Operating Room Efficiency Is A Team Sport
Susan Nicolson MD, Lindsey Loveland Baptist MD, James DiNardo MD, Viviane Nasr MD
Original article
Brown ML, Staffa SJ, Quinonez LG, DiNardo JA, Nasr VG. Predictors of anesthesia ready time: Analysis and benchmark data. JTCVS Open. 2023 Jul 6;15:446-453. doi: 10.1016/j.xjon.2023.06.016. PMID: 37808038; PMCID: PMC10556934.
Patients who present for congenital cardiac surgical procedures requiring cardiopulmonary bypass (CPB) have 4 epochs of care within the time they are in the Operating Room (OR):
1. Anesthesia Ready Time (ART) - time from patient entering OR to when patient is deemed ready by the anesthesia team to begin positioning and surgical preparation
2. Position and Prep Time (PPT) – time to place urinary catheter, positioning, skin prep and draping
3. Operating Time (OT) – time from skin incision to skin closure
4. Exit Time (ET) – time from skin closure to existing OR, includes dressing application, removal of drapes and possible extubation
ART consists of induction of anesthesia, placement of an endotracheal tube, vascular access and for most, insertion of a transesophageal echocardiography probe. The authors’ goal1 was to provide benchmark ART data for both individual cardiac anesthesiologists and institutions with pediatric cardiac surgical programs using a large national dataset from the Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database.2 In addition, their objective was to identify predictors of increasing ART, specifically any modifiable factors. They also harvested data to provide benchmarks for the other 3 epochs of care.
The STS Congenital Heart Surgery Database contains data on children and adults undergoing surgery for congenital heart defects. There is an optional module to acquire anesthesia related data. Anesthesia data was available from 62 different sites that represent 50% of the sites submitting surgical cases. 44,418 patients who underwent congenital heart surgery with CPB between 2017-2021 were identified. Univariate and multivariable regression modeling was used to predict ART using mixed-effects linear regression. “The median ART was 51 minutes (IQR, 38-66). The median PPT was 36 minutes (IQR, 25-48), the median OR time was 239 minutes (IQR 179-326), and the median ET was 18 minutes (IQR, 13-27). ART comprises on average only 15% of patient’s total time in the OR.”1
“On multivariable analysis, independent predictors of longer ART included prematurity, decreasing weight, presence of a genetic abnormality, elective procedure, morning start time, presence of an anesthesia trainee, placement of a central venous catheter and higher STAT mortality category. Preoperative presence of an endotracheal tube and/or an arterial line decreased ART.”1
The time spent on ART is often targeted with a goal to improve OR efficiency. Most of the variables that impact ART are not modifiable. Even focusing on all modifiable variables, one is unlikely to achieve a clinically significant difference in ART and even less likely to influence overall OR time. Another 15% of OR time is spent in epochs 2 and 4, PPT and ET. The modifiable variables in those domains need to be part of an OR efficiency platform. Some of those variables such as placement and removal of the drapes, application of the dressing are independent of patient characteristics and provider proficiency.
Achieving OR efficiencies in complex. Identification of the etiologies of OR inefficiency, combined with multidisciplinary awareness training and personal accountability, has potential to improve efficiency. The time savings realized are most cost-effective when combined with more flexible OR staffing and improved scheduling. In addition to potential cost savings, OR efficiency may affect patient safety and satisfaction and provider wellbeing. The case duration and case end time have downstream effects including an increased number of intraoperative handoffs, later arrival to the ICU with on call staffing, team fatigue and concern for burnout.
Despite providing benchmark data on ART, the study has several limitations including no data on anesthesia support (role of 2nd anesthesia attending, presence of an anesthesia technician who facilitates performance of ART procedures), level of experience of the anesthesia trainee, on time starts, turnover times, use of induction rooms and precise separation of ART and PPT.
PS from Myron: The PAAD’s cardiac review team did not comment on a couple of issues raised in this paper, most specifically the presence of a resident or fellow, which were independent predictors of longer ART 3.8 minutes (95% CI, 2.6-5.0; P<.001). To my mind, 3.8 minutes is hardly an issue in cases that take several hours. On the other hand, Brown et al. did raise issues that bedevil all of us working In teaching institutions, namely, “Strategies to remain true to the teaching mission while limiting ART include strictly defining the time interval or number of attempts allocated to the trainee to perform procedures, limiting the number of procedures performed by the trainee during any one case (ie, the central line or arterial line, but not both), and using an additional attending anesthesiologist to assist with patient management or trainee supervision. This latter strategy may be particularly useful in patients identified as high risk for a prolonged ART.”1 For those of you who are involved in resident, fellow, SRNA training, I’m wondering how you deal with these questions and why this is any different than surgical training in Position and Prep Time, Operating Time, and Exit Time.
Send your thoughts and responses to Myron who will post in a Friday Reader response.
References
1. Brown ML, Staffa SJ, Quinonez LG, DiNardo JA, Nasr VG: Predictors of anesthesia ready time: Analysis and benchmark data. JTCVS Open 2023; 15: 446-453
2. Kumar SR, Gaynor JW, Jones LA, Krohn C, Mayer JE, Jr., Nathan M, O'Brien JE, Jr., Pizarro C, Wellnitz C, Nelson JS: The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2022 Update on Outcomes and Research. Ann Thorac Surg 2023; 115: 807-819