Avoiding Disaster in the Operating Room

Fire in Labor and Delivery: Simulation Case Scenario

Operating rooms (ORs) are an important source of hospital revenue, and utilization rate is a key determinant of OR efficiency. Multiple factors contribute to OR underutilization, and OR managers may have biased views about which factors contribute most to OR underutilization. We examined various factors leading to OR underutilization at one academic tertriary care center.Data were collected retrospectively from over a 12-month period. Contribution to OR underutilization was measured in terms of hours of OR underutilization. Statistical significance between categories and days was calculated using an unpaired t test.By comparing means of the various contributors to OR underutilization (patient in the room, turnover time, scheduling gaps, OR holds, closed rooms), we determined that mid/end-of-day gaps and closed rooms contributed the most hours (9.7% and 4.6%, respectively; P < .0001) to OR underutilization, whereas turnover time and "patient in the room" contributed the least (2.0% and 0.8%, respectively; P < .0001).The contributors to OR underutilization are complex, and many OR staff from physicians to nurses and OR administrators may have biased views about which factors contribute most predominantly to inefficiency. Awareness of how various factors contribute to OR underutilization can pave the way for goal-directed changes on a systems-based level to improve efficiency in the OR by decreasing underutilization.

MP68-19 USE OF THE OR BLACK BOX® TO EVALUATE OPERATING ROOM ECONOMIC EFFICIENCY

Do Residents Receive the Same OR Guidance as Surgeons Report? Difference Between Residents’ and Surgeons’ Perceptions of OR Guidance

MP02-11 A SURVEY OF SURGICAL STAFF’S KNOWLEDGE, ATTITUDES, AND BARRIERS TO REDUCING OPERATING ROOM WASTE

Objective: To analyze operating room (OR) efficiency by evaluating fixed OR times for three common urologic robot-assisted procedures. Methods: Over a 24-month period, we prospectively collected intraoperative data for 635 consecutive robot-assisted surgeries. Fixed (nonprocedural) OR times were evaluated for robot-assisted partial nephrectomy (RAPN) (n = 146), robot-assisted radical cystectomy (RARC) (n = 77), and robot-assisted radical prostatectomy (RARP) (n = 412). Fixed OR times were defined as nonprocedural time in the OR, including in-room time to anesthesia release time (IRAT), anesthesia release to cut time (ARCT), in-room time to cut time (IRCT; IRAT+ARCT), and close time to wheels out time (CTWO). The effects of operation time of day and the number of anesthesia personnel (AP) present in procedure on fixed OR times were also analyzed. Results: Fixed OR times occupied 15.1% (IQR: 12.9%-17.1%) (RARC), 26.6% (22.9%-30.8%) (RAPN), and 20.1% (17.4%-23.1%) (RARP) of total OR time. Time of day did not have a negative effect on fixed OR times for robotic urologic surgeries. Median AP count was highest for RARC (median: 3 and range: 1-7). We did not find any association between AP count and fixed OR times for any of the procedures (p ≥ 0.19). Conclusions: Fixed OR times made up a significant percentage of total OR time for robot-assisted procedures and should be incorporated into OR efficiency analyses. The number of AP per case and time of day of procedure did not negatively impact fixed OR times in urologic robotic surgeries.

Exposure of workers to waste anaesthetic gases in the operating and recovery rooms of hospitals is an ongoing concern because a number of epidemiological and mortality studies have reported significant adverse effects. To evaluate the health risks if any, and to assist in the development of guidelines or regulations for the hospital sector in Ontario, the Health and Safety Support Services Branch of the Ontario Ministry of Labour conducted this extensive study. The results of the hygiene study show that exposure to waste anaesthetic occurs because of leaks in the anesthetic equipment. The three major sources of leaks (i.e. exhalation valves, masks and high-pressure fittings) produced concentrations above the limit of detection of nitrous oxide (1000 ppm of N2O) in a significant number of samples. Of the samples taken at leak sources those taken at the exhalation valve had the highest percentage of samples above 1000 ppm, which suggested that scavenging systems were not receiving proper service and maintenance. Only 23% of the operating rooms surveyed met the Ontario Ministry of Health Criterion of 24 air changes per hour. Dilution ventilation was less effective than scavenging in keeping down concentrations of air contaminants. The sampling data show that the anaesthetists have the highest time-weighted average exposure (median value range 56-79 ppm) of the major group of occupations surveyed and that the general surgeons' TWA is much lower (28 ppm). It was concluded that the dilution ventilation rate of 24 air changes per hour should be maintained in all operating rooms and that there should be no recirculation of exhaust air when operations are in progress. To keep down concentrations of anaesthetic gases scavenging systems should be provided in all operating rooms. In each hospital maintenance should be the responsibility of a qualified staff member who has been adequately trained in the repair and maintenance of anaesthetic delivery systems. Finally, a qualified staff member should be responsible for conducting periodic personal monitoring in operating rooms (ORs) and recovery rooms (RRs) and the sampling strategy should include individuals and the exhaust grilles.

Starting in October 2021, the Malcom Randall Veterans Affairs Medical Center Plastic Surgery Service began keeping patients undergoing hand surgery on the stretcher in the operating room (OR) as a time-saving initiative. The objective of this study was to evaluate this new process in terms of OR time efficiency, cost savings, and safety. A retrospective chart review was conducted for hand surgery cases performed in the same OR by the same surgeon over 2 year-long periods: October 1, 2020, through September 30, 2021, when surgeries were performed on the OR table, and June 1, 2022, through May 31, 2023, when surgeries were performed on the stretcher. Time intervals obtained from the electronic medical record were "patient in OR" to "operation begin," "operation end" to "patient out OR," and "patient out OR" to next "patient in OR." The median times were compared between the periods. The Patient Safety and Employee Health offices were queried for reported patient or employee-patient transfer injuries. The Inventory Supply department provided the cost of materials used in the transfer process. A total of 306 hand surgeries were performed on a table and 191 were performed on a stretcher. The median time interval from in-room to operation begin was 25 minutes for the table and 23 minutes for the stretcher. The median time from operation end to patient out of OR was 4 minutes for the table and 3 minutes for the stretcher. Median room turnover time was 27 minutes for both time periods. There were no reported employee or patient injuries attributed to OR transfers during either time period. Supply cost savings was $111.28 per case when surgery was performed on the stretcher. Hand surgery can be safely performed on the stretcher while reducing both time and costs. Over the course of a year, these savings can translate to $57,866 in supply costs and 26 hours of OR time.

Because most anesthesiologists work in the operating room setting, anesthesiologists are involved with the management of the operating room suite (or “theater”). Even if they are not responsible for the management, anesthesiologists still want to understand the decision-making process and metrics that affect their daily schedule and duties. In the United States, anesthesiologists can attend in-person conferences and seminars on leadership, practice management, and operating room management offered by national associations, online webinars and resources, and textbooks. Although these offerings will give anesthesiologists groundwork for calculations of metrics, e.g., productivity and efficiency, an in-depth discussion is not done.In contrast, Practical Operating Theater Management: Measuring and Improving Performance and Patient Experience provides the reader in-depth materials on data-driven metrics, including operating room efficiency, productivity, utilization, and scheduling. The book purposely is designed not to cover leadership or management styles but focuses on collecting and employing operating room data in a manner that is practical and applicable.The book has two functional sections. The first includes an introduction and eight chapters that cover the terms and principal content, as well as efficiency, productivity, scheduling, planning, staffing and contracts, operating room finances, and preoperative patient preparation. The second section contains five chapters examining operating room management in different countries, including Japan, The Netherlands, Switzerland, Australia, and the United States. Chapter 14 then covers operating room safety, and chapter 15 (the last) provides an overview of the book by a contributor.Some of the topics discussed include the different formats used to manage surgical block times, as well the importance of normalizing terms and definitions so the collected data can be reported, analyzed, and acted upon effectively. Among the data that proves useful to collect is operating room capacity, demand by surgeons, utilization rate, overruns, cancellation rate, start times, and turnover times, with some of these bundled into key performance indicators. Of these, efficiency (as defined in chapter 2), on-time start, and turnover times are considered fundamental.Chapter 2 is central to the book, and in it the author cautions that the much-used and maligned measurement of on-time starts or cancellation rates by themselves are a poor measure of overall operating room efficiency. Efficiency as a measurement is clearly defined in a mathematical formula, and the manner in which operating room management decisions affect it is discussed in detail. Subsequent chapters cover measures of productivity (chapter 3) and strategies for scheduling (chapter 4), with an emphasis on maintaining and utilizing a real-time database of facility-specific surgical times, capacity planning of schedules, and add-on operating room capacity (chapter 5). Operating room staff contracts and the prominent role of staffing in providing the capacity is covered in chapter 6. Chapters 7 and 8 cover operating room finances and preoperative patient preparation, respectively.Although the book’s editor and major contributors are from the United Kingdom, the concepts are applicable to operating room management in the United States as well as other countries. In fact, the latter half of the book explores the similarities and differences in operating room management in different countries, including New Zealand, Japan, The Netherlands, Switzerland, and the United States. It is amazing that anesthesiologists from many different countries face similar challenges.For data-driven metrics, it is not surprising that the book relies on a mathematical approach to data. This math-heavy approach would be more appealing to business-trained operating room managers rather than physicians, although the author did attempt to make it more accessible by incorporating these formulas into Excel spreadsheets. We believe anyone interested in implementing data-driven decision-making processes will be able to follow the mathematical progression that occurs in the first half of the book.Overall, this book is a useful resource to anesthesiologists, operating room managers, and financial analysts on the topics of data-driven metrics. It provides a unique educational resource for those who are new to the topic of operating room efficiency, utilization, and productivity. For those who have been working with these concepts, the book provides a resource to reexamine our formulas with an international perspective.

ABSTRACTThe perioperative services (periop) manager establishes policies to manage the operating room (OR) resources that affect both patient and surgeon satisfaction with the hospital's service. Both the surgeon and the patient are customers of the periop department, and their satisfaction is a measure of the service quality. The periop manager uses block scheduling to allocate OR time. This technique gives one surgical practice (or service specialty) priority access to a block of time for scheduling procedures in an OR. Hospitals seek to obtain more of the surgeon's practice by allocating blocks to the surgeon, but the hospital must balance this OR time allocation with the risk that the OR time may not be used. In doing so, the periop manager creates a schedule that balances the hospital's risk of staff working overtime (beyond the OR's scheduled hours of blocked time) with the risk of staff being idle during a block of time reserved for a surgical practice that did not use it. The authors propose an OR management policy that creates service-specific blocks of OR time as well as open-posting blocks (those blocks shared by all surgical practices) and propose that this policy can increase access to the OR for more surgeons and, consequently, increase both surgeon and patient satisfaction. Through the use of two quality metrics–averseness to overtime and flexibility in sharing block time across services–this article examines how the setting of these two metrics affects OR performance. Historical data were used as an input into a modeling framework that created a feasible block schedule for a set of ORs. The block allocation schedule was then evaluated, with a portion of the data set reserved for testing. In an experiment at a large teaching hospital, results indicated that for every 20 percent increase in a manager's averseness to overtime, the hours in reserved blocks increased by 3 percent and utilization decreased by 2 percent. Similarly, a 33 percent increase in open posting flexibility translated into a reduced need of one OR.

Operating room (OR) human traffic has been implicated as a cause of surgical site infection. We first observed the normal human traffic pattern in our Pediatric Orthopedic ORs, and then examined the effect of surveillance on that traffic pattern. This study consisted of 2 phases: phase I sought to observe the OR traffic pattern (number of door swings, maximum and minimum number of OR personnel, number of OR personnel at 30-minute intervals, or changes in nursing, anesthesia, or surgeon staff) during surgical cases without OR personnel being notified, and for phase II, the same traffic pattern was monitored with their knowledge. Two thousand four hundred forty-two minutes of surgical time were observed in phase I, and 1908 minutes were observed in phase II. There was no difference (P=0.06) in the time between door swings between phase I (1.39 min) and phase II (1.70 min), no difference (P=1.000) in the maximum number of people in the OR between phase I (11.5 people, range: 7-15 people) and phase II (11.5 people, range: 8-20 people), and no difference (P=1.000) in the minimum number of people in the OR between phase I (4.67 people, range: 4-6 people) and phase II (4.71 people, range: 3-6 people). There was a difference in the time between door swings (P=0.03) and maximum number of people in the OR (P=0.005) based on the length of the surgery (less or more than 120 min). There was no difference in the time between door swings (P=0.11), but there was a difference in the maximum number of people in the OR (P=0.002) based on type of surgery (spine vs. others). There was no role of surveillance of human traffic in the OR. To achieve any change in the OR traffic pattern, monitoring alone may not be sufficient; other novel techniques or incentives may need to be considered.

Appropriate usage of operating room (OR) time can improve efficiency of utilization of resources and help to decrease surgical waiting lists. This study was conducted to evaluate the pattern of usage of OR time in a tertiary referral cancer hospital. This was a prospective audit carried out over 2 months in 11 major ORs in a cancer hospital. OR anesthesiologists filled a standard form for all patients undergoing elective surgery and documented the following times: entry into OR, start of anesthesia, handover to surgeon, incision, start of reversal, end of anesthesia, and shifting out of patient. Median time utilized for various OR processes was calculated. An average of two surgeries were performed per OR session (828 surgeries in 407 OR sessions). Anesthesia and surgery-related processes contributed to 17% and 79%, respectively, of total OR time, with turnover time between cases accounting for the remaining 4%. Fifteen percent (60 out of 407) OR sessions started more than 10 min later than the planned start time, and 17% (70 of 407) of OR sessions ended more than 2 h after the scheduled finish time. An anesthesia procedure room was utilized in only 15% of cases where it could potentially have been used. This audit identified patterns of OR usage in a cancer hospital and helped to detect areas of inefficient utilization. Anesthesia-related processes contributed to 17% of the total OR time.

This study investigates the experience of health and medical personnel in hospital operating rooms and to evaluate the effectiveness of activities in operating rooms and ventilation conditions in hospitals. This study was designed as a qualitative research based on Heidegger's Hermeneutic Phenomenology Approach. The research method was carried out on health and medical personnel working in the operating room (OR) as observers. The research data were collected using an open and unstructured interview form. This form includes items that question the operating room design and operating room ventilation conditions. Data analysis used the Miles &amp; Huberman method with the stages of data reduction, data display, and conclusion or verification. The research findings were obtained from seven informants (health and medical personnel) consisting of three men and four women. Age ranged from 30 to 45 years. Two themes and twelve sub-themes were determined as a result of data analysis. The research themes are (1) the effectiveness of operating room layout and (2) the effectiveness of operating room ventilation. This study concludes and provides important information about the physical requirements of the hospital operating room and the effectiveness for working professionally experience workers in the operating room (OR). It is understood that the room layout in the hospital is very good in helping smooth preoperative and postoperative handling. And operating room ventilation already supports good air circulation and is easy to control its use. But still found another room that causes noise. Hospital management must consider the type of activity, use of equipment, and/or other sources of noise, whether in the operating room building, ventilation of the operating room without a positive pressure system. So, the hospital must be able to pay attention to air humidity and pay attention to the state of the ventilation system and air filtration in the operating room so as to reduce the risk of preoperative and postoperative wound infections.

Many surgical suites allocate operating room (OR) block time to individual surgeons. If block time is allocated to services/groups and yet the same surgeon invariably operates on the same weekday, for all practical purposes block time is being allocated to individual surgeons. Organizational conflict occurs when a surgeon with a relatively low OR utilization has his or her allocated block time reduced. The authors studied potential limitations affecting whether a facility can accurately estimate the average block time utilizations of individual surgeons performing low volumes of cases. Discrete-event computer simulation. Neither 3 months nor 1 yr of historical data were enough to be able to identify surgeons who had persistently low average OR utilizations. For example, with 3 months of data, the widths of the 95% CIs for average OR utilization exceeded 10% for surgeons who had average raw utilizations of 83% or less. If during a 3-month period a surgeon's measured adjusted utilization is 65%, there is a 95% chance that the surgeon's average adjusted utilization is as low as 38% or as high as 83%. If two surgeons have measured adjusted utilizations of 65% and 80%, respectively, there is a 16% chance that they have the same average adjusted utilization. Average OR utilization can be estimated more precisely for surgeons performing more cases each week. Average OR utilization probably cannot be estimated precisely for low-volume surgeons based on 3 months or 1 yr of historical OR utilization data. The authors recommend that at surgical suites trying to allocate OR time to individual low-volume surgeons, OR allocations be based on criteria other than only OR utilization (e.g., based on OR efficiency).

BackgroundSurgical safety may be improved using a medical data recorder (MDR) for the purpose of postoperative team debriefing. It provides the team in the operating room (OR) with the opportunity to look back upon their joint performance objectively to discuss and learn from suboptimal situations or possible adverse events. The aim of this study was to investigate the satisfaction of the OR team using an MDR, the OR Black Box®, in the OR as a tool providing output for structured team debriefing.MethodsIn this longitudinal survey study, 35 gastro-intestinal laparoscopic operations were recorded using the OR Black Box® and the output was subsequently debriefed with the operating team. Prior to study, a privacy impact assessment was conducted to ensure alignment with applicable legal and regulatory requirements. A structured debrief model and an OR Back Box® performance report was developed. A standardized survey was used to measure participant’s satisfaction with the team debriefing, the debrief model used and the performance report. Factor analysis was performed to assess the questionnaire’s quality and identified contributing satisfaction factors. Multivariable analysis was performed to identify variables associated with participants’ opinions.ResultsIn total, 81 team members of various disciplines in the OR participated, comprising 35 laparoscopic procedures. Mean satisfaction with the OR Black Box® performance report and team debriefing was high for all 3 identified independent satisfaction factors. Of all participants, 98% recommend using the OR Black Box® and the outcome report in team debriefing.ConclusionThe use of an MDR in the OR for the purpose of team debriefing is considered to be both beneficial and important. Team debriefing using the OR Black Box® outcome report is highly recommended by 98% of team members participating.