Reorganizing surgical workflow; perceptions of surgical errors; patient safety; postdischarge unplanned admissions

AORN Journal, Sept, 2006 by George Allen

Cost-effectiveness of reorganizing workflow in the OR

Surgery June 2006

Many surgeons believe that long turnover times between procedures are a major impediment to their productivity. As the demand for surgical services continues to rise, surgeons, nurses, and perioperative administrators often turn to new technologies to help solve the problem. These health care providers increasingly are realizing, however, that efficiency is critical for maintaining access to quality care. It is hypothesized that redesigning the OR and the perioperative process would shorten the time between procedures, and the resulting improved efficiency might reduce the cost to treat patients and allow more patients to be treated each day for short- to medium-duration surgical procedures.

A state-of-the-art, high-technology OR suite with augmented data collection systems, designated as the "OR of the future" (ORF), was designed and built at the Massachusetts General Hospital, Boston, to serve as a living laboratory to evaluate both new devices and perioperative systems of care. The ORF design features a central OR with attached induction and early recovery areas and a central room to provide workspace for surgeons between procedures. The OR itself is equipped with a commercially available integrated OR system, mobile booms to suspend surgical equipment, and OR beds that are combined transporter/bed systems. Additionally, the perioperative flow was redesigned to allow staff members to care for patients in a parallel fashion rather than using the traditional sequential process in which all patient care from induction of anesthesia through the surgical procedure and extubation occurs in the same room. The parallel process allows two or three patients to be cared for simultaneously in the induction area, OR, and early recovery area, but it requires more staff members than the standard OR process does. The purpose of this study was to examine the potential impact of implementing the ORF system in other hospitals by carrying out a formal cost-effectiveness analysis using nationally derived cost data. (1)

The performance of the ORF was evaluated in two phases. Phase I was designed to detect differences in three effectiveness measures, including patient wait time before surgical procedure, flow time through the OR system, and patient throughput per day. Phase I was conducted from February 2003 through March 2003. Seven surgeons, serving primarily as their own controls, performed surgical procedures designated as the study procedures in the ORF setting, and surgical procedures designated as the control procedures in the standard OR setting. Independent research assistants monitored the patients as they moved through the OR. Data that were recorded included times for

* start of anesthesia care,

* anesthesia induction,

* patient entrance into the OR,

* start of surgical procedure,

* procedure finish,

* patient extubation and stabilization for transfer, and

* patient exit from the OR.

Time intervals also were recorded for

* wait time (ie, time from patient arrival in the OR induction area to the start of the surgical procedure);

* surgical procedure time (ie, time from first incision to the application of the final stitch or dressing;

* OR emergence time (ie, time from the end of the procedure to the patient's arrival in the postanesthesia care unit); and

* total patient OR flow time (ie, time from initial entry into the OR suite to leaving the OR).

Phase II was designed to test the validity of the results and to explore additional factors responsible for the observed differences between procedures in the ORF and the standard ORs. For phase II, the OR scheduling system was queried from September 2002 through September 2003 for procedures carried out by the study surgeons in either the ORF or standard ORs. Surgical procedures were included only if the procedures were performed two or more times in each setting.

Additionally, the cost of the ORF was determined using a modified process-costing method that used nationally based cost estimates. The cost information was combined with the effectiveness information to estimate the incremental cost-effectiveness of the ORF using the following formula:

(cost of ORF--cost of standard OR) / (effectiveness of ORF--effectiveness of standard OR) = incremental cost-effectiveness.

The number of patients who might receive surgical care on a given workday was calculated for both the prospective and retrospective data set. Common statistical procedures, including analysis of variance and regression analysis techniques, were used to analyze the data.

Findings. All four time intervals were significantly shorter in the ORF compared to the standard ORs (P < .05), including the median

* wait time (12.5 minutes versus 23.8 minutes),

* surgical procedure time (56.1 minutes versus 70.5 minutes),

* OR emergence time (10.9 minutes versus 14.5 minutes), and

* the total patient OR flow time (79.5 minutes versus 108.9 minutes).

The median cost per patient was higher, but not significantly higher, in the ORF compared to in the standard ORs ($3,165 versus $2,645), and the potential change in patient throughput for the ORF was two additional patients per day. This improved throughput was attributable to a marked reduction in the nonoperative time (ie, those activities commonly accounting for turnover time) rather than faster surgical procedures. The incremental cost-effectiveness of the ORF was $260. The researchers concluded that the redesigned perioperative system improved patient flow, allowing more patients to be treated per day.