Increased efficiency through OR redesign and process simplification

AORN Journal, Dec, 2002 by Sandra S. Mangum, Katherine Cutler

Short turnover times and efficient use of time and personnel during surgical procedures are hallmarks of a competently run OR. Turnover time has been defined as "time from prior patient out of room to succeeding patient in room time for sequentially scheduled cases." (1) When delays between procedures occur, there can be as much as one to two hours of cumulative down time that extends the hours staff members are needed to complete the day's procedures.

With the proliferation of technology, increased complexity of procedures, and advances in surgical capabilities, procedures today are more complex and may require more equipment, more time to set up, and more staff members. This leads to increased potential for less efficient processes during procedures. (2) Often, doing things the way they always have been done keeps improvements from being made even when pressure to improve and simplify processes is foremost in the corporate mindset. Decreasing turnover time and increasing efficiency during procedures is important and can be accomplished with the simplification of processes and procedures.

The neurosurgical services department at Utah Valley Regional Medical Center, Provo, was under pressure to improve performance and efficiency. Managers and staff members wanted to decrease turnover times and increase efficiency during surgical procedures, so they redesigned the neurosurgical OR suite and simplified processes and procedures. The result was a 33% to 55% decrease in turnover time. Turnover times decreased from between 30 and 40 minutes to between 10 and 15 minutes. An increase in team efficiency led to further time savings during surgical procedures.

REDESIGNING THE NEUROSURGICAL SUITE

The neurosurgical service at Utah Valley Regional Medical Center consists of two neurosurgical ORs that are used every day of the week by three neurosurgeons with heavy patient caseloads. Most procedures are cervical and lower spinal discectomy with or without fusion, single or multilevel, and craniotomy for

* tumor,

* arteriovenous malformations,

* hematomas, and

* shunt placements.

Approximately 15 to 20 procedures are performed each week, and each procedure averages two to three hours, depending on the complexity of the procedure.

The neurosurgeons with whom team members work are systematic and pragmatic. They perform the same procedures the same way each time with little variation. This allowed team members to make standardized changes that would be acceptable to all the surgeons involved. In addition, a planned OR suite renovation created an opportunity to discard old processes and procedures, reorganize, and simplify. The neurosurgical clinical specialist and team members provided input into the OR renovation, which helped with reorganizing and simplifying processes because the physical layout of the neurosurgical OR was improved.

Some of the renovations that helped improve processes among surgical team members included a new supply area, OR configuration, and equipment placement. For example, a built-in base cabinet (Figure 1) was designed to contain supplies in large drawers rather than cupboards with pull-out doors that require two movements and more time to access what is needed. The cabinet and drawers replaced small carts that previously had been placed around the room to hold positioning aids, prep solutions, and miscellaneous equipment. Two banks of x-ray view boxes (Figure 2) were positioned on adjacent walls of the OR so surgeons can view the films from tables that can be positioned differently for a craniotomy than for spine surgery.

[FIGURES 1-2 OMITTED]

Double power, air, and suction lines were dropped from the ceiling at three different locations to allow for convenient and safe access from the surgical field (Figure 3). The neurosurgical OR is on a corner of the hallway in the OR suite, so a second door was installed. This door is useful when bringing in an x-ray machine for intraoperative x-rays. The door also allows a smoother transition when patients need to be transferred from one OR bed to another and repositioned during surgery. The second bed can be brought in through the second door and the primary bed removed through the primary door after transfer. A small alcove was constructed in the room to store the microscope so it can be readily accessible yet not in the way (Figure 4).

[FIGURES 3-4 OMITTED]

Overhead lights were situated to allow for different positions of the bed during a variety of procedures. A camera was installed in the ceiling above the OR bed, and an additional video line was installed to allow the microscope to be connected to the video system and projected on the three television monitors that were hung from the ceiling. This allows OR personnel the opportunity to see the surgical field on the monitors easily from any position in the room. Being able to view the surgical procedure gives staff members an additional few seconds of response time when something is needed.

Space on top of a counter was designed for writing and other office-type activities, such as computer charting. The height of the counter makes computer access and writing while standing convenient and ergonomically correct for most average-sized nurses (Figure 5). In addition, a small pull-out writing shelf was constructed in the bank of drawers to allow the surgeon to sit, write orders, and access the telephone for dictation. A rack for sutures was installed close to the desk/cabinet area. A second telephone line was installed for additional calls when the primary line is in use, and the intercom was placed by the center core door.