Richard A. Wiklund

Deliberate Perioperative Systems Design Improves Operating Room Throughput

Background:New operating room (OR) design focuses more on the surgical environment than on the process of care. The authors sought to improve OR throughput and reduce time per case by goal-directed design of a demonstration OR and the perioperative processes occurring within and around it. Methods:The authors constructed a three-room suite including an OR, an induction room, and an early recovery area. Traditionally sequential activities were run in parallel, and nonsurgical activities were moved from the OR to the supporting spaces. The new workflow was supported by additional anesthesia and nursing personnel. The authors used a retrospective, case- and surgeon-matched design to compare the throughput, cost, and revenue performance of the new OR to traditional ORs. Results:For surgeons performing the same case mix in both environments, the new OR processed more cases per day than traditional ORs and used less time per case. Throughput improvement came from superior nonoperative performance. Nonoperative Time was reduced from 67 min (95% confidence interval, 64–70 min) to 38 min (95% confidence interval, 35–40 min) in the new OR. All components of Nonoperative Time were meaningfully reduced. Operative Time decreased by approximately 5%. Hospital and anesthesia costs per case increased, but the increased throughput offset costs and the global net margin was unchanged. Conclusions:Deliberate OR and perioperative process redesign improved throughput. Performance improvement derived from relocating and reorganizing nonoperative activities. Better OR throughput entailed additional costs but allowed additional patients to be accommodated in the OR while generating revenue that balanced these additional costs.

Facilitation of fiberoptic orotracheal intubation with a flexible tracheal tube

Advancement of a tracheal tube (TT) over a flexible fiberoptic bronchoscope (FOB) is often impeded by obstruction at the arytenoid cartilage or epiglottis. We tested the hypothesis that the use of a flexible, spiral-wound TT, rather than the standard, preformed TT would facilitate tube passage into the trachea over the FOB. Forty patients scheduled to undergo general anesthesia with tracheal intubation were randomized to two groups. Then the trachea was intubated with a FOB, followed by passage of either a standard, preformed TT or a flexible, spiral-wound TT over the FOB. Ease of TT advancement over the FOB into the trachea was graded on a 1 (easy) to 3 (difficult) scale, and differences between the two groups were compared with X1 analysis. The overall scores were compared with Wilcoxons ranked sum test. Statistical significance was defined as P < 0.05. In patients randomized to the regular TT, only 35% (7/20) of first attempts to advance the TT over the FOB were successful. In the patients randomized to the spiral-wound TT, 95% (19/20) of first attempts were successful (P < 0.0001). Of the 13 regular TTs that were not successfully advanced on the first attempt, seven could not be passed after the second or third attempt (necessitating the use of the cross-over spiral-wound TT). In the only instance in which a spiral-wound tube was not successfully passed into the trachea on the first attempt, passage also was not achieved after the second or third attempt. The median scores for ease of tracheal passage (and 25–75 percentiles) were 2 (1–3) when the initial attempt was with the regular TT and 1 (1–1) when the initial attempt was with the spiral-wound TT (P < 0.0002). The authors conclude that a spiral-wound, wire-reinforced TT is less likely to encounter obstruction on glottic structures than its preformed counterpart. We attribute this difference to the greater side-to-side flexibility of the spiral-wound tube when compared with the preformed tube. This increased flexibility allows the spiral-wound tube to bend more easily and thus conform to the acute angle which the stenting FOB may develop in the posterior pharynx. An additional advantage may be conferred by the more obtuse angle of the wire-reinforced TTs distal end, making it less likely to impinge on pharyngeal soft tissue during its advancement into the trachea.

Reorganizing the System of Care Surrounding Laparoscopic Surgery: A Cost-Effectiveness Analysis Using Discrete-Event Simulation

Purpose. To determine the cost-effectiveness of a proposed reorganization of surgical and anesthesia care to balance patient volume and safety.Methods.Discrete-event simulation methods were used to compare current surgical practice with a newmodular system in which patient care is handed off between 2 anesthesiologists. Ahealth care system’s perspective, using hospital and professional costs, was chosen for the cost-effectiveness analysis. Outcomes were patient throughput, flow time, wait time, and resource use. Sensitivity analyses were performed on staffing levels, mortality rates, process times, and scheduled patient volume.Results.The new strategy was more effective (average 4.41 patients/d [median = 5] v. 4.29 [median = 4]) and had similar costs (average cost/ patient/d =

Clinicians consistently exceed a typical person's short-term memory during preoperative teaching.

5327 v.

Why should the anesthesiologist be concerned about endocarditis prophylaxis

5289) to the current strategywith an incremental cost-effectiveness of

Reorganizing patient care and workflow in the operating room: a cost-effectiveness study

318/additional patient treated/d. Surgical mortality rate must be >4% or hand-off delay >15min before the new strategy is no longermore effective.Conclusion.The proposed system is more cost-effective relative to current practice over a wide range of mortality rates, hand-off times, and scheduled patient volumes.

Preoperative preparation of patients with advanced liver disease

INTRODUCTION:Patient education is a critical part of preparation for surgery. Little research on provider-to-patient teaching has been conducted with systematic focus on the quantity of information provided to patients. This is important to assess because short-term memory capacity for information such as preoperative instruction is limited to roughly seven units of content. METHODS:We studied the information-giving practices of anesthesiologists and nurse practitioners during preoperative teaching by examining transcripts from 26 tape recorded preoperative evaluation appointments. We developed a novel coding system to measure: 1) quantity of information, 2) frequency of medical terminology, 3) number of patient questions, and 4) number of memory reinforcements used during the consultation. Results are reported as mean ± sd. RESULTS:Anesthesiologists and nurse practitioners vastly exceeded patients’ short-term memory capacity. Nurse practitioners gave significantly more information to patients than did physicians (112 ± 37 vs 49 ± 25 items per interview, P < 0.01). This higher level of information-giving was not influenced by the question-asking behaviors of the patients. Nurse practitioners and physicians used similar numbers of medical terms (4.0 ± 2.4 vs 3.7 ± 2.8 explained terms per interview), and memory-supporting reinforcements (2.3 ± 3.0 vs 1.4 ± 2.0 reinforcements per interview). DISCUSSION:Given the known limits of short-term memory, clinicians would be well advised to carefully consider their patterns of information-giving and their use of memory-reinforcing strategies for critical information.

The value of the dedicated orthopaedic trauma operating room.

Many patients have congenital or acquired cardiac conditions that predispose the four heart valves to serious infection when, during surgery, transient bacteremia results from manipulation of bacterially contaminated tissue. For patients without these predisposing conditions, transient bacteremia is seldom a problem; it is, in fact, an everyday event. This chapter reviews why the anesthesiologist should be concerned about infective endocarditis as a perioperative complication, defines which patients are at risk for infective endocarditis, and summarizes the current recommendations of the American Heart Association for infective endocarditis prophylaxis. Because mitral valve prolapse is the most common indication for infective endocarditis antibiotic prophylaxis, special emphasis will be placed on mitral valve prolapse.