Wednesday, January 20, 2016

OR delays: Who's responsible and what can be done?

Every two or three years, someone, usually a hospital administrator, decides that delays in operating room turnover time need to be looked into. A committee of 20 or 30 stakeholders (love that term) is appointed and assigns someone the job of measuring the time between cases and identifying reasons for delays. In years when turnover time is not being studied, first case starting delays are on the agenda.

In my nearly 24 years as a surgical department chair, one or the other of these issues was investigated at least 10 times. We were never able to conclusively determine the exact causes of delays or solutions to the problem, and we returned to business as usual.

An article in Anesthesiology News about a paper that looked at causes of operating room delays in over 15,500 cases at a single hospital got my attention.

The number one reason for delays was that the nurses did not have the operating room ready for the patient. Nursing also was responsible for the third most common cause "preop prep (IVs, meds, etc.)."

Surgeons were the reason for the second most common problem, "notes, consent, patient marking not complete." A few more of the top 10 included surgeons running two rooms, surgeon unavailable, and my favorite, "last case ended early." I’m not sure how a case ending early causes a delay in starting the next case. Usually we are blamed for underestimating the length of time we need to do an operation.

Anesthesiologists were cited for only one of the 10 most common reasons for delays—placement of an IV line or regional block.

Not surprisingly, the study was done by anesthesiologists using data they collected.

When I expressed skepticism about this on Twitter, I was accused of implying the research was fraudulent. Not so. Some of my best friends are anesthesiologists. In fact two of my medical school roommates became anesthesiologists. Fraud is not the issue. It's a matter of perspective.

For example when the nurses investigate OR delays, the problem never seems to be nursing.

I'm not saying that surgeons don't cause delays. A task force once found that one of my surgeons was late for his first case every time he operated because he had to take his kids to school.

Another surgeon would disappear between cases and was always late for his next one. No one knew where he went. Some thought he may have been calling his broker or perhaps having an affair.

Here’s what the anesthesiologist researchers may have overlooked.

In effort to avoid delays, I would often ask for an anesthesia consult on complicated inpatients booked for surgery a day or two later. On nearly every occasion, the anesthesiologist who saw the patient was not the one assigned to do the case. The consulting anesthesiologist never said a certain lab test was necessary, but in the holding room, the one who was going to put the patient to sleep said it was. A spirited discussion, phone calls, and a delay ensued.

Sometimes a day surgery patient who arrived 2 hours ahead of schedule wasn't interviewed by anesthesia until the scheduled time of the case.

Then there was my patient whose operation was postponed for 6 hours because she had a piece of hard candy in her mouth when she got to OR. The anesthesiologist said it was the equivalent of having a full stomach. Read the full story here.

Can delays be shortened by working together? A 2014 paper in the Journal of Surgical Research by a surgeon and four anesthesiologists found that “various events and organizational factors created an environment that was receptive to change.” The authors were able to decrease their general surgery OR turnaround times from 48.6 minutes to 44.8 minutes, a statistically significant (p < 0.0001) but hardly clinically important difference.

Let me hear your experiences with OR delays.


Anonymous said...

In my experience with academic medical centers, VA hospital ORs, multi-specialty group ORs and private ASC : its turn-over time that delays cases. In all cases except the private ASC, there is little incentive (besides avoiding a beat-down) for staff to keep cases starting and running on time. Delaying cases can sometimes be used as a tactic to avoid doing more cases ! Even in the private ASC setting, its never perfect, but initial room set up and turn-over times are faster. The staff is held to a higher, and usually measurable efficiency that is reviewed frequently. The lack of inpatients and emergency add-on cases also helps the ASC's efficiency.

AD said...

The first problem is the definition of late. I am constantly told by nurses that AORN defines turnaround as "wheels in to wheels out" and the "industry standard" for late, is later than 15 minutes form the scheduled time. I am not aware of any other industry where this is acceptable. I have defined my hospital's late as later than the scheduled start time. As for the wheels issue I have my own definition: Everything that is not operative time is turnaround time. they don't like it but it's an honest definition. The problem is the 4 way standoff. The nurses blame the surgeons for not showing up 15 minutes early. Those who do show late, do so because they know they never start on time. The anesthesiologists blame the nurses for the documentation not being ready, the IV not in (god forbid they place it themselves). And then theres the tech not having the room ready. The surgeon is the only one who will do anything to get things going: place the IV, sign whatever, wheel the patient in themselves. The two main problems are that no one except the surgeon has the incentive to get things going, they have no one to take over their shift mid operation, or at the end of the 8 hour day. The second is that there is no 'captain of the ship', no one is in command of the other, the nurses refuse to let anesthesia move them along, and anesthesia will not allow the nurses to push them along. In the meantime, we will continue to stand around and wait for the next case to "wheel in"

Skeptical Scalpel said...

Anon, I agree with you about why ASCs are more efficient. It's impossible to do what they do in an acute care hospital OR.

AD, did we ever work at the same hospital? You describe exactly what I experienced--no incentive to move quickly. The occasional team that was efficient soon learned that their reward for doing so was an extra case.

david said...

In our hospital, the main cause of delay is that patient arrive late at the or, followed by surgery lasting more than what it was programmed and delay of surgeons arriving at the or. The problem with the list of the referred article is thatit doesn't show any relative frequencies, do we wouldn't know in what percentage each item of the list causes the delay. I think it depends on the structure of different hospitals amount of o r personnel, nurses, secretaries and so on. Probably if we study ten different hospitals, the cause or relative frequency will not be the same in each one. That is why this reports do not have external validity, but they are locally important. This is important to consider, so nobody will think that it was done to undermine any specialty or hurt any particular feeling. I think it's important to note that this is an abstract that was presented at a medical congress and not an actual paper

Anonymous said...

I will give you kudos Skep for admitting you had gas passers as roomies. I'll also give you credit for no blood/brain barrier anesthesia jokes.

AD hit that one dead on. I had no line in the last time I was going for surgery. My blood pressure was starting to go through the roof because of dehydration. No one walking through there was responsible.

Oldfoolrn said...

Modern operating rooms have far too much movement of personnel into and out of the room between cases. If you can sashay in and out of the room in a willy nilly fashion, what is the sense of speeding things up? Whippersnappers are superb time wasters and as exhibit A, look no further than those ubiquitous cell phones. To be more expeditious, may I suggest how we ran things many decades ago. The only case to receive a fixed start time was the initial one which was always 7:15 AM. Subsequent cases were scheduled as TF (to follow.) There were 0 late cases using this method. The nurses and anesthetist stay in the room until all cases are done. This really provides an incentive to hustle. A common back table (about twice as big as contemporary back tables) is loaded with supplies and equipment for the full caseload that day. The scrub nurse sets up her Mayo stand for each case from a common back table which is covered between cases. If poor planning necessitates fetching something from the common back table during a case it is lasooed with a sponge ring forceps. Each OR is designated to be used by a specific surgical specialty. You could not do an ortho case in the gyne room. If you have to completely tear down and set up each room individually with OR personnel strolling in and out at will, you have really wasted time. The only person moving in and out of the room between cases should be the patient. I solved your problem Dr. Skeptical, next on the peace.

artiger said...

I'll give a rural small hospital perspective. I cringe when I get a consult request for an inpatient endoscopy, PEG tube, or even lap cholecystectomy. I can burn through a slate of outpatient procedures of any type, but if you take those same patients and procedures and convert them to inpatients, the pace slows to a crawl. The distance from the patient room to the surgical area is 40, maybe 50 yards, but for some reason it takes about an hour to transport a patient across that distance.

Funny, though, when it comes to getting those same patients from the surgical area back to their hospital rooms. That same 40-50 yards can be traversed in less than 5 minutes.

AD said...

Skeptical: With regard to the consulting vs assigned ordering new tests, that was a fairly simple solution. I pulled all the anesthesia literature regarding pre-operative work-up for them ("literature" at best, scanty at worst). I asked them to decide as a group, to agree to what work-up they all felt comfortable with in an effort to standardize the work-up. We automated the pre-op lab/EKG/X-ray/consult orders below the consent order. Anyone is allowed to deviate if warranted. Anyone who deviated, however, would be reviewed at the surgery committee. This has worked. We also have a "floating', or "hall" anesthesiologist. They are supposed to ensure that everything is ready to go. We lovingly call them the "doughnut guy"..... The one who's always eating the last cinnamon roll in the OR lounge, rather than moving things along... which ensures they are "available for the trauma room".
Nothing new under the sun, I suppose.

Skeptical Scalpel said...

Great comments. I agree that causes of delays may be different in different hospitals, but many have similar issues too.

People ambling around is common too. I've seen personnel grab one item at a time, bring it into the room, then go get another item.

Getting patients in and out of rooms proceeds at a glacial pace at times.

AD, I tried to convince my anesthesiology department that a piece of hard candy was not the equivalent of a full meal, but they wouldn't listen. Agreeing to a standard workup? No way.

Anonymous said...

I define turnover time as non operating time - as in the airplane is standing at the gate - rather than in the air. So the hospital and the surgeon (like the airline) are not productive / making money.
Anesthesiologists do not have an incentive. Like the nursing staff and administrators, they leave at 3:30 whether the cases are done or not. The surgeon must stay till the end.
Like artiger I can get through a slate of outpatient procedures quickly because the staff in my outpatient procedure area are hired by and report to me. They can be incentivized if done early and penalized (by staying late) if the procedures are delayed

Skeptical Scalpel said...

Anon, thanks for the comments. I agree with you, but I wonder why anesthesiologists aren't incentivized. They get paid by the case and how long the anesthetic takes. You would think they wouldn't mind doing an extra case on their shift. Is it a mind set? Do they feel they make enough money anyway?

Unknown said...

Interesting comments. As an anesthesiologist, I too stay until all my cases are done ( as I'm typing this, I'm about to go do an elective AV fistula at 8:30 PM).
As far as standardized tests go, we developed a simple guide booklet based on patient age, comorbidities, and procedure. We sent copies to surgeon's offices....and virtually none of them use it.EKGs, chest x-rays, and complete metabolic profiles still get ordered for healthy 17 year old knee arthroscopic patients while elderly patients with cardiomyopathy and ICDs still show up without any preop workup.
The causes for delays are multiple, and usually complex.

Skeptical Scalpel said...

James, I agree with you. I once prepared a report based on a literature survey that said preop PTs, INRs, and APTTs were useless unless a patient had a history of anticoagulant use or a clotting abnormality.

The number of clotting studies didn't decrease at all and will still had a lot of false positive APTTs that required a second test which often delayed a case. I think it's hopeless.

I also agree that the causes for delays are often multiple, and usually complex.

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