Clinicians consistently exceed a typical person's short-term memory during preoperative teaching.

INTRODUCTION: Patient education is a critical part of preparation for surgery. Little research on provider-to-patient teaching has been conducted with systematic focus on the quantity of information provided to patients. This is important to assess because short-term memory capacity for information such as preoperative instruction is limited to roughly seven units of content. METHODS: We studied the information-giving practices of anesthesiologists and nurse practitioners during preoperative teaching by examining transcripts from 26 tape recorded preoperative evaluation appointments. We developed a novel coding system to measure: 1) quantity of information, 2) frequency of medical terminology, 3) number of patient questions, and 4) number of memory reinforcements used during the consultation. Results are reported as mean +/- sd. RESULTS: Anesthesiologists and nurse practitioners vastly exceeded patients' short-term memory capacity. Nurse practitioners gave significantly more information to patients than did physicians (112 +/- 37 vs 49 +/- 25 items per interview, P < 0.01). This higher level of information-giving was not influenced by the question-asking behaviors of the patients. Nurse practitioners and physicians used similar numbers of medical terms (4.0 +/- 2.4 vs 3.7 +/- 2.8 explained terms per interview), and memory-supporting reinforcements (2.3 +/- 3.0 vs 1.4 +/- 2.0 reinforcements per interview). DISCUSSION: Given the known limits of short-term memory, clinicians would be well advised to carefully consider their patterns of information-giving and their use of memory-reinforcing strategies for critical information.

The value of the dedicated orthopaedic trauma operating room.

BACKGROUND: Trauma centers and orthopaedic surgeons have traditionally been faced with limited operating room (OR) availability for fracture surgery. Orthopaedic trauma cases are often waitlisted and done late at night. We investigated the feasibility of having an unbooked orthopaedic trauma OR to reduce nighttime cases and improve OR flow. METHODS: A retrospective analysis was performed for two 1 year time periods before and after the introduction of an unbooked trauma OR. The unbooked trauma OR is kept open for urgent and semi-urgent cases from 7:45 am to 5 pm 6 days per week, and is under the control of Orthopaedics; no elective cases are scheduled in the unbooked trauma room. We collected OR time data on two common surgical cases (dynamic hip screw and closed femoral nailing) done before and after introduction of the unbooked orthopaedic trauma OR. We also reviewed data on waitlist cases, surgical time, anesthetic times, OR utilization, and surgical complications before and after the introduction of the unbooked trauma room. RESULTS: The availability of the unbooked trauma OR significantly improved operating suite flow. The proportion of hip fractures done after 5 pm was reduced by 72% (p<0.01). The number of all orthopaedic waitlist cases started after 5 pm was reduced by 6% (p<0.021). The distinct shift toward performing add-on cases during daytime hours resulted in a 6% reduction in OR over-utilization. Closed femoral nailing done at night required significantly more OR time (261 minutes versus 219 minutes, p<0.04). Hip fracture surgeries and femoral nailings done at night were noted to have a higher incidence of surgical complications (p<0.04 and p<0.036). CONCLUSION: The availability of an unbooked orthopaedic trauma room resulted in a measurable shift from performing "add-on" cases to daytime surgery and may reduce complications. We recommend that hospitals and orthopaedic trauma services commit resources toward having an open OR reserved for orthopaedic trauma.

Reorganizing patient care and workflow in the operating room: a cost-effectiveness study.

BACKGROUND: Many surgeons believe that long turnover times between cases are a major impediment to their productivity. We hypothesized that redesigning the operating room (OR) and perioperative-staffing system to take advantage of parallel processing would improve throughput and lower the cost of care. METHODS: A state of the art high tech OR suite equipped with augmented data collection systems served as a living laboratory to evaluate both new devices and perioperative systems of care. The OR suite and all the experimental studies carried out in this setting were designated as the OR of the Future Project (ORF). Before constructing the ORF, modeling studies were conducted to inform the architectural and staffing design and estimate their benefit. In phase I a small prospective trial tested the main hypothesized benefits of the ORF: reduced patient intra-operative flow-time, wait-time and operative procedure time. In phase II a larger retrospective study was conducted to explore factors influencing these effects. A modified process costing method was used to estimate costs based on nationally derived data. Cost-effectiveness was evaluated using standard methods. RESULTS: There were 385 cases matched by surgeon and procedure type in the retrospective dataset (182 ORF, 193 standard operating room [SOR]). The median Wait Time (12.5 m ORF vs 23.8 m SOR), Operative Procedure Time (56.1 m ORF vs 70.5 m SOR), Emergence Time (10.9 m ORF vs 14.5 m SOR) and Total Patient OR Flowtime (79.5 m ORF vs 108.9 m SOR) were all shorter in the ORF (P < .05 for all comparisons). The median cost/patient was $3,165 in the ORF (interquartile range, $1,978 to $4,426) versus $2,645 in SORs (interquartile range, $1,823 to $3,908) (P = ns). The potential change in patient throughput for the ORF was 2 additional patients/day. This improved throughput was primarily attributable to a marked reduction in the non-operative time (ie, those activities commonly accounting for "turnover time") rather than facilitation of faster operations. The incremental cost-effectiveness ratio of ORF was $260 (interquartile range, $180 to $283). CONCLUSION: The redesigned perioperative system improves patient flow, allowing more patients to be treated per day. Cost-effectiveness analysis suggests that the additional costs incurred by higher staffing ratios in an ORF environment are likely to be offset by increases in productivity. The benefits of this system are realized when performing multiple, short-to-medium duration procedures (eg, <120 m).

Deliberate perioperative systems design improves operating room throughput.

BACKGROUND: New operating room (OR) design focuses more on the surgical environment than on the process of care. The authors sought to improve OR throughput and reduce time per case by goal-directed design of a demonstration OR and the perioperative processes occurring within and around it. METHODS: The authors constructed a three-room suite including an OR, an induction room, and an early recovery area. Traditionally sequential activities were run in parallel, and nonsurgical activities were moved from the OR to the supporting spaces. The new workflow was supported by additional anesthesia and nursing personnel. The authors used a retrospective, case- and surgeon-matched design to compare the throughput, cost, and revenue performance of the new OR to traditional ORs. RESULTS: For surgeons performing the same case mix in both environments, the new OR processed more cases per day than traditional ORs and used less time per case. Throughput improvement came from superior nonoperative performance. Nonoperative Time was reduced from 67 min (95% confidence interval, 64-70 min) to 38 min (95% confidence interval, 35-40 min) in the new OR. All components of Nonoperative Time were meaningfully reduced. Operative Time decreased by approximately 5%. Hospital and anesthesia costs per case increased, but the increased throughput offset costs and the global net margin was unchanged. CONCLUSIONS: Deliberate OR and perioperative process redesign improved throughput. Performance improvement derived from relocating and reorganizing nonoperative activities. Better OR throughput entailed additional costs but allowed additional patients to be accommodated in the OR while generating revenue that balanced these additional costs.

Introducing new technology into the operating room: measuring the impact on job performance and satisfaction.

BACKGROUND: The Massachusetts General Hospital (MGH) Operating Room of the Future (ORF) project is a test site for evaluating new surgical technologies and processes. Here we evaluate the effect on staff satisfaction and burnout of introducing a set of new technologies. METHODS: Staff satisfaction and burnout were measured via sequential surveys based on the Maslach Burnout Inventory during the introduction of a new technology system. Functional behavior of the OR was measured in terms of flow time (time to transit the OR) and wait time (time to access the OR). These data were gathered using time-motion analysis methods. RESULTS: Significant functional improvements were found in the ORF (more than 35% reduction in flow time and wait time, P < .05). During the same period, more exposure to the ORF resulted in greater sense of personal accomplishment among surgeons, a worse sense of personal accomplishment among nurses, more emotional exhaustion among surgeons, and less emotional exhaustion among nurses. However, the responses for emotional exhaustion were reversed the greater the time from exposure to the ORF. Staff with 6 to 10 years' experience were at highest risk for burnout across all categories. General surgeons experienced more emotional exhaustion than other physicians. CONCLUSIONS: Tracking the response of all users and identifying groups at high risk for burnout when exposed to new systems should be a central part of any new technology project.

Reorganizing the system of care surrounding laparoscopic surgery: a cost-effectiveness analysis using discrete-event simulation.

PURPOSE: To determine the cost-effectiveness of a proposed reorganization of surgical and anesthesia care to balance patient volume and safety. METHODS: Discrete-event simulation methods were used to compare current surgical practice with a new modular system in which patient care is handed off between 2 anesthesiologists. A health care system's perspective, using hospital and professional costs, was chosen for the cost-effectiveness analysis. Outcomes were patient throughput, flow time, wait time, and resource use. Sensitivity analyses were performed on staffing levels, mortality rates, process times, and scheduled patient volume. RESULTS: The new strategy was more effective (average 4.41 patients/d [median = 5] v. 4.29 [median = 4]) and had similar costs (average cost/ patient/d = 5327 dollars v. 5289 dollars) to the current strategy with an incremental cost-effectiveness of 318 dollars/additional patient treated/d. Surgical mortality rate must be >4% or hand-off delay >15 min before the new strategy is no longer more effective. CONCLUSION: The proposed system is more cost-effective relative to current practice over a wide range of mortality rates, hand-off times, and scheduled patient volumes.

Preoperative preparation of patients with advanced liver disease.

OBJECTIVE: To review the characteristic features of patients with advanced liver disease that may lead to increased perioperative morbidity and mortality rates. DESIGN: Literature review. RESULTS: Patients with end-stage liver disease are at high risk of major complications and death following surgery. The most common complications are secondary to acute liver failure and include severe coagulopathy, encephalopathy, adult respiratory distress syndrome, acute renal failure, and sepsis. The degree of malnutrition, control of ascites, level of encephalopathy, prothrombin time, concentration of serum albumin, and concentration of serum bilirubin predict the risk of complications and death following surgery. Other determinants of adverse outcome include emergency surgery, advanced age, and cardiovascular disease. Portal hypertension is a prominent feature of advanced liver disease, and it predisposes the patient to variceal hemorrhage, hepatorenal syndrome, hepatopulmonary syndrome, and uncontrolled ascites. Portal hypertension can be ameliorated by percutaneous or surgical portasystemic shunting procedures. If well-defined contraindications are not present, patients with advanced liver disease should be evaluated for orthotopic liver transplantation from a cadaver donor or possible living-related liver transplantation. CONCLUSIONS: Optimal preparation, which addresses the common features of advanced liver disease, may decrease the risk of complications or death following surgery. Preparation should include correcting coagulopathy, minimizing preexisting encephalopathy, preventing sepsis, and optimizing renal function.