M. Schuster

The effect of detailed, video-assisted anesthesia risk education on patient anxiety and the duration of the preanesthetic interview: a randomized controlled trial.

BACKGROUND:Video-assisted patient education during the preanesthetic clinic visit is a new intervention to increase knowledge transfer to the patient regarding anesthesia procedure and risks. However, little is known about whether video-based patient education influences patient anxiety and the duration of the preanesthetic visit. METHODS:Two hundred nine consecutive patients, who visited the anesthesia clinic before major operations, were randomly assigned to one of three groups: no-video (Group 1), video-before-interview (Group 2), and video-after-interview (Group 3). Anxiety levels were measured before and after the interview using the state trait anxiety inventory and a visual analog scale (anxiety). Patient knowledge regarding anesthesia technique, anesthesia-related risks, and patient satisfaction were assessed after the interview using standardized questionnaires. RESULTS:There were no significant differences in anxiety levels and patient satisfaction among the three groups. Patient knowledge was significantly higher in the video groups compared with the no-video group. The duration of the preanesthetic interview was significantly extended in Group 2 (video-before) (23.1 ± 14.0 min), compared with Group 1 (no-video) (17.6 ± 7.2 min), and Group 3 (video-after) (18.3 ± 9.6 min). This difference was even more profound in subgroups of patients scheduled for anesthesia techniques with invasive monitoring. CONCLUSION:Our study suggests that the use of a video for detailed anesthesia risk education does not change patient anxiety, but leads to a better understanding of the procedure and risks of anesthesia. When the video is shown before the preanesthetic interview, the interview is longer.

The effect of hospital size and surgical service on case cancellation in elective surgery: results from a prospective multicenter study.

BACKGROUND: Short-term case cancellation causes frustration for anesthesiologists, surgeons, and patients and leads to suboptimal use of operating room (OR) resources. In many facilities, >10% of all cases are cancelled on the day of surgery, thereby causing major problems for OR management and anesthesia departments. The effect of hospital type and service type on case cancellation rate is unclear. METHODS: In 25 hospitals of different types (university hospitals, large community hospitals, and mid- to small-size community hospitals) we studied all elective surgical cases of the following subspecialties over a period of 2 weeks: general surgery, trauma/orthopedics, urology, and gynecology. Case cancellation was defined as any patient who had been scheduled to be operated on the next day, but cancelled after the finalization of the OR plan on the day before surgery. A list of possible cancellation reasons was provided for standardized documentation. RESULTS: A total of 6009 anesthesia cases of 82 different anesthesia services were recorded during the study period. Services in university hospitals had cancellation rates 2.23 (95% confidence interval [CI] = 1.49 to 3.34) times higher than mid- to small-size community hospitals 12.4% (95% CI = 11.0% to 13.8%) versus 5.0% (95% CI = 4.0% to 6.2%). Of the surgical services, general surgical services had a significantly (1.78, 95% CI = 1.25 to 2.53) higher cancellation rate than did gynecology services—11.0% (95% CI = 9.7% to 12.5%) versus 6.6% (95% CI = 5.1% to 8.4%). CONCLUSIONS: When benchmarking cancellation rates among hospitals, comparisons should control for academic institutions having higher incidences of case cancellation than nonacademic hospitals and general surgery services having higher incidences than other services.

Kennzahlen der OP-Effizienz

ZusammenfassungEs steht eine Vielzahl von verschiedenen Kennzahlen zur Beurteilung der OP-Effizienz zur Verfügung, die in Prozessablaufkennzahlen und Finanzkennzahlen unterschieden werden können. Bestimmte Kennzahlen, wie Auslastung und Wechselzeiten, scheinen sich hierbei als allgemeiner Standard durchzusetzen und werden in sehr vielen Krankenhäusern verwendet, um die Prozessabläufe im OP zu beurteilen. Trotz ihrer allgemeinen Verfügbarkeit und Verwendung ist die wissenschaftliche Evidenz hinter den aktuell am häufigsten verwendeten Prozessablaufkennzahlen im OP-Bereich relativ gering. Die Prozessablaufkennzahlen werden stark von Artefakten beeinflusst und sind von Planungsprozessen, Ressourceneinsatz und der Dokumentation abhängig. Direkte Finanzkennzahlen gewinnen durch die zunehmende Eigenständigkeit des OP-Managements an Bedeutung. Hierzu gehört neben der Budgeteinhaltung zunehmend auch das Finanzergebnis der internen Leistungsverrechnung. Diese ermöglicht es, das OP-Management über die Budgetverantwortung von einem reinen Verursacher von Kosten zu einem aktiven Gestalter der perioperativen Prozesse zu wandeln. Hierzu ist aber eine genaue Kenntnis der Mechanismen der Kostenentstehung und der Fallstricke einer internen Leistungsverrechnung notwendig. Die erhöhte Transparenz durch die freie Zugänglichkeit der „Diagnosis-related-groups- (DRG-)Kostendaten“ kann dem OP-Management helfen, entsprechende Werkzeuge zu entwickeln, die ökonomischen Grundlagen des Leistungsprozesses korrekt zu analysieren.AbstractA variety of different key performance indicators, both for process and financial performance, are used to evaluate OR efficiency. Certain indicators like OR utilization and turnover times seem to become common standard in many hospitals to evaluate OR process performance. Despite the general use and availability of these indicators in OR management, the scientific evidence behind these data is relatively low. These process indicators are strongly influenced by artefacts and depend on planning process, resource allocation and documentation. Direct financial indicators become more important with increasing autonomy of OR management. Besides budgetary compliance the focus is set on the net results of internal transfer pricing systems. By taking part in an internal transfer pricing system, OR management develops from a mere passive cost center to an active shaper of perioperative processes. However, detailed knowledge of the origin of costs and pitfalls of internal transfer pricing systems is crucial. The increased transparency due to the free accessibility of diagnosis-related-groups (DRG) cost breakdown data can help to develop tools for economic analysis of OR efficiency.

Key performance indicators of OR efficiency. Myths and evidence of key performance indicators in OR management

ZusammenfassungEs steht eine Vielzahl von verschiedenen Kennzahlen zur Beurteilung der OP-Effizienz zur Verfügung, die in Prozessablaufkennzahlen und Finanzkennzahlen unterschieden werden können. Bestimmte Kennzahlen, wie Auslastung und Wechselzeiten, scheinen sich hierbei als allgemeiner Standard durchzusetzen und werden in sehr vielen Krankenhäusern verwendet, um die Prozessabläufe im OP zu beurteilen. Trotz ihrer allgemeinen Verfügbarkeit und Verwendung ist die wissenschaftliche Evidenz hinter den aktuell am häufigsten verwendeten Prozessablaufkennzahlen im OP-Bereich relativ gering. Die Prozessablaufkennzahlen werden stark von Artefakten beeinflusst und sind von Planungsprozessen, Ressourceneinsatz und der Dokumentation abhängig. Direkte Finanzkennzahlen gewinnen durch die zunehmende Eigenständigkeit des OP-Managements an Bedeutung. Hierzu gehört neben der Budgeteinhaltung zunehmend auch das Finanzergebnis der internen Leistungsverrechnung. Diese ermöglicht es, das OP-Management über die Budgetverantwortung von einem reinen Verursacher von Kosten zu einem aktiven Gestalter der perioperativen Prozesse zu wandeln. Hierzu ist aber eine genaue Kenntnis der Mechanismen der Kostenentstehung und der Fallstricke einer internen Leistungsverrechnung notwendig. Die erhöhte Transparenz durch die freie Zugänglichkeit der „Diagnosis-related-groups- (DRG-)Kostendaten“ kann dem OP-Management helfen, entsprechende Werkzeuge zu entwickeln, die ökonomischen Grundlagen des Leistungsprozesses korrekt zu analysieren.AbstractA variety of different key performance indicators, both for process and financial performance, are used to evaluate OR efficiency. Certain indicators like OR utilization and turnover times seem to become common standard in many hospitals to evaluate OR process performance. Despite the general use and availability of these indicators in OR management, the scientific evidence behind these data is relatively low. These process indicators are strongly influenced by artefacts and depend on planning process, resource allocation and documentation. Direct financial indicators become more important with increasing autonomy of OR management. Besides budgetary compliance the focus is set on the net results of internal transfer pricing systems. By taking part in an internal transfer pricing system, OR management develops from a mere passive cost center to an active shaper of perioperative processes. However, detailed knowledge of the origin of costs and pitfalls of internal transfer pricing systems is crucial. The increased transparency due to the free accessibility of diagnosis-related-groups (DRG) cost breakdown data can help to develop tools for economic analysis of OR efficiency.

Auslastung und Wechselzeit als Kennzahlen der OP-Effizienz

BACKGROUND In many hospitals operating room (OR) utilization rates and turnover times (the time from the end of the previous surgical procedure to the beginning of the next) are used as indicators of OR workflow inefficiency. However, there have been no detailed studies to determine whether these indicators really provide an adequate picture of avoidable wasting of time in the OR. METHODS All relevant OR processes in a busy surgical suite with nine ORs were studied in detail over an 8-week period. Productive OR processes, and also reasons for unused times, were recorded by independent observers at 5-minute intervals; they were able to code for 10 different productive activities and 20 different reasons for unused time. Unused time in the OR, the OR utilization rate and the average perioperative turnover times were calculated for each day and a correlation analysis was performed. RESULTS In all, 3,501 OR hours and 790 surgical cases were studied. Productive processes accounted for 85.7% of the total OR time; the unused times were times with no scheduled cases (7.7%) and waiting times that arose for many different reasons (6.6%). Correlation analysis showed that there was no close correlation between waiting time and OR utilization (Spearmans r(s) 0.104 and r(s) 0.233). The correlations between total unused time (r(s) 0.718 and r(s) 0.745) and time with no scheduled cases (r(s) 0.706 and r(s) 0.620) and utilization were more robust, but for any given OR utilization rate the range of corresponding unused time or time without scheduled cases per day was considerable. The correlation between waiting time and perioperative turnover times was negligible (r(s) 0.185 and r(s) 0.175). When different definitions of utilization rate or perioperative turnover were used the results obtained were virtually identical. CONCLUSIONS Utilization rate and perioperative turnover time cannot be used as indicators of OR workflow efficiency, since they cannot identify the days during which avoidable waiting times occur. If the aim is to identify underused OR time and factors that hamper workflow efficiency, waiting times and times without scheduled cases need to be recorded directly and separately.

Duration of mission time in prehospital emergency medicine: effects of emergency severity and physicians level of education

Background Prehospital emergency care is provided in many European countries by specialised emergency physicians. However, little is known about the impact of experience and educational level of emergency physicians on providing prehospital care. Methods During a 6-month period all deployments of an emergency physician-staffed ambulance in a metropolitan area were studied according to possible predictors of prehospital mission times. Results In the univariate comparison the junior emergency physicians had 6.3-minute longer prehospital mission times than senior emergency physicians. This difference was evident in several National Advisory Committee for Aeronautics (NACA) score subgroups. However, in multivariate analysis, patient conditions, like NACA score, Glascow coma scale or prehospital diagnosis had by far the more significant impact on mission times. Conclusion The effect of education on treatment process and outcome in prehospital emergency care should merit further research, especially to ensure that junior emergency physicians are properly trained before they work in prehospital emergency medicine.

Influence of resident training on anaesthesia induction times

BACKGROUND The effect of resident training in anaesthesiology on operating room (OR) economics is an issue of debate. Comparisons of anaesthesia process times between residents and consultants might be systematically skewed by interactions of anaesthesia technique and patient factors. METHODS In this prospective, observational study, we analysed anaesthesia process times in 599 cases performed for four different surgical services in a University hospital. The following factors were recorded for each case and used in multivariate analyses of process times: age, American Society of Anesthesiologist (ASA) status, BMI, emergency status, the educational level of the anaesthetist, and the anaesthesia technique. RESULTS In the non-adjusted comparison, only for two of seven anaesthetic techniques did resident cases have statistically significant longer induction times than consultant cases: general anaesthesia with placement of a central venous catheter [mean (sd) anaesthesia time for resident cases 38.2 (17.0) vs 22.3 (10.0) min for consultant cases, P=0.001] and general anaesthesia with a laryngeal mask airway [resident cases 11.3 (5.5) vs consultant cases 7.3 (5.0) min, P=0.003]. Anaesthetic technique had the greatest effect on anaesthesia induction time. Educational level of the anaesthetist and age of the patients had small, but significant effects. CONCLUSIONS Anaesthesia cases performed by residents have in some, but not in all, anaesthesia techniques increased process times compared with cases performed by consultants. This limits a possible negative impact on OR economics by resident education. Patient-based factors including ASA status, BMI, and emergency status have minimal or no effect on anaesthesia process times.

Zeitverzögerungen beim morgendlichen OP-Beginn

Delayed starts of operation room (OR) processes in the morning lead to suboptimal use of expensive OR personnel and resources. Therefore, the anaesthesiologist has to take care that anaesthesia preparation and induction are finished in time and the patients are ready for the surgical intervention according to the OR time schedule. However, if the anaesthesiologist starts too early, preincision waiting periods occur. The literature provides little data regarding the complex interaction of anaesthesia process times and delayed operation starts in the morning. In this prospective study 710 first operation positions in the morning were analyzed with respect to the incidence of and reasons for delayed finishing of anaesthesia induction and investigated the interaction of early and late finishing of anaesthesia induction. In 27.5% of anaesthesia inductions the preset time schedule was not reached and the average delay was 19.3+/-17.2 min. The main anaesthesia-dependent reasons for delays were complex anaesthesia inductions with difficult line placement. Also organizational difficulties such as changes in the OR case schedule and delayed patient transport were of major importance. The results of a simulation model showed that in 100% of the cases finishing anaesthesia induction in time would only be feasible if anaesthesia processes started much earlier. However, this would lead to a sharp increase in preincision waiting time with the patient being under anaesthesia but surgeons not ready to start, therefore having only a minor effect on surgical waiting time. Subsequently, on-time anaesthesia induction in all cases is not a reasonable target in OR management.

Intensivkapazitäten in Deutschland

BACKGROUND The development of provision and usage of intensive care capacity in Germany in the last two decades has not yet been sufficiently studied. METHODS Based on the official statistical data provided by the Federal Statistical Office (Statistisches Bundesamt) with respect to hospitals, the hospitals were analyzed in four categories: small hospitals (≤199 beds), medium size hospitals (200-499 beds), large hospitals (500-999 beds) and very large hospitals (≥1,000 beds). For the period between 1991 and 2009 the development of hospitals, hospital beds, the number and occupancy of intensive care unit beds, the number of cases and the length of stay of intensive care patients were analyzed. RESULTS While the total number of hospital beds decreased, the number of critical care beds increased. During the period between 1991 and 2009 the occupancy rate increased. Also the proportion of critical care beds from all hospital beds doubled and currently exceeds 8% for very large hospitals. An increase in the length of stay in the intensive care units was also observed. CONCLUSIONS The provision and usage of intensive care capacities have increased steadily and independently of the hospital size in Germany in the last two decades. Major effects of cost reduction measures, such as the introduction of diagnosis-related reimbursement on the provision and usage of intensive care medicine were not observed.

Time delay in beginning first OR positions in the morning

Delayed starts of operation room (OR) processes in the morning lead to suboptimal use of expensive OR personnel and resources. Therefore, the anaesthesiologist has to take care that anaesthesia preparation and induction are finished in time and the patients are ready for the surgical intervention according to the OR time schedule. However, if the anaesthesiologist starts too early, preincision waiting periods occur. The literature provides little data regarding the complex interaction of anaesthesia process times and delayed operation starts in the morning. In this prospective study 710 first operation positions in the morning were analyzed with respect to the incidence of and reasons for delayed finishing of anaesthesia induction and investigated the interaction of early and late finishing of anaesthesia induction. In 27.5% of anaesthesia inductions the preset time schedule was not reached and the average delay was 19.3+/-17.2 min. The main anaesthesia-dependent reasons for delays were complex anaesthesia inductions with difficult line placement. Also organizational difficulties such as changes in the OR case schedule and delayed patient transport were of major importance. The results of a simulation model showed that in 100% of the cases finishing anaesthesia induction in time would only be feasible if anaesthesia processes started much earlier. However, this would lead to a sharp increase in preincision waiting time with the patient being under anaesthesia but surgeons not ready to start, therefore having only a minor effect on surgical waiting time. Subsequently, on-time anaesthesia induction in all cases is not a reasonable target in OR management.