The single-day surgery scheduling problem: sequential decision-making and threshold-based heuristics

Predictors of Total Operating Room Time for Minimally Invasive Benign Hysterectomy

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.

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.

Due to its fast service and high utilization, day surgery is becoming more and more important in the medical system. As a result, an effective day surgery scheduling can reasonably release the supply and demand pressure. This paper aims to investigate the day surgery scheduling problem with patient preferences and limited operation room for the sake of increasing operation efficiency and further decreasing surgery costs. A multiple objective stochastic programming model is constructed to seek a satisfactory surgical scheduling for both patients and hospitals under different scenarios. Multi-objective genetic algorithm is designed to solve the model and different scales of scenarios are utilized to test the effectiveness of the algorithm and modeling process. Results show that the proposed model and algorithm can provide a feasible solution for maximizing individual preference of surgeons with surgery date and operation room utilization as well. Patient preference is proposed to be incorporated into day surgery scheduling, and the variability of surgery duration considered to seek a satisfactory surgery scheduling scheme for both patients and hospitals is more in line with the actual hospital situation.

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.

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.

Enhancement opportunities in operating room utilization; with a statistical appendix

An integrated approach for surgery scheduling under uncertainty

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

Operating Room (OR) is the core sector in hospital expenditure, the operation management of which involves a complete three-stage surgery flow, multiple resources, prioritization of the various surgeries, and several real-life OR constraints. As such reasonable surgery scheduling is crucial to OR management. To optimize OR management and reduce operation cost, a short-term surgery scheduling problem is proposed and defined based on the survey of the OR operation in a typical hospital in China. The comprehensive operation cost is clearly defined considering both under-utilization and overutilization. A nested Ant Colony Optimization (nested-ACO) incorporated with several real-life OR constraints is proposed to solve such a combinatorial optimization problem. The 10-day manual surgery schedules from a hospital in China are compared with the optimized schedules solved by the nested-ACO. Comparison results show the advantage using the nested-ACO in several measurements: OR-related time, nurse-related time, variation in resources' working time, and the end time. The nested-ACO considering real-life operation constraints such as the difference between first and following case, surgeries priority, and fixed nurses in pre/post-operative stage is proposed to solve the surgery scheduling optimization problem. The results clearly show the benefit of using the nested-ACO in enhancing the OR management efficiency and minimizing the comprehensive overall operation cost.

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.

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.

Introduction Esophageal stenosis in the upper third of the esophagus is a common complication to Epidermolysis Bullosa Dystrophica (EBD). Patients often have a recurring need of dilatations. The patients are as a rule malnourished and brittle. Surgical care of these patients is centralized to one hospital in Sweden since 2024. Method The charts of all patients with EBD that had undergone esophageal balloon dilatations at Akademiska sjukhuset, Uppsala, during 2017-2025 were scrutinized. Data regarding surgeon, operative time, total operating room (OR) time, width of the stenosis, complications as well as age and weight was extracted. Result Fifteen patients had undergone a total of 100 dilatations. The mean age at dilatation was 13,9 years (2,3-29,9) and the mean weight was 30,7 kg (9,9-50). Five patients had undergone ten or more dilatations (one had undergone 30). Ten dilatations had to be done in retrograde fashion through a gastrostomy-canal since it was impossible to intubate the esophagus from above. Mean width of the stenosis when presenting with symptoms was 2,5mm (0-6). In one case it was impossible to dilate the esophagus due to an elongated near total stenosis. The main surgeon was the same in 91 cases. No surgical complications occurred. The anesthesia was often complex, but no major complications occurred. Mean operative time was 26,7min (10-116) and mean total OR time was 97,9min (51-250). Discussion Balloon dilatations of esophageal stenosis of EBD-patients is safe in experienced hands. The long total OR time mirrors the complexity when caring for these patients.

Retrospective cohort. To compare robotics and navigation for minimally invasive elective lumbar fusion in terms of radiation exposure and time demand. Although various studies have been conducted to demonstrate the benefits of both navigation and robotics over fluoroscopy in terms of radiation exposure, literature is lacking in studies comparing robotics versus navigation. Patients who underwent elective one-level or two-level minimally invasive transforaminal lumbar interbody fusion (TLIF) by a single surgeon using navigation (Stryker SpineMask) or robotics (ExcelsiusGPS) were included (navigation 2017-2019, robotics 2019-2021, resulting in prospective cohorts of consecutive patients for each modality). All surgeries had the intraoperative computed tomography workflow. The two cohorts were compared for radiation exposure [fluoroscopy time and radiation dose: image capture, surgical procedure, and overall) and time demand (time for setup and image capture, operative time, and total operating room (OR) time]. A total of 244 patients (robotics 111, navigation 133) were included. The two cohorts were similar in terms of baseline demographics, primary/revision surgeries, and fusion levels. For one-level TLIF, total fluoroscopy time, total radiation dose, and % of radiation for surgical procedure were significantly less with robotics compared with navigation (20 vs. 25s, P <0.001; 38 vs. 42mGy, P =0.05; 58% vs. 65%, P =0.021). Although time for setup and image capture was significantly less with robotics (22 vs. 25min, P <0.001) and operative time was significantly greater with robotics (103 vs. 93min, P <0.001), there was no significant difference in the total OR time (145 vs. 141min, P =0.25). Similar findings were seen for two-level TLIF as well. Robotics for minimally invasive TLIF, compared with navigation, leads to a significant reduction in radiation exposure both to the surgeon and patient, with no significant difference in the total OR time.