Operational Efficiency in Perioperative Services

Educational Objectives

The goal of this program is to improve operational efficiency in perioperative care. After hearing and assimilating this program, the clinician will be better able to:

1. List demographic changes that contribute to shortage in supply of health care professionals.
2. Differentiate start time from cut time in operating room metrics.
3. Explain how optimal continuous improvement leads to changes in variability of turnover time.
4. Differentiate the elimination of sevoflurane from that of enflurane.

Summary

Definition of waste and cost in health care: waste is defined as spending that can be eliminated without reducing the quality of care; cost containment is an effort to control the high rate of increase in total costs; some cost containment is wasteful and can impact quality of care, depending on the situation

Factors affecting health care costs: there is an increasing number of elderly patients requiring medical care in the United States, whereas reimbursement continues to decrease; anesthesia services are costly; there is decreased availability of qualified staff; COVID-19 burnout has caused many people to reduce their work schedules and become disengaged; there is a “medical arms race” regarding the acquisition of expensive technology

Demographics: in addition to increase in the number of elderly patients, these people are living longer with increased care and intervention; there is currently a record shortage of supply of health care professionals; the incidence of prominent conditions, eg, hypertension, renal insufficiency are high and require a lot of intensive medical intervention; obesity is becoming more prevalent; COVID-19 burnout has resulted in early retirement, disengagement (aka quiet quitting), unsustainable salary inflation, and a shortage of all types of anesthesia personnel; the National certified registered nurse anesthetist (CRNA) unemployment rate is 0.2%

Reimbursement and payer issues: value-based care, outcomes, and satisfaction measurements play a role; patient surveys can cause issues because most patients cannot differentiate good medical care from a pleasant experience

Basic operating room metrics: include on-time start; anesthesia professionals are often blamed for late starts, but the reason for the delay could be attributed to many factors, eg, delay in patient arrival, surgeons not obtaining consent prior, other causes; failure of attending surgeons to engage also contributes to delay; on-time start is usually defined as wheels in the room; surgeons often consider start time as the cut time; however, they are different; cut times are hard to measure because there is variability from time in the room to cut time; hence, for record keeping, the start time is defined as the time in the operating room; in room to procedure start is defined as the time in the room to the start of the procedure; the University Hospitals Community Consortium defines the national gold standard in room to cut time as 15 min, which is an average across cases of varying complexity; another metric is surgery end to out of room time; turnover time is wheels out to wheels in time; utilization is the percentage of time that the patient was in the operating room per defined standard block; after hours/out-of-block time and percentage of cases that are add-ons are other metrics; add-ons decrease efficiency; the add-on percentage varies among institutions, with trauma centers usually having higher percentages than other hospitals

Fixing the metric issues: many have focused on the Toyota Production System; the American Society of Anesthesiologists (ASA) has advocated the concept of the perioperative surgical home; a medically optimized patient with a good anesthetic and medical optimization postoperatively should be a more efficient and cost effective method of care; the ASA proposes that anesthesiologists are most qualified to fill this role; lack of reimbursement, patience, and staffing are significant barriers to this model

Working of perioperative home: it works by partnering with hospitals to maximize efficiency of care and decrease the number of perioperative tests; it also decreases the unnecessary tests that are required preoperatively

Toyota Production System: ≈90% of processes add no value; the Toyota Production System was seen as a model to emulate; the problem is that these are industrial processes and are not human beings, whereas surgeons and anesthesiologists have variable abilities and time; in general, the Toyota Production System is a way of looking at perioperative processes to decrease processes that add no value; avoid unnecessary work, patient delay and inconvenience, medical errors, overstocking the inventories, inefficient utilization of personnel and space, and poor customer satisfaction; engage the stakeholders; hospital financing and hospital administration are among the big stakeholders; other big stakeholders are pharmacy and materials management; pharmacists are very good at line-item discussion

Operating room flow mapping: the process starts with mapping the flow and time-related processes; identify processes that are wasteful; it is important to engage with the people that do the work; the Toyota Production System has a standard work in the building of cars; in the same way, the standard work during the procedure could be anesthetizing the patient for a procedure; takt time is the most important metric, and is the time interval between the patients, ie, the time that takes to get the patient to the recovery room

Predictability: speaker proposes that the most important metric in perioperative services is predictability; a challenge to efficiency is an unpredictable process; in health care, surgeons, patients, and procedures are unpredictable; hence, it is important to focus on predictable time intervals as much as possible as certain factors can be controlled; surgery schedule leveling is an important element of control; it is very difficult to provide efficient staffing if surgical volumes are significantly different on different days of the week; this requires buy in from the stakeholders

Yakima Valley Memorial Hospital: uses a third-party company to do their continuous improvement; initially, there was a worry about the room turnover time, and was primarily related to variability and unpredictability of the turnover time; hence, they conducted a 100-day process of a rapid change trial wherein they instituted the measures after 100 days; this was considered successful as their variability decreased, able to achieve the turnover time accurately, accurate scheduling, decreased waste, and increased revenue

Anesthesia black box: as all the anesthetics are different, the ideal anesthetic involves elimination of variability, at least to some degree; most general anesthetics in the United States are based on the use of volatile agents to some degree; however, Europe, where there is a different culture of care and availability of targeted infusion pumps, uses mostly total intravenous anesthesia; sevoflurane and desflurane have very low blood gas partition coefficients and are insoluble; while the blood gas partition coefficients of sevoflurane and desflurane are similar, their tissue blood partition coefficients are different; sevoflurane is more soluble in all the tissues of the body outside the blood than desflurane; upon leaving the blood slowly because of its low solubility, sevoflurane slowly enters the tissues and also slowly leaves tissues; sevoflurane has almost the same fat solubility as halothane

Terminal decrement: the amount of time required to eliminate the volatile agent vs duration of anesthesia; because of the tissue solubility, sevoflurane seems better for short cases than enflurane and isoflurane because of its low blood solubility; with longer anesthetics, sevoflurane’s curve starts to resemble isoflurane and then enflurane; for a 3- to 4-hr procedure, it takes ≈1 hr for 90% elimination of sevoflurane; on the other hand, desflurane mathematically has a flatline relationship, indicating that, mathematically, with a procedure of infinite duration, desflurane still has 90% elimination in 5 min; this is because it does not accumulate in the tissues to the same degree as other volatile anesthetics; study from University of California, San Francisco (Mckay et al [2005]) investigated immediate recovery and swallowing; the study assessed time to ability to swallow in the postanesthesia care unit (PACU); swallowing is a very complicated neurologic reflex; swallowing can be suppressed by as little as one-twelfth minimum alveolar concentration of anesthesia; the study involved administering an oral water bolus 2 min after entering the PACU; among persons anesthetized with sevoflurane, only ≈40% could swallow the water bolus while the rest could not; however, among patients who received desflurane, ≈100% of patients could swallow; this was repeated at 6 min, and ≈80% with sevoflurane could swallow; this indicates that sevoflurane persists longer, affecting the patients; the faster and more predictably a patient is awake, the safer they are; this was manifested when they looked at time from anesthetic discontinuation to ability to swallow; time to swallow was similar among patients who received desflurane regardless of duration of surgery; with sevoflurane, the longer the procedure lasted, the longer the patients took to swallow; time to swallow was less predictable with sevoflurane compared with desflurane; older patients took longer to regain their swallowing, but time to swallow was more predictable with desflurane

Final thoughts: pharmacists are good at determining costs but are not good at determining value; interventions and medications with higher costs may be worthwhile if they result in increased value

Readings

Boy Y, Sürmeli M. Quiet quitting: A significant risk for global healthcare. J Glob Health. 2023;13:03014. Published 2023 Mar 31. doi:10.7189/jogh.13.03014; Garrison LP Jr. Assessment of the effectiveness of supply-side cost-containment measures. Health Care Financ Rev. 1992;1991(Suppl):13-20; Hoffman CR, Horrow J, Ranganna S, et al. Operating room first case start times: a metric to assess systems-based practice milestones?. BMC Med Educ. 2019;19(1):446. Published 2019 Dec 2. doi:10.1186/s12909-019-1886-2; Lipman JM, Colbert CY, Ashton R, et al. A systematic review of metrics utilized in the selection and prediction of future performance of residents in the United States. J Grad Med Educ. 2023;15(6):652-668. doi:10.4300/JGME-D-22-00955.1; Mckay RE, Large MJC, Balea MC, et al. Airway reflexes return more rapidly after desflurane anesthesia than after sevoflurane anesthesia. Anesth Analg. 2005;100(3):697-700. doi:10.1213/01.ANE.0000146514.65070.AE; Schouten AM, Flipse SM, van Nieuwenhuizen KE, et al. Operating room performance optimization metrics: A systematic review. J Med Syst. 2023;47(1):19. Published 2023 Feb 4. doi:10.1007/s10916-023-01912-9; Vetter TR, Goeddel LA, Boudreaux AM, et al. The perioperative surgical home: How can it make the case so everyone wins?. BMC Anesthesiol. 2013;13:6. Published 2013 Mar 14. doi:10.1186/1471-2253-13-6.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Mychaskiw was recorded at the 2023 Annual Convention and Conclave of the American Osteopathic College of Anesthesiologists, held September 30 to October 3, 2023, in St. Petersburg, FL, and presented by the American Osteopathic College of Anesthesiologists. For more information from this presenter, please visit www.acknowledg.org. Audio Digest thanks the speakers and the American Osteopathic College of Anesthesiologists for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.25 CE contact hours.

Lecture ID:

AN661001

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.