➢ In the operating room setting, optimal efficiency is achieved by the ability to deliver the highest-quality care with the minimal use of time, money, and space.
➢ Optimization of the operating room team by minimizing team size, staff turnover, and operating room traffic flow is essential for improving operating room efficiency.
➢ Surgeon dissatisfaction in response to forced modification of techniques and equipment may negate any improvements resulting from implemented operating room efficiency strategies, leading to suboptimal performance.
➢ A combination of preoperative briefings and postoperative debriefings can yield continuous improvements in surgical processes and can promote a positive operating room environment, leading to improved operating room efficiency.
➢ Parallel processing is a system of operating room scheduling in which the first phase of the second operation and the last phase of the first operation are parallel to each other in time, with the largest value of this process being dependent on the amount of parallel time. The benefit of parallel processing relies on the amount of time overlapped between subsequent procedures and effective utilization of surgeon idle time.
➢ The implementation of an operating room dedicated to emergency trauma procedures decreases the amount of disruption and the rate of cancellation of elective procedures due to unpredictable events, which may lead to cost savings in Level-I trauma centers.
Health-care expenditure in the United States is continually rising and is expected to reach $2.5 trillion by 20231. Not only are health-care costs rising, but their percentage of the gross domestic product is rising as well2. This progressive increase in cost and allocated funds has propelled the drive toward a more productive health-care system that continues to focus foremost on patient care3. There is a push for value within medicine, with an emphasis on decreasing unnecessary costs, improving efficiency, and retaining superior patient care4. Specifically, the operating room has been a target for improvements. At most institutions, the operating room is the foundation for financial gain, producing the majority of the hospitals’ gross revenue, with operating room costs averaging $62/min (range, $22/min to $133/min)5,6. However, it is also an area of large—and, at times, unnecessary—expenditure and resource allocation. The operating room has also been the subject of substantially decreased reimbursement rates, which, in addition to the increased cost and expenditure, ultimately would lead to decreased net revenues7. This makes the surgical process an excellent candidate for modification toward increased efficiency with high-yield, profitable results. We define the surgical process as the activities constituting three phases of the operating room experience: preoperative, intraoperative, and postoperative. Each phase is individually amenable to improvement via strategies to increase efficiency.
Restated from Part 1 of this two-part article, “efficiency” is defined as the relationship between time, cost, and quality (http://reviews.jbjs.org/content/3/10/e3)8. Quality involves safety, improved outcomes, and satisfaction of both the patient and the staff. Generally, a facility utilizing strategies to decrease intraoperative and postoperative time and cost within the surgical process can maintain optimal patient-centered care within the facility while also gaining financial stability6,7,9,10.
Operating room efficiency strategies leading to cost reduction may be particularly effective in the field of orthopaedics as the surgical interventions are costly, yet the demand for such procedures is expected to rise in the upcoming years10,11. This increased demand is due, in part, to the increase in the population of patients who are sixty-five years of age and older, who identify musculoskeletal ailments as the primary limitation on activities of daily living10,12. Furthermore, Medicare reimbursement for total joint arthroplasty has not paralleled the increased cost of the prosthetics themselves, thus providing an additional incentive for institutions to implement strategies to maintain a positive financial balance7,13. In Part 1 (http://reviews.jbjs.org/content/3/10/e3), we focused on operating room efficiency improvements related to general managerial ideals and preoperative-phase strategies within the field of orthopaedics8. In the current article, we will emphasize the intraoperative and postoperative phases.
Intraoperative Strategies for Improving Operating Room Efficiency (Table I)
Operating Room Staff Management
The majority of surgical adverse events occur intraoperatively, often as a result of poor communication and organizational structures14. A surgeon’s ability to provide efficient and optimal care to his or her patients is only as strong as the team with which he or she works. This team includes the surgical staff as well as the individuals associated with patient preparation, transport, and postoperative care6. Survey results have shown that there is a low level of knowledge about operating room efficiency principles among surgical staff, suggesting that education alone may provide a foundation of improved awareness and behavior, enabling staff to actively seek out efficiency improvements15.
A powerful nidus for change in the operating room is surgeon commitment to the efficiency-improvement project3. Attarian et al. reported that surgeons who lead by example in the operating room were influential in ensuring team adherence, whereas the failure to support new processes often resulted in apathy toward the project by other staff members3. Higgins et al. observed that poorly delineated operating room hierarchies result not only in longer delays but also in a greater potential for tension and frustration between staff members16. Clarification of professional responsibilities influences how delays are handled and who is ultimately responsible for making final decisions. Operating room delays potentially can be anticipated and averted through a well-established professional hierarchy16.
An operating room staff that is dedicated to a specific surgical specialty can increase operating room throughput while preserving patient care17,18. Additionally, a specialized team assigned to individual surgeons may present further team harmony and efficiency3. Retrospective studies from the United States, Canada, and China found a positive correlation between the number of operating room attendees and procedure time, with up to 34.7 minutes added for each additional person19-21. Additionally, staff turnover has been identified as a source of increasing procedure time and safety compromise in multiple studies, with the majority of the increased time being attributed to nurses for reasons such as lunch and other breaks14,16. The presence of extra attendees in the operating room also increases operating room traffic flow, which has been found to increase the risk of postoperative infections due to air contamination22. Thus, optimization of the operating room team by minimizing team size, staff turnover, and operating room traffic flow is essential for improving operating room efficiency.
Pugely et al. investigated the effects of surgical educational participants (residents and medical students) on operative time and found a potential for delay23. While this is an obvious source of operating room inefficiency, the benefit of medical education and sustained production of high-quality future surgeons currently relies on learner participation within the operating room24. Innovations in surgical simulation technology provide promising alternatives that reduce the need for intraoperative learning, thereby leading to improved operating room efficiency24. Cannon et al. found that, in an academic center, residents who had experience with a virtual reality arthroscopic knee simulator performed at a higher skill level compared with those who received traditional orthopaedic resident education25. The method described by those authors would provide residents with technical skills via simulators, with the goal of further developing those skills later in the operating room without the effect of causing delay25.
Operating Room Supplies
An understanding of a facility’s instrument inventory may result in better operating room efficiency by enabling operating room managers to track instrument use and availability26-28. Recently, two wireless instrument-tracking systems have been described, real-time locating and radiofrequency identification (RFID)26. These systems identify which instruments are seldom used, which are available in excess, and which are frequently in need26-28. RFID has been investigated for its potential use in health care owing to its tracking and organizational capabilities, which have been shown to be superior to those of current barcode systems. This technology may reduce costs, improve patient safety, and improve supply chain management by increasing an institution’s ability to track equipment, monitor theft, and improve distribution management27-30. The expenditure for this system ranges from $200,000 to $1,000,000, and a lack of cost-analysis investigation provides a barrier to utilization27-30.
A proper supply-management practice coordinates multiple processes to achieve optimal efficiency, including inventory, location, and transportation of surgical equipment31. Within the operating room, a well-defined supply-chain process can be difficult to establish but is efficacious for impacting health-care costs and patient care. By focusing on these needs alongside surgeon preference, a standardization of commonly used equipment could potentially be implemented, reducing the variability in the purchasing and setup of instruments32. In addition, reducing equipment tray variability between surgeons for common procedures may decrease wasted time by decreasing the workload of setup and minimizing confusion among surgical assistants. Implementing a supply-chain process can yield an estimated 15% to 30% reduction in supply costs per fiscal year32. However, potential surgeon dissatisfaction in response to forced modification of their techniques and equipment may lead to suboptimal performance, negating any improvements resulting from this strategy33.
Single-use instruments such as polycarbonate-polymer-based cutting blocks, saws, and size-specific trials can decrease orthopaedic operating room time and costs34,35. The demonstrated benefit of such instruments is primarily derived from their potential to decrease the duration of instrument setup and/or cleanup35. Single-use instruments may decrease the number of reusable instrument trays opened per case, resulting in cost savings due to decreased tool utilization and need for sterilization34. Reprocessing single-use equipment also has been evaluated with the goal of cost savings36. Sikka et al. described a list of orthopaedic devices approved for such use; however, these devices must contain the same level of sterility and functionality as novel equipment36.
Single-use instruments may have the additional benefit of reducing the risk of postoperative infections compared with standard reusable instruments35. A potential explanation is that incomplete sterilization of standard, multi-use tools may lead to septic sequelae, which are less prevalent with single-use instrumentation35. At this time, evidence is lacking and more investigation is needed.
Innovations in Surgery
Within the field of surgery, intraoperative equipment is at the forefront of innovation. The effect of these newly designed instruments on operating room efficiency should be well analyzed and described.
Patient-matched instrumentation, a technique involving the use of magnetic resonance imaging (MRI) or computed tomography (CT) images to engineer patient-specific cutting blocks, has received interest in the setting of total knee arthroplasty37-42. These blocks, designed on the basis of patient native anatomy, were expected to reduce intraoperative time while producing a better-aligned, more functional knee. Actual patient results and cost effectiveness, however, are still topics of debate37-42. Tibesku et al. found that the overall savings gained with patient-matched instrumentation offset the higher expenses of the customized block and the preoperative imaging (with a twenty-minute decrease in preparation time, a ten-minute decrease in cutting time, and a decrease in surgical tray utilization)37. Other studies have demonstrated only a potential benefit of patient-matched instrumentation, with minor improvements in the alignment of the prosthetic components, intraoperative time, and/or impact on the future need for revision total knee arthroplasty40,41. Slover et al. concluded that with an additional cost of $2500 ($1000 per custom block and $1500 per MRI), the application of patient-matched instrumentation would only be cost-effective if custom block expense and/or revision rates were considerably reduced40. Some studies have demonstrated no overall improvement in component alignment or reduction in operative time in association with the use of patient-matched instrumentation39-42. In addition, excessive preoperative time spent to acquire the MRI scans and to approve the patient-matched instrumentation engineering plans (five to fifteen minutes per case) are potential sources of delay39,42. Similar to using a patient’s native anatomy to produce patient-matched instrumentation, manufacturers are also designing custom femoral and tibial components for total knee arthroplasty43. Increased cost without added benefit is a primary concern related to custom total knee arthroplasty prostheses43. As there is a very wide range of findings related to patient-matched instrumentation, more information will be needed before recommendations regarding future utility and the effect on operating room efficiency can be made.
Advances in Equipment and Prosthetic Alignment
Another avenue of exploration for improving the process of prosthetic alignment includes assisted component-positioning techniques. The utilization of CT, radiographs, imageless techniques with an optical line of sight, and electromagnetic systems has not been reported to improve the accuracy and duration of component placement compared with standard techniques44. Robotic technologies can increase the precision of total knee arthroplasty procedures and may work synergistically with computer-navigated systems, but further studies are needed to determine their cost-effectiveness44.
Multiple computer-automated systems within the operating room may lead to incompatible control and communication standards45. To resolve this potential delay, a unified interface and communication system, such as Surgical Operative Network (SurgON), may be used to reduce complexity and provide more unified control over operating room systems46. This is a relatively new front in the field of orthopaedic surgery, with limited data. It is unknown if such systems will have a substantial impact on operating room efficiency and/or patient care.
There has been recent interest in using CT-image guided surgery (CT-IGS) in place of the traditional fluoroscopic images in spinal surgery47,48. One study demonstrated improved pedicle screw placement in association with the use of CT-IGS during sacral spine revision surgery47. Another study demonstrated no major difference in pedicle screw breach rates using either method; however, the investigators noted that CT exposed surgeons to more radiation and cadaveric subjects to less radiation48. The converse was true for fluoroscopy48. Hahn et al. investigated the potential use of an electromagnetic navigation system to improve pedicle screw placement and found no considerable advantages in association with this technology49. However, the ease of use and short setup time could be exploited in the future, with the advancement of this technology, as a method of improving operating room efficiency49.
Wound closure material is worthy of discussion in the move toward a more efficient operating room11,46,50-52. Previous studies in the literature have compared barbed sutures, staples, adhesives, and/or interrupted suture techniques for surgical incision closure in total joint arthroplasty in terms of their effects on procedure duration, complication rates, and cost11,46,50-52.
Multiple studies have demonstrated no substantial difference between barbed and traditional sutures with respect to incision length, complication rates, and wound-related outcomes in patients undergoing total knee and total hip arthroplasty11,50,51. However, several studies have demonstrated that barbed sutures result in less material and time being needed for incision closure during both total knee arthroplasty and total hip arthroplasty, leading to considerable cost reduction50,51. In fact, Smith et al. reported that the use of barbed sutures provided a calculated net savings of approximately $549.59 per arthroplasty51. Staples also may reduce closure times compared with barbed sutures during knee arthroplasty, with lower complication rates at twelve months of follow-up52. Hemming et al., in a meta-analysis, reported that staples reduced the mean operating time, yet there was no clear evidence that staples performed better than sutures in terms of postoperative outcome, the rate of surgical site infection, and the length of stay53. Similarly, both staples and adhesives have been reported to provide faster means of closure than traditional subcuticular suture for total knee arthroplasty54. Eggers et al. suggested the use of adhesives for cutaneous closure, with reinforcement of the underlying subcutaneous layer, as staple closure potentially increases the average length of hospital stay54. While the cause of increased length of stay was difficult to discern, Eggers et al. suggested that the increased drainage associated with staple closure might negatively affect the patient’s perception of well-being, eventually increasing the length of stay54.
Overall, barbed sutures may provide substantial cost and time savings compared with traditional sutures, but adhesives and staples provide the fastest means of wound closure during total joint arthroplasty procedures. The reluctance of surgeons and operating room supervisors to change to new materials and/or wound closure techniques may be barriers to improvement with this strategy; thus, educational programs may be useful for ensuring its success.
Postoperative Strategies for Improving Operating Room Efficiency (Table II)
Perioperative Briefings and Debriefings
Preoperative briefing is a tactic that is used to prepare the surgical team for the day’s scheduled procedures in terms of staff expectations, instrumentation, surgical techniques, and potential complications55,56. Likewise, postoperative debriefings provide feedback on each team member’s performance56-59. A combination of these two practices can yield continuous improvements in surgical processes and promote a positive operating room environment57.
The Veterans Health Administration (VHA) National Center for Patient Safety implemented the Medical Team Training Program to improve patient safety and operating room efficiency with checklist-driven preoperative briefings and postoperative debriefings57. The same authors also reported that strong organizational support and facility leadership are major predictors of program success57. Similarly, an electronic postoperative team debriefing system using input from all team members prior to leaving the operating room was found to stimulate an effective “after-action” discussion58. This system allowed for case analysis, identification of delay etiology, and gathering of suggested strategies for future improvement. After one year of implementation, a 9% decrease in mean delay time and a 39% reduction in overall un-utilized operating room time was achieved. Through the immediate identification of each delay as well as the root cause leading to it, the team was able to directly address and avoid specific problems, leading to reduced operating room time58.
Debriefing strategies improve communication and workflow among the members of an operating room team56-58. However, the use of such strategies in the academic setting has been meager. Attending surgeons and surgical residents both agree that debriefing would be beneficial and ideally should be provided during and after each procedure, but feedback has been reported to occur in <50% of all surgical cases59. Lack of time was reported to be the most common barrier hindering utilization, yet the absence of a debriefing culture within the field of surgery may be a more valid cause59.
Considerable improvements in turnover time and financial yield consistently have been produced with parallel processing variations by decreasing nonoperative operating room time between cases28,60-64. Parallel processing is a system of operating room scheduling in which subsequent operations are staggered in order to ensure that the second operation starts before the first is finished60. The name of this process is derived from the idea that the first phase of the second operation and the last phase of the first operation are essentially parallel to each other in time60. While there are many ways to adapt a parallel processing system to an individual institution, these systems generally include a designated room to allow for the induction of anesthesia before the patient is transported to the operating room18,60-62. According to Duffy, effective implementation of parallel processing utilizes two specialty-specific operating room teams, with an emphasis on standardization of techniques and limiting variability in instrument use62. Batun et al. developed computational theoretical models to assess the impact of parallel processing and operating room pooling on surgical schedules60. Operating room pooling is a process that relies on sharing the available operating rooms among surgeons as an alternative to the typical block-booking approach wherein an operating room is assigned to a surgeon for a prolonged period of time60. These models indicated that the value of parallel processing is largely dependent on the amount of parallel time (i.e., the amount of time available to overlap between a surgeon’s subsequent procedures) and the cost of surgeon idle time60.
One computerized simulation study suggested that a system utilizing a central anesthesia induction room, which included additional personnel consisting of two anesthesia nurses, one instrument nurse, and one anesthesiologist, could lead to the largest financial savings compared with the traditional parallel processing setup61.
Well-defined staff roles ensure productive involvement of all team members between cases, as outlined previously, and may play a role in optimizing parallel processing18. Additional efficiency may be obtained when assigning the task of closing the incision to a qualified member of the operating room team so that the surgeon can begin the next case sooner62.
Smith et al. implemented a combination of parallel processing strategies by creating an induction room adjacent to a designated high-throughput operating room for arthroplasties; hiring an additional circulating nurse for induction room care; recruiting a post-anesthesia care unit nurse to retrieve patients postoperatively; and instituting other minor changes such as providing radios to transport personnel, adding a dedicated recovery room nurse to aid in transporting patients from the operating room to the post-anesthesia care unit, and providing a medication-dispensing machine in the induction area to decrease foot traffic28. They achieved a 50% reduction in nonoperative time (thirty-six minutes per case) as well as a 19.6% improvement in financial contribution margin, despite the increased equipment and salary cost28.
Reconfiguration of staff members, including the development of new positions within the operating room and redefining the utility of staff switches, can improve operating room turnover time64,65. New positions such as a so-called support associate (who aids the scrub nurse in cleaning the operating room) and registered nurse first assistant (who cares for the patient on the way to the post-anesthesia care unit) may reduce turnover time by five to ten minutes per case64. These new positions can allow the circulating nurses to set up for the following case in a more timely fashion64.
In addition to the previously mentioned benefits, the use of a dedicated operating room staff may serve as an aid to appreciably reduce mean turnover time65,66. Specifically, benefits lie in repetitive tasks via the utilization of constant surgical teams who are highly familiar with the patients as well as the scheduled procedures65,66.
A recent study described the potential for operating room turnover-time improvement secondary to a financial incentive program for surgical staff within an academic trauma center67. In this program, the staff members were rated via a point system based on the percentage of turnover times of less than sixty minutes67. The larger the percentage, the greater the financial compensation. This program led to improvement in terms of on-time starts and turnover times, with an estimated total cost savings of $210,00067.
Decreasing the nonoperative time between surgical procedures has the highest potential for benefit when achieved within a schedule containing multiple short procedures in which the ratio of turnover time to operative time is the highest64. As such, hospitals can benefit by utilizing high-throughput rooms that enable surgeons to perform more procedures in a given day with a decreased turnover time-to-operative time ratio64.
Another consideration may be a facility’s ability to track and better predict patient turnover time in association with various procedures and various surgeons68. Marchand-Maillet et al. explored the possibility of using RFID technology in an academic center to record data on the length of stay from admission to discharge68. The use of such technology would allow for the establishment of a database for every surgeon’s case time, enabling more accurate future prediction of patient length of stay and discharge time68. As those data remain recent, their usefulness has yet to be thoroughly examined; however, they may support the development of a powerful tool in minimizing turnover times through schedule optimization68.
Reducing Post-Anesthesia Care Unit Delays
Postoperatively, patients may be transported to the post-anesthesia care unit or intensive care unit. Delayed discharge from the post-anesthesia care unit can produce a so-called bottleneck effect that disrupts surgical throughput69-72. Services with multiple short-duration procedures, including orthopaedic surgery, most often experience surgical delays secondary to post-anesthesia care unit backup69. While the delays may occur for unavoidable reasons, 15% of delayed discharges may be due to nonclinical reasons69. Poor post-anesthesia care unit processing is often associated with lack of predefined management and discharge criteria69,73.
A fairly consistent implementable strategy includes handover standardization via checklists and protocols. Better-structured clinical activities that decrease distraction by limiting disruptions and allocating time for staff questions are key to more efficient post-anesthesia care unit throughput and lessened backup72.
Fast-track post-anesthesia care unit methodologies (or so-called post-anesthesia care unit bypass methodologies) have been implemented as additional pathways for postoperative care71,73,74. Eichenberger et al. applied a nurse-driven fast track and a physician-driven slow track to guide post-anesthesia care unit patient care73. Stable patients followed the fast track, in which post-anesthesia care unit nurses could discharge them on the basis of vital signs and a pain assessment score, without the need of a physician referral. The slow track was reserved for higher-risk patients, for whom more comprehensive discharge criteria were used. This program led to significant decreases in the median length of stay in the post-anesthesia care unit (decrease, fifteen minutes; p < 0.001) and postoperative mortality rates (decrease, 0.8%; p < 0.001)73. In addition, Watkins and White’s criteria, which assess levels of consciousness, physical activity, hemodynamic stability, respiratory stability, oxygen saturation, pain assessment, and emetic symptoms, have been used to guide the decision to bypass74. However, patients utilizing bypass are three times more likely to require step-down nursing interventions than those utilizing the post-anesthesia care unit; thus, nursing staff must be able to sustain this strategy75.
Dedicated Emergency Trauma Operating Rooms
Many of the strategies discussed in this section are valuable for improving operating room efficiency yet fail to anticipate unplanned, emergency trauma surgery. Without a functional system, a delay in emergency surgery as well as cancellations of elective surgical procedures could result in negative financial and patient-care implications76-78.
A potential beneficial approach is the implementation of an operating room dedicated to trauma procedures only76-78. In addition to decreasing postoperative morbidity, mortality, and length of stay, the use of rooms that were specifically designated for trauma cases decreased the rate of cancellation of elective procedures76-78.
While a cost analysis was not performed, decreasing the amount of disruption due to unpredictable events may lead to cost savings. This intervention is economically sustained in Level-I trauma centers because of the high volume of procedures yet is unlikely to be economically efficient in Level-II or III trauma centers. Further investigation is needed to validate the utilization of this strategy as common practice.
Strategies for improving the operative process are essential in today’s health-care environment, given the current financial strains among medical facilities. Many strategies pertaining to the intraoperative and postoperative stages have been explored during the race to produce an optimally efficient operating room. Presenting these strategies is essential as surgeons are often most directly involved with these processes.
One of the most important foundations to achieving a more efficient operating room was found to be the demeanor of the surgeons involved. It is crucial that the surgeon assume a leadership role, as an educated, well-guided team can yield optimal efficiency. Furthermore, compliance of the surgeon with new strategies is often a hinge point for method acceptance. Complete support of the new concept more likely leads to success, whereas rejection by the surgeon is unlikely to yield measurable effects.
Additionally, surgeons are frequently introduced to novel operating room equipment that may improve operating room efficiency, including supply-tracking systems, instruments for improved component alignment, new incision-closure materials, and patient-specific prostheses. However, further studies are required to delineate a clear effect on operating-room efficiency.
Several published studies have focused on the optimization of parallel processing strategies, and the results are promising18,28,60-64. Similarly, studies regarding postoperative patient care have shown that manipulation of post-anesthesia care unit organization can improve operating room throughput by relieving downstream delays69-75. A trauma-dedicated operating room might improve operating room efficiency in Level-I trauma centers as a result of the high volume of procedures.
No single solution for improving operating room efficiency exists. Instead, multiple strategies are necessary to achieve the optimal balance in this multifactorial problem. Thus, identification of the root causes of suboptimal operating room efficiency at each individual facility is essential for personalizing remedies that produce the most impactful improvement.
Source of Funding: The authors declare that they possess no conflicts of interest in this study and that no external funding, apart from the support of the authors’ institutions, was utilized for this study.
Investigation performed at the Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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