Operating Room Efficiency measurement made simple by a single metric.

Operating room (OR) efficiency is a hot topic in OR management studies. Benefits of OR efficiency maximization include financial savings, improved patient safety, greater satisfaction for patients and health workers, and increased productivity. However, how to measure the efficiency of an OR suite still remains a pending question. Many performance indicators have been developed (1) and one of the most frequent approaches consists of choosing a set of indicators to create a dashboard for the monitoring of surgical activities. Macario proposed a scoring system based on eight performance indicators (2). A similar approach was used in The Canadian Paediatric Surgical Wait Times Project (3). Although the use of dashboards and scoring systems allows for a wide and in-depth understanding of the numerous factors that contribute to efficiency, it may also raise problems. The use of multiple indicators involves gathering large amounts of data that are not routinely available in every context and are subject to different interpretations if metrics show divergent trends. Moreover, it is not possible to properly establish relative weights among metrics. We propose a different approach, based on a single and overall indicator that can be used as a proxy for OR efficiency. We considered four elements as a minimum set for composing our indicator: raw utilization (RU), turn-over time (TT), preparation time (PT) and case cancellation (CC) (4). RU formed the basis for our considerations, as it is one of the most common and widespread performance indicators. RU represents the percent of time that patients spend in OR during resource hours.

Restructuring the surgical process after regional reform in Emilia-Romagna: an action-research project at Rizzoli Orthopedic Institute.

BACKGROUND: Hospitals performing surgery in Italy underwent important transformations in recent years, with decreasing economic resources and higher expected standards of care. Regional authorities acted differently across the country to adapt to the new scenario, generating heterogeneous outcomes. The Rizzoli Orthopedic Institute (ROI) in the Emilia-Romagna region started its reorganization in 2017, after the issue of new regional regulations about surgical activity. Aim of this paper is to describe the actions taken at ROI and discuss their outcomes. STUDY DESIGN: Action-research. METHODS: From 2017 to 2019 an action-research project was developed to introduce organizational changes within ROI and close the existing gaps between regional requirements and actual features of the Institute. Four areas of intervention were identified: surgical scheduling, appropriateness of surgical setting, monitoring and management of the surgical path and accountability. Progress was monitored through the collection of performance indicators and qualitative investigation of the organizational culture. RESULTS: Changes were implemented in all areas of intervention. Key features were the introduction of Operating Room Management (ORM) skills and the establishment of multiprofessional teams to drive the changes. Performance indicators showed a positive trend in the comparison between 2017 and 2018. Improvements were observed in terms of productivity, scheduling, and respect of standard waiting time, while case-mix did not significantly change. CONCLUSIONS: Effective ORM and collaborative practices can successfully drive the change towards a more efficient surgical process without increasing resources consumption.

Coagulation Day 2010: an Austrian survey on the routine of thromboprophylaxis in intensive care.

PURPOSE: Venous thromboembolism (VTE) is a common but often overlooked life-threatening complication of critical illness. The aim of this cross-sectional survey was to assess current practice of thromboprophylaxis as well as adherence to international guidelines. METHODS: After ethics committee approval, all intensive care units in Austrian hospitals treating adult patients were invited to participate in this web-based survey. Anonymized data on each patient treated at the participating intensive care units on Coagulation Day 2010 were collected using an electronic case report form. Risk assessment, choice and monitoring of anticoagulants, means of mechanical prophylaxis, and demographic data were recorded. RESULTS: Data from 325 critically ill patients were collected. Patients had a median of four risk factors for thrombosis and 6 % suffered from VTE. Of the 325 patients, 80 % received low molecular weight heparins subcutaneously, 10 % received unfractionated heparin intravenously, 1 % received alternative anticoagulants and 9 % received no pharmacological prophylaxis. Mechanical prophylaxis was used in 49 % with a predominant use of graduated compression stockings. In 39 % a combination of pharmacological and mechanical prophylaxis was applied and 5 % received no prophylaxis at all. Overall guideline adherence was 40 % on Coagulation Day 2010. CONCLUSION: Current practice of thromboprophylaxis is predominantly based on the administration of low molecular weight heparins prescribed at rather arbitrary doses without a discernible relationship to drug monitoring, thromboembolic risk factors, vasopressor use or fluid balance. The use of mechanical prophylaxis, evaluation of risk scores and overall guideline adherence must be further encouraged by education, training and communication.

[Preoperative evaluation of the bleeding history. Recommendations of the working group on perioperative coagulation of the Austrian Society for Anaesthesia, Resuscitation and Intensive Care]. / Präoperative Blutungsanamnese. Empfehlungen der Arbeitsgruppe perioperative Gerinnung der Osterreichischen Gesellschaft für Anästhesiologie, Reanimation und Intensivmedizin.

Unexpected bleeding in the perioperative period is largely caused by impaired inherited or drug-induced primary haemostasis. Standard tests for plasma coagulation are predominantly employed to gauge the risk of bleeding. In accordance with several reports the subcommittee for perioperative coagulation (AGPG) of the Austrian Society of Anaesthesia, Resuscitation and Intensive Care (OGARI) recommends the use of a standardised questionnaire to detect an increased risk of bleeding. Accordingly, healthy patients of the American Society of Anesthesiologists (ASA) grades I and II without any suspicion of impaired haemostasis who are scheduled for procedures without expected transfusion requirements, need no standard tests for coagulation. In all other patients (including patients taking medication affecting coagulation, or patients who are unable to provide adequate information) platelet count, platelet function, aPTT, PT, and fibrinogen levels should be assessed.

[Locoregional anesthesia and coagulation inhibitors. Recommendations of the Task Force on Perioperative Coagulation of the Austrian Society for Anesthesiology and Intensive Care Medicine]. / Lokoregionalanästhesien unter gerinnungshemmender Medikation. Empfehlungen der Arbeitsgruppe Perioperative Gerinnung (AGPG) der Osterreichischen Gesellschaft für Anästhesiologie und Intensivmedizin (OGARI).

More efficacious anticoagulant and antiplatelet agents have been introduced in vascular medicine and in the prevention of perioperative venous thromboembolisms. Patient management should be guided by familiarity with the pharmacology of coagulation-altering drugs and by consensus statements. The present paper reviews recommendations from the Austrian Task Force for Perioperative Coagulation which are based on thorough evaluation of the available pharmacological information and case reports. The consensus statement focuses on neuraxial and peripheral techniques and is designed to encourage safe and quality patient care.

[Myocardial metabolism during the pre-ischemic administration of metabolic myocardial protection in coronary surgical patients]. / Myokardialer Stoffwechsel während präischämischer Verabreichung einer metabolischen Myokardprotektion bei koronarchirurgischen Patienten.

Metabolic myocardial preservation by means of preischemic insulin administration (glucose-potassium-insulin, GPI; acute parenteral alimentation, APA) with the aim of a preischemic myocardial glycogen enrichment was performed in 20 consecutive CABG patients (12 in the APA group, 8 in the control group). Before and after 30 min of an infusion (APA or 0.9% NaCl solution), blood levels of potassium, glucose, NEFA (non-esterified fatty acids) and lactate were determined from arterial (a), central venous (cv) and coronary sinus (cs) blood. The cs potassium level in the APA group decreased from 4.06 to 3.56 mmol/l, whereas in the control group an increase from 3.78 to 4.36 mmol/l occurred. The difference between the two groups (interaction) was significant, p less than 0.002. The myocardial glucose extraction (a-cs difference) in the APA group increased from 3.83 to 10.08 mg/dl, whereas in the control group a change from 3.37 to 0.87 mg/dl occurred (p less than 0.0003). The myocardial NEFA (non-esterified fatty acids) extraction in the APA group decreased from 0.25 to -0.06 mmol/l, whereas in the control group no change (0.08 to 0.13 mmol/l) occurred (p less than 0.05). The myocardial lactate extraction in the APA group increased from 0.13 to 0.70 mmol/l, whereas in the control group no change occurred (0.47 to 0.51 mmol/l), interaction p less than 0.0001. It is concluded that a preischemic insulin administration (APA) for metabolic preservation leads to: (1) myocardial potassium extraction, obviously caused by intracellular potassium shifting; (2) increased myocardial glucose extraction; (3) decreased myocardial NEFA extraction, the last two obviously caused by a shift of the myocardial metabolism from predominant lipolysis to predominantly glycolysis; and (4) surprisingly, increased myocardial lactate extraction (decreased lactate production), obviously caused by the avoidance of a myocardial lactate accumulation by way of stimulated pyruvate oxidation. Increased anaerobically, available ATP without myocardial lactate production must be considered a metabolic contribution to myocardial protection against ischemic damage.