Which Patient Gets into the OR First?

The surgeon booking the case is responsible for categorizing the case, based on his or her knowledge of the clinical needs of the patient. For example, a surgeon can call an appendicitis case a 'B' case if he thinks that the patient's condition warrants surgery within two hours, even though most appendicitis cases are usually considered to be in the D (within eight hours) category. At the time of booking, no one can question the surgeon on this decision since it is assumed that he or she is the one with the most accurate assessment of the situation.

Monitoring Compliance
Like any system, this one can be manipulated, and oversight is necessary to maintain consistency and monitor compliance with the urgency categories. At WellStar Kennestone Hospital, the surgical services committee took on this role. Each month, the committee reviewed all 'A' cases and any other cases where the appropriateness of the urgency classification was questioned by another surgeon, an anesthesiologist, or surgical staff.

If further review appeared necessary, a member of the committee would talk with the surgeon in question, and if systematic or frequent problems occurred, the surgeon would be asked to appear before the committee to discuss the cases. This peer review system is critical to maintain accurate categorization and to avoid any gaming of the system. The review can also lead to revisions to the category guidelines over time.

Results
With the implementation of this approach to scheduling urgent/emergent cases into designated ORs, waiting times for these cases declined by 18% overall at WellStar Kennestone Hospital. For urgent and semi-urgent cases—types of cases that typically get delayed—the decreases in waiting time were even more dramatic, with waiting times decreasing 77% for C cases (maximum wait of four hours) and 33% for D cases (maximum wait of eight hours). In addition, E (non-urgent same day) cases no longer got pushed into nighttime hours—from 11 p.m. until 7 a.m.—because there was more time during the day to get these cases completed. The number of staff needed at night was reduced since it had only to care for more urgent cases.

The surgeons were pleased that their patients were getting into the OR more quickly. Surgeons, anesthesiologists and OR staff appreciated the transparency of the system. "Since we are able to get critical cases done more quickly we end up with less of a backlog during the day, and no longer find ourselves doing hip fractures at midnight," said an anesthesiologist at WellStar Kennestone.