1
|
Routman JS, Tran BK, Vining BR, Salei A, Gunn AJ, Raja J, Huang J. Non-operating room anesthesia workflow (NORA) implementation to improve start times in interventional radiology. Curr Probl Diagn Radiol 2024; 53:477-480. [PMID: 38553349 DOI: 10.1067/j.cpradiol.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 03/07/2024] [Indexed: 06/17/2024]
Abstract
BACKGROUND Non-OR Anesthesia (NORA) is rapidly becoming standard in many high-volume institutions and efficiency in these spaces has yet to be optimized. On-time first start percentage has been suggested to correlate with more efficient flow, and this correlation is established within the surgical space. PURPOSE To investigate the effects of timetable targets on first case on-time first start percentage within a NORA setting. MATERIALS AND METHODS A retrospective study of anesthesia-supported first start cases from October 2022 to April 2023 was performed to analyze the effect of timetable targets on on-time first-case starts for planned cases. Statistical analysis was calculated using Student's t-tests with statistical significance defined as p < 0.05. Additionally, analysis of variance was used to compare three or more groups, and Tukey Kramer was used to evaluate groups pairwise. RESULTS One hundred twenty-four first start cases were included in the evaluation. After intervention with timetable targets, average patient arrival to the room time improved from 7:49 AM to 7:40 AM (p < 0.05) and procedure start time improved from 8:31 AM to 8:20 AM (p < 0.01). The percentage of procedure start times occurring prior to the goal time increased from 35 % to 58 % after the implementation (p < 0.05). With exception of Tuesdays (Anesthesia Late Start Day), on-time starts improved from 17 % to 48 % (p < 0.01) and sustained this improvement throughout the post-implementation period. CONCLUSION Implementation of novel timetable targets yielded statistically significant improvement in first case start times. This improvement in efficiency and throughput results in increased room utilization, improved case throughput, and decreased block overrun times, all of which contribute toward increased revenues, decreased costs, and thus improved return on investment.
Collapse
Affiliation(s)
- Justin S Routman
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Benjamin K Tran
- University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, United States.
| | - Brooke R Vining
- Associate Vice President Perioperative Services, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Aliaksei Salei
- Department of Interventional Radiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Andrew J Gunn
- Department of Interventional Radiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Junaid Raja
- Department of Interventional Radiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Junjian Huang
- Department of Interventional Radiology, University of Alabama at Birmingham, Birmingham, AL, United States
| |
Collapse
|
2
|
Abouleish AE, Whitten CW, Hudson ME. Measuring and Comparing Clinical Productivity of Individual Anesthesiologists. Anesthesiology 2023; 139:684-696. [PMID: 37815474 DOI: 10.1097/aln.0000000000004722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
Measuring and comparing clinical productivity of individual anesthesiologists is confounded by anesthesiologist-independent factors, including facility-specific factors (case duration, anesthetizing site utilization, type of surgical procedure, and non-operating room locations), staffing ratio, number of calls, and percentage of clinical time providing anesthesia. Further, because anesthesia care is billed with different units than relative value units, comparing work with other types of clinical care is difficult. Finally, anesthesia staffing needs are not based on productivity measurements but primarily the number and hours of operation of anesthetizing sites. The intent of this review is to help anesthesiologists, anesthesiology leaders, and facility leaders understand the limitations of anesthesia unit productivity as a comparative metric of work, how this metric often devalues actual work, and the impact of organizational differences, staffing models and coverage requirements, and effectiveness of surgical case load management on both individual and group productivity.
Collapse
Affiliation(s)
- Amr E Abouleish
- Professor and Vice Chair, Faculty Development, Department of Anesthesiology, The University of Texas Medical Branch, Galveston, Texas
| | - Charles W Whitten
- Professor and Chair, Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Dallas, Texas
| | - Mark E Hudson
- Professor and Executive Vice Chair, Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
3
|
Schroeck H, Whitty MA, Martinez-Camblor P, Voicu S, Burian BK, Taenzer AH. Anaesthesia clinicians' perception of safety, workload, anxiety, and stress in a remote hybrid suite compared with the operating room. Br J Anaesth 2023; 131:598-606. [PMID: 37202262 DOI: 10.1016/j.bja.2023.04.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/06/2023] [Accepted: 04/15/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND Anaesthesia care outside of the standard operating room (OR) can be challenging. This prospective matched case-pair study describes the difference in anaesthesia clinicians' perception of safety, workload, anxiety, and stress in two settings by comparing similar neurosurgical procedures performed in either the OR or a remote hybrid room with intraoperative MRI (MRI-OR). METHODS A visual numeric scale for safety perception and validated instruments for workload, anxiety, and stress were administered to enrolled anaesthesia clinicians after induction of anaesthesia and at the end of eligible cases. The difference in outcomes reported by the same clinician for unique pairs of similar operations performed in both settings (OR vs MRI-OR) was compared using the Student t-test with the general bootstrap algorithm to address the presence of clusters. RESULTS Over 15 months, 37 clinicians provided data for 53 case pairs. Working in the remote MRI-OR vs OR was associated with lower perceived safety (7.3 [2.0] vs 8.8 [0.9]; P<0.001), higher scores in the workload subdomains effort and frustration (41.6 [24.1] vs 31.3 [21.6]; P=0.006 and 32.4 [22.9] vs 20.7 [17.2]; P=0.002, respectively), and higher anxiety (33.6 [10.1] vs 28.4 [9.2]; P=0.003) at the end of the case. Stress was rated higher in the MRI-OR after induction of anaesthesia (26.5 [15.5] vs 20.9 [13.4]; P=0.006). Effect sizes (Cohen's D) were moderate to good. CONCLUSIONS Anaesthesia clinicians reported lower perceived safety and higher workload, anxiety, and stress in a remote MRI-OR compared with a standard OR. Improving non-standard work settings should benefit clinician well-being and patient safety. CLINICAL TRIAL REGISTRATION .
Collapse
Affiliation(s)
- Hedwig Schroeck
- Geisel School of Medicine at Dartmouth College, Hanover, NH, USA; Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.
| | | | - Pablo Martinez-Camblor
- Geisel School of Medicine at Dartmouth College, Hanover, NH, USA; Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Stefana Voicu
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Barbara K Burian
- Human Systems Integration Division, NASA Ames Research Center, Mountain View, CA, USA
| | - Andreas H Taenzer
- Geisel School of Medicine at Dartmouth College, Hanover, NH, USA; Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| |
Collapse
|
4
|
Dexter F, Epstein RH, Fahy BG. Association of surgeons' gender with elective surgical lists in the State of Florida is explained by differences in mean operative caseloads. PLoS One 2023; 18:e0283033. [PMID: 36920948 PMCID: PMC10016664 DOI: 10.1371/journal.pone.0283033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 03/01/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND A recent publication reported that at three hospitals within one academic health system, female surgeons received less surgical block time than male surgeons, suggesting potential gender-based bias in operating room scheduling. We examined this observation's generalizability. METHODS Our cross-sectional retrospective cohort study of State of Florida administrative data included all 4,176,551 ambulatory procedural encounters and inpatient elective surgical cases performed January 2017 through December 2019 by 8875 surgeons (1830 female) at all 609 non-federal hospitals and ambulatory surgery centers. There were 1,509,190 lists of cases (i.e., combinations of the same surgeon, facility, and date). Logistic regression adjusted for covariables of decile of surgeon's quarterly cases, surgeon's specialty, quarter, and facility. RESULTS Selecting randomly a male and a female surgeons' quarter, for 66% of selections, the male surgeon performed more cases (P < .0001). Without adjustment for quarterly caseloads, lists comprised one case for 44.2% of male and 54.6% of female surgeons (difference 10.4%, P < .0001). A similar result held for lists with one or two cases (difference 9.1%, P < .0001). However, incorporating quarterly operative caseloads, the direction of the observed difference between male and female surgeons was reversed both for case lists with one (-2.1%, P = .03) or one or two cases (-1.8%, P = .05). CONCLUSIONS Our results confirm the aforementioned single university health system results but show that the differences between male and female surgeons in their lists were not due to systematic bias in operating room scheduling (e.g., completing three brief elective cases in a week on three different workdays) but in their total case numbers. The finding that surgeons performing lists comprising a single case were more often female than male provides a previously unrecognized reason why operating room managers should help facilitate the workload of surgeons performing only one case on operative (anesthesia) workdays.
Collapse
Affiliation(s)
- Franklin Dexter
- Division of Management Consulting, Department of Anesthesia, University of Iowa, Iowa City, Iowa, United States of America
| | - Richard H. Epstein
- Department of Anesthesiology, Perioperative Medicine & Pain Management, Miller School of Medicine, University of Miami, Miami, Florida
- * E-mail:
| | - Brenda G. Fahy
- Department of Anesthesiology, University of Florida, Gainesville, Florida
| |
Collapse
|
5
|
Dexter F, Epstein RH, Ledolter J, Pearson AC, Maga J, Fahy BG. Benchmarking Surgeons’ Gender and Year of Medical School Graduation Associated With Monthly Operative Workdays for Multispecialty Groups. Cureus 2022; 14:e25054. [PMID: 35719789 PMCID: PMC9200471 DOI: 10.7759/cureus.25054] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2022] [Indexed: 11/09/2022] Open
Abstract
Background Female surgeons reportedly receive less surgical block time and fewer procedural referrals than male surgeons. In this study, we compared operative days between female and male surgeons throughout Florida. Our objective was to facilitate benchmarking by multispecialty groups, both the endpoint to use for statistically reliable results and expected differences. Methodology The historical cohort study included all 4,060,070 ambulatory procedural encounters and inpatient elective surgical states performed between January 2017 and December 2019 by 8,472 surgeons at 609 facilities. Surgeons’ gender, year of medical school graduation, and surgical specialty were obtained from their National Provider Identifiers. Results Female surgeons operated an average of 1.0 fewer days per month than matched male surgeons (99% confidence interval 0.8 to 1.2 fewer days, P < 0.0001). The mean differences were 0.8 to 1.4 fewer days per month among each of the five quintiles of years of graduation from medical school (all P ≤ 0.0050). Results were comparable when repeated using the number of monthly cases the surgeons performed. Conclusions An average difference of ≤1.4 days per month is a conservative estimate for the current status quo of the workload difference in Florida. Suppose that a group’s female surgeons average more than two fewer operative days per month than the group’s male surgeons of the same specialty. Such a large average difference would call for investigation of what might reflect systematic bias. While such a difference may reflect good flexibility of the organization, it may show a lack of responsiveness (e.g., fewer referrals of procedural patients to female surgeons or bias when apportioning allocated operating room time).
Collapse
|
6
|
Dexter F, Epstein RH, Diez C, Fahy BG. More surgery in December among US patients with commercial insurance is offset by unrelated but lesser surgery among patients with Medicare insurance. Int J Health Plann Manage 2022; 37:2445-2460. [PMID: 35484705 PMCID: PMC9540063 DOI: 10.1002/hpm.3482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 01/11/2022] [Accepted: 03/30/2022] [Indexed: 11/16/2022] Open
Abstract
Study Objective Evaluate whether there is more surgery (in the US State of Florida) at the end of the year, specifically among patients with commercial insurance. Design Observational cohort study. Setting The 712 facilities in Florida that performed inpatient or outpatient elective surgery from January 2010 through December 2019. Results Among patients with commercial insurance, December had more cases than November (1.108 [1.092–1.125]) or January (1.257 [1.229–1.286]). In contrast, among patients with Medicare insurance (traditional or managed care), December had fewer cases than November (ratio 0.917 [99% confidence interval 0.904–0.930]) or January (0.823 [0.807–0.839]) of the same year. Summing among all cases, December did not have more cases than November (ratio 1.003 [0.992–1.014]) or January (0.998 [0.984–1.013]). Comparing December versus November (January) ratios for cases among patients with commercial insurance to the corresponding ratios for cases among patients with Medicare, years with more commercial insurance cases had more Medicare cases (Spearman rank correlation +0.36 [+0.25], both p < 0.0001). Conclusions In the US State of Florida, although some surgeons' procedural workloads may have seasonal variation if they care mostly for patients with one category of insurance, surgical facilities with patients undergoing many procedures will have less variability. Importantly, more commercial insurance cases were not causing Medicare cases to be postponed or vice‐versa, providing mechanistic explanation for why forecasts of surgical demand can reasonably be treated as the sum of the independent workloads among many surgeons. In US State of Florida, patients with commercial insurance had more surgery in December Patients with US Medicare insurance had less surgery in December than other months Years with more commercial insurance cases in December had more US Medicare cases too Implication for surgical suites: busier months for some patient groups balanced by less busy for others
Collapse
Affiliation(s)
- Franklin Dexter
- Department of Anesthesia, University of Iowa, Iowa City, Iowa, USA
| | - Richard H Epstein
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Christian Diez
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Brenda G Fahy
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| |
Collapse
|
7
|
Nonoperating room anesthesia: strategies to improve performance. Int Anesthesiol Clin 2021; 59:27-36. [PMID: 34456276 DOI: 10.1097/aia.0000000000000339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
8
|
Lu SY, Dalia AA, Lang M, Fitzsimons MG. Perioperative Outcomes of Thrombectomy Patients Using Venovenous Bypass and Suction Filtration With General Anesthesia. J Cardiothorac Vasc Anesth 2020; 35:1040-1045. [PMID: 33051147 DOI: 10.1053/j.jvca.2020.09.104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 08/23/2020] [Accepted: 09/09/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE AngioVac (Angiodynamics, Latham, NY) is a novel drainage system that offers a less-invasive approach compared with open surgical thromboembolectomy to remove intracardiac and intravascular thrombotic and embolic material. For this study, the authors' single-center experience with patients undergoing thromboembolectomy using the AngioVac system was reviewed retrospectively to evaluate anesthetic management and postoperative complications. DESIGN Retrospective, observational study. SETTING Single institution, quaternary care hospital. PARTICIPANTS The study comprised 20 consecutive patients whose treatment included the AngioVac between January 2016 and November 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Twenty patients underwent AngioVac suction filtration. The mean age was 56 years, and women comprised 35% of the patient cohort. Indications for AngioVac suction filtration included deep venous thrombosis involving the inferior vena cava (n = 12 [60%]), right atrial mass/thrombus (n = 11 [55%]), right ventricular mass/thrombus (n = 3 [15%]), and pulmonary embolism(n = 2 [10%]). All patients required vasopressor support, and nine patients (45%) required blood transfusion during the procedure. There was no intraoperative death or cardiac arrest associated with the procedure. The 30-day mortality was zero, and in-hospital mortality was 5% (1/20). Significant postoperative complications occurred in 11/20 patients (55%). Postoperative left ventricular dysfunction (36% v 0%; p < 0.05), preoperative shock requiring vasopressors (36% v 0%; p < 0.05), postoperative blood transfusion (100% v 56%; p < 0.05), and having undergone recent surgery (64% v 11%; p < 0.05) were associated with increased odds of experiencing postoperative complications. CONCLUSIONS The rate of intraoperative complication during AngioVac suction filtration is low, but vasopressors and blood transfusions often are required. Patients at increased risk of developing postoperative complications potentially can be identified as having undergone recent surgery, experiencing preoperative shock requiring vasopressors or postoperative left ventricular dysfunction, and requiring postoperative blood transfusion.
Collapse
Affiliation(s)
- Shu Y Lu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Adam A Dalia
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA.
| | - Maximilian Lang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Michael G Fitzsimons
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
9
|
Wong T, King BS, Boggs SD, Urman RD, Tsai MH. Utilizing the procedural times glossary as a roadmap to improve efficiency tracking in non-operating room environments. J Clin Anesth 2020; 59:72-73. [DOI: 10.1016/j.jclinane.2019.06.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 05/22/2019] [Accepted: 06/24/2019] [Indexed: 11/25/2022]
|
10
|
Tsai MH, Hall MA, Cardinal MS, Breidenstein MW, Abajian MJ, Zubarik RS. Changing Anesthesia Block Allocations Improves Endoscopy Suite Efficiency. J Med Syst 2019; 44:1. [DOI: 10.1007/s10916-019-1451-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 09/03/2019] [Indexed: 01/23/2023]
|
11
|
Sarraf E, Breidenstein MW, Carslon RE, O’Donnell SE, Tsai MH. Nonoperating Room Anesthesia Tardiness. A A Pract 2018; 11:285-287. [DOI: 10.1213/xaa.0000000000000814] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
12
|
Boggs SD, Tsai MH, Urman RD. The Association of Anesthesia Clinical Directors (AACD) Glossary of Times Used for Scheduling and Monitoring of Diagnostic and Therapeutic Procedures. J Med Syst 2018; 42:171. [PMID: 30097795 DOI: 10.1007/s10916-018-1022-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 07/25/2018] [Indexed: 11/29/2022]
Abstract
The Glossary of Times Used for Scheduling and Monitoring of Diagnostic and Therapeutic Procedures also known as the Procedural Times Glossary (PTG) was originally developed with the support of the Association of Anesthesia Clinical Directors (AACD). The goal was to establish standardized terms to measure and assess the performance of operating room and procedural areas. By incorporating standardized concepts of efficiency and utilization, the PTG codified operating room metrics and facilitated benchmarking and quality improvement initiatives. In the last three decades, these concepts have also served as the basis for research in operating room management, including incorporating frameworks from diverse fields. The metrics in the PTG are divided into four categories: (1) Procedural Times; (2) Procedural and Scheduling Definitions and Time Periods; (3) Utilization and Efficiency Indices; and (4) Patient Categories. We describe each of the categories and corresponding metrics. The PTG provides the fundamental building blocks for managing operating and non-operating room suites. We hope that reintroducing these important time markers will help facilitate the reporting of standardized metrics.
Collapse
Affiliation(s)
- Steven D Boggs
- Department of Anesthesiology, University of Tennessee Medical Center, Memphis, TN, USA
| | - Mitchell H Tsai
- Department of Anesthesiology, University of Vermont Larner College of Medicine, Burlington, VT, USA
- Department of Orthopedics and Rehabilitation (by courtesy), University of Vermont Larner College of Medicine, Burlington, VT, USA
- Department of Surgery (by courtesy), University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, 02115, USA.
- Center for Perioperative Research, Brigham and Women's Hospital, Boston, MA, USA.
| |
Collapse
|