Turnover Time Between Elective Operative Cases: Does the Witching Hour Exist for the Operating Room?

Elective change of surgeon during the OR day has an operationally negligible impact on turnover time

Communication failures between multidisciplinary teams can impact efficiency, performance, and morale. Academic operating rooms (ORs) often have surgical, anesthesia, and nursing teams, each teaching multiple trainees. Incorrectly identifying name and "rank" (postgraduate year [PGY]) of resident trainees can disrupt performance evaluations and team morale and even potentially impair delivery of quality care when miscommunication errors proliferate. Our OR-based survey asked 50 participants (18 surgeons, 14 anesthesiologists, and 18 nursing members), to recall basic identification data including provider names and PGY levels from their recent collaborating OR teams. Participants also weighed in on the importance of using accurate "names and ranks" for all OR participants. Each service reliably knew their own team members' names and rank. However, surgery and anesthesia teams displayed decreased knowledge about their lower level trainees, whereas nursing teams performed best, identifying all level nurses present. Deficits occurred whenever participants tried recalling basic identifying data about contributors from any other collaborating team. Typically, misidentified participants were lower level PGY residents working on other teams' services. All survey respondents desired improving systems to better remember "names and ranks" identifications among OR participants, citing both safety and team morale benefits. Many fail to know the names and ranks of contributors among members of different OR teams. Even our most reliable nursing team was inconsistent at identification information from collaborating practitioners. Despite universally acknowledged benefits, participants rarely learned basic background identification data beyond their own team. Those surveyed all desired improving identifications with suggestions including sterile name and rank tags and proper notification of entry and exit from the OR. Because successful collaborations require appropriate level task delegations, participants believed knowing a resident's name and rank is important not only for team bonding but also for safety. Academia furthermore demands fair performance evaluations, and displaying them clearly improves recall. Refining our own identified gaps in OR communications may demonstrate improved teamwork and safer task delegations and perhaps even stimulate other performance benefits for academic ORs.

IntroductionAccording to the Institute of Medicine (IOM), medical errors account for nearly 98,000 deaths in the United States each year. Given that almost half of all adverse events in hospitalized...

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

Fire in Labor and Delivery: Simulation Case Scenario

ABSTRACTMaintaining job satisfaction across the team in the operating room (OR) is essential for reducing staff turnover, stress, burnout, medical errors and increasing patient satisfaction. This literature review explores factors impacting on job satisfaction for OR team members, with a specific focus on nurses, anaesthetists and surgeons. A literature search from January 1997 to November 2017 was conducted using databases CINHAL, psychINFO, Medline and ABI/inform. Surgeon, anaesthetist, OR nurse and OR team job satisfaction studies were included. The search yielded 48 studies. Dominant contributing factors for all three disciplines included: work conditions, support and acknowledgement from management, and fulfilment from the clinical role. Career prospects, research opportunities, autonomy, utilising the full extent of one’s skills, team dynamics/communication, pressure from management, and social support systems were also identified as significant for specific disciplines within the team. This review highlights the importance of addressing factors relating to job satisfaction from an ‘OR team’ perspective and considering the inter-relationship between roles. Further research into ‘team satisfaction’ in the OR, its measurement and its relationship with retention and productivity would be of benefit.

The Operating Room (OR) is the financial engine of the modern hospital or surgical center. Over 40% of the hospital's cost is invested in the OR, but the facility recoups a monetary return of around 60-70%. Turnover time is a crucial factor in reducing costs. Uncontrolled, it can inflate operating costs, but when managed effectively, it can boost surgeon, patient, and staff satisfaction, enhance patient safety, and significantly reduce operational costs. The literature underscores the importance of reducing the time between operating room turnovers to improve OR efficiency. A key strategy that research consistently shows to be effective is the implementation of structured presurgical briefings, such as TeamSTEPPS. These briefings, with their structured approach, play a crucial role in reducing turnover time in an OR, thereby increasing efficiency. The initial investment in developing a standardized preoperative brief through the TeamSTEPPS program as part of the morning brief has the potential to boost OR productivity and revenue significantly. By reducing the time from wheels out to wheels in for each surgery during the operating room's surgical day, this approach can lead to substantial financial gains. The project information is collected from 308 surgical cases from various services over three weeks during the project to determine whether conducting a formal TeamSTEPPS style preoperative formatted brief would reduce turnover times (TOTS) in the operating room (OR). The data showed a mean average reduction of slightly over six minutes in mean average turnover times during the project. The data showed that 20% of all scheduled cases had a turnover time greater than 25 minutes. Of the 20% of the cases, 7.6% of the increased TOTs were attributed to processes controlled by the OR staff. The remaining 12.6% of turnover time was attributed to issues related to surgeons, SDS/ APU, and different services in the hospital. The data shows that the effects of a daily organized and standardized presurgical briefing will improve turnover times better than a presurgical briefing without structure or organization.

Operating room (OR) turnover time (TT) has a broad and significant impact on hospital administrators, providers, staff and patients. Our objective was to identify current problems in TT management and implement a consistent, reproducible process to reduce average TT and process variability. Initial observations of TT were made to document the existing process at a 511 bed, 24 OR, academic medical center. Three control groups, including one consisting of Orthopedic and Vascular Surgery, were used to limit potential confounders such as case acuity/duration and equipment needs. A redesigned process based on observed issues, focusing on a horizontally structured, systems-based approach has three major interventions: developing consistent criteria for OR readiness, utilizing parallel processing for patient and room readiness, and enhancing perioperative communication. Process redesign was implemented in Orthopedics and Vascular Surgery. Comparisons of mean and standard deviation of TT were made using an independent 2-tailed t-test. Using all surgical specialties as controls (n = 237), mean TT (hh:mm:ss) was reduced by 0:20:48 min (95 % CI, 0:10:46-0:30:50), from 0:44:23 to 0:23:25, a 46.9 % reduction. Standard deviation of TT was reduced by 0:10:32 min, from 0:16:24 to 0:05:52 and frequency of TT≥30 min was reduced from 72.5to 11.7 %. P < 0.001 for each. Using Vascular and Orthopedic surgical specialties as controls (n = 13), mean TT was reduced by 0:15:16 min (95 % CI, 0:07:18-0:23:14), from 0:38:51 to 0:23:35, a 39.4 % reduction. Standard deviation of TT reduced by 0:08:47, from 0:14:39 to 0:05:52 and frequency of TT≥30 min reduced from 69.2 to 11.7 %. P < 0.001 for each. Reductions in mean TT present major efficiency, quality improvement, and cost-reduction opportunities. An OR redesign process focusing on parallel processing and enhanced communication resulted in greater than 35 % reduction in TT. A systems-based focus should drive OR TT design.

Constraints on the scheduling of urgent and emergency surgical cases: Surgeon, equipment, and anesthesiologist availability

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.

BackgroundPatient safety depends on effective teamwork. The similarity of team members’ mental models - or their shared understanding–regarding clinical tasks is likely to influence the effectiveness of teamwork. Mental models have not been measured in the complex, high-acuity environment of the operating room (OR), where professionals of different backgrounds must work together to achieve the best surgical outcome for each patient. Therefore, we aimed to explore the similarity of mental models of task sequence and of responsibility for task within multidisciplinary OR teams.MethodsWe developed a computer-based card sorting tool (Momento) to capture the information on mental models in 20 six-person surgical teams, each comprised of three subteams (anaesthesia, surgery, and nursing) for two simulated laparotomies. Team members sorted 20 cards depicting key tasks according to when in the procedure each task should be performed, and which subteam was primarily responsible for each task. Within each OR team and subteam, we conducted pairwise comparisons of scores to arrive at mean similarity scores for each task.ResultsMean similarity score for task sequence was 87 % (range 57–97 %). Mean score for responsibility for task was 70 % (range = 38–100 %), but for half of the tasks was only 51 % (range = 38–69 %). Participants believed their own subteam was primarily responsible for approximately half the tasks in each procedure.ConclusionsWe found differences in the mental models of some OR team members about responsibility for and order of certain tasks in an emergency laparotomy. Momento is a tool that could help elucidate and better align the mental models of OR team members about surgical procedures and thereby improve teamwork and outcomes for patients.Electronic supplementary materialThe online version of this article (doi:10.1186/s12909-016-0752-8) contains supplementary material, which is available to authorized users.

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.

Medical team training (MTT) has been touted as a way to improve teamwork and patient safety in the operating room (OR). OR personal completed a 1-day intensive MTT training. A standardized briefing/debriefing/perioperative routine was developed, including documentation of OR miscues, delays, and a case score (1-5) assigned by the OR team. A multidisciplinary MTT committee reviewed and rectified any systems problems identified. Debriefing items were analyzed comparing baseline data with 12 and 24-month follow-up. A safety attitudes questionnaire was administered at baseline and 1 year. A total of 4863 MTT debriefings were analyzed. One year following MTT, case delays decreased (23% to 10%, P < 0.0001), mean case score increased (4.07-4.87, P < 0.0005), and both changes were sustained at 24 months. One-year and 24-month follow-up data demonstrated decreased frequency of preoperative delays (16%-7%, P = 0.004), hand-off issues (5.4%-0.3%, P < 0.0001), equipment issues/delays (24%-7%, P < 0.0001), cases with low (<3) case scores (23%-3%, P < 0.0005), and adherence to timing guidelines for prophylactic antibiotic administration improved (85%-97%, P < 0.0001). Surveys documented perception of improved teamwork and patient safety. A major systems issue regarding perioperative medication orders was identified and corrected. MTT produced sustained improvement in OR team function, including decreased delays and improved case scores. When combined with a high-level debriefing/problem-solving process, MTT can be a foundation for improving OR performance. This is the largest case analysis of MTT and one of the few to document an impact of MTT on objective measures of operating room function and patient safety.

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.

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.