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.

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.

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.