Managing Service-Specific and Open-Posting Block Sizes when Allocating Operating Room Time

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).

ABSTRACTPurpose: Reducing operating room (OR) time is of interest to hospital administrators because of high costs of OR utilization. Neuromuscular blocking agents (NMBAs) induce muscle relaxation during surgery. Several acetylcholinesterase inhibitors are used to reverse neuromuscular blockade to shorten recovery time. This study explored the relationship between elapsed OR time and the use of specific NMBAs and reversal agents among patients undergoing selected surgeries based on data from two large hospitals. Specifically, this study sought to test the hypothesis that the application of reversal agents in surgeries using a neuromuscular block would be associated with a decrease in elapsed OR time.Methods: This retrospective cohort study used clinical data from two large hospitals. The authors selected seven types of surgical cases involving thoracic, cardiac, vascular, abdominal, peripheral, urological, and neurological systems. Eligible cases were elective surgeries performed under general anesthesia and using one or more NMBAs (including rocuronium, vecuronium, cisatracurium, and/or pancuronium). Multivariate linear regressions were conducted to examine the relationships among neuromuscular blockade, reversal agent use (including neostigmine, pyridostigmine, and edrophonium), and elapsed OR time by controlling for age, gender, and patient comorbidities.Results: A total of 9670 surgeries were included in this analysis. The mean elapsed OR time across all surgeries was 227 min, and vecuronium was the most commonly used NMBA. Approximately 67% of all surgeries used a reversal agent. After controlling for confounding factors, use of a reversal agent was shown to be associated with the reduction of elapsed OR time in six of seven types of surgery. The magnitude of this effect ranged from 12 to 46 min of OR time saved. The exception was thoracic surgeries, for which use of a reversal agent was shown to be associated with longer OR time (approximately 26 min). Multivariate regression analyses revealed that the type of NMBA used was also a significant predictor of elapsed time for all surgeries (except cardiac).Conclusions: This analysis has shown that use of selected neuromuscular blockade reversal agents may lead to more efficient OR resource use.

Enhancement opportunities in operating room utilization; with a statistical appendix

Predictors of Total Operating Room Time for Minimally Invasive Benign Hysterectomy

Management of surgery units and operating room (OR) play key roles in optimizing the utilization of hospitals. On this line Case Mix Planning (CMP) is normally applied to long term planning of OR. This refers to allocating OR time to each patient’s group. In this paper a mathematical model is applied to optimize the allocation of OR time among surgical groups. In addition, another technique is applied to provide an Order of Preference by Similarity to Ideal Solution (TOPSIS) considering different hospital performance measures. Furthermore, robust estimation approach is used to estimate the models' parameters using real data. The proposed model is solved using GAMS software. The results of the study performed in this paper reveal that the proposed methods results in an increase in total hospital operated “value of patients” by 21.5%. This value is defined according to hospital priority and includes moral and ethical considerations. In addition, for each resource, a sensitivity analysis of the findings to the changes is conducted. The results of the sensitivity analysis indicated that the value of the objective function significantly increased via reallocating OR time to surgical groups and/or enhancing the OR facilities to support more surgical specialties.

Gains in operating room (OR) scheduling may be obtained by using accurate statistical models to predict surgical and procedure times. The 3 main contributions of this article are the following: (i) the validation of Strum's results on the statistical distribution of case durations, including surgeon effects, using OR databases of 2 European hospitals, (ii) the use of expert prior expectations to predict durations of rarely observed cases, and (iii) the application of the proposed methods to predict case durations, with an analysis of the resulting increase in OR efficiency. We retrospectively reviewed all recorded surgical cases of 2 large European teaching hospitals from 2005 to 2008, involving 85,312 cases and 92,099 h in total. Surgical times tended to be skewed and bounded by some minimally required time. We compared the fit of the normal distribution with that of 2- and 3-parameter lognormal distributions for case durations of a range of Current Procedural Terminology (CPT)-anesthesia combinations, including possible surgeon effects. For cases with very few observations, we investigated whether supplementing the data information with surgeons' prior guesses helps to obtain better duration estimates. Finally, we used best fitting duration distributions to simulate the potential efficiency gains in OR scheduling. The 3-parameter lognormal distribution provides the best results for the case durations of CPT-anesthesia (surgeon) combinations, with an acceptable fit for almost 90% of the CPTs when segmented by the factor surgeon. The fit is best for surgical times and somewhat less for total procedure times. Surgeons' prior guesses are helpful for OR management to improve duration estimates of CPTs with very few (<10) observations. Compared with the standard way of case scheduling using the mean of the 3-parameter lognormal distribution for case scheduling reduces the mean overreserved OR time per case up to 11.9 (11.8-12.0) min (55.6%) and the mean underreserved OR time per case up to 16.7 (16.5-16.8) min (53.1%). When scheduling cases using the 4-parameter lognormal model the mean overutilized OR time is up to 20.0 (19.7-20.3) min per OR per day lower than for the standard method and 11.6 (11.3-12.0) min per OR per day lower as compared with the biased corrected mean. OR case scheduling can be improved by using the 3-parameter lognormal model with surgeon effects and by using surgeons' prior guesses for rarely observed CPTs. Using the 3-parameter lognormal model for case-duration prediction and scheduling significantly reduces both the prediction error and OR inefficiency.

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.

AimsOpportunity cost (OC) analysis is key when evaluating surgical techniques. Operating room (OR) time is one potential source of OC in laparoscopic surgery. This study quantifies differences in OR time between 3D- and 2D-imaging technology in laparoscopic surgery, translates these into OC and models the economic impact in real-world hospitals. MethodsFirst a systematically performed literature review and meta-analysis were conducted. Then, methods to translate OR time savings into OC were theorised and a budget impact model was created. After that, the potential time savings of real-world hospital case mixes were extrapolated. Finally, the opportunity costs of not using 3D-imaging in laparoscopic surgery were evaluated. ResultsAverage OR time saving per laparoscopic procedure was −19.4 min (−24.3; −14.5) (−14%) in favour of 3D. The Budget Impact Model demonstrated an economic impact of using 3D-laparoscopy instead of 2D laparoscopy, ranging from £183,045-£866,316 in the British and 73,049€-437,829€ in German hospitals, modelling a mixture of cost savings and performing additional procedures (earning additional revenue). ConclusionThe OC analysis revealed significant economic benefits of introducing 3D-imaging technology in laparoscopic surgery, on the basis that average procedure time is reduced. Utilising the saved OR time to perform additional procedures was the biggest driver of OC. Hospital case mix and procedure volume indicated the magnitude of the OC.

Operating room (OR) efficiency requires coordinated teamwork between the staff surgeon, anesthesia team, circulating nurse, surgical technician, and surgical trainee or assistant. Bariatric cases present unique challenges including difficult airways, challenging intravenous access, use of specialized surgical equipment, and synchronized exchange of orogastric tubes. The high contribution margin of these complex bariatric procedures rests on OR efficiency. To compare the efficiency of bariatric surgeries performed by a single surgeon at a tertiary academic medical center with its inherent variability of OR staff to that of a private hospital with a standardized surgical team. All laparoscopic Roux-en-Y gastric bypasses (LRYGB) performed by a single surgeon at University Hospitals Cleveland Medical Center (UHCMC) and a Community Affiliate (CA) from 2013 to 2015 were retrospectively reviewed.Patient demographics and preoperative comorbidities were compared. The variability of OR staff at each site was described. Four primary endpoints of the different OR phases were measured at the 2 locations and analyzed using standard statistical methods. The OR data of 74 cases of LRYGB at UHCMC and 106 cases at the CA were analyzed. Patient cohorts were comparable by age (45 ± 12 vs. 45 ± 10; p = 0.88), sex (82% vs. 79% female; p = 0.62), BMI (47.16 ± 7.33 vs. 45.91 ± 6.85; p = 0.25), and comorbidities.At CA, the teams who participated in LRYGB cases were fairly constant (8 circulating and scrub nurses, 4 anesthetists, 3 anesthesiologists), whereas at UHCMC there was great variability in the number of staff with 108 staff (39 circulating nurses, 57 scrub nurses/technicians, 59 anesthetists or anesthesia residents, 24 anesthesiologists) participated in LRYGB cases. There was no statistical difference between the total mean OR time and surgical time of the cases performed at the 2 sites (203 ± 59min vs. 188 ± 39min; p = 0.06; 152 ± 56min; 145 ± 37min; p = 0.36). However, the pre- and post-case times were longer at UHCMC compared to the CA (38 ± 9min vs. 33 ± 6min; p < 0.0001; 13 ± 6min vs. 10 ± 3min; p = 0.01). The academic center has much greater variability in staff for these complex bariatric procedures. There was a trend toward longer OR times at the tertiary center as demonstrated by the difference in pre- and post-case times, but the consistent surgeon and assistant allowed for consistent surgical case time regardless of the setting. The implication of variability in OR staff can be overcome by the surgeon directing the procedure itself. The opportunity for improving the efficiency of bariatric surgery should focus on the perioperative care of the patient in OR that requires everyone to be familiar with the procedure.

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

The aim of this study is to identify risk factors for prolonged operative duration in anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA) for patients with glenohumeral osteoarthritis (GHOA). A retrospective chart review of electronic medical records was conducted to identify patients who underwent shoulder arthroplasty for GHOA by one of six surgeons across two academic institutions between 2017 and 2023. Multivariate linear regression was used to identify factors associated with operative duration. In total, 513 patients underwent primary ATSA, and 528 underwent primary RTSA. The mean operating room (OR) time was significantly longer in patients undergoing ATSA (183.5 ± 39.5 minutes) compared to those undergoing RTSA (150.5 ± 33.4 minutes). For ATSA, older patient age, male sex, increased body mass index, lower Charlson comorbidity index (CCI), increased preoperative retroversion, increased preoperative inclination, and a glenoid Walch classification of B2 or B3 were significant predictors of OR time. For RTSA, younger patient age, lower CCI, and increased preoperative retroversion were significant predictors of OR time. ATSA has a significantly longer mean OR time than RTSA for the treatment of isolated GHOA. Preoperative demographic and radiographic data can be used to predict operative duration.

Thoracoscopic versus laparoscopic modified Heller myotomy for achalasia: efficacy and safety in 87 patients

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.

Perioperative services have a high impact on a hospital's financial success. In order to increase patients' privacy and satisfaction, while restraining cost, a redesign of the existing Post-Anesthesia Care Unit (PACU) was suggested at the Mayo Clinic. A simulation model was created to determine the number of beds required in the redesign of the PACU to maintain Operating Room (OR) blocking below 5 %. Since OR time and resources are more costly than the PACU, limiting the resource scarcity of the PACU should minimize delays through the surgical suites. By assuming PACU resourcing as secondary to managing the OR, the underlying complexity of the surgical scheduling did not have to be analyzed. Real data was fed into the simulation model that successfully captured the complexity of the system without the work-intensive requirements of theoretical modeling. The results of the analysis were incorporated into the design plans for remodeling the PACU.

The objective of this study was to assess the cost effectiveness of alternative treatment algorithms for the management of isolated mandibular fractures. This is an institutional review board-approved retrospective study consisting of a chart review of 25 patients who underwent operative repair of an isolated mandible fracture between July 1, 1999, and June 30, 2000. Patients were stratified into two groups: patients who were immediately admitted to the hospital from the emergency department (ED) versus patients who were discharged from the ED and who returned for elective scheduled operative repair. Patients' total hospital charges were compared on the basis of operating room (OR) time, operative materials, and hospital charges. Seventeen of the study patients were directly admitted from the ED, and eight underwent elective scheduled operative repair. Of the patients directly admitted from the ED, the mean age was 34.9 years (range, 19-57 years), and the study population consisted of 16 men and 1 woman. This group had a mean OR time of 161 minutes, a mean OR time charge of $1,978.66, a mean OR supply charge of 1,049.43 US dollars, a mean hospital floor charge of 5,041.02 US dollars, and an average hospital stay of 2.82 days. The treatment group of patients undergoing scheduled operative repair (n = 8) had a mean age of 30.3 years (range, 19-49 years), and all were men. This second treatment group had a mean OR time of 167.1 minutes, a mean OR time charge of 2,162.03 US dollars, a mean OR supply charge of 871.00 US dollars, a mean hospital floor charge of 2,759.38 US dollars, and a mean hospital stay of 0.88 days. Comparison of the two study groups demonstrated operative charges were made on the basis of time and materials and were shown to have no statistically significant difference (p = 0.753 and p = 0.289, respectively). Comparison of hospital charges revealed that patients admitted directly from the ED had a mean charge 2,276.70 US dollars higher (p = 0.019) and stayed 1.95 days longer in the hospital than patients discharged from the emergency department who returned for elective scheduled repair. There were two complications in the study patients; both occurred in the group admitted directly from the emergency room. The results of this study indicate that the most cost-effective management of an isolated mandibular fracture is initial evaluation in the ED with elective interval operative repair. This management protocol is, of course, only applicable if the patient is clinically stable and has no other injuries or comorbidities necessitating in-hospital observation.