Patient and System Factors Affecting Anesthesiologist First Case Start Performance

Authors: George Hoffman, M.D. et al

Introduction: Performance of anesthesiologists, surgical teams, and perioperative systems is commonly measured by the percent of first case on time start (FCOTS) as percent of first cases of the day (FCOD) and by first case start delay (FCSD) time. Although these metrics have reported variable relationships to other measures of operating room efficiency and safety, they are increasingly used as measures of individual performance, especially of anesthesiologists. Sub-specialization of anesthesiologists across divisions of surgical subspecialties, patient disease severity, and service tracks within a practice group may confound individual measures of FCOTS performance. The aim of this study was to examine the effect of patient and system factors on individual-level FCOTS performance measures.

Methods: Anesthesia process and performance data were extracted from our perioperative anesthesia data warehouse for all cases from 2013-2018 at Children’s Hospital of Wisconsin and it surgicenter. Primary outcome measures were FCOTS percent and FCSD minutes for individual anesthesiologists, with modifiers of FCOD exposure, patient age and complexity (ASA -PS), primary surgical service, duration of anesthesia and recovery. Balancing measures of anesthesia procedural intensity, process safety measures, and mortality were also included. All data were de-identified prior to export for analysis. Data were reported as mean±sd, median (irq), and [range]. Associations between anesthesiologist identify and outcomes were tested by chi-squared tests and in multivariable regression models incorporating modifiers using Stata V15.2 (Statacorp, College Station, TX).

Results: Data from 139586 cases over 6 years for 50 anesthesiologists were analyzed. The median individual FCOTS was 63 (12), [0-84]%; median FCSD was 6.4 (2.4), [-4-94] minutes (figure 1). There was a strong relationship between delay minutes and FCOTS% (0.2 minutes/percent, r2=0.70) with one outlier anesthesiologist (figure 2), suggesting a predominance of non-anesthesiologist factors related to delays. The FCSD was strongly related to ASA-PS (2.9 minutes/ASA-PS class, r2=0.16) and to anesthesia case time (0.04 minutes/case minutes, R2=0.22). Anesthesiologist exposure to FCOD ranged from 12-100%, and median ASA-PS ranged from 1.47 – 3.35.

Conclusions: Patient and system factors contribute strongly to first case on time start performance of anesthesiologists. Exposure to these factors must be accounted for when benchmarking individual performance.