SCIENTIFIC ARTICLE
The Efficiency of a Dedicated Staff on Operating Room Turnover Time in Hand Surgery Daniel M. Avery III, MD, Kristofer S. Matullo, MD
Purpose To evaluate the effect of orthopedic and nonorthopedic operating room (OR) staff on the efficiency of turnover time in a hand surgery practice. Methods A total of 621 sequential hand surgery cases were retrospectively reviewed. Turnover times for sequential cases were calculated and analyzed with regard to the characteristics of the OR staff being primarily orthopedic or nonorthopedic. Results A total of 227 turnover times were analyzed. The average turnover time with all nonorthopedic staff was 31 minutes, for having only an orthopedic surgical technician was 32 minutes, for having only an orthopedic circulator was 25 minutes, and for having both an orthopedic surgical technician and a circulator was 20 minutes. Statistical significance was seen when comparing only an orthopedic surgical technician versus both an orthopedic circulator and a surgical technician and when comparing both nonorthopedic staff versus both an orthopedic circulator and a surgical technician. Conclusions OR efficiency is being increasingly evaluated for its effect on hospital revenue and OR staff costs. Reducing turnover time is one aspect of a multifaceted solution in increasing efficiency. Our study showed that, for hand surgery, orthopedic-specific staff can reduce turnover time. (J Hand Surg Am. 2014;39(1):108e110. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Economic/Decision Analysis III. Key words Hand surgery, operating room efficiency, turnover time.
O
VER THE PAST DECADE,
efficiency in the operating room (OR) has become an area of focus for many hospitals. With an increasing patient population, increasing cost of procedures, and decreasing reimbursements, it is challenging to deliver quality care in the rapidly changing health care system. Numerous studies have looked at various strategies to increase efficiency to keep ORs financially more viable.1e8 Most of these studies have shown From the Division of Hand Surgery, St. Luke’s University Health Network; the Department of Orthopaedic Surgery, St. Luke’s Hospital, Bethlehem, Pennsylvania. Received for publication April 23, 2013; accepted in revised form September 26, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Kristofer S. Matullo, MD, St. Luke’s University Health Network, 801 Ostrum Street, PPH-2, Bethlehem, PA 18015; e-mail: [email protected]. 0363-5023/14/3901-0016$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.09.039
108
r
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
that decreasing the turnover time between cases isone way of making a surgeon’s and staff’s throughput easier.1e8 However, many of these studies have examined all specialties within their system or focused on a specialty other than hand surgery.1e9 In orthopedics, only turnover time for total joint arthroplasties has been examined for strategies to increase efficiency.5 Hand surgery stands as a unique subset of orthopedics to benefit from increased OR efficiency. Even minimal reductions in time between cases could translate to additional scheduling of cases because hand surgery cases often take far less time than other orthopedic OR procedures. This study was conducted to evaluate the effect of OR staff on the efficiency of turnover time in a hand surgery practice. Our hypothesis was that having an orthopedic surgical technician and a circulating nurse would reduce turnover time when compared with
109
EFFICIENCY OF STAFF ON OPERATING ROOM TURNOVER TIME
TABLE 1.
Number of Turnovers and Average Time by Staff Category OR Staff
Number of Turnovers
Average Turnover Time in Minutes (range)
Nonorthopedic surgical technician and circulator
53
30.5 (9e67)
Orthopedic surgical technician and nonorthopedic circulator
71
31.9 (7e88)
Nonorthopedic surgical technician and orthopedic circulator
34
24.8 (4e69)
Orthopedic surgical technician and circulator
69
19.8 (5e58)
227
Total
26.8
nonorthopedic staff in a hospital ambulatory surgery center environment.
using a Student 2-tailed t test assuming equal variance. A P of less than .05 denoted statistical significance.
MATERIALS AND METHODS After approval by our institutional review board, we conducted a retrospective review of K.S.M.’s case logs for hand surgery cases from July 2011 to June 2012 at our level I academic institution. All cases were performed in our outpatient ambulatory surgery center, located within the main hospital. A total of 621 sequential cases were identified, and operative records were reviewed. Cases included for evaluation were elective hand-specific cases regardless of patient age and running sequentially in a single operating suite but not involving microsurgery. Cases were excluded when the hand surgeon operated simultaneously in multiple operating suites, when they involved acute trauma care on inpatients, when cases were performed outside standard day shift hours (8:00 AMe3:00 PM), when turnover times greater than 90 minutes were likely outside the control of the OR staff, when there was a change of staff between cases, and when records were incomplete or electronically unavailable. Turnover time was defined as the difference between the time the previous patient left the room and the time the following patient came into the room as recorded in the nursing record. The OR surgical technician and circulating nurse were categorized for each turnover time as being either orthopedic staff or nonorthopedic staff. Individuals were classified as orthopedic staff if greater than 75% of their typical time in the operating room was spent delivering care to orthopedic patients or performing orthopedic procedures. All nurses and technicians were nonunionized, non-incentivized hospital employees compensated according to an equal and standardized pay rate regardless of specialty.
RESULTS A total of 227 turnover times were included. Of these, 53 turnovers were performed with both nonorthopedic circulators and surgical technicians, 71 turnovers were performed with an orthopedic surgical technician and a nonorthopedic circulator, 34 turnovers were performed with a nonorthopedic surgical technician and an orthopedic circulator, and 69 turnovers were performed with both an orthopedic surgical technician and an orthopedic circulator. The average turnover time in all cases, irrespective of staff, was 27 minutes. The average turnover time with respect to the type of staff involved is reported in Table 1. The differences in turnover time (11 min) was significantly different when a complete nonorthopedic staff was compared with a complete orthopedic staff (P ¼ .005). Also the differences in turnover time (12 min) were significant when an orthopedic technician was compared with a complete orthopedic staff (P < .001). The other differences were statistically insignificant. DISCUSSION Increasing OR efficiency is a multifaceted task that includes turnover time, Dexter8 and Patterson2 advised that hospitals should focus on other aspects of OR efficiency such as perioperative nursing preparation, communication within the OR, and anesthesia policies such as performing pre-procedural regional blocks. However, their advice was based on observing multiple specialties with operations requiring long operative times. Hand surgery, with many procedures of less than 1 hour long, falls into one of the exceptions cited by Dexter.8 For example, if a hand surgeon performed 10 cases per day, the difference in turnover time between all orthopedic staff and nonorthopedic staff would be approximately 96 minutes. This efficiency would possibly allow time for additional cases or could
Statistics Turnover times were logged into a spreadsheet based on their respective staff grouping. Average turnover time and analysis between staff groups were compared J Hand Surg Am.
r
Vol. 39, January 2014
110
EFFICIENCY OF STAFF ON OPERATING ROOM TURNOVER TIME
sedation. At our institution, the patient is transported into the room only after the room is completely set up. All turnover times are reflective of actual times to prepare the room for the next case. The possibility of hurrying turnover by opening equipment after the patient is in the operating suite is, therefore, eliminated. Lastly, one surgeon performed all cases. With this information, variables such as differing instrumentation and preferences by multiple surgeons were not factors. The surgeon did not change the quality of care delivered to each patient or typical operative technique in an attempt to increase speed or decrease turnover. Our study also has several limitations. The retrospective nature of the study did not allow for precise identification of confounding variables such as equipment or anesthesia delay; however, we feel that such variables outside of the surgical team would be present despite orthopedic experience. We eliminated turnovers where there were staff changes, because we could not identify what part each staff member had in turnover responsibilities. Also excluded were add-on cases at the end of the day because the case equipment may not have been readily available or complete. Because our hospital does not employ staff specifically for orthopedics, selection bias in categorizing staff could be present, although categorizing staff by the percentage of cases within a specialty helped to determine frequency and experience in cases. Our results support the strategy of using orthopedic-specific staff for hand surgery to decrease OR turnover time. Implementing this strategy in a prospective manner in a similar setting with a cost model analysis could validate these results and ascertain its economic benefits.
reduce or redistribute the OR staff earlier in the day, perhaps preventing increased overtime or on-call pay. Our study demonstrated that having consistent OR staff well versed in orthopedic surgery increased efficiency. We believe this falls in line with other studies such as Stepaniak et al6 and Attarian et al4 that demonstrated working with a consistent OR staff lowered turnover time. All orthopedic-specific staff familiar with the practice should perform at a similar level of efficiency, even if rotated through breaks or lunches throughout the day. It also agrees with one of the hindrances identified by Scheriff et al7 that limitations in staff familiarity with procedures decreases OR efficiency. With the frequency of use of wrist arthroscopy and microscopes, it is also feasible that dedicated orthopedic staff would be more competent with the setup, draping, and maneuvering of these devices to decrease perioperative time, analogous to the results of Lasser et al5 with dedicated staff in robot-assisted prostatectomy. In our study, the worst turnover time was not with the combination of nonorthopedic technician and circulator but with an orthopedic surgical technician and a nonorthopedic circulator. The explanation may be that when our group identifies that we have unfamiliar staff, we (attending, resident, or physician assistant) tend to assist in room preparation. We feel the difference between these groups is reflective of additional assistance outside of what we studied. Our study has several strengths. It evaluated a large contiguous segment of cases performed at one institution with consistent staff. We took care to eliminate confounding variables such as only evaluating single operating suite days and removing obvious prolonged turnover times due to equipment availability issues, level I trauma holds, and so forth. By analyzing less complex operative cases and excluding polytrauma and longer microvascular procedures, the instrumentation required to perform a majority of these surgeries is minimal. We used objectively recorded patient-out and patient-in times, which do not rely on a surgeon’s perception and which do not include induction and waking the patient from general anesthesia or time taken to transfer the patient to and from the operating table. Elective outpatient cases were reviewed to eliminate the sometimes-prolonged times while transporting in-patients and preparing them for surgery. Therefore, only patients with stable comorbidities were analyzed. Although not a separate entity, our hospital ambulatory surgical center functions similar to stand-alone entities with its own preoperative holding area and with a consistent anesthesiologist and nurse anesthetist staff. A majority of patients underwent procedures with local anesthesia and light J Hand Surg Am.
REFERENCES 1. Innovative approaches to turnover time. OR Manager. 2006;22(3):5, 7. 2. Patterson P. Time busters: a lean team tackles OR turnover. OR Manager. 2011;28(7):6e8. 3. Patterson P. Restructuring circulator nurse role aids turnover. OR Manager. 2012;28(7):9e10, 12. 4. Attarian DE, Wahl JE, Wellman SS, Bolognesi MP. Developing a high-efficiency operating room for total joint arthroplasty in an academic setting. Clin Orthop Relat Res. 2013;471(6):1832e1836. 5. Lasser MS, Patel CK, Elsamra SE, Renzulli II JF, Haleblian GE, Pareek G. Dedicated robotics team reduces pre-surgical preparation time. Indian J Urol. 2012;28(3):263e266. 6. Stepaniak PS, Vrijland WW, de Quelerij M, de Vries G, Heij C. Working with a fixed operating room team on consecutive similar cases and the effect on case duration and turnover time. Arch Surg. 2010;145(12):1165e1170. 7. Scheriff K, Gunderson D, Intelisano A. Implementation of an OR efficiency program. AORN J. 2008;88(5):775e789. 8. Dexter F. Why try to reduce turnover time? OR Manager. 2000;16(1): 25e26. 9. Patterson P. Turnover? Focus on everything else. OR Manager. 2011;27(4):20e22.
r
Vol. 39, January 2014
The Efficiency of a Dedicated Staff on Operating Room Turnover Time in Hand Surgery Daniel M. Avery III, MD, Kristofer S. Matullo, MD
Purpose To evaluate the effect of orthopedic and nonorthopedic operating room (OR) staff on the efficiency of turnover time in a hand surgery practice. Methods A total of 621 sequential hand surgery cases were retrospectively reviewed. Turnover times for sequential cases were calculated and analyzed with regard to the characteristics of the OR staff being primarily orthopedic or nonorthopedic. Results A total of 227 turnover times were analyzed. The average turnover time with all nonorthopedic staff was 31 minutes, for having only an orthopedic surgical technician was 32 minutes, for having only an orthopedic circulator was 25 minutes, and for having both an orthopedic surgical technician and a circulator was 20 minutes. Statistical significance was seen when comparing only an orthopedic surgical technician versus both an orthopedic circulator and a surgical technician and when comparing both nonorthopedic staff versus both an orthopedic circulator and a surgical technician. Conclusions OR efficiency is being increasingly evaluated for its effect on hospital revenue and OR staff costs. Reducing turnover time is one aspect of a multifaceted solution in increasing efficiency. Our study showed that, for hand surgery, orthopedic-specific staff can reduce turnover time. (J Hand Surg Am. 2014;39(1):108e110. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Economic/Decision Analysis III. Key words Hand surgery, operating room efficiency, turnover time.
O
VER THE PAST DECADE,
efficiency in the operating room (OR) has become an area of focus for many hospitals. With an increasing patient population, increasing cost of procedures, and decreasing reimbursements, it is challenging to deliver quality care in the rapidly changing health care system. Numerous studies have looked at various strategies to increase efficiency to keep ORs financially more viable.1e8 Most of these studies have shown From the Division of Hand Surgery, St. Luke’s University Health Network; the Department of Orthopaedic Surgery, St. Luke’s Hospital, Bethlehem, Pennsylvania. Received for publication April 23, 2013; accepted in revised form September 26, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Kristofer S. Matullo, MD, St. Luke’s University Health Network, 801 Ostrum Street, PPH-2, Bethlehem, PA 18015; e-mail: [email protected]. 0363-5023/14/3901-0016$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.09.039
108
r
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
that decreasing the turnover time between cases isone way of making a surgeon’s and staff’s throughput easier.1e8 However, many of these studies have examined all specialties within their system or focused on a specialty other than hand surgery.1e9 In orthopedics, only turnover time for total joint arthroplasties has been examined for strategies to increase efficiency.5 Hand surgery stands as a unique subset of orthopedics to benefit from increased OR efficiency. Even minimal reductions in time between cases could translate to additional scheduling of cases because hand surgery cases often take far less time than other orthopedic OR procedures. This study was conducted to evaluate the effect of OR staff on the efficiency of turnover time in a hand surgery practice. Our hypothesis was that having an orthopedic surgical technician and a circulating nurse would reduce turnover time when compared with
109
EFFICIENCY OF STAFF ON OPERATING ROOM TURNOVER TIME
TABLE 1.
Number of Turnovers and Average Time by Staff Category OR Staff
Number of Turnovers
Average Turnover Time in Minutes (range)
Nonorthopedic surgical technician and circulator
53
30.5 (9e67)
Orthopedic surgical technician and nonorthopedic circulator
71
31.9 (7e88)
Nonorthopedic surgical technician and orthopedic circulator
34
24.8 (4e69)
Orthopedic surgical technician and circulator
69
19.8 (5e58)
227
Total
26.8
nonorthopedic staff in a hospital ambulatory surgery center environment.
using a Student 2-tailed t test assuming equal variance. A P of less than .05 denoted statistical significance.
MATERIALS AND METHODS After approval by our institutional review board, we conducted a retrospective review of K.S.M.’s case logs for hand surgery cases from July 2011 to June 2012 at our level I academic institution. All cases were performed in our outpatient ambulatory surgery center, located within the main hospital. A total of 621 sequential cases were identified, and operative records were reviewed. Cases included for evaluation were elective hand-specific cases regardless of patient age and running sequentially in a single operating suite but not involving microsurgery. Cases were excluded when the hand surgeon operated simultaneously in multiple operating suites, when they involved acute trauma care on inpatients, when cases were performed outside standard day shift hours (8:00 AMe3:00 PM), when turnover times greater than 90 minutes were likely outside the control of the OR staff, when there was a change of staff between cases, and when records were incomplete or electronically unavailable. Turnover time was defined as the difference between the time the previous patient left the room and the time the following patient came into the room as recorded in the nursing record. The OR surgical technician and circulating nurse were categorized for each turnover time as being either orthopedic staff or nonorthopedic staff. Individuals were classified as orthopedic staff if greater than 75% of their typical time in the operating room was spent delivering care to orthopedic patients or performing orthopedic procedures. All nurses and technicians were nonunionized, non-incentivized hospital employees compensated according to an equal and standardized pay rate regardless of specialty.
RESULTS A total of 227 turnover times were included. Of these, 53 turnovers were performed with both nonorthopedic circulators and surgical technicians, 71 turnovers were performed with an orthopedic surgical technician and a nonorthopedic circulator, 34 turnovers were performed with a nonorthopedic surgical technician and an orthopedic circulator, and 69 turnovers were performed with both an orthopedic surgical technician and an orthopedic circulator. The average turnover time in all cases, irrespective of staff, was 27 minutes. The average turnover time with respect to the type of staff involved is reported in Table 1. The differences in turnover time (11 min) was significantly different when a complete nonorthopedic staff was compared with a complete orthopedic staff (P ¼ .005). Also the differences in turnover time (12 min) were significant when an orthopedic technician was compared with a complete orthopedic staff (P < .001). The other differences were statistically insignificant. DISCUSSION Increasing OR efficiency is a multifaceted task that includes turnover time, Dexter8 and Patterson2 advised that hospitals should focus on other aspects of OR efficiency such as perioperative nursing preparation, communication within the OR, and anesthesia policies such as performing pre-procedural regional blocks. However, their advice was based on observing multiple specialties with operations requiring long operative times. Hand surgery, with many procedures of less than 1 hour long, falls into one of the exceptions cited by Dexter.8 For example, if a hand surgeon performed 10 cases per day, the difference in turnover time between all orthopedic staff and nonorthopedic staff would be approximately 96 minutes. This efficiency would possibly allow time for additional cases or could
Statistics Turnover times were logged into a spreadsheet based on their respective staff grouping. Average turnover time and analysis between staff groups were compared J Hand Surg Am.
r
Vol. 39, January 2014
110
EFFICIENCY OF STAFF ON OPERATING ROOM TURNOVER TIME
sedation. At our institution, the patient is transported into the room only after the room is completely set up. All turnover times are reflective of actual times to prepare the room for the next case. The possibility of hurrying turnover by opening equipment after the patient is in the operating suite is, therefore, eliminated. Lastly, one surgeon performed all cases. With this information, variables such as differing instrumentation and preferences by multiple surgeons were not factors. The surgeon did not change the quality of care delivered to each patient or typical operative technique in an attempt to increase speed or decrease turnover. Our study also has several limitations. The retrospective nature of the study did not allow for precise identification of confounding variables such as equipment or anesthesia delay; however, we feel that such variables outside of the surgical team would be present despite orthopedic experience. We eliminated turnovers where there were staff changes, because we could not identify what part each staff member had in turnover responsibilities. Also excluded were add-on cases at the end of the day because the case equipment may not have been readily available or complete. Because our hospital does not employ staff specifically for orthopedics, selection bias in categorizing staff could be present, although categorizing staff by the percentage of cases within a specialty helped to determine frequency and experience in cases. Our results support the strategy of using orthopedic-specific staff for hand surgery to decrease OR turnover time. Implementing this strategy in a prospective manner in a similar setting with a cost model analysis could validate these results and ascertain its economic benefits.
reduce or redistribute the OR staff earlier in the day, perhaps preventing increased overtime or on-call pay. Our study demonstrated that having consistent OR staff well versed in orthopedic surgery increased efficiency. We believe this falls in line with other studies such as Stepaniak et al6 and Attarian et al4 that demonstrated working with a consistent OR staff lowered turnover time. All orthopedic-specific staff familiar with the practice should perform at a similar level of efficiency, even if rotated through breaks or lunches throughout the day. It also agrees with one of the hindrances identified by Scheriff et al7 that limitations in staff familiarity with procedures decreases OR efficiency. With the frequency of use of wrist arthroscopy and microscopes, it is also feasible that dedicated orthopedic staff would be more competent with the setup, draping, and maneuvering of these devices to decrease perioperative time, analogous to the results of Lasser et al5 with dedicated staff in robot-assisted prostatectomy. In our study, the worst turnover time was not with the combination of nonorthopedic technician and circulator but with an orthopedic surgical technician and a nonorthopedic circulator. The explanation may be that when our group identifies that we have unfamiliar staff, we (attending, resident, or physician assistant) tend to assist in room preparation. We feel the difference between these groups is reflective of additional assistance outside of what we studied. Our study has several strengths. It evaluated a large contiguous segment of cases performed at one institution with consistent staff. We took care to eliminate confounding variables such as only evaluating single operating suite days and removing obvious prolonged turnover times due to equipment availability issues, level I trauma holds, and so forth. By analyzing less complex operative cases and excluding polytrauma and longer microvascular procedures, the instrumentation required to perform a majority of these surgeries is minimal. We used objectively recorded patient-out and patient-in times, which do not rely on a surgeon’s perception and which do not include induction and waking the patient from general anesthesia or time taken to transfer the patient to and from the operating table. Elective outpatient cases were reviewed to eliminate the sometimes-prolonged times while transporting in-patients and preparing them for surgery. Therefore, only patients with stable comorbidities were analyzed. Although not a separate entity, our hospital ambulatory surgical center functions similar to stand-alone entities with its own preoperative holding area and with a consistent anesthesiologist and nurse anesthetist staff. A majority of patients underwent procedures with local anesthesia and light J Hand Surg Am.
REFERENCES 1. Innovative approaches to turnover time. OR Manager. 2006;22(3):5, 7. 2. Patterson P. Time busters: a lean team tackles OR turnover. OR Manager. 2011;28(7):6e8. 3. Patterson P. Restructuring circulator nurse role aids turnover. OR Manager. 2012;28(7):9e10, 12. 4. Attarian DE, Wahl JE, Wellman SS, Bolognesi MP. Developing a high-efficiency operating room for total joint arthroplasty in an academic setting. Clin Orthop Relat Res. 2013;471(6):1832e1836. 5. Lasser MS, Patel CK, Elsamra SE, Renzulli II JF, Haleblian GE, Pareek G. Dedicated robotics team reduces pre-surgical preparation time. Indian J Urol. 2012;28(3):263e266. 6. Stepaniak PS, Vrijland WW, de Quelerij M, de Vries G, Heij C. Working with a fixed operating room team on consecutive similar cases and the effect on case duration and turnover time. Arch Surg. 2010;145(12):1165e1170. 7. Scheriff K, Gunderson D, Intelisano A. Implementation of an OR efficiency program. AORN J. 2008;88(5):775e789. 8. Dexter F. Why try to reduce turnover time? OR Manager. 2000;16(1): 25e26. 9. Patterson P. Turnover? Focus on everything else. OR Manager. 2011;27(4):20e22.
r
Vol. 39, January 2014
