A Psychological Basis for Anesthesiologists’ Operating Room Managerial Decision-Making on the Day of Surgery

Larger anesthesia practitioner per operating room ratios are needed to prevent unnecessary non-operative time than to mitigate patient risk: A narrative review

When choosing the anesthesia practitioner to operating room (OR) ratio for a hospital, objectives are applied to mitigate patient risk: 1) ensuring sufficient anesthesiologists to meet requirements for presence during critical intraoperative events (e.g., anesthesia induction) and 2) ensuring sufficient numbers to cover emergencies outside the ORs (e.g., emergent reintubation in the post-anesthesia care unit). At a 24-OR suite with each anesthesiologist supervising residents in 2 ORs, because critical events overlapped among ORs, ≥14 anesthesiologists were needed to be present for all critical events on >90% of days. The suitable anesthesia practitioner to OR ratio would be 1.58, where 1.58 = (24 + 14)/24. Our narrative review of 22 studies from 17 distinct hospitals shows that the practitioner to OR ratio needed to reduce non-operative time is reliably even larger. Activities to reduce non-operative times include performing preoperative evaluations, making prompt evidence-based decisions at the OR control desk, giving breaks during cases (e.g., lunch or lactation sessions), and using induction and block rooms in parallel to OR cases. The reviewed articles counted the frequency of these activities, finding them much more common than urgent patient-care events. Our review shows, also, that 1 anesthesiologist per OR, working without assistants, is often more expensive, from a societal perspective, than having a few more anesthesia practitioners (i.e., ratio > 1.00). These results are generalizable among hundreds of hospitals, based on managerial epidemiology studies. The implication of our narrative review is that existing studies have already shown, functionally, that artificial intelligence and monitoring technologies based on increasing the safety of intraoperative care have little to no potential to influence anesthesia or OR productivity. There are, in contrast, opportunities to use sensor data and decision-support to facilitate communication among anesthesiologists outside of ORs to choose optimal task sequences that reduce non-operative times, thereby increasing production and OR efficiency.

Contribution of Coordination Theories to the Determination of Human Factors Associated With Operating Room Perceived Performance

BACKGROUND

The efficient and fluid organization of surgical interventions in an operating room (OR) and operating suite (OS) is important as these are among the most expensive units to run in medical-surgical facilities. The complexity of OS organization requires careful coordination, defined here as the directing of individuals' efforts toward achieving common and explicitly recognized goals. There is currently sparse literature on OS coordination, especially in the French context. This study aimed to respond to this gap by reporting on the coordination mechanisms associated with the perceived performance of OS across 4 facilities in an urban setting in France.

METHODS

We used a qualitative comparative case study based on ethnographic methodology to explore 4 facilities (2 teaching, 1 general, and 1 private). Several investigation techniques were used for data collection (semistructured interviews, participant and nonparticipant observations, and informal interviews) in the OR, the OS, the regulation council (dedicated to adapting the necessary resources to specific procedures and patients' health status), and the OS council (dedicated to strategic and operational OS transformations and adaptations, and responsible for finding solutions to organizational problems). Analysis was guided by Okhuysen and Bachky's theoretical framework on coordination and multi-team systems theory. Data were compared across the 4 facilities and triangulated using the different techniques to ensure coherence and accuracy.

RESULTS

Overall, 48 interviews with health care providers and hospital managers and 200 hours of direct observations were performed. The OR exhibited a high degree of coordination, whereas improved perception of performance in the OS depended on managerial competency, trust, and authority. Perceived performance in the regulation council and OS council, on the other hand, depended on the identification of formal objectives by all stakeholders and the development of common understanding (developing agreement, direct information sharing, creating common perspective, substitution, bringing groups together, and storing of knowledge).

CONCLUSIONS

Based on existing literature on multi-team systems (as represented in the OS organization), this study identifies success factors influencing OS coordination. These include the OS manager's leadership skills; the identification of formal system objectives; and professional differentiation between stakeholders (absence/decrease of a sense of belonging to a multi-team system). This differentiation was related to the high degree of specialization within OS teams, each bringing different norms, cultures, and contingencies that induce dissonance in organization and task performance. Interventions targeting these success factors might improve coordination, and thus performance, in the OS.

Bibliometric Analysis of Contributions of Anesthesiology Journals and Anesthesiologists to Operating Room Management Science

BACKGROUND

Anesthesiology journals appear to have been progressively publishing a smaller percentage of operating room (OR) management studies. Similarly, non-anesthesiologists have increasingly been authors of these publications. Five hypotheses were formulated to evaluate these impressions based on 2 of the authors' curation of an online, comprehensive bibliography of OR management articles and corresponding referenced course materials.

METHODS

We studied all 2938 publications having Scopus' SciVal topic T.6319 (OR management) more than 28 years from 1996 through May 2023, including 8608 distinct authors.

RESULTS

Half (50%) of the publications were absent from PubMed, and the percentage absent has been increasing progressively (Kendall's τ = 0.71; P < .0001). Fewer than half were published in journals including anesthesiology as the sole classification (20%) or as one of the classifications (27%). The anesthesiology journals have been publishing a progressively decreasing fraction (τ = -0.61; P < .0001). Among the 11 authors each contributing at least 1% of the OR management science publications, 9 were anesthesiologists and the other 2 had anesthesiologists as coauthors on all these publications. Only 3% of authors had at least 10 OR management publications from earlier years. There were 75% of authors with no such earlier publications and 85% with 0 or 1. There was a progressive increase in the number of authors publishing OR management annually and with at most 1 such earlier publication (τ = 0.90; P < .0001). Only 20% of publications had any author with at least 10 earlier OR management publications, 48% had every author with no such earlier publications, and 60% had all authors with 0 or 1.

CONCLUSIONS

Although most of the authors with the greatest production of OR management science were anesthesiologists, the percentage of publications in anesthesiology journals has been decreasing progressively. Anesthesiologists cannot rely solely on anesthesiology journals to keep up with the field. For most publications, every author had few or no earlier publications on the topic. Clinicians and managers relying on OR management science will continue to need to apply more information when judging whether published results can reliably be applied to their facilities.

Managing capacity for urgent surgery: staffing, staff scheduling in-house or on-call from home, and work assignments

Parmar and colleagues developed and validated a graphical method for choosing the number of operating theatres to set aside for urgent surgical cases. We address appropriate usage of their new method for calculating anaesthesia staffing, including comparison with previously published techniques. Parmar and colleagues' method is based on all staff scheduled in-house, rather than some on-call from home. We review that this is not nearly as large a limitation as it may seem because of behavioural factors of staff assignment.

Briefest Time to Perform a Series of Preoperative Nerve Blocks in Multiple Patients: A Simulation Study

Introduction

To mitigate first-case delays in operating rooms, sufficient additional time must be allotted when anesthesiologists perform preoperative nerve blocks in multiple patients who are scheduled as the initial cases of the day. We used spinal anesthetics performed in dedicated block rooms located just outside the operating room suite to estimate the briefest times needed to complete a series of spinal, epidural, peripheral, or other regional nerve blocks. We followed this approach because even though the studied hospital had a busy regional anesthesia service, sample sizes were insufficient and electronic data were not available to directly study the time to perform the many other nerve blocks they perform.

Methods

We studied a historical cohort of 8,462 adult patients undergoing spinal anesthesia between 2005 and 2017. Preoperative evaluation, consent, and holding area tasks were completed before entering the block room; the times to complete these tasks were not available for study. Upon block room entry, the electronic anesthetic record was started, a timeout conducted with patient participation, vital signs taken, and the spinal performed. The interval from entry until intrathecal injection was the spinal block time. Because fits of these times to probability distributions previously used for anesthesia times were poor (p < 0.001), percentiles of times to perform one or more spinal anesthetics were calculated using Monte-Carlo simulation (100,000 samples with replacement) from the empirical distributions.

Results

The mean spinal block time was 8.8 minutes. The 90% upper prediction limit for one block was 14 minutes, with progressively decreasing times for each subsequent block for a 90% chance of finishing on time. For example, for three first-case regional or neuraxial blocks performed outside the operating room by one anesthesiologist, the first patient needs to arrive at least 38 minutes earlier than non-block patients to mitigate operating room start delays.

Conclusions

These minimum time estimates can help nursing leadership ensure that sufficient time will be available after patients are ready for anesthesia to avoid first-case delays when preoperative regional anesthesia is performed outside the operating room. Given that inadequate sample size and documentation issues likely exist universally for the various non-neuraxial preoperative nerve blocks, we recommend that hospitals use our estimates as a minimum starting point rather than try to calculate times using their own data. Then, as a systems-based metric to assess all steps in the process, track the percentages of days for which all blocks were completed in sufficient time to avoid a first-case delay for those patients. Adjustments to the arrival times would then be implemented, if needed, to meet hospital objectives for on-time starts.

The anesthetizing sites supervised to anesthesiologist ratio is an invalid surrogate for group productivity in academic anesthesia departments when used without consideration of the corresponding managerial decisions

When the anesthesiologist does not individually perform the anesthesia care, then to make valid comparisons among US anesthesia departments, one must consider the staffing ratio (i.e., how many cases each anesthesiologist supervises when working with Certified Registered Nurse Anesthetists [CRNAs] or Certified Anesthesiologist Assistants [CAA]). The staffing ratio also must be considered when accurately measuring group productivity. In this narrative review, we consider anesthesia departments with non-physician anesthesia providers and anesthesiology residents. We investigate the validity of such departments assessing the overall ratio of anesthetizing sites supervised per anesthesiologist as a surrogate for group clinical productivity. The sites/anesthesiologist ratio can be estimated accurately using the arithmetic mean calculated by anesthesiologist, the harmonic mean calculated by case, or the harmonic mean calculated by CRNA or CAA, but not by the arithmetic mean ratio by case. However, there is lack of validity to benchmarking the percentage time that anesthesiologists are supervising the maximum possible number of CRNAs or CAAs when some of the anesthesiologists also are supervising resident physicians. Assignments can differ in the total number anesthesiologists needed while every anesthesiologist is supervising as many sites as possible. Similarly, there is lack of validity to limiting assessment to the anesthesiologists supervising only CRNAs or CAAs. There also is lack of validity to limiting assessment only to cases performed by supervised CRNAs or CAAs. When cases can be assigned to anesthesiology residents or CRNAs or CAAs, increasing sites/anesthesiologist while limiting consideration to the CRNAs or CAAs creates incentive for the CRNAs or CAAs to be assigned cases, even when lesser productivity is the outcome. Decisions also can increase sites/anesthesiologist without increasing productivity (e.g., when one anesthesiologist relieves another before the end of the regular workday). A suitable alternative approach to fallaciously treating the sites/anesthesiologist ratio as a surrogate for productivity is that, when a teaching hospital supplies financial support, a responsibility of the anesthesia department is to explain annually the principal factors affecting productivity at each facility it manages and to show annually that decisions were made that maximized productivity, subject to the facilities' constraints.

Strategies for daily operating room management of ambulatory surgery centers following resolution of the acute phase of the COVID-19 pandemic

We performed a narrative review to explore the economics of daily operating room management decisions for ambulatory surgery centers following resolution of the acute phase of the Coronavirus Disease 2019 (COVID-19) pandemic. It is anticipated that there will be a substantive fraction of patients who will be contagious, but asymptomatic at the time of surgery. Use multimodal perioperative infection control practices (e.g., including patient decontamination) and monitor performance (e.g., S. aureus transmission from patient to the environment). The consequence of COVID-19 is that such processes are more important than ever to follow because infection affects not only patients but the surgery center staff and surgeons. Dedicate most operating rooms to procedures that are not airway aerosol producing and can be performed without general anesthesia. Increase throughput by performing nerve blocks before patients enter the operating rooms. Bypass the phase I post-anesthesia care unit whenever possible by appropriate choices of anesthetic approach and drugs. Plan long-duration workdays (e.g., 12-h). For cases where the surgical procedure does not cause aerosol production, but general anesthesia will be used, have initial (phase I) post-anesthesia recovery in the operating room where the surgery was done. Use anesthetic practices that achieve fast initial recovery of the brief ambulatory cases. When the surgical procedure causes aerosol production (e.g., bronchoscopy), conduct phase I recovery in the operating room and use multimodal environmental decontamination after each case. Use statistical methods to plan for the resulting long turnover times. Whenever possible, have the anesthesia and nursing teams stagger cases in more than one room so that they are doing one surgical case while the other room is being cleaned. In conclusion, this review shows that while COVID-19 is prevalent, it will markedly affect daily ambulatory workflow for patients undergoing general anesthesia, with potentially substantial economic impact for some surgical specialties.

Patient and personnel factors affect operating room start times

BACKGROUND

Perioperative efficiency has been studied, although little is known about patient and personnel factors associated with a timely operating room start. We hypothesize that patient, personnel factors, and induction-order decisions are associated with anesthesia induction time.

METHODS

An institutional database was used to identify the anesthesia induction time of adults undergoing first-start, elective operations from January 2014 to May 2017 at an academic quaternary care center. Data included patient demographics; surgeon and anesthesiologist, as well as their seniority (years since initial board certification); certified registered nurse anesthetist versus anesthesia resident staffing; and use of neuraxial anesthesia. Times were measured as minutes from scheduled start to induction. Univariate and multivariate analyses were performed to identify factors associated with induction time.

RESULTS

We identified 15,823 cases. Predictors of later induction included add-on cases (1,224 cases were add-ons, 7.73%), American Society of Anesthesiologists classification ≥ 3, neuraxial anesthesia, and certified registered nurse anesthetist staffing. Surgeon seniority-but not gender-affected induction time. In 11,093 cases (70.1%), the anesthesiologist was scheduled for multiple first starts with a choice of which patient to induce first. Surgeon gender was predictive of induction order, with cases of male surgeons induced first more frequently than female surgeons' (47.0% vs 44.1%, P = .02). Cases staffed by anesthesiology residents were more likely to be induced first compared with those staffed by certified registered nurse anesthetists (52.1% vs 41.5%, P < .01).

CONCLUSION

Patient and personnel factors affect the order of case induction, but induction time is most dependent on patient factors. Hospitals should focus on improving preparedness and limiting bias to create a more equitable and efficient perioperative process.

US National Anesthesia Workload on Saturday and Sunday Mornings

BACKGROUND

In order to provide guidance to organizations considering elective weekend surgical case scheduling, we analyzed data from the American Society of Anesthesiologist's Anesthesia Quality Institute. We determined the US anesthesia workload on Saturdays and Sundays.

METHODS

The American Society of Anesthesiologist's Anesthesia Quality Institute data were from all US anesthesia groups that submitted cases to the National Anesthesia Clinical Outcomes Registry for 2013. For each of the N = 2,075,188 cases, we identified the local date and time of the start of anesthesia care and the duration of anesthesia care. Anesthesia workload was measured as the time from the start to the end of continuous anesthesia care. Because elective cases are rarely scheduled on Sundays, we considered the difference in workload between Saturday and Sunday to estimate elective case scheduling. This difference would be an overestimate if some patients' scheduled cases were postponed from Friday to Saturday. Data are reported as mean ± standard error; N = 13 four-week periods.

RESULTS

The difference in the anesthesia minutes between Saturdays versus Sundays 7:00 AM to 2:59 PM (ie, elective caseload) represented just 0.38% ± 0.02% of the total minutes nationwide; Saturday 1.57% ± 0.03% versus Sunday 1.19% ± 0.02%. The P < .00001 comparing the 0.38% with 1.0% and, also, with 0.5% (upper 99% confidence interval = 0.42%).

CONCLUSIONS

The imputed Saturday elective schedule represents a tiny percentage of overall anesthetic workload nationwide. Saturday elective surgery is currently an uncommon practice in the United States. Based on this prior knowledge, organizations considering changes to their current scheduling strategies should perform a thorough statistical analysis of their local workload prior to implementation and apply evidence-based criteria to guide their decision-making process.

"What Have We Done for Us Lately?"--Defining Performance and Value at the Individual Clinician Level

Consolidation in anesthesiology practice and the rest of health care creates pressure to improve the product offered by anesthesia professionals. Anesthesia professionals must offer more than a reliable stream of anesthetized, operated, and recovered patients to remain competitive. By pooling resources and application of leadership effort, large departments and group practices can conduct individual-level value assessments of clinicians. Individual clinicians can be incentivized to improve their personal value proposition. By creating an interlocking program of ongoing assessment, career development coaching and opportunities, as well as compensation, departments and group practices can return value to individual clinicians by curating and accelerating their career and capability development.

Success of commonly used operating room management tools in reducing tardiness of first case of the day starts: evidence from German hospitals

BACKGROUND

One of the declared objectives of surgical suite management in Germany is to increase operating room (OR) efficiency by reducing tardiness of first case of the day starts. We analyzed whether the introduction of OR management tools by German hospitals in response to increasing economic pressure was successful in achieving this objective. The OR management tools we considered were the appointment of an OR manager and the development and adoption of a surgical suite governance document (OR charter). We hypothesized that tardiness of first case starts was less in ORs that have adopted one or both of these tools.

METHODS

Using representative 2005 survey data from 107 German anesthesiology departments, we used a Tobit model to estimate the effect of the introduction of an OR manager or OR charter on tardiness of first case starts, while controlling for hospital size and surgical suite complexity.

RESULTS

Adoption reduced tardiness of first case starts by at least 7 minutes (mean reduction 15 minutes, 95% confidence interval (CI): 7-22 minutes, P < 0.001).

CONCLUSION

Reductions in tardiness of first case starts figure prominently the objectives of surgical suite management in Germany. Our results suggest that the appointment of an OR manager or the adoption of an OR charter support this objective. For short-term decision making on the day of surgery, this reduction in tardiness may have economic implications, because it reduced overutilized OR time.

Decision support system for the operating room rescheduling problem

Due to surgery duration variability and arrivals of emergency surgeries, the planned Operating Room (OR) schedule is disrupted throughout the day which may lead to a change in the start time of the elective surgeries. These changes may result in undesirable situations for patients, wards or other involved departments, and therefore, the OR schedule has to be adjusted. In this paper, we develop a decision support system (DSS) which assists the OR manager in this decision by providing the three best adjusted OR schedules. The system considers the preferences of all involved stakeholders and only evaluates the OR schedules that satisfy the imposed resource constraints. The decision rules used for this system are based on a thorough analysis of the OR rescheduling problem. We model this problem as an Integer Linear Program (ILP) which objective is to minimize the deviation from the preferences of the considered stakeholders. By applying this ILP to instances from practice, we determined that the given preferences mainly lead to (i) shifting a surgery and (ii) scheduling a break between two surgeries. By using these changes in the DSS, the performed simulation study shows that less surgeries are canceled and patients and wards are more satisfied, but also that the perceived workload of several departments increases to compensate this. The system can also be used to judge the acceptability of a proposed initial OR schedule.

Using information technology to improve quality in the OR

This article summarizes the current state of technology as it pertains to quality in the operating room, ties the current state back to its evolutionary pathway to understand how the current capabilities and their limitations came to pass, and elucidates how the overlay of information technology (IT) as a wrapper around current monitoring and device technology provides a significant advance in the ability of anesthesiologists to use technology to improve quality along many axes. The authors posit that IT will enable all the information about patients, perioperative systems, system capacity, and readiness to follow a development trajectory of increasing usefulness.

Event-based knowledge elicitation of operating room management decision-making using scenarios adapted from information systems data

Background

No systematic process has previously been described for a needs assessment that identifies the operating room (OR) management decisions made by the anesthesiologists and nurse managers at a facility that do not maximize the efficiency of use of OR time. We evaluated whether event-based knowledge elicitation can be used practically for rapid assessment of OR management decision-making at facilities, whether scenarios can be adapted automatically from information systems data, and the usefulness of the approach.

Methods

A process of event-based knowledge elicitation was developed to assess OR management decision-making that may reduce the efficiency of use of OR time. Hypothetical scenarios addressing every OR management decision influencing OR efficiency were created from published examples. Scenarios are adapted, so that cues about conditions are accurate and appropriate for each facility (e.g., if OR 1 is used as an example in a scenario, the listed procedure is a type of procedure performed at the facility in OR 1). Adaptation is performed automatically using the facility's OR information system or anesthesia information management system (AIMS) data for most scenarios (43 of 45). Performing the needs assessment takes approximately 1 hour of local managers' time while they decide if their decisions are consistent with the described scenarios. A table of contents of the indexed scenarios is created automatically, providing a simple version of problem solving using case-based reasoning. For example, a new OR manager wanting to know the best way to decide whether to move a case can look in the chapter on "Moving Cases on the Day of Surgery" to find a scenario that describes the situation being encountered.

Results

Scenarios have been adapted and used at 22 hospitals. Few changes in decisions were needed to increase the efficiency of use of OR time. The few changes were heterogeneous among hospitals, showing the usefulness of individualized assessments.

Conclusions

Our technical advance is the development and use of automated event-based knowledge elicitation to identify suboptimal OR management decisions that decrease the efficiency of use of OR time. The adapted scenarios can be used in future decision-making.

Curriculum providing cognitive knowledge and problem-solving skills for anesthesia systems-based practice

BACKGROUND

Residency programs accredited by the ACGME are required to teach core competencies, including systems-based practice (SBP). Projects are important for satisfying this competency, but the level of knowledge and problem-solving skills required presupposes a basic understanding of the field. The responsibilities of anesthesiologists include the coordination of patient flow in the surgical suite. Familiarity with this topic is crucial for many improvement projects.

INTERVENTION

A course in operations research for surgical services was originally developed for hospital administration students. It satisfies 2 of the Institute of Medicine's core competencies for health professionals: evidence-based practice and work in interdisciplinary teams. The course lasts 3.5 days (eg, 2 weekends) and consists of 45 cognitive objectives taught using 7 published articles, 10 lectures, and 156 computer-assisted problem-solving exercises based on 17 case studies. We tested the hypothesis that the cognitive objectives of the curriculum provide the knowledge and problem-solving skills necessary to perform projects that satisfy the SBP competency. Standardized terminology was used to define each component of the SBP competency for the minimum level of knowledge needed. The 8 components of the competency were examined independently.

FINDINGS

Most cognitive objectives contributed to at least 4 of the 8 core components of the SBP competency. Each component of SBP is addressed at the minimum requirement level of exemplify by at least 6 objectives. There is at least 1 cognitive objective at the level of summarize for each SBP component.

CONCLUSIONS

A curriculum in operating room management can provide the knowledge and problem-solving skills anesthesiologists need for participation in projects that satisfy the SBP competency.

Influence of procedure classification on process variability and parameter uncertainty of surgical case durations

BACKGROUND

Predictive variability of operating room (OR) times influences decision making on the day of surgery including when to start add-on cases, whether to move a case from one OR to another, and where to assign relief staff. One contributor to predictive variability is process variability, which arises among cases of the same procedure(s). Another contributor is parameter uncertainty, which is caused by small sample sizes of historical data.

METHODS

Process variability was quantified using absolute percentage errors of surgeons' bias-corrected estimates of OR time. The influence of procedure classification on process variability was studied using a dataset of 61,353 cases, each with 1 to 5 scheduled and actual Current Procedural Terminology (CPT) codes (i.e., a standardized vocabulary). Parameter uncertainty's sensitivity to sample size was quantified by studying ratios of 90% prediction bounds to medians. That studied dataset of 65,661 cases was used previously to validate a Bayesian method to calculate 90% prediction bounds using combinations of surgeons' scheduled estimates and historical OR times.

RESULTS

(1) Process variability differed significantly among 11 groups of surgical specialty and case urgency (P < 0.0001). For example, absolute percentage errors exceeded the overall median of 22% for 57% of urgent spine surgery cases versus 42% of elective spine surgery cases. (2) Process variability was not increased when scheduled and actual CPTs differed (P = 0.23 without and P = 0.47 with stratification based on the 11 groups), because most differences represented known (planned) options inherent to procedures. (3) Process variability was not associated with incidence of procedures (P = 0.79), after excluding cataract surgery, a procedure with high relative variability. (4) Parameter uncertainty from uncommon procedures (0-2 historical cases) accounted for essentially all of the uncertainty in decisions dependent on estimates of OR times. The Bayesian method moderated the effect of small sample sizes on uncertainty in estimates of OR times. In contrast, from prior work, the use of broad categories of procedures reduces parameter uncertainty but at the expense of increased process variability.

CONCLUSIONS

For procedures with few historic data, the Bayesian method allows for effective case duration prediction, permitting use of detailed procedure descriptions. Although fine resolution of scheduling procedures increases the chance of performed procedure(s) differing from scheduled procedure(s), this does not increase process variability. Future studies need both to address differences in process variability among specialties and accept the limitation that findings from one may not apply to others.

Prospective trial of thoracic and spine surgeons' updating of their estimated case durations at the start of cases

BACKGROUND

Surgeon estimates of case durations are important for operating room (OR) management decision making because many cases are rare combinations of procedures with few or no historical data. Thoracic and spine surgeons updated their scheduled OR times on the day of surgery just before the "time out" in the OR.

METHODS

All elective (scheduled) general thoracic (n = 39) and spine surgery (n = 48) cases at 1 hospital were studied over 3-month and 1.5-month periods, respectively.

RESULTS

Among cases with a change in predicted duration, most changes were made based on updates to the surgical or anesthetic procedures (thoracic 85%, spine 86%). For thoracic surgery, there was overall no significant median reduction in absolute prediction error (median 0 minutes, 95% confidence interval [CI] 0-0 minutes). Among the 37% of cases with changed predicted durations, there was a significant reduction in absolute error (median 38 minutes, 95% CI >7.5 minutes). For spine surgery, there was overall no reduction in the absolute error (median 0 minutes, 95% CI 0-0 minutes). Among the 29% of cases with changed predicted durations, absolute error was no worse, but not significantly better (point estimate of median reduction 34 minutes, 95% CI >0 minutes). Secondary observations made were no effect of updates on bias, frequent rounding of scheduled durations to the nearest half hour, and increased predictive error caused by decisions that reduced expected overutilized OR time.

CONCLUSIONS

A systematic program of routinely and/or always asking for updated case duration predictions will not substantively improve OR management decision making. However, when a change in surgical approach, surgical procedure, or anesthetic procedure is identified (e.g., at the intraoperative briefing before case start), the updated estimate of case duration should be used, because such updates are not worse and often better than original estimates.