Although many institutions would like to improve operating room (OR) efficiency, a University of Colorado School of Medicine research team his taken it one step further by documenting the details of their case-start and turnover delays. As their study revealed, improving efficiencies can only lead to financial benefits when health care professionals across a range of specialties work together.
“With the aid of our technology department, we modified our electronic medical record with an electronic anesthesia record that included a delay-tracking system within each patient’s record,” said Matthew W. Victor, MD, assistant professor of anesthesiology at the research institution, in Aurora, Colo. “That was implemented in 2011, but I realized that nobody had mined the data. So, I wanted to dig deeper and see what the data would show.”
Delay codes were entered into the record by in-room anesthesia providers as part of their documentation flow. Patients not in the OR by 7:30 a.m. (8:30 a.m. on Mondays) or case turnovers exceeding 30 minutes were considered delays. Delay codes were broadly classified as anesthesia, surgery, nursing, patient or system delays. Further refinement is allowed within each classification, as multiple delay codes can be entered for each case.
Oftentimes Not the Anesthesiologist’s Fault
Dr. Victor and his colleagues analyzed data from 15,532 cases performed at the institution’s main ORs between September 2011 and December 2014. They found that clinicians documented a variety of reasons for delays, the most common of which was nursing—“OR not ready for patient”—which accounted for 13.2% of surgical cases involving delays.
This was followed by surgery—“notes, consent, patient marking not complete”—which comprised 7.0% of cases involving delays. The third most common delay was again nursing related—“pre-op prep (IVs, meds, etc.)”—accounting for 6.8% of delayed cases.
The seven remaining most common reasons for delays were:
- surgeons running two rooms;
- regional block/line placement;
- patient arrived late;
- transport delay;
- last case ended early;
- family religion, et cetera; and
- surgeon unavailable.
“Anesthesia often gets blamed for delayed starts, but the reality is that’s not the case,” Dr. Victor discussed at the 2015 annual meeting of the American Society of Anesthesiologists (abstract A1161). “Interestingly, of the top 10 reasons for delays, anesthesia was only implicated in one. We are a teaching institution, so regional anesthesia—particularly epidural placement—tends to be the one we struggle with the most, and that accounted for about 5.7% of the cases that had delays.”
As Dr. Victor explained, identifying delays might give clinicians and institutions the opportunity to achieve greater OR efficiency by identifying areas with the greatest room for improvement. Documenting delays has a natural place within the anesthetic record portion of the electronic medical record. “We’re perfectly positioned for that, because we sit in the preoperative area and wait for the room to be ready; we make sure the patient’s ready. So, we know specifically what’s going on. So, when the anesthesia provider walks into the room, identifying delays is just another part of their natural workflow.”
While implementing the automated system has eliminated the ambiguity of determining whether a delay has, indeed, occurred, the institution has taken its analysis one step further. It now emails daily OR efficiency reports to relevant personnel.
However, as much as a system such as this may help improve OR efficiency, the session’s moderators pointed out that it’s a far cry from the bottom line of saving money.
“With all of this work that we do on quality improvement and improved efficiency, ultimately the question becomes how your hospital funds its workers for their time,” said Satya Krishna Ramachandran, MD, assistant professor of anesthesiology at the University of Michigan Health System, in Ann Arbor. “Because if you’re saving a total of six hours and it doesn’t translate to a savings at the hospital level, is it really worth it?”
“Studies have shown that improving turnover times don’t necessarily allow for the addition of another case at the end of the day,” Dr. Victor replied. “But if you think about the people who work within the hospital, a lot of them are on an hourly wage. And if you can show six hours of savings, that’s six hours of operating room personnel that you don’t have to pay for.”
“At my institution we have 54 ORs that run every day, of which 18 to 22 run past 5:00,” said co-moderator Aalok V. Agarwala, MD, MBA, assistant division chief for general surgery anesthesia at Massachusetts General Hospital, in Boston. “If we can save enough time that you can get some of those done before 5:00, then we’re not paying overtime. If there’s a financial benefit, that’s where it lies. If a room is going to finish at 4:15 and now it finishes at 4:00, it doesn’t matter if staff are paid until 5:00 anyway.”