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Vanneman MW, Thuraiappah M, Feinstein I, Fielding-Singh V, Peterson A, Kronenberg S, Angst MS, Aghaeepour N. Variability and relative contribution of surgeon- and anesthesia-specific time components to total procedural time in cardiac surgery. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00676-1. [PMID: 37574007 DOI: 10.1016/j.jtcvs.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 07/20/2023] [Accepted: 08/07/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Decreasing variability in time-intensive tasks during cardiac surgery may reduce total procedural time, lower costs, reduce clinician burnout, and improve patient access. The relative contribution and variability of surgeon control time (SCT) and anesthesia control time (ACT) to total procedural time is unknown. METHODS A total of 669 patients undergoing coronary artery bypass graft (CABG) surgery were enrolled. Using linear regression, we estimated adjusted SCTs and ACTs, controlling for patient and procedural covariates. The primary endpoint compared overall SCTs and ACTs. The secondary endpoint compared the variability in adjusted SCTs and ACTs. Sensitivity analyses quantified the relative importance of the specific surgeon and anesthesiologist in the adjusted linear models. RESULTS The median SCT was 4.1 hours (interquartile range [IQR], 3.4-4.9 hours) compared to a median ACT of 1.0 hours (IQR, 0.8-1.2 hours; P < .001). Using linear regression, the variability in adjusted SCT among surgeons (range, 1.8 hours) was 3.5-fold greater than the variability in adjusted ACT among anesthesiologists (range, 0.5 hour; P < .001). The specific surgeon and anesthesiologist accounted for 50% of the explanatory power of the predictive model (P < .001). CONCLUSIONS SCT variability is significantly greater than ACT variability and is strongly associated with the surgeon performing the procedure. Although these results suggest that SCT variability is an attractive operational target, further studies are needed to determine practitioner specific and modifiable attributes to reduce variability and improve efficiency.
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Affiliation(s)
- Matthew William Vanneman
- Division of Cardiovascular & Thoracic Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, Calif.
| | - Melan Thuraiappah
- Division of Cardiovascular & Thoracic Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Igor Feinstein
- Division of Cardiovascular & Thoracic Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Vikram Fielding-Singh
- Division of Cardiovascular & Thoracic Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Ashley Peterson
- Division of Cardiovascular & Thoracic Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Scott Kronenberg
- Department of Cardiovascular Health Quality, Stanford Healthcare, Stanford, Calif
| | - Martin S Angst
- Division of Cardiovascular & Thoracic Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Nima Aghaeepour
- Division of Cardiovascular & Thoracic Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, Calif; Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, Calif
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Abstract
PURPOSE OF REVIEW Operating rooms are critical financial centers for hospital systems, with surgical care representing about a third of all health care spending. However, not all of the costs are appropriate or necessary, as there are sometimes significant inefficiencies in how operating rooms are utilized. RECENT FINDINGS Recent innovations utilizing patient-centered data, systems principles from manufacturing industries, and enhanced communication processes have made significant improvements in improving operating room efficiency. By focusing on improving communication, standardizing processes, and embracing a learning health system with innovations, significant improvements in operating room efficiency can be seen to improve outcomes and costs for the health system and patient.
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Affiliation(s)
- Daniel J Lee
- Division of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, West Pavilion 3rd Floor, Philadelphia, PA, 19104, USA.
| | - James Ding
- Division of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas J Guzzo
- Division of Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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von Strauss Und Torney M, Aghlmandi S, Zeindler J, Nowakowski D, Nebiker CA, Kettelhack C, Rosenthal R, Droeser RA, Soysal SD, Hoffmann H, Mechera R. High-resolution standardization reduces delay due to workflow disruptions in laparoscopic cholecystectomy. Surg Endosc 2018; 32:4763-4771. [PMID: 29785458 DOI: 10.1007/s00464-018-6224-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 05/09/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Optimal resource utilization in high-cost environments like operating theatres is fundamental in today's cost constrained health care systems. Interruptions of the surgical workflow, i.e. microcomplications (MC), lead to prolonged procedure times and higher costs and can be indicative of surgical mistakes. Reducing MC can improve operating room efficiency and prevent intraoperative complications. We, therefore, aimed to evaluate the impact of a high-resolution standardized laparoscopic cholecystectomy protocol (HRSL) on operative time and intraoperative interruptions in a teaching hospital. METHODS HRSL consisted of a detailed stepwise protocol for the procedure, supported by a teaching video, both to be reviewed as mandatory preparation by each team member before surgery. Audio-video records of laparoscopic cholecystectomies were reviewed regarding type, frequency and duration of MC before and after implementation of HRSL. RESULTS Thirty-nine (20 control and 19 HRSL) audio-video records of laparoscopic cholecystectomies with a total duration of 51.36 h (28.92 pre 22.44 post) were reviewed. The majority of operations (86%) were performed by teams who had completed less than 10 procedures together previously. Communication-related interruptions and instrument changes accounted for the majority of MC. Median frequency and duration of MC were 95 events/h and 15.6 min/h, respectively, of surgery pre-intervention. With HRSL this was reduced to 76 events/h and 10.6 min/h of operating. In multivariable analysis, HRSL was an independent predictor for shorter delay and lower frequency of MC [percentage decrease 27% (95% CI 18-35%), resp. 30% (95% CI 19-40%)]. Procedure-related risk factors for the longer delay due to MC in multivariable analysis were less experience of the surgeon and intraoperative adhesiolysis. CONCLUSIONS HRSL is effective in reducing delays due to MC in a teaching institution with limited team experience. These findings should be tested in larger potentially cluster-randomized controlled trials. The trial has been registered with clinicaltrials.gov: NCT03329859.
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Affiliation(s)
| | - Sohelia Aghlmandi
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jasmin Zeindler
- Department of General and Visceral Surgery, University Hospital Basel, Basel, Switzerland
| | - Debora Nowakowski
- Department of General and Visceral Surgery, University Hospital Basel, Basel, Switzerland
| | - Christian A Nebiker
- Department of General and Visceral Surgery, University Hospital Basel, Basel, Switzerland.,Department of Surgery, Cantonal Hospital of Aarau, Aarau, Switzerland
| | - Christoph Kettelhack
- Department of General and Visceral Surgery, University Hospital Basel, Basel, Switzerland
| | - Rachel Rosenthal
- Department of General and Visceral Surgery, University Hospital Basel, Basel, Switzerland
| | - Raoul A Droeser
- Department of General and Visceral Surgery, University Hospital Basel, Basel, Switzerland
| | - Savas D Soysal
- Department of General and Visceral Surgery, University Hospital Basel, Basel, Switzerland
| | - Henry Hoffmann
- Department of General and Visceral Surgery, University Hospital Basel, Basel, Switzerland
| | - Robert Mechera
- Department of General and Visceral Surgery, University Hospital Basel, Basel, Switzerland
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Fong AJ, Smith M, Langerman A. Efficiency improvement in the operating room. J Surg Res 2016; 204:371-383. [PMID: 27565073 DOI: 10.1016/j.jss.2016.04.054] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 03/15/2016] [Accepted: 04/20/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND In the changing health care environment, health systems, hospitals, and health care providers must focus on improving efficiency to meet an increasing demand for high-quality, low-cost health care. Much has been written about strategies and efforts to improve efficiency in the perioperative periods, yet the time when the patient is in the operating room-the intraoperative period-has received less attention. Yet, this is the period in which surgeons may have the most influence. METHODS Systematically review published efforts to improve intraoperative efficiency; assess the outcomes of these efforts, and propose standardized reporting of future studies. RESULTS A total of 39 studies were identified that met inclusion criteria. These divided naturally into small (single operative team), medium (multi-operative team), and large (institutional) interventions. Most studies used time or money as their metric for efficiency, though others were used as well. CONCLUSIONS There is substantial opportunity to enhance operating room efficiency during the intraoperative period. Surgeons may have a particular role in procedural efficiency, which has been relatively unstudied. Common themes were standardizing tasks, collecting and using actionable data, and maintaining effective team communication.
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Affiliation(s)
- Abigail J Fong
- University of Chicago Operative Performance Research Institute, Chicago, Illinois; Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Meghan Smith
- University of Chicago Operative Performance Research Institute, Chicago, Illinois; Department of Surgery, Section of Otolaryngology-Head and Neck Surgery, University of Chicago, Chicago, Illinois
| | - Alexander Langerman
- University of Chicago Operative Performance Research Institute, Chicago, Illinois; Department of Surgery, Section of Otolaryngology-Head and Neck Surgery, University of Chicago, Chicago, Illinois.
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Wadey VMR, Halpern J, Younger ASE, Dev P, Olshen RA, Walker D. Orthopaedic surgery core curriculum: foot and ankle reconstruction. Foot Ankle Int 2007; 28:831-7. [PMID: 17666177 DOI: 10.3113/fai.2007.0831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to develop a core curriculum for orthopaedic surgery and to conduct a national survey to assess the importance of 281 curriculum items. Attention was focused on 45 items pertaining to the foot and ankle. METHODS A 281-item curriculum was developed. A content review and cross-sectional survey of a random selection of orthopaedic surgeons with primary nonacademic affiliations was completed. Data were analyzed descriptively and quantitatively using histograms, modified Hotelling's T(2)-statistic, and the Benjamini-Hochberg procedure. Our analyses assumed that each respondent answered questions independently of the answers of any other respondent but that the answers to different questions by the same respondent might be dependent. RESULTS Of the 156 orthopaedic surgeons contacted, 131 (86%) participated in this study. Eighty-two percent (37 of 45) of the items were ranked by respondents with an average mean score higher than 3.5/4.0 and 42 higher than 3.0/40, thus suggesting that 93% of the items are important or probably important to know by the end of residency (p <or= 0.07). CONCLUSION This study demonstrated agreement on the importance of 93% of the items that pertain to foot and ankle reconstruction to be included in a core curriculum for orthopaedic surgery. The ability to make diagnoses and to manage common fractures, soft-tissue conditions, and arthritic conditions of the foot and ankle are very important for residents to know upon graduation from their residency programs. The exceptions to these are the ability to perform primary and revision arthroplasty of the ankle.
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Affiliation(s)
- Veronica M R Wadey
- Department of Surgery, The Faculty of Medicine, University of Toronto, Ontario, Canada.
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