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Schematic diagram of the times recorded (top) and the calculated time intervals (bottom). AET indicates anesthesia end time; AR, anesthesia ready; AST, anesthesia start time; OPT, operative procedure time; PF, procedure finish; PIR, patient in room; POR, patient out of room; PST, procedure surgery start; and SPT, surgical procedure time.

Schematic diagram of the times recorded (top) and the calculated time intervals (bottom). AET indicates anesthesia end time; AR, anesthesia ready; AST, anesthesia start time; OPT, operative procedure time; PF, procedure finish; PIR, patient in room; POR, patient out of room; PST, procedure surgery start; and SPT, surgical procedure time.

Table 1 
Operative Times by Setting and Procedure*
Operative Times by Setting and Procedure*
Table 2 
Operative Times for 3 Surgeons Performing Tonsillectomy and Adenoidectomy in Both Settings*
Operative Times for 3 Surgeons Performing Tonsillectomy and Adenoidectomy in Both Settings*
1.
Not Available Physicians' Current Procedural Terminology. 4th ed. Chicago, Ill: American Medical Association; 2000.
2.
Donham  RTMazzei  WJJones  RL Association of Anesthesia Clinical Directors' procedural times glossary: glossary of times used for scheduling and monitoring of diagnostic and therapeutic procedures. Am J Anesthesiol Suppl.1996;23(suppl 5S):1-12.
3.
Strum  DPSampson  ARMay  JHVargas  LG Surgeon and type of anesthesia predict variability in surgical procedure times. Anesthesiology.2000;92:1454-1466.
4.
Mazzei  WJ Operating room start times and turnover times in a university hospital. J Clin Anesth.1994;6:405-408.
Original Article
April 2003

Analysis of Efficiency of Common Otolaryngology OperationsComparison of Operating Room vs Short Procedure Room in a Pediatric Tertiary Hospital

Author Affiliations

From the Department of Anesthesiology (Dr Brenn), the Division of Otolaryngology (Drs Reilly, Deutsch, and Cook), and the Department of Nursing (Ms Hetrick), Alfred I. duPont Hospital for Children, Nemours Children's Clinic–Wilmington, Wilmington, Del.

Arch Otolaryngol Head Neck Surg. 2003;129(4):435-437. doi:10.1001/archotol.129.4.435
Abstract

Objective  To compare the operative times of routine otolaryngologic procedures performed with 2 different operating room staffing models: the traditional model with 2 staff, a scrub nurse and a circulator, and the short procedure room (SPR) setting, with a circulator only.

Design  Retrospective comparison of operative procedure times. Data were extracted from a prospectively maintained database of electronic medical records.

Setting  All data were from procedures performed at a tertiary care children's hospital operating room suite.

Patients or Other Participants  Data for the year 2000 were extracted for all outpatient otolaryngology cases of bilateral myringotomy and tube placement (BMT), tonsillectomy and adenoidectomy (TA), and adenoidectomy alone.

Main Outcome Measures  The mean ± SD operative time intervals (operative procedure times and total operative procedure time), anesthesia start times, surgical preparation times, and anesthesia end times of the 2 sites were compared. These time intervals were also compared for the 3 surgeons performing TAs in both settings.

Results  Total operative procedure times were significantly shorter in the SPR setting for TA and BMT, but not for adenoidectomy. For TA procedures, operative procedure times and anesthesia end times were significantly shorter in the SPR setting (P<.05). For BMT procedures, all operative times were significantly shorter in the SPR setting. All 3 surgeons who performed TAs in both settings had significantly shorter total operative procedure times in the SPR setting than in the traditional setting.

Conclusions  Despite fewer assisting staff, the SPR setting showed a statistically significant reduction in total operative procedure times for TA and BMT, and results were similar for adenoidectomy. Reducing operating room personnel costs is possible in addition to achieving modest gains in efficiency.

THE INCREASING costs of managing a suite of operating rooms (ORs) have led to efforts to optimize OR staffing and operative times. One currently popular solution is to send patients undergoing brief procedures with predictable outcomes to off-site outpatient "surgicenters" when their conditions are uncomplicated. Combining selection, standardization, and creative staffing models may increase operative time efficiency, which would result in improved utilization of resources. Our surgical services responded to an increasing number of otolaryngology outpatients by designing a short procedure room (SPR), an operative site within the hospital staffed by 1 OR circulator—as opposed to the traditional 2-person model of circulator and scrub nurse. Patients initially scheduled for this site were to undergo bilateral myringotomy and tube placement (BMT), a procedure that unfolds predictably and requires limited equipment. Within weeks, however, our surgeons decided that tonsillectomy and adenoidectomy (TA) and adenoidectomy alone (AA), 2 procedures that do not necessarily require an operative assistant, could also be scheduled in the SPR.

Concerns regarding this innovative project included whether the procedures would be performed less efficiently with the surgeon working with fewer assisting staff. The purpose of this study was to compare the operative time characteristics of routine otolaryngology procedures performed with 2 staffing models, the SPR and the traditional OR, and to evaluate the operative times of 3 surgeons who performed TAs in both settings.

METHODS

All cases of TA, AA, and BMT were extracted from the billing data for 2000 using an appropriate Current Procedure Terminology1 code query. These cases were linked to data obtained from our hospital's anesthesia electronic medical record (Compurecord, Pittsburgh, Pa [now Philips Medical Systems, Best, the Netherlands]). For each procedure the following punctual times were recorded based on the Association of Anesthesia Clinical Directors' glossary of standardized times2: patient in room, anesthesia start, anesthesia ready, procedure start, procedure finish, and patient out of room (Figure 1). The following time intervals were calculated from these recorded punctual times: anesthesia start time, surgical preparation time, operative procedure time (OPT), and anesthesia end time (Figure 1). The total operative procedure time (TOPT), ie, the total time a patient spends in the OR, was also calculated as the difference between the punctual times recorded for patient out of room and patient in room.

The time intervals for TA, AA, and BMT procedures in the OR and SPR settings were compared using SPSS version 10 statistical software (SPSS Inc, Chicago, Ill). In the initial analysis, the procedure times of each surgeon in each setting were compared. Not all surgeons, however, operated in both settings. We therefore also examined the operative times of 3 surgeons who performed TAs in both settings. In this way, these surgeons acted as their own controls. The means ± SDs of all the time intervals, measured in minutes, were compared using an independent samples t test and the Levene test for equality of variability. The working hypothesis was that there would be no differences in operative times between the 2 settings. P<.05 was considered statistically significant.

RESULTS

A total of 4579 otolaryngologic procedures were performed between January 1 and December 31, 2000 (1242 in the OR setting and 3417 in the SPR setting). The times of 2226 single Current Procedure Terminology procedures (as opposed to combinations of procedures) were extracted from the database. This resulted in a study file of 743 procedures from the OR sites and 1483 procedures from the SPR site.

When analyzing procedures by site, mean TOPTs for TA and BMT procedures were significantly shorter (P<.05) in the SPR than in the OR (Table 1). There was a slight but nonsignificant difference in TOPTs between the settings for AA procedures (Table 1). The breakdown of the TOPTs into the other time intervals is also shown in Table 1. For TA procedures, OPTs were found to be significantly different in the SPR and OR settings. The mean anesthesia end times and anesthesia start times were not significantly different for these procedures. Time intervals were shorter for BMT procedures in the SPR setting, and time differences between the settings were statistically significant for all intervals. For AA procedures, although TOPTs were not significantly different, it was found that the anesthesia end time interval was significantly longer inthe SPR setting.

When comparing settings by surgeon, all 3 surgeons who operated in both settings had significantly shorter TOPTs for TA procedures in the SPR than in the OR (Table 2). Two of the surgeons (surgeons A and B) had significant OPT reductions, whereas the third surgeon (surgeon C) had an OPT reduction that did not reach statistical significance (Table 2).

COMMENT

We demonstrated in our institution that the SPR setting results in significantly shorter TA and BMT procedure times and in similar AA procedure times compared with the the OR setting. For TAs, when the settings were compared controlling for the surgeon, a significantly shorter TOPT was achieved in the SPR. For 2 of the 3 surgeons who operated in both settings, OPT, the time spent actually operating, was found to be significantly shorter in the SPR (single assistant) setting. We additionally analyzed the components of the time that a patient spends in the OR to see what procedure times, if any, were shorter in this setting. For TA procedures, OPTs and anesthesia end times were shorter in the OR setting, although the actual time difference was only about 4 minutes. For BMT, the time reductions were statistically significant for all intervals compared and resulted in a 7-minute difference, which would have a greater impact on the overall OR day. For AA procedures, the overall TOPTs were similar in the 2 settings.

Given that this is a retrospective analysis, we can only speculate about the causes for our findings. We presume that the SPR setting emulated the surgicenter environment, whose efficiency has been praised by many members of the health care profession. We also speculate that SPR surgeons' receiving their own instruments may have contributed to the reduction in OPTs.

The analysis of operative procedure times is fraught with confounding variables. Strum et al3 determined that surgeon and type of anesthesia were chief predictors of surgical time variability across specialties in a tertiary care setting. We sought to limit this variability in several ways. In all of our cases, only single subspecialty procedures were performed, and only under general anesthesia. At the outset, we set up our database to collect operational times based on the Association of Anesthesia Clinical Directors' glossary of standardized times to clearly define times and time intervals that could be compared with others within our institution. We also limited our analysis to single Current Procedure Terminology code cases. We thus avoided combined procedures that may lead to more variable times and excluded patients with more complex conditions. Mindful that not all surgeons operated in both settings, we expanded the analysis to the operative times of surgeons who routinely performed TAs in both settings. In this way, the surgeons were used as their own controls to compare differences between settings. The effect of operating residents on surgical times was not analyzed, but could be the objective of a future study.

This study did not compare turnover times. We have previously analyzed turnover times for the 2 settings for all otolaryngology procedures performed, and found that they were shorter in the SPR than in the OR (12 minutes vs 17 minutes, unpublished data). While turnover times are often considered a benchmark of efficiency, we chose not to include such an analysis for several reasons. True turnover time is the time elapsed between the exit of one patient and the entry of another patient for sequentially scheduled procedures by a single surgeon.2 Because our data set was limited to single Current Procedure Terminology cases, the procedures we analyzed were not necessarily sequentially performed, which made the analysis of turnover times meaningless. Additionally, Mazzei4 demonstrated that reductions in turnover times have not been shown to reliably create time for additional patients, except, perhaps, in the case of the shortest procedures (such as BMT).

In conclusion, the development of the SPR setting within our institution has been successful in terms of the operational efficiency examined thus far. Although such a reduction in staffing is not revolutionary in freestanding surgicenters, we have achieved it within our hospital, which is not common for tertiary pediatric hospitals. The SPR setting provides a potential economic benefit by using half the assisting staff of a regular OR while not compromising the efficiency of surgical procedures.

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Article Information

Corresponding author and reprints: B. Randall Brenn, MD, Department of Anesthesiology, Alfred I. duPont Hospital for Children, NCC–Wilmington, PO Box 269, Wilmington, DE 19899 (e-mail: brbrenn@nemours.org).

Accepted for publication September 5, 2002.

References
1.
Not Available Physicians' Current Procedural Terminology. 4th ed. Chicago, Ill: American Medical Association; 2000.
2.
Donham  RTMazzei  WJJones  RL Association of Anesthesia Clinical Directors' procedural times glossary: glossary of times used for scheduling and monitoring of diagnostic and therapeutic procedures. Am J Anesthesiol Suppl.1996;23(suppl 5S):1-12.
3.
Strum  DPSampson  ARMay  JHVargas  LG Surgeon and type of anesthesia predict variability in surgical procedure times. Anesthesiology.2000;92:1454-1466.
4.
Mazzei  WJ Operating room start times and turnover times in a university hospital. J Clin Anesth.1994;6:405-408.
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