Dedicated Orthopedic Operating Room Unit Improves Operating Room Efficiency

doi:10.1016/j.arth.2013.01.033

The Journal of Arthroplasty

Volume 28, Issue 7, August 2013, Pages 1066-1071.e2

https://doi.org/10.1016/j.arth.2013.01.033 Get rights and content

Abstract

We investigated the effectiveness of dedicated orthopedic operating rooms (OR) on minimizing time spent on perioperative processes to increase OR throughput in total knee and hip arthroplasty procedures. The use of a dedicated orthopedic unit that included 6 ORs with staff allocated only for those ORs was compared to the use of a traditional staffing model. After matching to simulate randomization, each group consisted of 422 procedures. The dedicated orthopedic unit improved average anesthesia controlled time by 4 minutes (P < .001), operative time by 7 minutes (P = .004) and turnover time by 8 minutes (P < .001). An overall improvement of 19 minutes per procedure using the dedicated unit was observed. Utilizing a dedicated orthopedic unit can save time without increasing adverse events.

Section snippets

Materials and Methods

The Institutional Review Board reviewed and approved the study. A process improvement commission was created in 2008 by the surgical operations department of a tertiary medical center to reorganize the flow of orthopedic ORs performing total knee arthroplasty (TKA) and total hip arthroplasty (THA) procedures. Beginning on April 1, 2009, the total joints orthopedic ORs at our Institution began to function as an isolated unit (i.e., dedicated OR) from other services. The unit remained “dedicated”

Results

There were 475 cases (n = 200 primary THA; n = 275 primary TKA) in the traditional OR control group spanning 181 OR days (Appendix 1). In the dedicated OR study group, 529 cases (n = 215 primary THA; n = 314 TKA) spanning 181 OR days were performed (Appendix 1). Turnover time was recorded for 164 cases in the control group and 209 cases in the dedicated group from the total cases as described above. Before PS matching there were differences between the number of TKA procedures performed by adult

Discussion

Process redesign in large teaching hospitals may substantially improve operational performance without compromising patient safety. These data demonstrate that using staff members familiar with orthopedic equipment and procedural needs can decrease operative time by an average of 19 minutes per operation, which extrapolates to a total average savings of just over 1.25 hours for a surgeon who performs 4 primary arthroplasty procedures per day. Unlike previous studies which have required additional

References (27)

K.J. Bozic et al.
An analysis of Medicare payment policy for total joint arthroplasty
J Arthroplasty
(2008)
M. Harders et al.
Improving operating room efficiency through process redesign
Surgery
(2006)
S. Breslawski et al.
Operating room scheduling. Choosing the best system.
AORN J
(1991)
B.A. Williams et al.
Making an ambulatory surgery centre suitable for regional anaesthesia
Best Pract Res Clin Anaesthesiol
(2002)
S. Hariri et al.
Medicare physician reimbursement: past, present, and future
J Bone Joint Surg Am
(2007)
J.K. Iglehart
Medicare's declining payments to physicians
N Engl J Med
(2002)
G.R. Wilensky
Reforming Medicare's physician payment system
N Engl J Med
(2009)
D.C. Krupka et al.
Operating room design and its impact on operating room economics
Curr Opin Anaesthesiol
(2006)
F.J. Overdyk et al.
Successful strategies for improving operating room efficiency at academic institutions
Anesth Analg
(1998)
M.P. Smith et al.
High-throughput operating room system for joint arthroplasties durably outperforms routine processes
Anesthesiology
(2008)

B.A. Williams et al.

Process analysis in outpatient knee surgery: effects of regional and general anesthesia on anesthesia-controlled time

Anesthesiology

(2000)

P. Morton

Synergy at work: using quality improvement to reduce OR delay starts

Todays OR Nurse

(1995)

J.C. Cendán et al.

Interdisciplinary work flow assessment and redesign decreases operating room turnover time and allows for additional caseload

Arch Surg

(2006)

Cited by (30)

Specific Factors Affecting Operating Room Efficiency: An Analysis of Case Time Estimates
2022, Journal of Hand Surgery
Operating room (OR) efficiency has an impact on surgeon productivity and patient experience. Accuracy of case duration estimation is important to optimize OR efficiency. The purpose of this study was to identify factors associated with inaccurate case time estimates in outpatient hand surgery. A better understanding of these findings may help to improve OR efficiency and scheduling.
All outpatient hand surgical cases from 2018 to 2019 were reviewed. Poorly-estimated cases (i.e., poor scheduling accuracy) were defined as those cases where the actual operative time differed from the predicted time by >50% (either quicker by >50% or slower by >50% than the predicted time). The percentages of poorly-estimated cases were analyzed, categorized, and compared by surgeon, procedure type, and scheduled case length.
A total of 6,620 cases were identified. Of 1,107 (16.7%) cases with poorly estimated case durations, 75.2% were underestimated. There was no difference in the likelihood of poor estimation related to start time. Well-estimated cases tended to have longer scheduled case duration, but shorter realized case duration and surgical time. Our systems analysis identified specific surgeons and procedures as predictable outliers. Cases scheduled for 15–30 minutes frequently were inaccurate, whereas cases scheduled for 30–45 and 106–120 minutes had accurate estimates.
The accuracy of case time estimations in a standard outpatient hand surgery practice is highly variable. Nearly one-fifth of outpatient hand surgery case durations are poorly estimated, and inaccurate case time estimation can be predicted based on surgeon, procedure type, and case time.
Maximizing OR efficiency should be a priority for surgeons and hospital systems. With multiple surgeries done per day, the efficiency of the OR has an impact on surgeon productivity and patient experience.
Operating room efficiency and cost reduction in shoulder arthroplasty: is there an advantage of a dedicated operating room team?
2021, Seminars in Arthroplasty JSES
Citation Excerpt :
It is therefore in the best interest of the hospital's administration to save time, and to do so without interfering in patient safety. Previous studies have evaluated methods to improve OR efficiency with the use of dedicated teams, parallel processing, and modified physician behaviors. [1,2,4,5,9,10,13] Attarian et al found a 29% increase in case volume and a 40% improvement in TT by implementing a multidisciplinary method to improve OR efficiency. [1]
Operating room (OR) efficiency is a crucial component in the delivery of high quality, cost-efficient healthcare in orthopedic shoulder arthroplasty, and generally in surgery. Utilizing a dedicated OR team may lead to higher clinical efficiency by potentially reducing total OR time and cost while avoiding operational redundancies or errors. The purpose of this study is to identify specific parameters influencing OR efficiency with a 2-roomed system with dedicated OR staff and evaluate its influence on operational cost of the OR per min.
From 2017 to 2018, 348 patients underwent primary shoulder arthroplasty at one institution, that had 2 established OR systems: A traditional “1-room” system (TS) with general OR staff, and a “2-room” shoulder service (SS) with a dedicated OR team. Medical health records were accessed to obtain pertinent study data, which included demographics, surgical indication, and time-points per surgical case. Anesthesia preparatory time (APT) was time from patient OR entry to skin incision; surgery time (ST) – from skin incision to skin closure; conclusion time (CT) – from skin closure to patient exiting OR; and turnover time (TT) – time from 1 patient's exiting to the next patient's admittance into the OR. Nonoperative time was a summation of APT, CT, and TT, while Total OR time comprised of nonoperative time and ST. Cost equivalent per minute OR operation was then used to calculate differences between the 2 interest groups.
The SS treated 270 patients (77.6%) and TS treated 78 patients (22.4%). The SS demonstrated a 74 minutes decrease in total OR time (116 vs. 190 minutes) when compared to the TS (P< .0001). When surgeon factor (“surgery time”) was removed, the SS consistently demonstrated a 23-minute decrease in nonoperative time (76 vs. 99 minutes, P< .0001) and a 26-minute decrease in turnover time (14 vs. 40 minutes, P< .0001) – about a 3-fold reduction. When analyzing cost, the SS demonstrated a $291 decrease in nonoperative cost per case ($1090 vs. $1381, P< .0001) despite the staffing cost of 3 floating staff members. The TT reduction translated to $360 savings in OR cost per case ($198 vs. $558, P< .0001).
A dedicated OR team using 2 ORs improves both clinical efficiency (decreases total OR time) and reduces cost (decreases total OR cost) - despite having more staff members and associated staffing costs - compared to a traditional 1-room system. When surgeon-specific factors were removed, the largest reduction in OR cost was associated with decrease in turnover time.
Level III.
The effect of an orthopedic specialty hospital on operating room efficiency in shoulder arthroplasty
2019, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
However, the effect of OSH use on OR efficiency has yet to be analyzed until now. Many strategies to improve OR efficiency have been studied, including Lean and Six Sigma methodology,8,29 system design,14,16,27 parallel processing,11,27 dedicated orthopedic operating rooms,5,26 team assessment,2,12,16 ambulatory surgical centers,24 and use of a 2-room model.17 Results of this study suggest that use of an OSH may be another avenue to decreased OR time and therefore cost savings.
Operating room (OR) time is a major cost to the health care system. Therefore, increasing OR efficiency to save time may be a cost-saving tool. This study analyzed OR efficiency in shoulder arthroplasty at an orthopedic specialty hospital (OSH) and a tertiary referral center (TRC).
All primary shoulder arthroplasties performed at our OSH and TRC were identified (2013-2015). Manually matched cohorts from the OSH and TRC were compared for OR times. Three times (minutes) were recorded: anesthesia preparation time (APT; patient in room to skin incision), surgical time (ST; skin incision to skin closed), conclusion time (CT; skin closed to patient out of room).
There were 136 primary shoulder arthroplasties performed at the OSH and matched with 136 at the TRC. OSH and TRC patients were similar in age (P = .95), body mass index (P = .97), Charlson Comorbidity Index (P = 1.000), sex (P = 1.000), procedure (P = 1.000), insurance status (P = .714), discharge destination (P = .287), and diagnoses (P = .354). These matched populations had similar ST (OSH: 110.0 ± 26.6 minutes, TRC: 113.4 ± 28.7 minutes; P = .307). APT (39.2 ± 8.0 minutes) and CT (7.6 ± 3.8 minutes) were shorter in the OSH patients than APT (46.3 ± 8.8 minutes; P < .001) and CT (11.2 ± 4.7 minutes; P < .001) in TRC patients. Total nonoperative time (sum of APT and CT) at the OSH (46.8 ± 8.9 minutes) was shorter than at the TRC (57.5 ± 10.4 minutes; P < .001).
Despite similar patient populations and case complexity, the OR efficiency at an OSH was superior to a TRC. Further analysis is needed to determine the financial implications of this superior OR efficiency.
Perioperative Safety: Keeping Our Children Safe in the Operating Room
2018, Orthopedic Clinics of North America
The Volume-Value Relationship in Shoulder Arthroplasty
2018, Orthopedic Clinics of North America
Evidence-Based Thresholds for the Volume and Cost Relationship in Total Hip Arthroplasty: Outcomes and Economies of Scale
2018, Journal of Arthroplasty
Citation Excerpt :
This phenomenon may be explained by the ability of high-volume institutions to reduce fixed costs (ie, implants) as well as variable expenses (ie, staff, dedicated orthopedic operating room) [32–34]. High-volume institutions are more likely to use specialized care teams and postoperative care plans, allowing for increased efficiency as multidisciplinary team members gain familiarity with the procedure [35,36]. It is important to note this study does not elucidate what operational factors specifically contribute to this, which necessitates further study.
High-volume surgeons and hospital systems have been shown to deliver higher-value care in several studies. However, no evidence-based volume thresholds for cost currently exist in total hip arthroplasty (THA). The objective of this study was to establish meaningful thresholds in cost for surgeons and hospitals performing THA. A secondary objective was to analyze the market share of THAs for each surgeon and hospital stratifications.
Using a database of 136,501 patients undergoing THA, we used stratum-specific likelihood ratio analysis of a receiver operating characteristic curve to generate volume thresholds based on costs for surgeons and hospitals. In addition, we examined the relative proportion of annual THA cases performed by each surgeon and hospital stratifications.
Stratum-specific likelihood ratio analysis of cost by annual surgeon THA volume produced stratifications at: 0-73 (low), 74-123 (medium), and 124 or more (high). Analysis by annual hospital THA volume produced stratifications at: 0-121 (low), 122-309 (medium), and 310 or more (high). Hospital costs decreased significantly (P < .05) in progressively higher volume stratifications. High-volume centers perform the largest proportion of THA cases (48.6%); however, low volume surgeons perform the greatest share of these cases (44.6%).
Our study establishes economies of scale in THA by demonstrating a direct relationship between volume and cost reduction. High-volume hospitals are performing the greatest proportion of THAs; however, low-volume surgeons perform the largest share of these cases, which highlights a potential area for enhanced value in the care of patients undergoing THA.

View all citing articles on Scopus

: Supplementary material available at www.arthroplastyjournal.org.

: The Conflict of Interest statement associated with this article can be found at http://dx.doi.org/10.1016/j.arth.2013.01.033.

View full text

Dedicated Orthopedic Operating Room Unit Improves Operating Room Efficiency

Abstract

Section snippets

Materials and Methods

Results

Discussion

J Arthroplasty

Surgery

AORN J

Best Pract Res Clin Anaesthesiol

Medicare physician reimbursement: past, present, and future

J Bone Joint Surg Am

Medicare's declining payments to physicians

N Engl J Med

Reforming Medicare's physician payment system

N Engl J Med

Operating room design and its impact on operating room economics

Curr Opin Anaesthesiol

Successful strategies for improving operating room efficiency at academic institutions

Anesth Analg

High-throughput operating room system for joint arthroplasties durably outperforms routine processes

Anesthesiology

Process analysis in outpatient knee surgery: effects of regional and general anesthesia on anesthesia-controlled time

Anesthesiology

Synergy at work: using quality improvement to reduce OR delay starts

Todays OR Nurse

Interdisciplinary work flow assessment and redesign decreases operating room turnover time and allows for additional caseload

Arch Surg