Which Patient Gets into the OR First?
When several patients needing urgent or emergent surgery arrive at a hospital simultaneously, who decides which case gets into the OR first? For true emergencies, the decision is generally straightforward, with the patient rushed into the first available room.
But in many other situations, the decision is not as clear: Should the patient with an open fracture go first; should it be the patient with an ectopic pregnancy, or perhaps the patient with an intestinal obstruction? Does the most senior surgeon get the first available OR slot? Should the decision be made on the basis of first-come, first-served? Or maybe the most assertive surgeon gets his or her case in first?
Often the decision falls to the anesthesiologist of the day in the OR. But no matter who makes the decision, the competition between surgeons over this matter, and the daily arguments with anesthesiologists, cause frustrations to both surgeons and anesthesiologists. And at times, patients end up waiting for surgery longer than is clinically optimal.
Ideally, the decision should be based on an objective measure that reflects the clinical needs of the patient and gives surgeons, anesthesiologists, and OR staff a predictable and fair system for prioritizing their cases.
An Innovative Approach
Wellstar Kennestone Hospital, a 600-bed hospital in Marietta, GA, working with Press Ganey, developed an innovative approach to this problem. As part of a significant initiative to improve patient flow through the OR, the surgical services committee—a committee composed of well-respected surgeons and anesthesiologists representing different services—developed criteria for classifying all emergent and urgent cases based on the medical needs of the patient.
The classification system was then used to determine the order in which cases were taken into the OR. It created a system that was fair, predictable and based on clinically-defined criteria. The clinical urgency system was used in conjunction with other patient flow improvement initiatives, including designating separate ORs for these add-on cases.
The surgical services committee decided to use five categories to classify its urgent and emergent cases. Time limits were set for each category, defining the maximum amount of time that should pass between the time a case was posted and when the patient was taken into the OR. Each specialty reviewed its common procedures and placed them into the category into which they would most commonly fall.
The five categories, and their corresponding time limits, were:
- A. Acute life and death emergencies (30 - 60 minutes). Examples: Massive bleeding and airway emergencies.
- B. Emergent but not immediately life threatening (< 2 hours). Examples: Acute spinal cord compression, bladder rupture, ectopic pregnancy.
- C. Urgent cases (< 4 hours). Examples: Asymptomatic foreign body, appendicitis with sepsis/rapid progression, biliary obstruction, open fracture.
- D. Semi-urgent (< 8 hours). Examples: Appendicitis, closed reduction of fracture, empyema.
- E. Non-urgent cases (< 24 hours). Examples: Facial nerve decompression, femoral neck fractures, mastoidectomy.
Once the categories were developed and accepted by the surgeons, they began to use them to specify the urgency of add-on cases as they posted them. The system works in the following way:
When a surgeon posts a case, he or she classifies its urgency by using one of the five categories based on the needs of the patient. The appropriateness of the classification is never questioned at the time the case is posted but may be reviewed by the committee retrospectively. The order in which add-on urgent/emergent cases are then scheduled into the OR is based on the urgency of the case and the amount of time that has passed since the case was posted. If two cases within the same category arrive close together, they are taken in order of first-come, first-served.
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