Influence of Data and Formulas on Trust in Information from Journal Articles in an Operating Room Management Course

Association of surgeons' gender with elective surgical lists in the State of Florida is explained by differences in mean operative caseloads

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.

Most surgeons' daily elective lists in Florida comprise only 1 or 2 elective cases, making percent utilization unreliable for planning individual surgeons' block time

STUDY OBJECTIVE

Operating room (OR) utilization has been shown in multiple studies to be an inappropriate metric for planning OR time for individual surgeons. Among surgeons with low daily caseloads, percentage utilization cannot be measured accurately because confidence limits are extremely wide. In Iowa, a largely rural state, most surgeons performed only 1 or 2 elective cases on their OR days. To assess generalizability, we analyzed Florida, a state with many high-population density areas.

DESIGN

Observational cohort study.

SETTING

The 602 facilities in Florida that performed inpatient or outpatient elective surgery from January 2010 through December 2019.

SUBJECTS

The providers licensed to perform surgery in Florida (physician, oral surgeons, dentists, and podiatrists) were identified by their national provider number. Hospitals were deidentified before analysis.

MEASUREMENTS

The primary endpoint was the mean among facilities in percentages of surgeon-day combinations ("lists") containing 1 or 2 cases. Proportions were calculated using Freeman-Tukey transformation and the harmonic mean of the number of lists at each facility. Comparison to "most" (>50%) used Student's two-sided one-group t-test.

MAIN RESULTS

Averaging among hospitals, most surgeons' lists included 1 or 2 cases (64.4%; 99% confidence interval [CI] 61.3%-67.4%) P < 0.00001). Many lists had 1 case (44.2%, 99% CI 41.2%-47.2%). Nearly all (96.7%) surgeons operated at just one hospital on their OR days.

CONCLUSIONS

Most surgeons' lists of elective surgical cases comprised 1 or 2 cases in the largely urban state of Florida, as previously found in the largely rural state of Iowa. Results were insensitive to organizational size or county population. Thus, our finding is generalizable in the United States. Consequently, neither adjusted nor raw utilization should be used solely when allocating OR time to individual surgeons. Anesthesia and nursing coverage of cases can be based on maximizing the efficiency of use of OR time.

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.

Resident Physicians Improve Nontechnical Skills When on Operating Room Management and Leadership Rotation

BACKGROUND

Anesthesiology residency primarily emphasizes the development of medical knowledge and technical skills. Yet, nontechnical skills (NTS) are also vital to successful clinical practice. Elements of NTS are communication, teamwork, situational awareness, and decision making.

METHODS

The first 10 consecutive senior residents who chose to participate in this 2-week elective rotation of operating room (OR) management and leadership training were enrolled in this study, which spanned from March 2013 to March 2015. Each resident served as the anesthesiology officer of the day (AOD) and was tasked with coordinating OR assignments, managing care for 2 to 4 ORs, and being on call for the trauma OR; all residents were supervised by an attending AOD. Leadership and NTS techniques were taught via a standardized curriculum consisting of leadership and team training articles, crisis management text, and daily debriefings. Resident self-ratings and attending AOD and charge nurse raters used the Anaesthetists' Non-Technical Skills (ANTS) scoring system, which involved task management, situational awareness, teamwork, and decision making. For each of the 10 residents in their third year of clinical anesthesiology training (CA-3) who participated in this elective rotation, there were 14 items that required feedback from resident self-assessment and OR raters, including the daily attending AOD and charge nurse. Results for each of the items on the questionnaire were compared between the beginning and the end of the rotation with the Wilcoxon signed-rank test for matched samples. Comparisons were run separately for attending AOD and charge nurse assessments and resident self-assessments. Scaled rankings were analyzed for the Kendall coefficient of concordance (ω) for rater agreement with associated χ and P value.

RESULTS

Common themes identified by the residents during debriefings were recurrence of challenging situations and the skills residents needed to instruct and manage clinical teams. For attending AOD and charge nurse assessments, resident performance of NTS improved from the beginning to the end of the rotation on 12 of the 14 NTS items (P < .05), whereas resident self-assessment improved on 3 NTS items (P < .05). Interrater reliability (across the charge nurse, resident, and AOD raters) ranged from ω = .36 to .61 at the beginning of the rotation and ω = .27 to .70 at the end of the rotation.

CONCLUSIONS

This rotation allowed for teaching and resident assessment to occur in a way that facilitated resident education in several of the skills required to meet specific milestones. Resident physicians are able to foster NTS and build a framework for clinical leadership when completing a 2-week senior elective as an OR manager.