Donald H. Penning

Calculating a potential increase in hospital margin for elective surgery by changing operating room time allocations or increasing nursing staffing to permit completion of more cases: a case study.

Administrators routinely seek to increase contribution margin (revenue minus variable costs) to better cover fixed costs, provide indigent care, and meet other community service responsibilities. Hospitals with high operating room (OR) utilizations can allocate OR time for elective surgery to surgeons based partly on their contribution margins per hour of OR time. This applies particularly when OR caseload is limited by nursing recruitment. From a hospital’s annual accounting data for elective cases, we calculated the following for each surgeon’s patients: variable costs for the entire hospitalization or outpatient visit, revenues, hours of OR time, hours of regular ward time, and hours of intensive care unit (ICU) time. The contribution margin per hour of OR time varied more than 1000% among surgeons. Linear programming showed that reallocating OR time among surgeons could increase the overall hospital contribution margin for elective surgery by 7.1%. This was not achieved simply by taking OR time from surgeons with the smallest contribution margins per OR hour and giving it to the surgeons with the largest contribution margins per OR hour because different surgeons used differing amounts of hospital ward and ICU time. We conclude that to achieve substantive improvement in a hospital’s perioperative financial performance despite restrictions on available OR, hospital ward, or ICU time, contribution margin per OR hour should be considered (perhaps along with OR utilization) when OR time is allocated.

A Preliminary Investigation of Remifentanil as a Labor Analgesic

Implications In this preliminary investigation, we evaluated the safety and analgesic efficacy of IV remifentanil for labor pain. Four women were studied, and then the trial was terminated because administration of this novel synthetic opioid produced significant maternal side effects in the absence of effective pain control.

Use of linear programming to estimate impact of changes in a hospital's operating room time allocation on perioperative variable costs.

Background Administrators at hospitals with a fixed annual budget may want to focus surgical services on priority areas to ensure its community receives the best health services possible. However, many hospitals lack the detailed managerial accounting data needed to ensure that such a change does not increase operating costs. The authors used a detailed hospital cost database to investigate by how much a change in allocations of operating room (OR) time among surgeons can increase perioperative variable costs. Methods The authors obtained financial data for all patients who underwent outpatient or same-day admit surgery during a year. Linear programming was used to determine by how much changing the mix of surgeons can increase total variable costs while maintaining the same total hours of OR time for elective cases. Results Changing OR allocations among surgeons without changing total OR hours allocated will likely increase perioperative variable costs by less than 34%. If, in addition, intensive care unit hours for elective surgical cases are not increased, hospital ward occupancy is capped, and implant use is tracked and capped, perioperative costs will likely increase by less than 10%. These four variables predict 97% of the variance in total variable costs. Conclusions The authors showed that changing OR allocations among surgeons without changing total OR hours allocated can increase hospital perioperative variable costs by up to approximately one third. Thus, at hospitals with fixed or nearly fixed annual budgets, allocating OR time based on an OR-based statistic such as utilization can adversely affect the hospital financially. The OR manager can reduce the potential increase in costs by considering not just OR time, but also the resulting use of hospital beds and implants.

Iliohypogastric-ilioinguinal peripheral nerve block for post-Cesarean delivery analgesia decreases morphine use but not opioid-related side effects

PurposeTo examine if ilioinguinal-iliohypogastric nerve block could reduce the need for post-Cesarean delivery morphine analgesia and thus reduce the incidence of opioid related adverseeffects.MethodsA multi-level technique for performing the nerve block with bupivacaine was developed and then utilized in this two-part study. Part one was a retrospective assessment of Cesarean delivery patients with and without ilioinguinal-iliohypogastric blocks to determine if the technique reduced patient controlled analgesia morphine use and thus would warrant further study. The second phase was a randomized double-blind placebo-controlled trial to compare post-Cesarean morphine use and the appearance of opioid-related side effects between the anesthetic and placebo-injected groups.ResultsBoth phases demonstrated that our method of ilioinguinaliliohypogastric nerve block significantly reduced the amount ofiv morphine used by patients during the 24 hr following Cesarean delivery. In the retrospective assessment, morphine use was 49 ± 30 mg in the block groupvs 79 ± 25 mg in the no block group (P = 0.0063). For the prospective trial, patients who received nerve blocks with bupivacaine had a similar result, self-administering 48 ± 27 mg of morphine over 24 hr compared to 67 ± 28 mg administered by patients who received infiltrations of saline. However, despite the significant decrease in morphine use, there was no reduction in opioid-related adverse effects: the incidences of nausea were 41 % and 46% (P = 0.70) and for itching were 79% and 63% (P = 0.25) in the placebo and nerve block groups, respectively.ConclusionA multi-level ilioinguinal-iliohypogastric nerve block technique can reduce the amount of systemic morphine required to control post-Cesarean delivery pain but this reduction was not associated with a reduction of opioid related adverse effects in our study group.RésuméObjectifVérifier si l’anesthésie par blocage nerveux ilioinguinal et iliohypogastrique peut réduire ies besoins postcésarienne de morphine et l’incidence des effets indésirables des opioïdes.MéthodeUne technique de blocage nerveux multiniveau, avec de la bupivacaïne, a été mise au point et utilisée pour une étude en deux phases. La première consistait en une évaluation rétrospective des accouchements par césarienne avec et sans biocages ilioinguinal et iliohypogastrique dans le but de déterminer si la technique réduit l’usage de morphine autoadministrée, ce qui pourrait justifier des études plus poussées. La seconde phase était un essai, randomisé et contrôlé en double aveugle contre placebo, réalisé pour comparer l’usage intergroupe de morphine postcésarienne et l’apparition d’effets secondaires reliés aux opioïdes.RésultatsPour les deux phases de l’étude, l’anesthésie par blocage nerveux ilioinguinal et iliohypogastrique a permis de réduire significativement la quantité de morphine iv utilisée pendant les 24 premières heures suivant la césarienne. Dans l’évaluation rétrospective, la morphine utilisée a été de 49 ± 30 mg chez les patientes qui ont reçu un bloc vs 79 ± 25 mg, sans bloc (P = 0,0063). Les résultats de l’essai prospectif sont comparables, l’autoadministration de morphine pendant 24 h étant de 48 ± 21 mg et de 67 ± 28 mg avec et sans bupivacaïne, respectivement. Cependant, il n’y a pas eu de réduction des effets indésirables reliés aux opioïdes: les incidences de nausée ont été de 41 % et de 46 % (P = 0,70) et de prurit, 79 % et 63 % (P = 0,25) chez les patientes avec placebo et bloc nerveux, respectivement.ConclusionUn blocage nerveux ilioinguinal et iliohypogastrique a permis de réduire la quantité de morphine à action générale utilisée pour soulager la douleur postcésarienne, mais cette réduction n’a pas été associée à une baisse des effets secondaires reliés aux opioïdes.

An Evaluation of the Effect of Anesthetic Technique on Reproductive Success After Laparoscopic Pronuclear Stage Transfer - Propofol Nitrous-Oxide Versus Isoflurane Nitrous-Oxide

Background Laparoscopic pronuclear stage transfer (PROST) is the preferred method of embryo transfer after in vitro fertilization in many infertility programs. There are scant data to recommend the use or avoidance of any particular anesthetic agent for use in women undergoing this procedure. The authors hypothesized that propofol would be an ideal anesthetic for laparoscopic PROST because of its characteristic favorable recovery profile that includes minimal sedation and a low incidence of postoperative nausea and vomiting. The purpose of the study was to compare propofol and isoflurane with respect to postanesthetic recovery and pregnancy outcomes after laparoscopic PROST. Methods One hundred twelve women scheduled for laparoscopic PROST were randomized to receive either propofol/nitrous oxide or isoflurane/nitrous oxide for maintenance of anesthesia. Results Visual analog scale scores for sedation were lower in the propofol group than in the isoflurane group at all measurements between 30 min and 3 h after surgery. More women experienced emesis and were given an antiemetic during recovery in the isoflurane group than in the propofol group. However, the percentage of pregnancies with evidence of fetal cardiac activity was 54% in the isoflurane group compared with only 30% in the propofol group (P = 0.023). Also, the ongoing pregnancy rate was greater in the isoflurane group than in the propofol group (54% vs. 29%, P = 0.014). Conclusions Propofol/nitrous oxide anesthesia was associated with lower clinical and ongoing pregnancy rates compared with isoflurane/nitrous oxide anesthesia.

Magnesium sulfate adversely affects fetal lamb survival and blocks fetal cerebral blood flow response during maternal hemorrhage.

Magnesium sulfate is commonly used in high-risk pregnancies, even though its actions in the fetus during maternal/fetal stress are not completely understood. The present study tested the hypothesis that magnesium sulfate alters the fetal cerebral blood flow response to hypoxemia produced during maternal hemorrhage. It was conducted in instrumented near-term fetal lambs at 123 days of gestation. Experimental treatment involved four periods of maternal hemorrhage over a 60-min period during fetal infusion of 0.25 g (n = 5) or 0.30 g (n = 6) magnesium sulfate, or normal saline (n = 11). The level of fetal cerebral blood flow was determined using radiolabeled microspheres. For all three treatment groups, maternal hemorrhage produced fetal hypoxemia and some fetal demise. During fetal infusion of saline, 1 of 11 (9%) of the fetuses died; with the 0.25-g magnesium sulfate regimen, 1 of 5 (20%) died; and with the 0.30-g magnesium sulfate regimen, 3 of 6 (50%) of the fetuses died. Magnesium sulfate caused an increase in the proportion of fetal death produced by maternal hemorrhage (P < 0.05). Among surviving fetuses, hemorrhage-induced hypoxemia increased fetal cerebral blood flow during saline infusion. In contrast, infusion of magnesium sulfate had an inhibitory effect on this compensatory increase in fetal cerebral blood flow (P = 0.003). These data indicate that, in the sheep, magnesium sulfate increases fetal mortality and inhibits the compensatory increase in fetal cerebral blood flow during maternal hemorrhage-induced fetal hypoxemia. (Anesth Analg 1996;83:493-9)

Statistical Analysis of Postanesthesia Care Unit Staffing at a Surgical Suite with Frequent Delays in Admission from the Operating Room—a Case Study

At some surgical suites, if each nurse in the postanesthesia care unit (PACU) is caring for as many patients as staffing standards permit (typically two), then patients remain in their operating rooms (ORs) until PACU nurses become available to care for them. Surgical suite staffing costs increase if patients frequently remain in the OR resulting in overtime to finish the day’s scheduled cases. In this case study, we describe PACU staffing at a surgical suite in which on more than half of the workdays at least one patient waited in their OR for an opening in the PACU. We applied a statistical method we previously developed for analysis of weekend staffing requirements (1) to determine the method of scheduling the existing nurses, without increasing staffing hours, so as to minimize the percentage of workdays with patients waiting in their ORs, and the minimum number of additional PACU nursing hours that would be needed to satisfy the hospital’s objective to decrease this rate to 5% of days or less. We knew that the statistical method would identify the least expensive PACU staffing solution (1). However, we did not know whether the statistical method would provide for significantly fewer workdays with patients waiting in their ORs than the staffing solution being used by the PACU nursing managers based on their experience. We also did not know whether the statistical method could identify a staffing solution that was more accurate than the PACU nursing managers’ proposed staffing solution at achieving the hospital’s objective of having the minimum number of PACU nursing hours required for the percentage of workdays with patients waiting in their ORs to be 5% of days or less. Finally, our case study provided information into whether the statistical method can run sufficiently quickly on a personal computer as to be useful in practice.

How Much Labor Is in a Labor Epidural?Manpower Cost and Reimbursement for an Obstetric Analgesia Service in a Teaching Institution

Background: Some anesthesiologists avoid provision of obstetric analgesia services (OAS) because of low reimbursement rates for the work involved. This study defines the manpower costs of operating an OAS in a tertiary referral center and examines reimbursement for this cost. Methods: The time spent providing OAS in a total of 55 parturients was studied prospectively using a modification of classic time and motion studies. Results: Mean duration of OAS in our population was 412 ± 313 min. Mean bedside anesthesia staff time was 90 ± 40 min, and mean number of visits to each patient’s bedside was 6.3 ± 2.0 visits. Assuming staffing on demand for service (intermittent staffing), a minimum of 2.5 full-time equivalent (FTE) attending anesthesiologists was required to meet demand. With intermittent staffing, labor cost was

Subarachnoid Meperidine (Pethidine) Causes Significant Nausea and Vomiting during Labor

325 per patient. Actual practice at Duke University Medical Center is around-the-clock (dedicated) staffing, which requires 4.4 FTEs at a cost of

Ethanol increases uterine blood flow and fetal arterial blood oxygen tension in the near-term pregnant ewe

728 per patient. Neither average indemnity reimbursement (