contribution margin). Macario et al. also stated that institutions need to confront the implications of adopting such practices25.
In a subsequent study, Dexter et al. demonstrated that application of a linear programming mathematical model to reallocate operating-room time among surgeons could increase the hospital contribution margin for elective surgical cases by 7.1%26. Sokal et al. combined parallel processing with surgeon profiling to determine whether time saved could be allocated to specific case-surgeon combinations to increase operating-room throughput27. At their institution, they converted four operating rooms into a high-efficiency pod consisting of three parallel-processing operating rooms and a dedicated three-bed postanesthesia recovery room. The authors noted that, by structuring the high-efficiency pod, they had effectively removed one operating room from production for the postanesthesia care unit and thus needed to compensate through incremental case volume in the remaining three parallel-processing rooms. By producing surgeon profiles, Sokal et al. determined that specific surgeons and surgeon-case combinations could lead to the completion of more cases per block in the parallel-processing setting, yielding additional throughput that was more than adequate to compensate for the operating room converted to a postanesthesia care unit27.
It bears mentioning that many of the factors that influence contribution margin are beyond an individual surgeon's control, such as standards of care and individual payer reimbursement rates. The other major issue about the use of contribution margins as a way to allocate operating-room time involves the complex legal and financial relationships surgeons can have with hospitals, outpatient clinics, and ancillary services that specific federal regulations have attempted to govern28-31. While the purpose of these regulations is to curb the tendency for surgeons to refer patients having operations that are more lucrative to institutions with which they have financial ties, it is unclear what impact this potential practice was having on the inpatient setting before or after their enactment. Nonetheless, surgeon profiling has been demonstrated to be an effective technique for increasing operating-room throughput and efficiency.
What Impact Do Residents Have on Operating-Room Efficiency, and How Can Their Productivity Be Improved?
In 1997, the annual cost of training general surgery residents in the operating room was conservatively estimated to be $53 million32. This cost has been accepted as an inherent inefficiency in graduate medical education and necessary for appropriate training and high-quality surgical care33. Farnworth et al. examined the financial impact of training orthopaedic surgery residents at their institution by comparing operative times for arthroscopic reconstruction of the anterior cruciate ligament between orthopaedic attending physicians and residents34. They found a large difference in both operative time and cost between faculty and residents for this procedure. The additional anesthesia and operating-room times required by residents resulted in an average increased cost of $228.73 per patient for anesthesia and $661.85 per patient for operating-room time34.
Babineau et al. examined the difference in operative times required for academic surgeons to perform four common surgical procedures with and without a postgraduate year-3 resident33. They determined that there was in fact an increased time cost when a resident was assisting in a surgical case because of an increase in the operative time. However, Babineau et al. also determined that the extra costs associated with operating-room schedule inefficiencies and overtime represent a small percentage of total operating-room costs and that, if surgical residencies were to be entirely removed from academic hospitals, those hospitals would be unlikely to experience any substantial monetary gain from a consequent reduction in operating-room expenses. Rather, they concluded that the increased time cost is primarily borne by the attending academic surgeon in the form of opportunity cost33.
A number of authors have investigated more efficient methods of training surgical residents. Bridges and Diamond recognized a need for training facilities outside the operating room, including virtual reality training, to allow surgical residents to develop operative technical skills32. Seymour et al. performed a prospective, randomized, blinded study to assess the efficacy of virtual reality training for the acquisition of operative skills and error risk reduction35. Sixteen surgical residents were randomized to either virtual reality training or a control group that had standard training without the use of virtual reality. All of the residents eventually performed laparoscopic cholecystectomy with a blinded attending surgeon, and videos of the procedures were subsequently assessed by reviewers blinded to resident identity and training status for predefined errors. The authors found that gallbladder dissection was 29% faster for the virtual reality-trained residents. Furthermore, the residents who had not had virtual reality training were nine times more likely to transiently fail to make progress and five times more likely to injure the gallbladder or burn nontarget tissue. Seymour et al. concluded that virtual reality training represented an improved means of training surgical residents for performing laparoscopic cholecystectomy in the operating room, and that their virtual reality-acquired skills could be successfully transferred to the operative field. In addition, they pointed out a number of advantages to adopting virtual reality training. For example, surgical residents can be trained to high levels of objectively measured skill prior to performing surgical procedures on patients. Virtual reality simulators allow for the necessary time required to attain specific training goals. With use of virtual reality, resident performance can be continuously assessed until proficiency is achieved. Residents can accomplish much of their learning of technical skills using a simulator, rather than through performing operations on patients, and simulators can relieve the burden on the attending surgeon's time. Furthermore, virtual reality simulators serve as objective, automatic monitors of quality assurance. Seymour et al. concluded that their findings support the introduction of virtual reality training in surgical education35. In consideration of these findings, it is reasonable to infer that operating-room throughput can be increased through the implementation of virtual reality in resident training, by reducing operative times and producing higher-quality outcomes.
What Is the Contribution of Postanesthesia-Care-Unit Gridlock to Operating-Room Inefficiency?
The postoperative phase of operating-room processing represents a period during which a number of inefficiencies can manifest. The point of focus for these impairments of operating-room throughput is the postanesthesia care unit. Prolonged lengths of stay in the postanesthesia care unit are an important cause of operating-room inefficiency. McGowan et al. identified postanesthesia-care-unit gridlock as a major source of compromise in operating-room throughput36. Chung found that most delays in the departures of patients from the postanesthesia care unit, once they were determined to be fit for discharge, were nonmedical in nature37. Consequences of a prolonged length of stay include prevention of timely discharge from the postanesthesia care unit, occupation of bed space and nursing staff, and delays in surgical case scheduling38. Reducing inefficiencies in the postanesthesia care unit is particularly relevant to orthopaedic surgery, as orthopaedic patients can require relatively longer stays in the postanesthesia care unit following surgery. For example, in a study of ambulatory surgery patients, Chung found that those who underwent an orthopaedic procedure compared with those who had cataract extraction or dilation and curettage had a sixfold increased risk of having persistent postoperative symptoms in the postanesthesia care unit and a 2.5-fold longer time to discharge to home37.
How Does Anesthesia Recovery Time Affect Operating-Room Efficiency?
As Dexter et al. pointed out, faster emergence of patients from anesthesia reduces the time between the completion of surgery and the time when the patient leaves the operating room39. The application of anesthetic techniques that require minimal postanesthesia nursing care permits bypassing of the phase-I postanesthesia care unit directly to the phase II step-down recovery unit, resulting in substantial reductions in the average time that patients spend in the postanesthesia care unit. Dexter et al. developed a computer simulation for ambulatory surgery centers that could estimate potential decreases in labor costs for the operating room and postanesthesia care unit using financial and processing data from their own institution. In the study validating their simulation, the authors found that operating-room managers must confront causes of delayed discharge following surgery in order to decrease costs, that ambulatory surgery centers must develop postanesthesia-care-unit criteria that permit bypass of the phase-I postanesthesia care unit directly to the step-down unit and timely discharge, and that decreases in labor costs are possible from faster anesthesia emergence and increased rates of bypass of the phase-I postanesthesia care unit39.
What Factors Affect Utilization of Beds in the Postanesthesia Care Unit?
Marcon et al. indicated that there is no clear definition of the appropriate ratio of postanesthesia-care-unit beds to the number of surgical rooms in an operating-room suite40. In order to gain clarity on the issue, they applied computer simulation in order to model operating-room suite flow and to determine the number of beds required for appropriate function of the postanesthesia care unit. Their simulation revealed several important findings. The authors determined that the number of porters has a noticeable impact on the hourly utilization of postanesthesia-care-unit beds. Decreasing the number of porters resulted in an increased number of beds to be staffed in the postanesthesia care unit. Furthermore, porters were determined to be the potential bottlenecks in postoperative patient flow. Marcon et al. also determined the most common nonmedical causes of delay in patient discharge from the postanesthesia care unit. They included (1) no assigned bed for the patient, (2) preoccupation of postanesthesia-care-unit nurses with other tasks, and (3) porter unavailability. As a consequence of an inadequate number of porters, patient discharge from the postanesthesia care unit is delayed and the number of beds required for postanesthesia-care-unit use increases. Patients to be transferred or discharged accumulate in the postanesthesia care unit, eventually occupying all available beds and causing some postoperative patients to remain in the operating room during recovery, effectively removing that room from the pool available for additional surgical procedures. Thus, limitation in transport assistance for patients effectively serves as a bottleneck and disrupts flow through the operating-room suite. Marcon et al. also determined that porter quantity has a larger impact on determining the number of beds necessary for function of the postanesthesia care unit than the length of stay in the postanesthesia care unit. Therefore, their simulation demonstrated that porter availability is more important for operating-room managers to consider when optimizing efficiency than minimizing length of stay in the postanesthesia care unit. Marcon et al. concluded that their simulation can serve as a valuable tool for operating-room management when designing a new operating-room suite40.
What Role Does Parallel Processing Play in Postoperative Operating-Room Efficiency?
In a study investigating how to maximize capacity in the operating room and the recovery room, Sokal et al. determined that accommodating additional surgical patients generally requires additional operating rooms and working overtime under the traditional serial model of operating-room processing41. They recognized that a different model of processing is necessary to perform additional surgeries in existing block time without reducing operative time. For their study, the authors adopted a parallel processing model, in which anesthesia induction and operating-room setup could be accomplished simultaneously. They found that by reorganizing four operating rooms into a pod consisting of three operating rooms and a dedicated postanesthesia-care-unit space, they could achieve simultaneous induction and operating-room setup while facilitating emergence from anesthesia and postanesthesia-care-unit handoff of care. Also, the close proximity of the postanesthesia-care-unit space improved efficiency and the safety of patient transfer. Sokal et al. were able to achieve their pod conversion and its operation without adding more staff. However, adopting the pod model removed an operating room from the pool available for procedures and resulted in an increased number of handoffs of care, as the patients were transferred from the mini-postanesthesia care unit in the pod to the main postanesthesia care unit of the operating-room suite prior to discharge to the wards or home. They found that their pod model could be implemented across the surgical specialties. The authors effectively demonstrated that they were able to perform more operations using the same resources originally available to them41. On the basis of this study, parallel processing has a role in the improvement of operating-room throughput during the postoperative phase. The pod model represents an advancement in operating-room processing, and it clearly has the potential to improve workflow efficiency once adopted.
Specific to orthopaedic surgery, there has been much support for designating a dedicated orthopaedic trauma room to enhance patient flow and efficiency in the operating room42-44. Studies have shown that use of a trauma room decreased the need for after-hours resources44; decreased morbidity, mortality, and the wait time for surgery43; and decreased the need to add cases to the regular surgery schedule42.
How Can a Multidisciplinary Approach Improve Operating-Room Throughput?
McGowan et al. adopted a multidisciplinary approach to addressing problems in operating-room throughput in their study at the University of Virginia36. In their analysis of operating-room efficiency at maximum hospital capacity, they found that holding patients in the operating-room suite after completion of their surgery ("OR holds") prevented follow-up of patients having elective surgery. They proposed and implemented a number of strategies in order to address shortcomings in operating-room efficiency. In order to relieve gridlock in the postanesthesia care unit during the operative day, the authors moved appropriate postoperative patients to a patient transition unit, a site in the hospital where the patients could wait for transportation home, thus freeing up their previously occupied beds for additional patients. As an additional measure to relieve gridlock, nurses with any surgical experience would be redistributed from the internal staffing pool to appropriate areas, such as the postanesthesia care unit and patient transition unit, to assist with postoperative patients. Utilizing technology in the form of the Vocera wireless pendant communication device (Vocera Communications, San Jose, California), the authors were able to improve patient flow in the operating room. The device permits immediate two-way and conference communication between care areas. It allows for rapid identification of appropriate sites for holding recovering postoperative patients and helps to avoid delays in the care of subsequent surgical patients. Timeliness of discharge was improved by implementation of a discharge-by-noon program, which incorporated an incentives system. Nursing and house staff who achieved change by adhering to the discharge-by-noon program were rewarded with recognition and additional financial support of their respective clinical units. Also, a standard of sixty minutes or less for all bed turnovers was established for environmental services. The institution enjoyed a number of improvements as a consequence of implementing these strategies. For example, the discharge-by-noon policy improved hospital capacity by 11% overall and by 10% in adult surgical services, representing an increase of five hospital beds per day. All operating-room holds were reduced by 37%, and holds over sixty minutes were decreased by 67%. The reduction in operating-room holds contributed toward an increase in operating-room patient volume of 8%, an additional 1035 operating-room hours during the period of study, and a decrease in operating-room case cancellations from 4.3% to 1.3%. Bed turnaround times by environmental services improved by 39%, and utilization of the patient transition unit effectively relieved congestion in the postanesthesia care unit36.
The work of McGowan et al. represents a successful multidisciplinary systems approach to improved operating-room efficiency during the postoperative phase. Not only was their institution able to stop accumulating additional inefficiencies, it was able to achieve gains in efficiency by adopting these policies. The collection of strategies detailed by McGowan et al. represents an example that can be followed by other academic medical centers seeking to improve the throughput of their operating rooms, particularly when patient occupancy is near or at capacity.
The idea of maximizing the value of multidisciplinary teams is amplified when data are used to help to drive improvement efforts. The example of the National Surgical Quality Improvement Program shows what remarkable changes can be made when comprehensive data analysis is linked to specific improvement projects with the goal of reducing morbidity and mortality45. The results from this national effort have led to an 8.7% reduction in overall postoperative morbidity, a 9.1% reduction in surgical site infections, and a 23.7% reduction in renal complications in private hospitals45. In the Department of Veterans Affairs hospitals, thirty-day mortality decreased by 27% and thirty-day morbidity was reduced by 45%46. Most of the changes recommended by this program, including the use of self-assessment tools, incorporation of team communication strategies, and improving care coordination47,48, can be accomplished without the need for additional funding, although they require strong management and department support for efforts to break down traditional department barriers, especially between professions such as nursing and various physician specialties.
One of the inherent difficulties in improving efficiency is the double-pronged problem of determining what to measure and then obtaining reliable data to evaluate performance over time. Many groups have advocated the development of standards for specific measurements as a way to compare performance between and within operating-room environments, including the use of cross-industry benchmarks; however, for the most part, the development and definition of standards is left up to the individual institution or group of institutions49-51. National comparisons of hospitals on some metrics are available on the Internet, but these comparisons focus mostly on mortality, complications following surgery, and case volume and not necessarily on efficiency measures. In fact, several articles have criticized the use of volume as a stand-alone measure of efficiency or quality, since the relationship between case volume and risk-adjusted outcomes following surgery is not linear52-54.
Despite the current limitations on available standards data for the individual institution, specific metrics to monitor for determining efficiency in the operating-room environment have been recommended, but each requires careful definition and buy-in from the various stakeholders involved in operating-room management45,49,51. The metrics are:Thirty-day postoperative mortalityThirty-day postoperative complications and infectionsThirty-day readmissions for the same and/or a similar diagnosisScheduled compared with actual utilization by surgeon and specialtyPrime-time compared with second shift and/or weekend utilization by surgeon and specialtyPercentage of "on-time" starts by surgeon and specialty for the first patient of the dayStart-time accuracy by surgeon and specialty for subsequent patientsAccuracy of estimated duration of operationAdd-on rate (patients added to surgery schedule each day)Cancellation rate (day of surgery)Turnover time and/or nonoperative time between patientsUse of overtime by type of staffProduct standardizationInventory managementPreference card managementCost-per-case management (supplies and personnel)Patient satisfactionStaff satisfactionStaff turnover
Thirty-day postoperative mortality
Thirty-day postoperative complications and infections
Thirty-day readmissions for the same and/or a similar diagnosis
Scheduled compared with actual utilization by surgeon and specialty
Prime-time compared with second shift and/or weekend utilization by surgeon and specialty
Percentage of "on-time" starts by surgeon and specialty for the first patient of the day
Start-time accuracy by surgeon and specialty for subsequent patients
Accuracy of estimated duration of operation
Add-on rate (patients added to surgery schedule each day)
Cancellation rate (day of surgery)
Turnover time and/or nonoperative time between patients
Use of overtime by type of staff
Product standardization
Inventory management
Preference card management
Cost-per-case management (supplies and personnel)
Patient satisfaction
Staff satisfaction
Staff turnover
In an effort to further our understanding of operating-room processing flow, sources of inefficiency, and strategies for ameliorating such inefficiency, we conducted a review of the literature. We found that there is a body of work on this subject that has been produced largely out of necessity for the continued function of health-care institutions and their operating suites in an ever-changing health-care system. Much of the work to this point has been managerial in nature, addressing matters of infrastructure and models of day-to-day operation. It has been mainly within the past decade that studies have examined the actual phases of the operative day, determining intrinsic causes for inefficiency and seeking to make changes that result in improved processing flow. The bulk of this type of work has been conducted in the field of anesthesiology. Our hope was that by examining the available literature on the issue of operating-room efficiency, we could determine causes of inefficiency and make recommendations for improving throughput within the context of maintaining safe, effective patient care.
Most of the work that has addressed efficiency at the distinct phases within the operative day has been focused on streamlining the traditional linear model of operating-room processing, maximizing capacity, and reducing labor costs. While this work has been demonstrated to be effective in improving efficiency and has established a foundation for further research, there is, in the era of declining reimbursements, an approaching end point to the gains to be made by implementing the strategies that have come out of these studies. This reality has forced researchers in operating-room efficiency to devise modifications to the linear model, such as anesthesia induction and short procedure rooms, or to consider new models altogether, such as parallel processing and the high-efficiency operating-room pod. Exploiting advances in technology is also a potential means toward improving operating-room processing and throughput, as has been shown by training surgical residents with virtual reality. A multidisciplinary approach toward improving efficiency is recommended, as gains made by individual groups involved in the functioning of an operating-room suite can have synergistic effects when joined in a combined effort. However, there are also potential issues that arise in bringing the often disparate priorities of the various specialties involved in operating-room environments (surgeons, anesthesiologists, nurses, and technologists) together to form cohesive strategies for improvement, and care must be taken to incorporate the viewpoints of these stakeholders in any decisions made.
There seems to be no clear single answer to the question of how to improve operating-room processing and throughput. Rather, there are a number of individual strategies directed at improving particular aspects of operating-room processing. What is clear is that more work is needed in this area, particularly within orthopaedic surgery, so as to elucidate further recommendations for the refinement of operating-room efficiency within this surgical specialty, as it continues to assume greater importance in the health care of the population.
Note: The authors thank Jonathan Mason, MD, for his assistance in the preparation of this manuscript.
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