The OR should run like a well-oiled machine with patients moving through each stage seamlessly as the slightest factor can have lasting negative effects (See: Top 5 Challenges in the OR & How to Overcome Them). In this offering of Off the Shelf, we look at steps your hospital can take to improve its perioperative throughput.
As with most things, the process of improvement must start at the beginning with Pre-admission Preparation. Ensure patient files have an up-to-date History and Physical (H&P), Laboratory and Radiology reports, and medical and financial clearances to aid in the improvement process. (See: Tips on Operating Room Scheduling)
One of the keys to improving preoperative performance is involving physicians. Assess where things stand by asking these questions:
- Is Anesthesia involved in team decision making?
- Are Medical staff taking an active role in throughput?
- Is your Anesthesia staff reviewing patient charts for the next day?
- Anesthesia staff should assess a scheduled patient when the health history suggests potential problems.
Holding Area or Not? It depends. Most hospitals do not use holding areas for all patients, even though the areas may exist. Typical uses for holding areas include inpatient surgery patients and anesthesia services for line insertions, etc. For smoother OR transitions, consider eliminating multiple stops for outpatients.
Operative throughput should include the following:
- Assess your instrument and supplies and review your case cart readiness, including the number of trays and instruments, used and unused.
- The goal of this review is to eliminate any additional unneeded instrument counting/processing.
- To avoid case delays, ensure preferences cards are updated and all materials and supplies pulled for the case are correct.
- Make sure equipment is functioning correctly and all personnel are fully trained for the job.
- Perform proper maintenance checks ahead of time and review storage and organization procedures to ensure equipment is readily available for the next case start time.
- Unreliable items that frequently break/malfunction can have a huge effect on turnover.
To continue the momentum, make strides in post-op procedures starting with discharging from the Post-Anesthesia Care Unit (PACU). Acute care facilities should consider discharging select, low acuity patients directly from PACU.
PACU Overload, Dealing with Inpatients
Are there inpatients in your PACU delaying surgical starts? You have two options.
- First, the easity solution: deal with it. Have alternative staffing available, either a staffing agency or float pool, to stage inpatients in a dedicated part of PACU and train PACU nurses to care for their inpatients. This solution assumes there are PACU beds available for this function.
- Second, the harder solution: fix it. Fixing it requires a larger discussion with the affected inpatient departments and how to improve LOS for inpatient units stressing teamwork with these departments.
Protocols for Discharge & LOS
For a smooth, seamless transition through the discharge process, ensure Anesthesia staff use the appropriate, up-to-date medications to reduce postoperative LOS. Adhering to protocols in PACU and Day Surgery, nursing staff will be able to discharge in a timely manner.
Team Approach to Improve Turnover
It is imperative that OR staff be ready to start on time and every person in surgery should have a part of the turnover process. Surgeons can set the stage for expectations, especially if they are present during turnover/set-up, and work with the surgeon's office staff on scheduling issues can help if there continues to be a problem. (See: Soyring Consulting Case Study: Improving Prep, Execution, & Discharge in the OR)
For Anesthesia, Scrub, and Circulator staff, create buy-in for quick turnover time, utilize teams, publicize turnover results (monthly), and celebrate improvements. Anesthesia can help transport patients from Holding/Day Surgery to the OR and housekeeping needs to be readily available to assist with cleanup. Nursing staff can assist with room cleanup and patient transport. The bottom line, everyone needs to pitch in whether it is in their "job description" or not.