Association of Reduced Delay in Care With a Dedicated Operating Room in Pediatric Otolaryngology | Otolaryngology | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
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Figure.  Days From Consult to Operating Room
Days From Consult to Operating Room

Run chart shows reduction in time to operating room after introduction of the dedicated time block.

Table 1.  Summary of Data
Summary of Data
Table 2.  Add-on Cases Performed
Add-on Cases Performed
1.
Segal  B, Lam  E, Amar  J,  et al.  Add-on cases in the endoscopy unit: Factors that affect volume.  Can J Gastroenterol. 2009;23(7):485-488.PubMedGoogle ScholarCrossref
2.
Zhou  J, Dexter  F.  Method to assist in the scheduling of add-on surgical cases—upper prediction bounds for surgical case durations based on the log-normal distribution.  Anesthesiology. 1998;89(5):1228-1232.PubMedGoogle ScholarCrossref
3.
Dexter  F, Maxbauer  T, Stout  C, Archbold  L, Epstein  RH.  Relative influence on total cancelled operating room time from patients who are inpatients or outpatients preoperatively.  Anesth Analg. 2014;118(5):1072-1080.PubMedGoogle ScholarCrossref
4.
Chacko  AT, Ramirez  MA, Ramappa  AJ, Richardson  LC, Appleton  PT, Rodriguez  EK.  Does late night hip surgery affect outcome?  J Trauma. 2011;71(2):447-453.PubMedGoogle ScholarCrossref
5.
Wixted  JJ, Reed  M, Eskander  MS,  et al.  The effect of an orthopedic trauma room on after-hours surgery at a level one trauma center.  J Orthop Trauma. 2008;22(4):234-236.PubMedGoogle ScholarCrossref
6.
Bhattacharyya  T, Vrahas  MS, Morrison  SM,  et al.  The value of the dedicated orthopaedic trauma operating room.  J Trauma. 2006;60(6):1336-1340.PubMedGoogle ScholarCrossref
7.
Ogrinc  G, Davies  L, Goodman  D, Batalden  P, Davidoff  F, Stevens  D.  SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process.  J Am Coll Surg. 2016;222(3):317-323.PubMedGoogle ScholarCrossref
8.
Tyler  DC, Pasquariello  CA, Chen  CH.  Determining optimum operating room utilization.  Anesth Analg. 2003;96(4):1114-1121.PubMedGoogle ScholarCrossref
9.
Agnoletti  V, Buccioli  M, Padovani  E,  et al.  Operating room data management: improving efficiency and safety in a surgical block.  BMC Surg. 2013;13:7.PubMedGoogle ScholarCrossref
10.
Perkins  JN, Chiang  T, Ruiz  AG, Prager  JD.  Auditing of operating room times: a quality improvement project.  Int J Pediatr Otorhinolaryngol. 2014;78(5):782-786.PubMedGoogle ScholarCrossref
11.
Carter  JM, Riley  C, Ananth  A, Guarisco  JL, Rodriguez  K, Amedee  R.  Improving outcomes in a high-output pediatric otolaryngology practice.  Int J Pediatr Otorhinolaryngol. 2014;78(12):2229-2233.PubMedGoogle ScholarCrossref
12.
Shah  RK, Cohen  J, Patel  A, Derkay  C.  Analysis of pediatric direct laryngoscopy and bronchoscopy operative flow: opportunities for improved safety outcomes.  Arch Otolaryngol Head Neck Surg. 2012;138(7):624-627.PubMedGoogle ScholarCrossref
13.
Brenn  BR, Reilly  JS, Deutsch  ES, Hetrick  MH, Cook  SC.  Analysis of efficiency of common otolaryngology operations: comparison of operating room vs short procedure room in a pediatric tertiary hospital.  Arch Otolaryngol Head Neck Surg. 2003;129(4):435-437.PubMedGoogle ScholarCrossref
14.
Bhattacharyya  N.  Benchmarks for the durations of ambulatory surgical procedures in otolaryngology.  Ann Otol Rhinol Laryngol. 2011;120(11):727-731.PubMedGoogle ScholarCrossref
15.
Epstein  RH, Dexter  F.  Management implications for the perioperative surgical home related to inpatient case cancellations and add-on case scheduling on the day of surgery.  Anesth Analg. 2015;121(1):206-218.PubMedGoogle ScholarCrossref
16.
Weinbroum  AA, Ekstein  P, Ezri  T.  Efficiency of the operating room suite.  Am J Surg. 2003;185(3):244-250.PubMedGoogle ScholarCrossref
17.
Dexter  F, Macario  A, Traub  RD.  Which algorithm for scheduling add-on elective cases maximizes operating room utilization? Use of bin packing algorithms and fuzzy constraints in operating room management.  Anesthesiology. 1999;91(5):1491-1500.PubMedGoogle ScholarCrossref
18.
Mathews  M, Ryan  D, Gadag  V, West  R.  Patient satisfaction with wait-times for breast cancer surgery in Newfoundland and Labrador.  Healthc Policy. 2016;11(3):42-53.PubMedGoogle Scholar
19.
Holbrook  A, Glenn  H  Jr, Mahmood  R, Cai  Q, Kang  J, Duszak  R  Jr.  Shorter perceived outpatient MRI wait times associated with higher patient satisfaction.  J Am Coll Radiol. 2016;13(5):505-509.PubMedGoogle ScholarCrossref
20.
Lizaur-Utrilla  A, Martinez-Mendez  D, Miralles-Muñoz  FA, Marco-Gomez  L, Lopez-Prats  FA.  Negative impact of waiting time for primary total knee arthroplasty on satisfaction and patient-reported outcome.  Int Orthop. 2016;40(11):2303-2307.PubMedGoogle ScholarCrossref
21.
Haraden  C, Resar  R.  Patient flow in hospitals: understanding and controlling it better.  Front Health Serv Manage. 2004;20(4):3-15.PubMedGoogle ScholarCrossref
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Original Investigation
April 2018

Association of Reduced Delay in Care With a Dedicated Operating Room in Pediatric Otolaryngology

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, University Cincinnati, Cincinnati, Ohio
  • 2Department of Otolaryngology–Head and Neck Surgery, St Johns Providence Health System, Madison Heights, Michigan
  • 3Division of Pediatric Otolaryngology–Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
JAMA Otolaryngol Head Neck Surg. 2018;144(4):330-334. doi:10.1001/jamaoto.2017.3165
Key Points

Question  Could a dedicated block of operating room time help reduce the time from inpatient consult to operating room, and would it be adequately utilized?

Findings  In this review of 316 cases, the institution of a dedicated block of operating room time was associated with decreased time of 3 days from consult to operating room and had an adjusted utilization rate of 86%.

Meaning  Institution of a dedicated block of operating room time to triage inpatient consults is highly utilized and is associated with decreased time to operating room for consult patients.

Abstract

Importance  Obtaining sufficient operating room time for inpatient consults requiring an operative intervention is a persistent challenge for otolaryngologists.

Objective  To examine the institution of an otolaryngology-specific operating room (OR) for unscheduled (add-on) cases for its association with time from initial consultation to surgery and, secondarily, to determine utilization of a dedicated block of time.

Design, Setting, and Participants  Retrospective review of medical records of a tertiary care pediatric hospital for patients treated between January 1, 2015, and March 31, 2016; analysis was concluded by June 2016. Included were all patients undergoing inpatient otolaryngology consultations who required nonemergency operative procedures.

Interventions  In August 2015, a once-weekly 5-hour block of OR time dedicated to inpatient otolaryngology consults was instituted. Prior to this, cases were placed on an add-on list shared between all surgical services.

Main Outcomes and Measures  It was hypothesized that institution of a dedicated block of OR time would decrease the time from initial consultation to operative intervention and would be utilized at a high rate. Operating room utilization was calculated by dividing scheduled OR time by actual OR time utilized. Time from initial consultation to OR intervention was compared before and after the institution of the dedicated OR block.

Results  A total of 316 inpatient add-on pediatric cases (including 108 patients from the intensive care unit [ICU]) were scheduled during the study period. The most common cases were microlaryngoscopy/bronchoscopy (79%) and tracheostomy (8%). Mean (SD) time between consultation and OR intervention was 7.8 (1.6) days prior to establishing the add-on OR and 4.4 (1.3) days after it was established (absolute difference of 3.4 days; 95% CI, 3.1-3.7 days). Mean (SD) time between consultation and OR intervention was 7.4 (5.0) days for ICU patients prior to intervention and 5.6 (3.0) days after intervention (absolute difference of 1.8 days; 95% CI, 1.6-2.0 days). Total utilization of the OR block time was 74%, and adjusted utilization was 86%. There was a 15% drop in the number of unscheduled add-on cases after the intervention (from 10 cases/mo to 8.5 cases/mo; absolute difference of 1.5 cases; 95% CI, 1.1-1.9 cases).

Conclusions and Relevance  Instituting a dedicated otolaryngology add-on OR was associated with significantly reduced time between initial consultation and operative care, by approximately 3 days, decreased the number of unscheduled add-on cases, and was utilized at a high level.

Introduction

Availability and utilization of operating room (OR) time is a challenge for surgical specialties, with both economic and patient care implications. Unscheduled, or “add-on,” cases have substantial impact on availability and utilization of OR resources. Such cases often overload specific time periods such as Monday mornings (after the weekend) and evenings (after the scheduled OR cases are finished).1 Add-on cases also lead to increased difficulty in providing consistent staffing and can overload systems.2,3 When OR capacity is reached for a particular day, elective cases are either delayed to the next day or pushed into the evenings, neither of which is optimal for patient care. Previous reports in the literature have shown that delaying cases into the night increases morbidity and mortality, and delaying cases to another day simply postpones necessary care.4 Efforts to optimize scheduling, particularly of add-on cases, has led to the concept of dedicated OR time for inpatient add-on cases to facilitate completion of cases in a timely manner and improve surgical quality.5,6

At our large, tertiary pediatric referral center, there is a high volume of otolaryngology consults, many of which require nonemergency operative intervention. Accommodating these add-on cases is challenging because it requires coordinating availability of an OR with anesthesia and OR staff and the attending otolaryngologist. The resulting coordination difficulty may often lead to delays in care for patients and, anecdotally, leads to patient dissatisfaction. Thus, the goals of our study were to examine the association of dedicated otolaryngology-specific OR block time with time from consultation to operative intervention for inpatients and to evaluate the utilization rates of this block time. Specifically, we hypothesized that a dedicated block of OR time would decrease the time between consultation and operative intervention and would be utilized at a high rate compared with national norms.

Methods

We performed a retrospective medical chart review of all inpatient otolaryngology consultations requiring a nonemergency operative procedures from January 1, 2015, to March 31, 2016, at a 584-bed tertiary care pediatric medical center. The study period was split into an 8-month preintervention period (January 1, 2015, through August 31, 2015) and a 7-month postintervention period (September 1, 2015, through March 31, 2016). All emergency cases (such as posttonsillectomy hemorrhage, imminent airway compromise, and airway foreign bodies) were excluded. The electronic medical record (EMR) was queried for all otolaryngology add-on cases, which were then cross-matched with billing records to ensure validity. Variables examined included case type, date of consultation, date of surgery, intensive care unit (ICU) status, actual operative time, turnover time, and scheduled operative time. The SQUIRE 2.0 guidelines for quality improvement research were used to report findings.7 Institutional review board approval was obtained from the Cincinnati Children’s Hospital and Medical Center, waiving written informed consent for deidentified data in a quality-improvement project. All patients and/or their parents or guardians provided written informed consent for the surgical procedures.

Intervention

In August 2015, the Division of Pediatric Otolaryngology instituted a once-weekly 5-hour block of OR time on Thursday afternoons dedicated to inpatient otolaryngology consults. The block time was reallocated from existing otolaryngology block time previously assigned to specific otolaryngology physicians for scheduled elective cases, so the net amount of time assigned to the otolaryngology service remained unchanged. This block of time is staffed on a rotating basis by 1 of 4 fellowship-trained pediatric otolaryngology attending physicians. The OR is made available to other services if no cases are scheduled by Thursday morning. Once the dedicated block time is filled, additional cases are either scheduled for the following week’s block of time or added to a general add-on list shared between all surgical services depending on the urgency of the procedure. Prior to the institution of this block time, all otolaryngology cases were placed on an add-on list shared between all surgical services with either the consulting attending physician staying until the case was completed or the on-call pediatric otolaryngology attending performing the procedure.

Outcome Measures

The primary outcome measure was the time from consultation to the time an operation was performed. This was determined from review of the EMR. The secondary outcome measure was OR utilization, which was calculated using the following standard method: dividing scheduled OR time by actual OR time utilized.3 The time it took to turn over the room was not included in OR utilization times and was classified as unutilized time. Procedures performed in conjunction with other services (most commonly pulmonary flexible bronchoscopy) were counted as utilized OR time. Adjusted OR utilization was calculated to account for cases from other surgical services running over into the dedicated block of otolaryngology time by subtracting this overrun from the block time. Cases canceled on the day of the procedure were included as unutilized time. Outcome measures were compared before and after intervention. The t test was used for continuous variables. A 2-tailed P = .05 was considered statistically significant for this study. All analyses were performed using the PSPP statistical package (Free Software Foundation).

Results

During the 15-month study period, 316 inpatient nonemergency add-on procedures were performed, including 108 patients (34%) admitted to the ICU (Table 1). On average, 20 add-on procedures were performed each month before the intervention, and 19 add-on procedures were performed after the intervention, and there was no significant difference in case makeup before and after the intervention. There was a 15% drop in the number of add-on cases after the intervention from 10 cases/mo prior to intervention to 8.5 cases/mo after intervention (absolute difference 1.5 cases; 95% CI, 1.1-1.9 cases), and the percentage of cases performed on the weekend dropped from 10% to 8% (absolute difference 2%; 95% CI, −0.76% to 4.8%). Overall, 79% of the procedures performed were microlaryngoscopy and bronchoscopy (n = 251), either without intervention (n = 180) or with intervention (n = 71). The next most commonly performed procedure was tracheostomy, accounting for 8% of cases performed (n = 26). Other cases performed are summarized in Table 2.

Prior to the institution of the add-on OR, the mean (SD) time between otolaryngology consultation and OR procedure was 7.8 (1.6) days preintervention vs 4.4 (1.3) days postintervention, with an absolute difference of time of 3.4 days (95% CI, 3.08-3.72; Cohen d = 2.3). The mean (SD) time between initial consultation and OR for ICU patients preintervention was 7.4 (5.0) days vs 5.6 (3.0) days postintervention, for an absolute difference of time of 1.8 days (95% CI, 1.6-2.0; Cohen d = 0.4). Changes from preintervention to postintervention are graphically illustrated in the Figure.

The total available add-on room OR time during the study period was 8700 minutes, of which 6449 minutes were utilized by otolaryngology procedures for an overall utilization of 74%. After accounting for delays due to other services, the adjusted block time utilized by the otolaryngology service was 7617 minutes (8700−1083 minutes of overrun from other services), for an adjusted OR utilization rate of 85%. During the intervention, there was 1 instance where the block time was utilized for a semi-emergency airway reconstruction case that required moving other cases to an add-on list that otherwise would have utilized the block time.

Discussion

To our knowledge, this is the first study looking at the impact of a dedicated block of OR time on timeliness of care in pediatric otolaryngology. Our data indicate that use of this block of dedicated OR time decreased the mean time between initial consultation and the OR by nearly 3.5 days (approximately 40%). For ICU patients, there was a trend toward decreased time from consultation to OR. This population is difficult to analyze because ICU patients tend to fall into 1 of 2 categories: (1) patients who acutely require intervention and cannot wait for the once-a-week block of OR time and (2) patients requiring long-term ventilation who need nonurgent tracheostomy, which is delayed until the next open block of dedicated OR time.

Recent studies from orthopedic surgery, a specialty with a high number of urgent, nonemergency add-on cases, suggest that dedicated OR time for unscheduled cases decreased time from initial consultation to operative care by 50%, decreased the number of after-hours operations, and decreased overall complication rates.5,6 Since a large number of ORs run late to accommodate add-on otolaryngology cases, and since patient satisfaction is degraded by prolonged wait times between consultation and OR evaluation, we proposed the institution of a block of OR time for add-on cases as a quality-improvement initiative. After discussions with the departments of anesthesia and surgery and OR administration, a trial of the dedicated block time was initiated for the present study. This approach to scheduling add-on cases was a substantial change from the normal scheduling process, and the support of the chief surgeon was necessary to facilitate approval of the trial. A strong relationship between perioperative services and a willingness to pursue interventions outside of generally accepted policies is necessary to allow any such intervention to succeed, and the importance of cross-department communication cannot be overstated.

We gathered data on time from consultation to operative care because it was a primary concern of inpatient consulting services requiring surgical services, and it is important for patient satisfaction. We also gathered data on OR utilization because there were initially concerns that the block time might not be used to the full capacity. Our results compared favorably with the previous orthopedic literature, showing a 40% decrease in the amount of time from initial consultation to operative care (for inpatient cases). Utilization of the dedicated block time was 74%, which is comparable to generally reported norms and to the ideal utilization rates of 60% to 80%.8,9 Our utilization results are also similar to previously reported OR utilization rates in pediatric otolaryngology.10-14

Scheduling for the OR is a complex process, and the myriad factors contributing to this complexity are more pronounced for inpatients requiring surgical care, particularly for cases that are unscheduled. Inpatient add-on cases have a high cancelation rate, are difficult to schedule with respect to appropriate time and ancillary staffing, and decrease OR utilization rates.3,15,16 Managing these complexities is of paramount importance to streamline OR flow and to decrease patient waiting times. Although various scheduling algorithms have been suggested, none have gained widespread acceptance.2,17

The potential benefits of dedicated time for unscheduled cases are numerous. For patients, having a scheduled time minimizes the period of time that a patient must refrain from eating and allows for better planning of other diagnostic or care activities that may have been put on hold while awaiting the OR. Additionally, it allows families to plan accordingly for a scheduled procedure with the potential to improve patient and caregiver satisfaction. It is well documented that shorter wait times improve patient satisfaction scores.18-20 While complication rates were not directly examined in this study, published literature also supports that these may decrease when procedures have a scheduled time.5,6 Anecdotally, one of us (A.J.R.) was the resident responsible for taking inpatient consultations at the time the add-on OR time block was instituted, and he noted that being able to give a defined day to families who were waiting for elective procedures such as airway evaluation was very warmly received.

Additionally, the health care system benefits from dedicated OR time for add-on cases. For hospitals and OR staff, having scheduled cases decreases variability and allows more consistent staffing by decreasing after-hours utilization of anesthesia care and OR staff. The use of a dedicated OR allows for the surgical schedule to avoid overutilization of OR resources during certain periods of the week and underutilization during other periods. Performing cases earlier may also decrease the likelihood of elective cases evolving into emergency cases, especially for children with airway symptoms, indicating a potential opportunity for improved quality. Decreased wait times may also facilitate earlier discharge, which theoretically should improve the overall patient flow of the hospital and may improve patient satisfaction.21 Finally, for surgeons, having scheduled cases allows OR staff familiar with otolaryngology procedures to be present, thus improving OR flow and surgeon satisfaction. In addition, there is a theoretical benefit of decreasing the number cases performed after hours, though our study did not specifically evaluate this. We did, however, find a slight decrease in the number of add-on cases performed on the weekend.

Limitations

Limitations of this study include those inherent to retrospective data collection. There may have also been some add-on cases that were not captured by our review, but given that we used both the EMR and billing records, this seems unlikely. Prior to the intervention, some inpatient cases may have been scheduled through regular channels and were not tagged as add-on cases, but we are unable to capture that data, as these cases were not identified as add-on’s in the EMR. Additionally, we did not evaluate the impact of the dedicated OR on cost, hospital length of stay, or complication rate. The success of a dedicated add-on OR also may not translate to other institutions with smaller numbers of unscheduled cases but is likely applicable to other large tertiary care centers. Further research will be necessary to determine the impact of a dedicated OR block on these factors.

Conclusions

The institution of a dedicated block of OR time for a pediatric otolaryngology service reduces the time between initial consult and operative care by 3 days. The dedicated add-on room utilization rates were greater than 70%, suggesting that the OR time was effectively used. A dedicated add-on room may also positively affect hospital flow, may streamline OR staffing, and has the potential to improve quality and improve patient satisfaction.

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Article Information

Accepted for Publication: December 5, 2017.

Corresponding Author: Catherine K. Hart, MD, Division of Pediatric Otolaryngology, the Cincinnati Children’s Hospital and Medical Center, 3333 Burnet Ave, OSB-3, Cincinnati, OH 45229-3039 (Catherine.hart@cchmc.org).

Published Online: March 1, 2018. doi:10.1001/jamaoto.2017.3165

Author Contributions: Dr Hart had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Redmann, Robinette, Myer, de Alarcón, Hart.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Redmann, Robinette, Veid.

Administrative, technical, or material support: Redmann, Myer, de Alarcón, Veid.

Study supervision: Myer, de Alarcón, Hart.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. No disclosures were reported.

References
1.
Segal  B, Lam  E, Amar  J,  et al.  Add-on cases in the endoscopy unit: Factors that affect volume.  Can J Gastroenterol. 2009;23(7):485-488.PubMedGoogle ScholarCrossref
2.
Zhou  J, Dexter  F.  Method to assist in the scheduling of add-on surgical cases—upper prediction bounds for surgical case durations based on the log-normal distribution.  Anesthesiology. 1998;89(5):1228-1232.PubMedGoogle ScholarCrossref
3.
Dexter  F, Maxbauer  T, Stout  C, Archbold  L, Epstein  RH.  Relative influence on total cancelled operating room time from patients who are inpatients or outpatients preoperatively.  Anesth Analg. 2014;118(5):1072-1080.PubMedGoogle ScholarCrossref
4.
Chacko  AT, Ramirez  MA, Ramappa  AJ, Richardson  LC, Appleton  PT, Rodriguez  EK.  Does late night hip surgery affect outcome?  J Trauma. 2011;71(2):447-453.PubMedGoogle ScholarCrossref
5.
Wixted  JJ, Reed  M, Eskander  MS,  et al.  The effect of an orthopedic trauma room on after-hours surgery at a level one trauma center.  J Orthop Trauma. 2008;22(4):234-236.PubMedGoogle ScholarCrossref
6.
Bhattacharyya  T, Vrahas  MS, Morrison  SM,  et al.  The value of the dedicated orthopaedic trauma operating room.  J Trauma. 2006;60(6):1336-1340.PubMedGoogle ScholarCrossref
7.
Ogrinc  G, Davies  L, Goodman  D, Batalden  P, Davidoff  F, Stevens  D.  SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process.  J Am Coll Surg. 2016;222(3):317-323.PubMedGoogle ScholarCrossref
8.
Tyler  DC, Pasquariello  CA, Chen  CH.  Determining optimum operating room utilization.  Anesth Analg. 2003;96(4):1114-1121.PubMedGoogle ScholarCrossref
9.
Agnoletti  V, Buccioli  M, Padovani  E,  et al.  Operating room data management: improving efficiency and safety in a surgical block.  BMC Surg. 2013;13:7.PubMedGoogle ScholarCrossref
10.
Perkins  JN, Chiang  T, Ruiz  AG, Prager  JD.  Auditing of operating room times: a quality improvement project.  Int J Pediatr Otorhinolaryngol. 2014;78(5):782-786.PubMedGoogle ScholarCrossref
11.
Carter  JM, Riley  C, Ananth  A, Guarisco  JL, Rodriguez  K, Amedee  R.  Improving outcomes in a high-output pediatric otolaryngology practice.  Int J Pediatr Otorhinolaryngol. 2014;78(12):2229-2233.PubMedGoogle ScholarCrossref
12.
Shah  RK, Cohen  J, Patel  A, Derkay  C.  Analysis of pediatric direct laryngoscopy and bronchoscopy operative flow: opportunities for improved safety outcomes.  Arch Otolaryngol Head Neck Surg. 2012;138(7):624-627.PubMedGoogle ScholarCrossref
13.
Brenn  BR, Reilly  JS, Deutsch  ES, Hetrick  MH, Cook  SC.  Analysis of efficiency of common otolaryngology operations: comparison of operating room vs short procedure room in a pediatric tertiary hospital.  Arch Otolaryngol Head Neck Surg. 2003;129(4):435-437.PubMedGoogle ScholarCrossref
14.
Bhattacharyya  N.  Benchmarks for the durations of ambulatory surgical procedures in otolaryngology.  Ann Otol Rhinol Laryngol. 2011;120(11):727-731.PubMedGoogle ScholarCrossref
15.
Epstein  RH, Dexter  F.  Management implications for the perioperative surgical home related to inpatient case cancellations and add-on case scheduling on the day of surgery.  Anesth Analg. 2015;121(1):206-218.PubMedGoogle ScholarCrossref
16.
Weinbroum  AA, Ekstein  P, Ezri  T.  Efficiency of the operating room suite.  Am J Surg. 2003;185(3):244-250.PubMedGoogle ScholarCrossref
17.
Dexter  F, Macario  A, Traub  RD.  Which algorithm for scheduling add-on elective cases maximizes operating room utilization? Use of bin packing algorithms and fuzzy constraints in operating room management.  Anesthesiology. 1999;91(5):1491-1500.PubMedGoogle ScholarCrossref
18.
Mathews  M, Ryan  D, Gadag  V, West  R.  Patient satisfaction with wait-times for breast cancer surgery in Newfoundland and Labrador.  Healthc Policy. 2016;11(3):42-53.PubMedGoogle Scholar
19.
Holbrook  A, Glenn  H  Jr, Mahmood  R, Cai  Q, Kang  J, Duszak  R  Jr.  Shorter perceived outpatient MRI wait times associated with higher patient satisfaction.  J Am Coll Radiol. 2016;13(5):505-509.PubMedGoogle ScholarCrossref
20.
Lizaur-Utrilla  A, Martinez-Mendez  D, Miralles-Muñoz  FA, Marco-Gomez  L, Lopez-Prats  FA.  Negative impact of waiting time for primary total knee arthroplasty on satisfaction and patient-reported outcome.  Int Orthop. 2016;40(11):2303-2307.PubMedGoogle ScholarCrossref
21.
Haraden  C, Resar  R.  Patient flow in hospitals: understanding and controlling it better.  Front Health Serv Manage. 2004;20(4):3-15.PubMedGoogle ScholarCrossref
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