Warren S. Sandberg

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.

Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study

Objective To determine whether use of intermediate acting neuromuscular blocking agents during general anesthesia increases the incidence of postoperative respiratory complications. Design Prospective, propensity score matched cohort study. Setting General teaching hospital in Boston, Massachusetts, United States, 2006-10. Participants 18 579 surgical patients who received intermediate acting neuromuscular blocking agents during surgery were matched by propensity score to 18 579 reference patients who did not receive such agents. Main outcome measures The main outcome measures were oxygen desaturation after extubation (hemoglobin oxygen saturation <90% with a decrease in oxygen saturation after extubation of >3%) and reintubations requiring unplanned admission to an intensive care unit within seven days of surgery. We also evaluated effects on these outcome variables of qualitative monitoring of neuromuscular transmission (train-of-four ratio) and reversal of neuromuscular blockade with neostigmine to prevent residual postoperative neuromuscular blockade. Results The use of intermediate acting neuromuscular blocking agents was associated with an increased risk of postoperative desaturation less than 90% after extubation (odds ratio 1.36, 95% confidence interval 1.23 to 1.51) and reintubation requiring unplanned admission to an intensive care unit (1.40, 1.09 to 1.80). Qualitative monitoring of neuromuscular transmission did not decrease this risk and neostigmine reversal increased the risk of postoperative desaturation less than 90% (1.32, 1.20 to 1.46) and reintubation (1.76, 1.38 to 2.26). Conclusion The use of intermediate acting neuromuscular blocking agents during anesthesia was associated with an increased risk of clinically meaningful respiratory complications. Our data suggest that the strategies used in our trial to prevent residual postoperative neuromuscular blockade should be revisited.

Postoperative residual curarization from intermediate-acting neuromuscular blocking agents delays recovery room discharge

BACKGROUND Postoperative residual curarization (PORC) [train-of-four ratio (T4/T1) <0.9] is associated with increased morbidity and may delay postoperative recovery room (PACU) discharge. We tested the hypothesis that postoperative T4/T1 <0.9 increases PACU length of stay. METHODS At admission to the PACU, neuromuscular transmission was assessed by acceleromyography (stimulation current: 30 mA) in 246 consecutive patients. The potential consequences of PORC-induced increases in PACU length of stay on PACU throughput were estimated by application of a validated queuing model taking into account the rate of PACU admissions and mean length of stay in the joint system of the PACU plus patients recovering in operation theatre waiting for PACU beds. RESULTS PACU length of stay was significantly longer in patients with T4/T1 <0.9 (323 min), compared with patients with adequate recovery of neuromuscular transmission (243 min). Age (P=0.021) and diagnosis of T4/T1 <0.9 (P=0.027), but not the type of neuromuscular blocking agent, were independently associated with PACU length of stay. The incidence of T4/T1 <0.9 was higher in patients receiving vecuronium. Delayed discharge significantly increases the chances of patients having to wait to enter the PACU. The presence of PORC is estimated to be associated with significant delays in recovery room admission. CONCLUSIONS PORC is associated with a delayed PACU discharge. The magnitude of the effect is clinically significant. In our system, PORC increases the chances of patients having to wait to enter the PACU.

Automated Documentation Error Detection and Notification Improves Anesthesia Billing Performance

Background:Documentation of key times and events is required to obtain reimbursement for anesthesia services. The authors installed an information management system to improve record keeping and billing performance but found that a significant number of their records still could not be billed in a timely manner, and some records were never billed at all because they contained documentation errors. Methods:Computer software was developed that automatically examines electronic anesthetic records and alerts clinicians to documentation errors by alphanumeric page and e-mail. The softwares efficacy was determined retrospectively by comparing billing performance before and after its implementation. Staff satisfaction with the software was assessed by survey. Results:After implementation of this software, the percentage of anesthetic records that could never be billed declined from 1.31% to 0.04%, and the median time to correct documentation errors decreased from 33 days to 3 days. The average time to release an anesthetic record to the billing service decreased from 3.0 ± 0.1 days to 1.1 ± 0.2 days. More than 90% of staff found the system to be helpful and easier to use than the previous manual process for error detection and notification. Conclusion:This system allowed the authors to reduce the median time to correct documentation errors and the number of anesthetic records that were never billed by at least an order of magnitude. The authors estimate that these improvements increased their departments revenue by approximately

Real-Time Checking of Electronic Anesthesia Records for Documentation Errors and Automatically Text Messaging Clinicians Improves Quality of Documentation

400,000 per year.

The risk and outcomes of epidural hematomas after perioperative and obstetric epidural catheterization: a report from the Multicenter Perioperative Outcomes Group Research Consortium.

INTRODUCTION:The quality of electronic anesthesia documentation is important for downstream communication and to demonstrate appropriate diligence to care. Documentation quality will also impact the success of reimbursement contracts that require timely and complete documentation of specific interventions. We implemented a system to improve completeness of clinical documentation and evaluated the results over time. METHODS:We used custom software to continuously scan for missing clinical documentation during anesthesia. We used patient allergies as a test case, taking advantage of a unique requirement in our system that allergies be manually entered into the electronic record. If no allergy information was entered within 15 min of the “start of anesthesia care” event, a one-time prompt was sent via pager to the person performing the anesthetic. We tabulated the daily fraction of cases missing allergy data for the 6 mo before activating the alert system. We then obtained the same data for the subsequent 9 mo. We tested for systematic performance changes using statistical process control methodologies. RESULTS:Before initiating the alert system, the fraction of charts without an allergy comment was slightly more than 30%. This decreased to about 8% after initiating the alerts, and was significantly different from baseline within 5 days. Improvement lasted for the duration of the trial. Paging was suspended on nights, weekends, and holidays, yet weekend documentation performance also improved, indicating that weekday reminders had far-reaching effects. DISCUSSION:Electronic anesthesia documentation performance can be rapidly managed and improved by using an automatic process monitoring and alerting system.

Operating room design and its impact on operating room economics

BACKGROUND:In this study, we sought to determine the frequency and outcomes of epidural hematomas after epidural catheterization. METHODS:Eleven centers participating in the Multicenter Perioperative Outcomes Group used electronic anesthesia information systems and quality assurance databases to identify patients who had epidural catheters inserted for either obstetrical or surgical indications. From this cohort, patients undergoing laminectomy for the evacuation of hematoma within 6 weeks of epidural placement were identified. RESULTS:Seven of 62,450 patients undergoing perioperative epidural catheterizations developed hematoma requiring surgical evacuation. The event rate was 11.2 × 10−5 (95% confidence interval [CI], 4.5 × 10−5 to 23.1 × 10−5). Four of the 7 had anticoagulation/antiplatelet therapy that deviated from American Society of Regional Anesthesia guidelines. None of 79,837 obstetric patients with epidural catheterizations developed hematoma (upper limit of the 95% CI, 4.6 × 10−5). The hematoma rate in obstetric epidural catheterizations was significantly lower than in perioperative epidural catheterizations (P = 0.003). CONCLUSIONS:In this series, the 95% CI for the frequency of epidural hematoma requiring laminectomy after epidural catheter placement for perioperative anesthesia/analgesia was 1 event per 22,189 placements to 1 event per 4330 placements. Risk was significantly lower in obstetric epidurals.

Loss of alveolar macrophages during anesthesia and operation in humans

Purpose of review Operating rooms are high-cost/high-revenue environments. In an era of rising costs and declining reimbursement, it is essential to optimize the effectiveness of the operating room suite, maximizing throughput of profitable cases while minimizing the costs of necessary, but unprofitable, procedures. Recent findings Operating room management focuses on reducing wasted time in order to perform more cases in regular business hours, reduce overtime, or provide a better experience for staff and patients. It has been difficult to improve perioperative efficiency enough to reliably add cases during regular hours because the required time savings are so large, while most interventions can save only a few minutes per case. Recent work, however, has changed the basic paradigms for turning over operating rooms, dramatically reducing nonproductive time and increasing operating room throughput. In some situations, the additional expense required to achieve throughput improvements is more than offset by financial gains. Summary Redesigning perioperative systems can increase operating room throughput, but not all case mixes benefit from the required additional resources. Thus hospitals should choose judiciously if, and to what degree, high throughput environments are implemented. Once implemented, access to these environments can be used as an incentive for improved surgical performance.

High-throughput operating room system for joint arthroplasties durably outperforms routine processes.

Pulmonary macrophages play an important role in the host defense against infection, and the importance of this role is probably enhanced when the upper airway defenses are circumvented by endotracheal intubation.Studies in animals suggest that exposure to volatile anesthetics compromises the viability and function of alveolar macrophages. We studied the effect of surgery and anesthesia on the alveolar macrophages of 41 human subjects undergoing lower abdominal procedures of varying lengths during nitrous oxide-isoflurane anesthesia. Alveolar macrophages were harvested from bronchoalveolar lavage fluid obtained before incision and compared to those recovered just before emergence from anesthesia. Macrophages were analyzed for aggregation and viability, assessed by the ability of viable cells to exclude trypan blue dye. Operations lasting 2 h or less led to little aggregation and had little effect on viability. However, there was a strong correlation between loss of macrophages and the duration of surgery and anesthesia. Aggregation increased and viability decreased as a function of procedure length. Studies are needed to determine whether prolonged surgery contributes to the incidence of postoperative pulmonary complications by disturbing the function and survival of alveolar macrophages in humans. (Anesth Analg 1995;81:1255-62)

The extended Mallampati score and a diagnosis of diabetes mellitus are predictors of difficult laryngoscopy in the morbidly obese.

Background:Recent publications have focused on increased operating room (OR) throughput without increasing total OR time. The authors hypothesized that a system of parallel processing for lower extremity joint arthroplasties sustainably reduces nonoperative time and increases throughput. Methods:The high-throughput parallel processing strategy included neuraxial anesthesia performed in an “induction room” adjacent to the OR, patient selection, an additional circulating nurse, and end-of-case transfer of care to a recovery room nurse who transported the patient from the OR to recovery. Instruments and supplies were prepared in a dedicated sterile setup area. Data were extracted from administrative databases. Group comparisons used standard statistical methods; statistical process control was used to evaluate performance over time. Results:There were 688 historic control cases from 299 days over 16 months, and 905 high-throughput cases from 304 days spanning 24 consecutive months starting September 1, 2004. Throughput increased from 2.6 ± 0.7 (mean ± SD) to 3.4 ± 0.8 arthroplasties per day per room. Nonoperative time decreased by 36 min (or 50%) per case. Operative time also decreased by 14 min (12%) per case. The end time for the high-throughput OR day was only 16 min later than control. Nonoperative time, operative time, and throughput remained significantly improved after 2 yr of operation. Contribution margin increased 19.6%. Conclusion:Reorganizing the perioperative work process for total joint replacements sustainably increased OR throughput. Because joint arthroplasties generated a positive margin greater than the incremental cost, the high-throughput system improved financial performance.