International Journal of Pediatric Otorhinolaryngology 78 (2014) 782–786
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Auditing of operating room times: A quality improvement project Jonathan N. Perkins a,b,c, Tendy Chiang a,b, Amanda G. Ruiz a,b, Jeremy D. Prager a,b,* a
Department of Pediatric Otolaryngology, Children’s Hospital Colorado, Aurora, CO, USA Department of Otolaryngology, University of Colorado School of Medicine, Aurora, CO, USA c Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ, USA b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 5 November 2013 Received in revised form 5 February 2014 Accepted 6 February 2014 Available online 15 February 2014
Objective: A quality improvement project to evaluate operating room efficiency and utilization and to identify areas for improvement. Methods: A retrospective assessment of a single surgeon’s surgical cases over a 6-month period at a tertiary children’s hospital. Primary outcomes included case timing defined as T1, T2, T3 and T4. (T1)— Patient enters OR-to-procedure start. (T2)—Procedure start-to-procedure end. (T3)—Procedure end-topatient exits OR. (T4)—Patient exits OR-to-next patient enters OR (turnover). Comparison to existing literature was performed and results were presented to stakeholders. Results: A total of 180 surgical cases were reviewed, 92 adenotonsillectomies (T&A), 33 Bilateral Pressure Equalization Tube Placement (PET) and 55 microlaryngoscopies and bronchoscopies (MLB). All outcomes were calculated by case type, except T4, and compared to available published data. T2 was compared to published benchmarks for otolaryngology demonstrating favorable operative times for T&A and PET. However, T4 was considerably longer at our institution (average 31.09). Overall OR efficiency was 20.58%. Conclusions: The operating room represents one of a hospital’s most costly resources. Ensuring that this resource is designed, staffed and utilized efficiently is of major importance to both the quality of patient care and financial productivity. Surgeons are key components of operating room efficiency, utilization and other measurements of institutional performance. How surgeons schedule and perform cases directly impacts, and is impacted by, these measurements of performance. For fields dominated by high volume, short duration procedures such as pediatric otolaryngology, T4 may be the most important variable in determining OR efficiency. By utilizing modern electronic medical records, surgeons can easily track OR time points thereby determining the potential causes of and solutions for OR inefficiency. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Otolaryngology Operating room efficiency Quality improvement
Introduction Operating room (OR) efficiency and utilization are of vital importance to hospitals. These resource-intense rooms and the patient flow within them are the subject of numerous studies. Most projects begin with examinations of a single operating room or surgeon while some larger studies have involved entire hospitals [1– 10]. All are labor-intensive projects designed to identify areas for improvement in patient throughput and efficient care delivery, thereby improving the quality of the patient’s experience and hospital resource utilization. Several of these projects were
* Corresponding author at: Children’s Hospital Colorado, Pediatric Otolaryngology, B-455, 13123 East 16th Avenue, Aurora, CO 80045, USA. Tel.: +1 720 777 5120; fax: +1 720 777 7345. E-mail addresses: [email protected], [email protected] (J.D. Prager). http://dx.doi.org/10.1016/j.ijporl.2014.02.010 0165-5876/ß 2014 Elsevier Ireland Ltd. All rights reserved.
conducted as quality improvement (QI) exercises using specific and proven methodologies. These studies have demonstrated benefit at their respective institution, in quality of care (measured by increased on time starts, shorter length of stay for specific procedures, and improved patient perception of care quality) and in resource management (more rooms finishing on time, more cases completed with same or reduced OR resource expenditure, increased OR financial performance, and increased OR capacity) [2–4,7–10]. One confounding factor in applying conclusions from various studies to one’s own situation is the lack of standardized nomenclature for this field of study. For the purposes of this manuscript, the definitions employed by Varughese et al. have been used [1]:
OR utilization ¼
sum of time OR occupied by patients 100% sum of block time available
J.N. Perkins et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 782–786
OR efficiency ¼
sum of operative time 100% sum of case process time
Case process time ¼ previous patient out of OR to current patient out of OR Despite the growing literature regarding OR efficiency and utilization, many surgeons may not be familiar with their role in these performance measures. Although surgeons may know how long it takes to complete a certain procedure, they may not be involved in the decisions that affect how well the OR functions and that therefore impacts their patients and their ability to perform these procedures. The present inquiry began when the senior author reviewed a day in the OR on which cases started late, families expressed frustration with long preoperative stays at the hospital for short procedures, the OR finished later than scheduled, and little operating had occurred because the room was often not occupied by a patient. In addition there were no identified representatives or committees responsible for addressing these concerns to whom the author could present these issues. On this particular day, 7 cases were performed in one room (3 adenotonsillectomies (T&As), one adenoidectomy and ventilation tube placement (adenoidectomy with PET), one T&A with examination of ears under anesthesia, one T&A with PET, and one adenoidectomy with microlaryngoscopy and bronchoscopy (MLB) and endoscopic repair of laryngeal cleft). During this day, there were 159 min of operating time, 144 min of turnover (room was empty between cases), 291 min of time with a patient in the room and 438 min of
case process time (sum of previous patient out of room to current patient out of room) in a 450 min block (Table 1). The surgeon operated for 55% of the time that the patient was in the room (159/291). This day reflects 36% OR efficiency and 65% OR utilization. Since there were only 6 periods of time in which the room was being cleaned and readied for the next patient (turnover time), this period averaged 24 min. In addition, all procedures took less operating time than the planned operating times, including the last case which was booked for 150 min of operating and took 82 min to perform. While the procedure times compared favorably to published averages, the turnover time did not [1,10]. In addition, the length/percentage of time that patients spent in the room not being operated upon seemed excessive. While standards for operating room efficiency and utilization for these types of procedures do not exist, this day subjectively failed to deliver quality and efficient care. Experiences such as this led to the creation of a QI project designed to examine efficiency and utilization more closely, with particular attention to identifying areas for improvement. The results of this study are presented in this manuscript. The aim was to identify opportunities to improve the efficiency and quality of care as well as to present this data to stakeholders in the perioperative environment in order to increase the surgeon’s role in decision making. Methods A 6-month period of operating room use by a single pediatric otolaryngologist was examined. This project was approved as a QI study by the Organizational Research Risk and Quality Improvement Panel of Children’s Hospital Colorado (CHCO) Research
Table 1 Representative day in the OR.
Case #
1
Procedure
T&A
Time Booked (min.)
Schedule d Start Time
30
7:30
2
Adenoidectomy & PET
3
T&A with examination of ears under anesthesia
30
T&A
30
4
5
T&A with PET
6
T&A
7
Adenoidectomy with MLB & Endoscopic Repair of Laryngeal Cleft
783
30
45
45
165
8:00
8:30
9:00
9:30
10:15
11:00
Actual Times In: 7:44 Start: 7:54 Stop: 8:06 Out: 8:12 In: 8:31 Start: 8:45 Stop: 8:58 Out: 9:05 In: 9:26 Start: 9:38 Stop: 9:50 Out: 9:55 In: 10:18 Start: 10:30 Stop: 10:40 Out: 10:46 In: 11:04 Start: 11:15 Stop: 11:32 Out: 11:39 In: 11:56 Start: 12:08 Stop: 12:21 Out: 12:26 In: 1:11 Start: 1:27 Stop: 2:49 Out: 2:58
Case Process Time (min.) 42*
53
50
Study Times (min.) T1: 10 T2: 12 T3: 6 T1: 14 T2: 13 T3: 7 T1: 12 T2: 12 T3: 5
51
T1: 12 T2: 10 T3: 6
53
T1: 11 T2: 17 T3: 7
47
T1: 12 T2: 13 T3: 5
142
Turnove r (min.)
T4: 19
T4: 21
T4: 23
T4: 19
T4: 17
T4: 45
T1: 16 T2: 82 T3: 9
Notes: * For Case no. 1, the scheduled start time was used to calculate case process time instead of the time the previous patient left the OR as this was the first case of the day.
J.N. Perkins et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 782–786
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Table 2 Definitions of time intervals used in this quality improvement study. Time interval measurement
Definition
Time Time Time Time
Patient enters OR-to-procedure start Procedure start-to-procedure end Procedure end-to-patient exits OR Patient exits OR-to-next patient enters OR (turnover)
1 2 3 4
(T1) (T2) (T3) (T4)
Institute. Time points that had been previously recorded within the CHCO electronic medical record (EMR), EPIC, were extracted and imported into a secure Microsoft Access database. Next these time points which included when the patient entered the OR, when the procedure started and stopped, and when the patient exited the OR, were used to calculate 4 time intervals. Please see Table 2 for a breakdown of these time intervals (Table 2). Due to the complexity of the calculations, only short duration, single-case, clean or clean-contaminated cases with little required room preparation or clean up were examined (PET, T&A and MLB). T1, T2 and T3 were calculated for these case types, whereas T4 was calculated for all of the cases. Emergent cases and those with T4 greater than 60 min were excluded. Data were analyzed by running queries of the Microsoft Access database. Data were then compared to published data and presented to stakeholders, leading to changes in institutional expectations for efficiency and utilization as well as more active pursuit of interventions to improve these metrics. Results A total of 477 cases were done. 179 of these cases were multicases and were excluded from the analysis. Of the remaining 298 cases, 180 cases were T&A, PET, or MLB only. These included 92 T&A’s, 33 PET’s and 55 MLB’s. All of the cases were conducted in a tertiary pediatric hospital by a single surgeon. One of the patients included in the analysis was over 18 years of age at the time of the procedure. All time intervals and standard deviations were calculated by case type except T4 and compared to available published data. T4 was calculated for all cases rather than for individual types of cases so that turnover time would accurately reflect the number of patients who underwent surgery as well as the order in which the surgeries occurred. Results are presented in Table 3. The average T4 was 31.09 min with a standard deviation of 16.09 min. This project revealed many areas of efficient care (T2 and T3) and many areas the senior author identified as in need of improvement, in particular the length of the T1 and T4 intervals. This information was readily available to the surgeon for extraction and analysis via the EMR in self-sustaining, regularly updated Table 3 Procedures and time intervals. Procedure
T&A
PET
MLB
Total no. T1 Mean (SD) Median (IQR) T2 Mean (SD) Median (IQR) T3 Mean (SD) Median (IQR) T4 Mean (SD) Median (IQR)
92
33
55
12.77 (3.21) 12 (11, 15)
5.33 (1.69) 5 (4, 6)
11.16 (4.22) 11 (8.5, 13)
13.72 (6.51) 12 (9, 17)
4.94 (1.73) 4 (4, 5)
13.11 (14.85) 9 (5, 15)
7.40 (3.27) 7 (5, 9.25)
2.61 (1.30) 2 (2, 3)
6.07 (3.78) 5 (4.5, 6)
31.09 (16.09) 26 (20, 33)
Time measures are in minutes. SD = Standard deviation; IQR = Interquartile range.
fashion with minimal investment of resources. However, this analysis was but one viewpoint of efficiency and utilization issues. In order to be more widely accepted, data first had to be compared to existing data regarding similar cases. Second, data needed to be presented to the other stakeholders invested in the efficiency and success of our operating rooms. In our study, T2 (T&A: Mean 13.72 min SD 6.51 min; PET: Mean 4.94 min SD 1.73 min) was compared to published benchmarks for otolaryngology demonstrating favorable operative times for T&A (Mean 20.3 min, Standard Error [SE] 0.8 min) and PET (Mean 8.0 min, SE 0.5 min) [10]. Our MLB T2 compares favorably to that of ‘‘direct laryngoscopy and biopsy’’ reported by Bhattacharyya et al. (Mean 20.3 min, SE 3.5 min). In addition, our operating room times for each type of procedure (T1 + T2 + T3) compare favorably to the corresponding times from that study as well (T&A: Mean 40.7 min, SE 1.1 min; PET: Mean 17.6 min, SE 0.9 min, direct laryngoscopy and biopsy: Mean 49.9 min, SE 3.4 min) [10]. Our T1 (T&A: Median 12 min, IQR (11,15); PET: Median 5 min, IQR (4,6), MLB: Median 11 min, IQR (8.5,13) was similar to ‘‘anesthesia time’’ (Median 9 min, IQR (5,11) as recorded by Varughese et al. in their study of the impact of OR vs. induction room (IR) inhalation inductions on OR efficiency and utilization [1]. For this reason we reconsidered our first judgment regarding T1 (that it was too long) and focused on T4. Varughese et al. examined 498 pediatric otolaryngology procedures including PET, T&A, adenoidectomy, tonsillectomy and MLB performed at a tertiary childrens’ hospital. T4 was considerably longer at our institution (Median (IQR), 26 min (20,33) versus 9 min (6,13)) [1]. T4 appears to contribute disproportionately to OR inefficiency and poor utilization at our institution. Varughese et al. also reported room efficiency for their operating rooms when induction occurred in the room itself (29 12.7%) or in an induction room (25.9 12.8%). Our audit revealed an overall OR efficiency of 20.58%, suggesting that while the Varughese study may not serve as a benchmark for OR efficiency in pediatric otolaryngology, there is certainly room for efficiency improvement in our process when performing similar cases. Of note, once averages for time intervals and an agreed-upon goal for turnover time are known, OR efficiency and utilization target benchmarks can be calculated depending upon the types of cases scheduled in a room. Once our data had been compared to other published data regarding similar cases, our project was presented to surgical leadership within the hospital, as well as to leadership within anesthesia, perioperative services, and quality & safety. The high volume, short duration procedures characteristic of Pediatric Otolaryngology were presented as the ideal environment in which to expose the additive effects of inefficiencies at each step in the perioperative and operative experience for our patients. Concerns regarding quality of care as well as inefficient and therefore expensive utilization of hospital resources were communicated. OR efficiency and utilization were predicted to remain lower than comparable environments unless each step within the perioperative and operative process was examined (with particular attention to T4) and addressed by a multidisciplinary team of operating room stakeholders prepared and empowered to intervene and measure the impact of interventions. These concerns were welcomed, coincided with the concurrent creation of just such a committee, and resulted in Pediatric Otolaryngology representation. A multidisciplinary committee tasked with improving OR efficiency (especially T4) and composed of operating room stakeholders was convened and now meets monthly. This group includes representation from perioperative services (Nursing, Surgical Technologists, Anesthesia Technologists and Sterile Processing), anesthesia, urology and otolaryngology. This committee employs an automated software mechanism by which data are extracted from the EMR and analyzed for changes in time intervals,
J.N. Perkins et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 782–786
efficiency and utilization before and after interventions. Interventions gleaned from literature review and multidisciplinary communication within the committee are proposed and then trialed in the OR environment. Discussion High-volume, short duration procedures in pediatric otolaryngology represent a large percentage of surgical procedures performed in the academic children’s hospital. As such, our practice places stress on perioperative and operative mechanics. If these mechanics are not maximized for high efficiency and utilization of block time, the result is poor efficiency and utilization, frustrated surgeons and families, and ultimately poorer quality care. Improving these performance measures has already demonstrated multiple benefits [2–4,7–10]. The EMR permits facile self-audit of operating room time intervals. The results of self-audit can be translated into terms of efficiency and utilization, allowing for comparison to existing literature and interdisciplinary conversation with other stakeholders in order to identify issues and plan methods to improve efficiency and utilization. These performance measures may be rapidly and easily assessed for improvements or diminutions after interventions. In addition, the information gained from self-audit affords the surgeon data with which to strengthen requests for
785
parallel processing resources, second anesthesia teams, additional capital equipment requests, additional block time and so on. At our institution, a newly created committee reviewed several potential interventions designed to improve efficiency and utilization (Table 4). These interventions are specific to our hospital but the take-away lesson is the applicability of this process to any perioperative efficiency or utilization issue. Of note, an early consensus decision within our committee was the expectation that T4 should not exceed 15 min for high-volume, short duration cases without extensive set-up needs. With the data from this QI study, our institution can use our average T1–T3 and ideal T4 to build an OR day that maximizes the block time provided to the surgeon. For instance, with a 450 min block day and an average case process time (T1 + T2 + T3 + T4) of 48.89 min for a T&A, the scheduled block time can be optimized by scheduling 9 T&A’s, making for a T&A only day. This T&A only day yields a utilization of 97.78% and an efficiency of 28.06%, similar to that reported by Varughese. Average case process time for an MLB was 45.34 min. An OR day of 10 MLB’s cases yields an OR utilization of 100% and efficiency of 28.9%. At our institution average case process time for a PET was 27.88 min. To maximize a single surgeon’s OR block time one could schedule 16 PET’s, resulting in 99.1% utilization and 17.7% efficiency. Any combination of procedures can be scheduled and the target utilization and efficiency easily calculated, establishing an institutional
Table 4 Proposed strategies for improving operating room efficiency. Interval
Variables that contribute to delay
Proposed process improvements
T1: Patient enters OR-to-procedure start
Perioperative variables—difficult IV placement
Proposed more rapid activation of alternative personnel and equipment for difficult IV placement If surgeon is aware, can specify in orders that patient is a difficult IV If anesthesia is aware, can specify personnel and equipment ahead of time Discussion of a dedicated ENT anesthesia team to facilitate homogeneity in induction and arousal times; creates expectations Manage flow of family similar to OR flow so surgeon can find them between cases
Anesthesia variables—duration of induction Surgeon variables—surgeon present and ready to start case; surgeon often trying to find family of previous patient T2: Procedure start-to-procedure end
Perioperative variables—needed equipment not present for case; malfunctioning equipment/OR staff unfamiliar with equipment
Anesthesia variables—none identified Surgeon variables—equipment needed but not requested; variability in case lengths
T3: Procedure end-to-patient exits OR
Perioperative variables—none identified Anesthetic variables—variability in duration of arousal Surgeon variables–none identified
T4: Patient exits OR-to-next patient enters OR (turnover)
Perioperative variables—circulating RN occupied with patient handoff; prolonged equipment set up for case to follow; pre-surgical documentation incomplete by pre-operative staff; waiting for environmental services
Anesthesia variables
Surgeon variables—no consent present; improved clustering of like cases; surgeon availability for questions
Accurate/routinely audit preference cards with surgeons Additional training of OR staff for audio/visual/other commonly used equipment Place like cases back to back to minimize moving equipment (e.g. Microscope for PET) Anesthesia variables–predicting the depth of adequate anesthesia throughout the case Audit preference cards for accuracy Improve accuracy of case scheduling by requesting special equipment ahead of time Division level expectations about how long certain procedures should take Perioperative variables–availability of stretchers and monitors for transport. Assistance with transport Discussion of a dedicated ENT anesthesia team to facilitate homogeneity in induction and arousal times; creates expectations Surgeon variables—assistance with transport Straightforward ENT cases no longer require RN handoff to PACU OR equipment set up concurrent with induction Cluster similar cases to reduce equipment changing Resource allocation commensurate with operative volume (e.g. increase pre-operative staff, environmental services) N Surgeons using N + 1 ORs Use of procedure rooms with different turnover/cleaning requirements for shorter cases Early anesthesia evaluation of patient & identification of the need for pre-medication Discussion of a dedicated ENT anesthesia team to facilitate homogeneity in efficiency; expectation that anesthesia will stay at least a patient ahead in evaluations Get consent in clinic and place into chart morning of case Schedulers instructed to cluster similar cases for equipment needs Minimize absence from OR
786
J.N. Perkins et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 782–786
benchmark for that particular combination of procedures. Each individual surgeon and/or institution can determine their ‘‘ideal’’ T1–T4 by case type and calculate its own ideal utilization and efficiency by using any combination of cases. Actual efficiency and utilization can then be compared to expected/targeted rates, in ongoing self-audits. Individual interventions can easily be tracked (Table 4) for their impact on efficiency and utilization, and if desired on more downstream measurement of resource management and patient satisfaction.
Conflicts of interest statement None.
Acknowledgements The authors would like to thank Tony Burch for his assistance with data extraction from the electronic medical records.
Conclusion References High volume, short duration procedures like T&A, PET and MLB in pediatric otolaryngology lend themselves to quality improvement time audits like the one presented in this paper. Modern EMR allows for the tracking of OR timing (T1–T4) for areas that need improvement. Interventions to address these areas can be implemented and an EMR audit can be used to assess their impact. Ideal T1–T4 can then be determined and target utilization and efficiency rates can be calculated and used to determine the distribution of cases that maximize OR efficiency, utilization and quality of care. The authors recommend that individual surgeons or divisions/ departments use the EMR to audit time intervals, gain familiarity with QI processes compare their results to the growing body of literature, and either open or broaden the dialogue between otolaryngologists and those in positions of leadership within perioperative services and anesthesia. Surgical services are vital elements in delivering efficient, high quality care and are positioned most appropriately among those making decisions that directly affect us and our patients. Financial disclosure None.
[1] A.M. Varughese, N. Hagerman, M. Patino, et al., A comparison of inhalational inductions for children in the operating room vs. the induction room, Paediatr. Anaesth. 22 (4) (2012) 327–334. [2] R.R. Cima, M.J. Brown, J.R. Hebl, et al.,Surgical Process Improvement Team, Mayo Clinic, Rochester, Use of lean and six sigma methodology to improve operating room efficiency in a high-volume tertiary-care academic medical center, J. Am. Coll. Surg. 213 (1) (2011) 83–92, discussion 93-4. [3] R. Adams, P. Warner, B. Hubbard, T. Goulding, Decreasing turnaround time between general surgery cases, JONA 34 (3) (2004) 140–148. [4] C.B. Fairbanks, Using six sigma and lean methodologies to improve OR throughput, AORN J. 86 (1) (2007) 73–82. [5] C.R. Nicolay, S. Purkayastha, A. Greenhalgh, et al., Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare, Br. J. Surg. 99 (2011) 324–335. [6] R.A. Marjamaa, P.M. Torkki, E.J. Hirvensalo, O.A. Kirvela, What is the best workflow for an operating room? A simulation study of five scenarios, Health Care Manage. Sci. 12 (2009) 142–146. [7] P.M. Torkki, A.I. Alho, A.V. Peltokorpi, et al., Managing urgent surgery as a process: case study of a trauma center, Int. J. Technol. Assess. Health Care 22 (2006) 255– 260. [8] R. Cantwell, N. Mirza, T. Short, Continuous quality improvement efforts increase operating room efficiency, J. Healthcare Qual. 19 (1997) 32–36. [9] R.J.M.M. Does, T.M.B. Vermaat, J.P.S. Verver, et al., Reducing start time delays in operating rooms, J. Qual. Technol. 41 (2009) 95–109. [10] N. Bhattacharyya, Benchmarks for the Durations of Ambulatory Surgical Procedures in Otolaryngology, Ann. Otol. Rhinol. Laryngol. 120 (11) (2011) 727–731.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Auditing of operating room times: A quality improvement project Jonathan N. Perkins a,b,c, Tendy Chiang a,b, Amanda G. Ruiz a,b, Jeremy D. Prager a,b,* a
Department of Pediatric Otolaryngology, Children’s Hospital Colorado, Aurora, CO, USA Department of Otolaryngology, University of Colorado School of Medicine, Aurora, CO, USA c Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ, USA b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 5 November 2013 Received in revised form 5 February 2014 Accepted 6 February 2014 Available online 15 February 2014
Objective: A quality improvement project to evaluate operating room efficiency and utilization and to identify areas for improvement. Methods: A retrospective assessment of a single surgeon’s surgical cases over a 6-month period at a tertiary children’s hospital. Primary outcomes included case timing defined as T1, T2, T3 and T4. (T1)— Patient enters OR-to-procedure start. (T2)—Procedure start-to-procedure end. (T3)—Procedure end-topatient exits OR. (T4)—Patient exits OR-to-next patient enters OR (turnover). Comparison to existing literature was performed and results were presented to stakeholders. Results: A total of 180 surgical cases were reviewed, 92 adenotonsillectomies (T&A), 33 Bilateral Pressure Equalization Tube Placement (PET) and 55 microlaryngoscopies and bronchoscopies (MLB). All outcomes were calculated by case type, except T4, and compared to available published data. T2 was compared to published benchmarks for otolaryngology demonstrating favorable operative times for T&A and PET. However, T4 was considerably longer at our institution (average 31.09). Overall OR efficiency was 20.58%. Conclusions: The operating room represents one of a hospital’s most costly resources. Ensuring that this resource is designed, staffed and utilized efficiently is of major importance to both the quality of patient care and financial productivity. Surgeons are key components of operating room efficiency, utilization and other measurements of institutional performance. How surgeons schedule and perform cases directly impacts, and is impacted by, these measurements of performance. For fields dominated by high volume, short duration procedures such as pediatric otolaryngology, T4 may be the most important variable in determining OR efficiency. By utilizing modern electronic medical records, surgeons can easily track OR time points thereby determining the potential causes of and solutions for OR inefficiency. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Otolaryngology Operating room efficiency Quality improvement
Introduction Operating room (OR) efficiency and utilization are of vital importance to hospitals. These resource-intense rooms and the patient flow within them are the subject of numerous studies. Most projects begin with examinations of a single operating room or surgeon while some larger studies have involved entire hospitals [1– 10]. All are labor-intensive projects designed to identify areas for improvement in patient throughput and efficient care delivery, thereby improving the quality of the patient’s experience and hospital resource utilization. Several of these projects were
* Corresponding author at: Children’s Hospital Colorado, Pediatric Otolaryngology, B-455, 13123 East 16th Avenue, Aurora, CO 80045, USA. Tel.: +1 720 777 5120; fax: +1 720 777 7345. E-mail addresses: [email protected], [email protected] (J.D. Prager). http://dx.doi.org/10.1016/j.ijporl.2014.02.010 0165-5876/ß 2014 Elsevier Ireland Ltd. All rights reserved.
conducted as quality improvement (QI) exercises using specific and proven methodologies. These studies have demonstrated benefit at their respective institution, in quality of care (measured by increased on time starts, shorter length of stay for specific procedures, and improved patient perception of care quality) and in resource management (more rooms finishing on time, more cases completed with same or reduced OR resource expenditure, increased OR financial performance, and increased OR capacity) [2–4,7–10]. One confounding factor in applying conclusions from various studies to one’s own situation is the lack of standardized nomenclature for this field of study. For the purposes of this manuscript, the definitions employed by Varughese et al. have been used [1]:
OR utilization ¼
sum of time OR occupied by patients 100% sum of block time available
J.N. Perkins et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 782–786
OR efficiency ¼
sum of operative time 100% sum of case process time
Case process time ¼ previous patient out of OR to current patient out of OR Despite the growing literature regarding OR efficiency and utilization, many surgeons may not be familiar with their role in these performance measures. Although surgeons may know how long it takes to complete a certain procedure, they may not be involved in the decisions that affect how well the OR functions and that therefore impacts their patients and their ability to perform these procedures. The present inquiry began when the senior author reviewed a day in the OR on which cases started late, families expressed frustration with long preoperative stays at the hospital for short procedures, the OR finished later than scheduled, and little operating had occurred because the room was often not occupied by a patient. In addition there were no identified representatives or committees responsible for addressing these concerns to whom the author could present these issues. On this particular day, 7 cases were performed in one room (3 adenotonsillectomies (T&As), one adenoidectomy and ventilation tube placement (adenoidectomy with PET), one T&A with examination of ears under anesthesia, one T&A with PET, and one adenoidectomy with microlaryngoscopy and bronchoscopy (MLB) and endoscopic repair of laryngeal cleft). During this day, there were 159 min of operating time, 144 min of turnover (room was empty between cases), 291 min of time with a patient in the room and 438 min of
case process time (sum of previous patient out of room to current patient out of room) in a 450 min block (Table 1). The surgeon operated for 55% of the time that the patient was in the room (159/291). This day reflects 36% OR efficiency and 65% OR utilization. Since there were only 6 periods of time in which the room was being cleaned and readied for the next patient (turnover time), this period averaged 24 min. In addition, all procedures took less operating time than the planned operating times, including the last case which was booked for 150 min of operating and took 82 min to perform. While the procedure times compared favorably to published averages, the turnover time did not [1,10]. In addition, the length/percentage of time that patients spent in the room not being operated upon seemed excessive. While standards for operating room efficiency and utilization for these types of procedures do not exist, this day subjectively failed to deliver quality and efficient care. Experiences such as this led to the creation of a QI project designed to examine efficiency and utilization more closely, with particular attention to identifying areas for improvement. The results of this study are presented in this manuscript. The aim was to identify opportunities to improve the efficiency and quality of care as well as to present this data to stakeholders in the perioperative environment in order to increase the surgeon’s role in decision making. Methods A 6-month period of operating room use by a single pediatric otolaryngologist was examined. This project was approved as a QI study by the Organizational Research Risk and Quality Improvement Panel of Children’s Hospital Colorado (CHCO) Research
Table 1 Representative day in the OR.
Case #
1
Procedure
T&A
Time Booked (min.)
Schedule d Start Time
30
7:30
2
Adenoidectomy & PET
3
T&A with examination of ears under anesthesia
30
T&A
30
4
5
T&A with PET
6
T&A
7
Adenoidectomy with MLB & Endoscopic Repair of Laryngeal Cleft
783
30
45
45
165
8:00
8:30
9:00
9:30
10:15
11:00
Actual Times In: 7:44 Start: 7:54 Stop: 8:06 Out: 8:12 In: 8:31 Start: 8:45 Stop: 8:58 Out: 9:05 In: 9:26 Start: 9:38 Stop: 9:50 Out: 9:55 In: 10:18 Start: 10:30 Stop: 10:40 Out: 10:46 In: 11:04 Start: 11:15 Stop: 11:32 Out: 11:39 In: 11:56 Start: 12:08 Stop: 12:21 Out: 12:26 In: 1:11 Start: 1:27 Stop: 2:49 Out: 2:58
Case Process Time (min.) 42*
53
50
Study Times (min.) T1: 10 T2: 12 T3: 6 T1: 14 T2: 13 T3: 7 T1: 12 T2: 12 T3: 5
51
T1: 12 T2: 10 T3: 6
53
T1: 11 T2: 17 T3: 7
47
T1: 12 T2: 13 T3: 5
142
Turnove r (min.)
T4: 19
T4: 21
T4: 23
T4: 19
T4: 17
T4: 45
T1: 16 T2: 82 T3: 9
Notes: * For Case no. 1, the scheduled start time was used to calculate case process time instead of the time the previous patient left the OR as this was the first case of the day.
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Table 2 Definitions of time intervals used in this quality improvement study. Time interval measurement
Definition
Time Time Time Time
Patient enters OR-to-procedure start Procedure start-to-procedure end Procedure end-to-patient exits OR Patient exits OR-to-next patient enters OR (turnover)
1 2 3 4
(T1) (T2) (T3) (T4)
Institute. Time points that had been previously recorded within the CHCO electronic medical record (EMR), EPIC, were extracted and imported into a secure Microsoft Access database. Next these time points which included when the patient entered the OR, when the procedure started and stopped, and when the patient exited the OR, were used to calculate 4 time intervals. Please see Table 2 for a breakdown of these time intervals (Table 2). Due to the complexity of the calculations, only short duration, single-case, clean or clean-contaminated cases with little required room preparation or clean up were examined (PET, T&A and MLB). T1, T2 and T3 were calculated for these case types, whereas T4 was calculated for all of the cases. Emergent cases and those with T4 greater than 60 min were excluded. Data were analyzed by running queries of the Microsoft Access database. Data were then compared to published data and presented to stakeholders, leading to changes in institutional expectations for efficiency and utilization as well as more active pursuit of interventions to improve these metrics. Results A total of 477 cases were done. 179 of these cases were multicases and were excluded from the analysis. Of the remaining 298 cases, 180 cases were T&A, PET, or MLB only. These included 92 T&A’s, 33 PET’s and 55 MLB’s. All of the cases were conducted in a tertiary pediatric hospital by a single surgeon. One of the patients included in the analysis was over 18 years of age at the time of the procedure. All time intervals and standard deviations were calculated by case type except T4 and compared to available published data. T4 was calculated for all cases rather than for individual types of cases so that turnover time would accurately reflect the number of patients who underwent surgery as well as the order in which the surgeries occurred. Results are presented in Table 3. The average T4 was 31.09 min with a standard deviation of 16.09 min. This project revealed many areas of efficient care (T2 and T3) and many areas the senior author identified as in need of improvement, in particular the length of the T1 and T4 intervals. This information was readily available to the surgeon for extraction and analysis via the EMR in self-sustaining, regularly updated Table 3 Procedures and time intervals. Procedure
T&A
PET
MLB
Total no. T1 Mean (SD) Median (IQR) T2 Mean (SD) Median (IQR) T3 Mean (SD) Median (IQR) T4 Mean (SD) Median (IQR)
92
33
55
12.77 (3.21) 12 (11, 15)
5.33 (1.69) 5 (4, 6)
11.16 (4.22) 11 (8.5, 13)
13.72 (6.51) 12 (9, 17)
4.94 (1.73) 4 (4, 5)
13.11 (14.85) 9 (5, 15)
7.40 (3.27) 7 (5, 9.25)
2.61 (1.30) 2 (2, 3)
6.07 (3.78) 5 (4.5, 6)
31.09 (16.09) 26 (20, 33)
Time measures are in minutes. SD = Standard deviation; IQR = Interquartile range.
fashion with minimal investment of resources. However, this analysis was but one viewpoint of efficiency and utilization issues. In order to be more widely accepted, data first had to be compared to existing data regarding similar cases. Second, data needed to be presented to the other stakeholders invested in the efficiency and success of our operating rooms. In our study, T2 (T&A: Mean 13.72 min SD 6.51 min; PET: Mean 4.94 min SD 1.73 min) was compared to published benchmarks for otolaryngology demonstrating favorable operative times for T&A (Mean 20.3 min, Standard Error [SE] 0.8 min) and PET (Mean 8.0 min, SE 0.5 min) [10]. Our MLB T2 compares favorably to that of ‘‘direct laryngoscopy and biopsy’’ reported by Bhattacharyya et al. (Mean 20.3 min, SE 3.5 min). In addition, our operating room times for each type of procedure (T1 + T2 + T3) compare favorably to the corresponding times from that study as well (T&A: Mean 40.7 min, SE 1.1 min; PET: Mean 17.6 min, SE 0.9 min, direct laryngoscopy and biopsy: Mean 49.9 min, SE 3.4 min) [10]. Our T1 (T&A: Median 12 min, IQR (11,15); PET: Median 5 min, IQR (4,6), MLB: Median 11 min, IQR (8.5,13) was similar to ‘‘anesthesia time’’ (Median 9 min, IQR (5,11) as recorded by Varughese et al. in their study of the impact of OR vs. induction room (IR) inhalation inductions on OR efficiency and utilization [1]. For this reason we reconsidered our first judgment regarding T1 (that it was too long) and focused on T4. Varughese et al. examined 498 pediatric otolaryngology procedures including PET, T&A, adenoidectomy, tonsillectomy and MLB performed at a tertiary childrens’ hospital. T4 was considerably longer at our institution (Median (IQR), 26 min (20,33) versus 9 min (6,13)) [1]. T4 appears to contribute disproportionately to OR inefficiency and poor utilization at our institution. Varughese et al. also reported room efficiency for their operating rooms when induction occurred in the room itself (29 12.7%) or in an induction room (25.9 12.8%). Our audit revealed an overall OR efficiency of 20.58%, suggesting that while the Varughese study may not serve as a benchmark for OR efficiency in pediatric otolaryngology, there is certainly room for efficiency improvement in our process when performing similar cases. Of note, once averages for time intervals and an agreed-upon goal for turnover time are known, OR efficiency and utilization target benchmarks can be calculated depending upon the types of cases scheduled in a room. Once our data had been compared to other published data regarding similar cases, our project was presented to surgical leadership within the hospital, as well as to leadership within anesthesia, perioperative services, and quality & safety. The high volume, short duration procedures characteristic of Pediatric Otolaryngology were presented as the ideal environment in which to expose the additive effects of inefficiencies at each step in the perioperative and operative experience for our patients. Concerns regarding quality of care as well as inefficient and therefore expensive utilization of hospital resources were communicated. OR efficiency and utilization were predicted to remain lower than comparable environments unless each step within the perioperative and operative process was examined (with particular attention to T4) and addressed by a multidisciplinary team of operating room stakeholders prepared and empowered to intervene and measure the impact of interventions. These concerns were welcomed, coincided with the concurrent creation of just such a committee, and resulted in Pediatric Otolaryngology representation. A multidisciplinary committee tasked with improving OR efficiency (especially T4) and composed of operating room stakeholders was convened and now meets monthly. This group includes representation from perioperative services (Nursing, Surgical Technologists, Anesthesia Technologists and Sterile Processing), anesthesia, urology and otolaryngology. This committee employs an automated software mechanism by which data are extracted from the EMR and analyzed for changes in time intervals,
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efficiency and utilization before and after interventions. Interventions gleaned from literature review and multidisciplinary communication within the committee are proposed and then trialed in the OR environment. Discussion High-volume, short duration procedures in pediatric otolaryngology represent a large percentage of surgical procedures performed in the academic children’s hospital. As such, our practice places stress on perioperative and operative mechanics. If these mechanics are not maximized for high efficiency and utilization of block time, the result is poor efficiency and utilization, frustrated surgeons and families, and ultimately poorer quality care. Improving these performance measures has already demonstrated multiple benefits [2–4,7–10]. The EMR permits facile self-audit of operating room time intervals. The results of self-audit can be translated into terms of efficiency and utilization, allowing for comparison to existing literature and interdisciplinary conversation with other stakeholders in order to identify issues and plan methods to improve efficiency and utilization. These performance measures may be rapidly and easily assessed for improvements or diminutions after interventions. In addition, the information gained from self-audit affords the surgeon data with which to strengthen requests for
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parallel processing resources, second anesthesia teams, additional capital equipment requests, additional block time and so on. At our institution, a newly created committee reviewed several potential interventions designed to improve efficiency and utilization (Table 4). These interventions are specific to our hospital but the take-away lesson is the applicability of this process to any perioperative efficiency or utilization issue. Of note, an early consensus decision within our committee was the expectation that T4 should not exceed 15 min for high-volume, short duration cases without extensive set-up needs. With the data from this QI study, our institution can use our average T1–T3 and ideal T4 to build an OR day that maximizes the block time provided to the surgeon. For instance, with a 450 min block day and an average case process time (T1 + T2 + T3 + T4) of 48.89 min for a T&A, the scheduled block time can be optimized by scheduling 9 T&A’s, making for a T&A only day. This T&A only day yields a utilization of 97.78% and an efficiency of 28.06%, similar to that reported by Varughese. Average case process time for an MLB was 45.34 min. An OR day of 10 MLB’s cases yields an OR utilization of 100% and efficiency of 28.9%. At our institution average case process time for a PET was 27.88 min. To maximize a single surgeon’s OR block time one could schedule 16 PET’s, resulting in 99.1% utilization and 17.7% efficiency. Any combination of procedures can be scheduled and the target utilization and efficiency easily calculated, establishing an institutional
Table 4 Proposed strategies for improving operating room efficiency. Interval
Variables that contribute to delay
Proposed process improvements
T1: Patient enters OR-to-procedure start
Perioperative variables—difficult IV placement
Proposed more rapid activation of alternative personnel and equipment for difficult IV placement If surgeon is aware, can specify in orders that patient is a difficult IV If anesthesia is aware, can specify personnel and equipment ahead of time Discussion of a dedicated ENT anesthesia team to facilitate homogeneity in induction and arousal times; creates expectations Manage flow of family similar to OR flow so surgeon can find them between cases
Anesthesia variables—duration of induction Surgeon variables—surgeon present and ready to start case; surgeon often trying to find family of previous patient T2: Procedure start-to-procedure end
Perioperative variables—needed equipment not present for case; malfunctioning equipment/OR staff unfamiliar with equipment
Anesthesia variables—none identified Surgeon variables—equipment needed but not requested; variability in case lengths
T3: Procedure end-to-patient exits OR
Perioperative variables—none identified Anesthetic variables—variability in duration of arousal Surgeon variables–none identified
T4: Patient exits OR-to-next patient enters OR (turnover)
Perioperative variables—circulating RN occupied with patient handoff; prolonged equipment set up for case to follow; pre-surgical documentation incomplete by pre-operative staff; waiting for environmental services
Anesthesia variables
Surgeon variables—no consent present; improved clustering of like cases; surgeon availability for questions
Accurate/routinely audit preference cards with surgeons Additional training of OR staff for audio/visual/other commonly used equipment Place like cases back to back to minimize moving equipment (e.g. Microscope for PET) Anesthesia variables–predicting the depth of adequate anesthesia throughout the case Audit preference cards for accuracy Improve accuracy of case scheduling by requesting special equipment ahead of time Division level expectations about how long certain procedures should take Perioperative variables–availability of stretchers and monitors for transport. Assistance with transport Discussion of a dedicated ENT anesthesia team to facilitate homogeneity in induction and arousal times; creates expectations Surgeon variables—assistance with transport Straightforward ENT cases no longer require RN handoff to PACU OR equipment set up concurrent with induction Cluster similar cases to reduce equipment changing Resource allocation commensurate with operative volume (e.g. increase pre-operative staff, environmental services) N Surgeons using N + 1 ORs Use of procedure rooms with different turnover/cleaning requirements for shorter cases Early anesthesia evaluation of patient & identification of the need for pre-medication Discussion of a dedicated ENT anesthesia team to facilitate homogeneity in efficiency; expectation that anesthesia will stay at least a patient ahead in evaluations Get consent in clinic and place into chart morning of case Schedulers instructed to cluster similar cases for equipment needs Minimize absence from OR
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benchmark for that particular combination of procedures. Each individual surgeon and/or institution can determine their ‘‘ideal’’ T1–T4 by case type and calculate its own ideal utilization and efficiency by using any combination of cases. Actual efficiency and utilization can then be compared to expected/targeted rates, in ongoing self-audits. Individual interventions can easily be tracked (Table 4) for their impact on efficiency and utilization, and if desired on more downstream measurement of resource management and patient satisfaction.
Conflicts of interest statement None.
Acknowledgements The authors would like to thank Tony Burch for his assistance with data extraction from the electronic medical records.
Conclusion References High volume, short duration procedures like T&A, PET and MLB in pediatric otolaryngology lend themselves to quality improvement time audits like the one presented in this paper. Modern EMR allows for the tracking of OR timing (T1–T4) for areas that need improvement. Interventions to address these areas can be implemented and an EMR audit can be used to assess their impact. Ideal T1–T4 can then be determined and target utilization and efficiency rates can be calculated and used to determine the distribution of cases that maximize OR efficiency, utilization and quality of care. The authors recommend that individual surgeons or divisions/ departments use the EMR to audit time intervals, gain familiarity with QI processes compare their results to the growing body of literature, and either open or broaden the dialogue between otolaryngologists and those in positions of leadership within perioperative services and anesthesia. Surgical services are vital elements in delivering efficient, high quality care and are positioned most appropriately among those making decisions that directly affect us and our patients. Financial disclosure None.
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