Increasing efficiency; precursor events; redistribution hypothermia; steroid administration after cataract surgery

AORN Journal, August, 2006 by George Allen

Parallel processing to increase efficiency

Annals of Surgery

January 2006

As hospitals strive to balance the forces of shrinking reimbursements, advances in technology, and the logistics of running an operationally complex and successful business without compromising patient safety, the OR generally serves as the area for testing strategies to overcome these challenges. Studies aimed at increasing OR efficiency and controlling costs while providing high-quality, technologically advanced surgical services often focus on streamlining the steps involved in the perioperative process. These studies commonly are structured based on the belief that moving patients through the OR in a parallel rather than linear manner would require a second team, thus creating higher costs without clear benefits. The aim of this study was to determine whether changing patient flow processes would allow for increased caseloads in ambulatory surgery ORs while maintaining patient satisfaction and safety. (1)

The ambulatory care center at one hospital in Boston traditionally has used a linear model for surgical patient preparation. A patient was brought into the OR, IV sedation was administered, the patient's hair was removed by the surgeon, and the local anesthesia was injected. For this study, a parallel rather than linear model was followed. The surgeon removed the patient's hair and administered the local anesthesia in the preoperative holding area while the previous patient was being transported to the postanesthesia care unit (PACU) and the OR was being prepared for the next procedure (ie, turned over). Four key factors were kept constant, including

* a similar type of procedure,

* a single surgeon,

* accurate timing of specific intervals throughout the surgical day, and

* a well-defined routine for all members of the surgical team.

Only patients undergoing hernia surgery by the same surgeon and for whom a combination of local anesthesia and IV sedation was the anesthetic plan were included in the study.

Three specific time intervals were identified. The first period (ie, the sedate, block, and prep period) began as the patient entered the induction room, and it involved three activities: initiating IV sedation as the patient's anesthetic, injecting local anesthetic as a preoperative block, and preparing the patient for surgery by removing hair at the surgical site and applying topical cleansers and sterile draping. The second time period (ie, the operative period) was the period including the actual surgical procedure, and it consisted of the time between finishing patient preparation and finishing the surgical procedure. The third time period (ie, the turnover period) included the turnover time for the OR.

The standard personnel for an inguinal hernia repair under IV sedation included a surgeon, an assisting surgical resident, a scrub person, a circulating nurse, and a nurse providing IV sedation. The surgical team was assembled at the beginning of the day and remained together for the entire day. The team members were assigned specific duties to perform during each of the three measured time periods. During the turnover period, one nurse and the scrub person remained in the OR to prepare for the next procedure while the second nurse and the surgeon went to the preoperative holding area to start sedation and perform the block on the next patient. When the OR was ready, the surgeon and nurse transported the sedated and blocked patient into the OR, where the surgical prep took place. The entire surgical team was present during the surgical procedure. At the end of the procedure, one nurse and the surgical resident transported the patient to the PACU while the surgeon went to the preoperative area to begin with the next patient. When the nurse was finished in the PACU, she joined the surgeon in the preoperative area.

The surgeon in this study performed hernia repair procedures all day Wednesday and on Thursday afternoons. Careful measurements were made of all the time intervals during the Wednesday and Thursday procedures for two months before the beginning of the study to establish a historical control group. Wednesday was designated as a study day, and patients who were treated on Wednesdays were designated as the study group. Thursday was designated as a control day, and patients who were treated on Thursdays were designated as the concurrent control group. Patients were assigned to surgical procedures on Wednesdays or Thursdays based exclusively on the preoperative scheduling availability and the patient's own availability.

During the study days, the four key factors were strictly followed. Patients treated during the study days were given a survey to analyze their degree of satisfaction with their surgical experience. Common statistical procedures, including means, standard deviation, and analysis of variance, were used to compare the three study groups.

Findings. There were 66 patients in the study group, 17 patients in the concurrent control group, and 55 patients in the historical control group. There was no significant difference between the surgical time (ie, the operative period) for all three groups; the study group mean time was 25.2 minutes [ or -] 9.5 minutes compared to 23 minutes [ or -] 9.2 minutes for the concurrent control group and 23.9 minutes [ or -] 6.8 minutes for the historical control group.