Anesthesiology Focus for Operating Room Efficiency

This article appears in the December 2012 issue of HealthLeaders magazine.

Anesthesiology may be a sleeper in healthcare, in a manner of speaking. While not traditionally regarded among the top service lines, anesthesiology programs are a direct link to a hospital's biggest moneymaker: surgery in the operating rooms.

As much as 60% to 70% of hospital revenues are tied to the operating room, and anesthesia administered in the OR or other parts of the hospital are critical because of their widespread impact, according to Sabrina Bent, MD, MS, clinical associate professor of anesthesiology and director of research at Tulane University in New Orleans.

Yet throughout the United States, when surgeries are canceled at the last minute—often because patients decide to delay or forego the procedure, and sometimes because of scheduling problems in hospitals—it can cost healthcare facilities millions of dollars in lost revenue.

Hospitals are homing in on anesthesia programs to buttress their ORs and improve coordination with patients to reduce delays. They are also initiating changes to improve scheduling and staffing, and overcome bottlenecks in patient flow, which are the result of inefficient and unpredictable OR scheduling.

"Anesthesiologists are the traffic cops" in the OR, says Martin De Ruyter, MD, associate professor in the department of anesthesiology at the 606-bed Kansas University Medical Center in Kansas City, Kan. De Ruyter says effective partnerships with the anesthesia department help improve physician communication and accountability, which directly impacts perioperative care.

That coordination is essential to reducing inefficiencies in care caused by the cancellations of procedures, which cost $1 million in 2009 at the 235-bed Tulane Medical Center, according to Bent. This financial fallout prompted Tulane to take steps to revise its scheduling programs, with anesthesia service a key element for improved preoperative procedures, she says.

For several years, the 866-bed St. John's Regional Health Center in Springfield, Mo., organized programs to improve flow in surgical cases for its 39 surgical suites. Anesthesiology was a major focus of a physician-led committee exploring patient flow, says Jeff Hawkins, RN, MHA, OR administrative director for Mercy Health, which runs St. John's. "There is an oversight coordinator who works hand-in-hand with anesthesia, looking at the rooms, what's open, what's not, where we can put people in," Hawkins says. "There's a lot of communication going back and forth. There is a long list: What did we capture, what did we miss?"

By focusing on OR efficiency and service, the scheduling changes are often coordinated by anesthesiology leaders, says John Herring, MD, the anesthesia medical director at the 280-staffed-bed St. Luke's Hospital, in Cedar Rapids, Iowa, who also practices with Linn County Anesthesiologists. One of the areas that the hospital focuses on is block scheduling, a procedure in which anesthesiologists have flexibility in scheduling to ensure that different ORs are utilized and reducing the number of empty suites on some days and overcrowded ones on others.

"It's beneficial for everyone to improve scheduling processes and define block scheduling," says Herring, noting that there should be efforts to "reduce the unintended but frustrating competition for resources."

Success key No. 1:  Avoiding cancellations

Patients forget they have a surgery appointment. They get lost going to the hospital. For whatever reason—or excuse—they may fail to show up for a scheduled operation.

Sometimes hospitals themselves mess up the OR schedules because of lack of bed space or equipment. 

The missed appointments and scheduling miscues can have a huge dollar impact on hospitals, with surgeries canceled on short notice. But meticulous preoperative coordination can improve care and reduce the possibility of cancellations, ensuring that patients are medically ready for surgery and have received the proper preoperative instructions for the day of the procedure, says Bent.

In a 2009 study at Tulane University Medical Center, Bent and her colleagues found that cancellations occurred in 487, or 6.7%, of scheduled surgeries at the hospital. That amounted to a $1 million financial loss in one year, she says. The losses showed that there was a need for preoperative clinic visits by patients, which are now mandatory, she says.

Last-minute cancellations may stem from various reasons. More than 30% of patients in Bent's study failed to show up at the time of surgery because of transportation problems, confusion over the date of the procedure, forgetting about the appointment, or for other reasons, she said. Another one-third of the procedures were canceled because of issues at the hospital itself, such as a lack of beds or equipment. "There are multifactorial reasons for cancellations," says Bent.

Scheduling errors also can occur when one piece of expensive equipment is needed in two ORs at once, other equipment fails, or the intensive care units happen to be full, leaving no place for patients to recover following procedures.

The cancellations were more likely among patients who did not have a preoperative clinic visit with the anesthesiologist; nearly 11% of the surgeries were ultimately canceled compared with less than 4% of those that were preceded by a clinic visit.

The canceled cases show the need for preoperative evaluation. Of the canceled cases, 19% had undergone preoperative evaluation and 76% had no preoperative assessment at all, says Bent.

A new scheduling paradigm was established, with a focus on mandatory preoperative clinic visits and stopping cancellations, she says. There was a "concerted effort" among administrators, providers, and fiscal analysts at the hospital to carry out the program, she says.

The hospital initiated a mandatory preoperative clinic visit by patients to ensure proper fasting prior to surgery, for instance, and having their blood pressure monitored or EKG performed. Online educational programs are also available for patients, who are considered otherwise healthy without comorbidities.

While many hospitals and surgery centers have some form of preoperative clinic or evaluation, many aren't mandatory and the compliance of patients being evaluated "is not 100% and frequently a lot less," Bent says. "Surgical referral to an anesthesiologist for a preoperative clinic or to a preoperative online is not consistent." Since Tulane adopted the mandatory program, compliance has been estimated at near 100% among patients and staff, and follow-up studies are continuing, Bent says.

Hospitals also have been historically at fault for needless surgery cancellations and failure to adhere to preoperative clinic programs, Bent says. Surgeons, for instance, have been reluctant to tell patients they should attend such programs. "The whole point is to be able to recognize and treat or otherwise optimize the patient for surgery before the day of surgery," she says.

One of the most important elements in dealing with postoperative care is the variability among specialties.  Some surgeries simply have more cancellations or delays, depending on the patients and kinds of care.

"The cost of cancellation varies by specialty, so you might concentrate on the cost of canceled cases," Bent adds. "For those implementing processes, specialties stand to be the greatest in lost revenue."

According to Bent's 2009 study on revenue loss by specialty, general surgery had an average loss per case of $2,000 and a total revenue loss of $200,478; neurosurgery had an average loss per case of $5,962 and a total revenue loss of $41,735; ophthalmology, $2,927 per case and a total of $46,828 lost; and orthopedics, $2,779 and a total of $71,807 lost.

Success key No. 2:  Block time scheduling

When anesthesiologists and physicians at St. Luke's Hospital began to look at OR inefficiencies, they didn't have to look far: Surgeons were competing with each other for time and space in the OR. And they experienced a shortage of available anesthesiologists.

As St. Luke's and another hospital tapped into an anesthesiology group, they found that they sometimes had to "take a number" to get a doctor. The anesthesiologists were sent from hospital to hospital as needs arose. Sometimes, one surgeon's need conflicted with another's. Sometimes, there were too many physicians and anesthesiologists available for surgery; at other times, too few. St. Luke's officials knew they were in the midst of a money-losing proposition. The problem, as they saw it, was limited resources and an inefficient scheduling system.

The various demands, particularly on the anesthesiology group, "shot holes in the schedule for the operating rooms at each institution," Herring says. "There was a huge variability for surgical loads at each place. You would have peak times that were difficult to staff and cause the hospital to spend overtime, yet there were low periods, too. Surgeons would compete with each other for personnel and equipment, and there was a need for anesthesiologists as well. For the hospital, it was a costly and very significant dissatisfaction. The anesthesiologists were trying to satisfy the surgeons' needs, not realizing it was creating a disadvantageous position for the hospital. The hospital made it apparent this was a problem and needed the resources to be more stable."

Block time was the solution. With this technique, it is important to coordinate all the surgical equipment needed for a specific surgery but also to involve anesthesiologists. By establishing the block times, office space and surgery space is coordinated for the different physicians, nurses, and anesthesiologists involved in the process, he says.

By utilizing the block schedule, the hospital has reduced conflicts in using the OR and avoided delays in the start of surgery, says Herring. Over the past two years, available block hours—reserved time for specific surgeons and procedures—have increased from 300 to 1,000 per month.  The hospital estimates that it has improved overall utilization of the OR, without empty spaces, from 50% to 77% over that time, Herring adds. The hospital also anticipates it can reduce staff attrition by improving the OR efficiency, with an ultimate savings of $2 million in direct cost and the potential for $2 million of savings in indirect costs, Herring adds.

The New Milford (Conn.) Hospital also has used block scheduling to avoid delays and eliminate competing schedules, says Edward A. Zane, MD, chief of the department of anesthesiology and medical director for the OR. Surgeons are held accountable for their schedules and may lose their scheduled surgeries if there are conflicts. But if they are efficient in their scheduling, are high utilizers, and have a high volume of low-acuity cases, they are allotted additional block time, Zane says.

On each scheduled shift, anesthesiologists play a key role, Zane adds. For surgeons, it's important that each day they book their schedules early and coordinate with anesthesiologists. "We work with the surgeons and assign an anesthesiologist to a room each day," Zane says.

Success key No. 3:  Alignment

To improve the flow of patient utilization in the OR, St. Luke's Hospital created a perioperative governing council, says Herring, the anesthesia medical director. The key word in the council, he says, is "governing." This group is empowered to dictate OR improvements, so it has clout. That wasn't always the case. Previously, the hospital had an advisory council that made recommendations, but their suggestions for improvement weren't always addressed—and that, Herring says, wasn't good enough.

The perioperative governing council is composed of hospital administration officials, surgeons, and anesthesiologists. Physician involvement and leadership are essential, Herring says. As a result, physician membership originally was assigned and approved by the St. Luke's C-suite and now the committee itself decides its membership. The governing council's decisions are forwarded to responsible hospital personnel and medical staff committees as appropriate.

The council is responsible for scheduling surgery start times, anesthesia schedule management, and block times prior to surgery, with an effort to ease caseloads, Herring says. The 16-member council includes five members from anesthesia, seven members from surgery, and four members from administration as a way to give balance in efforts to improve efficiency, according to Herring. The council also works with a surgery executive committee, which includes the director of surgery, the anesthesia director, the COO, and director of surgical services to focus on start times and set the agenda for the council.

The hospital changed from an advisory to a governing council with physicians to give the group enough power to go forward, he adds. The system was used to complete a block scheduling arrangement in which anesthesiologists, who work for their own groups, sign contracts about their availability with the hospital, Herring says. He characterizes the contracting process as the result of a collaborative effort that defines scheduling and block times.

Although there was initial resistance to the coordinated effort, "we gained a lot of political support as the doctors came to understand what we were trying to do," Herring says. "It began to make sense, to have a focus."

Coordinating care and improving patient flow are often the responsibility of the medical director of the OR. At New Milford, that role is assigned to Zane, chief of the department
of anesthesiology.

As head of the OR, Zane coordinates staff as well as anesthesiologists. He belongs to a physician network, the Western Connecticut Medical Group, which provides anesthesiologists to New Milford Hospital and two other healthcare facilities. Many of the anesthesiologists interchange their role based on the needs of the particular hospital, "matching the supply with the demand," Zane says. "It's very flexible and very good for staffing," he explains. "When it is busy in one place, we can shift staff to another place, if one staff is slow."

Along the way, they built a multidisciplinary team, with anesthesiologists having a key role. As anesthesiology chief and medical director of the operating room, he coordinates staff. "It's an OR team, and that's an important factor," Zane says. "We're a team."

Success key No. 4:  Pain management

In many surgeries, postoperative pain is a particular concern for patients, physicians, and hospitals. Severe pain can result in readmissions, which is undesirable for the patients and costly for healthcare facilities. To help eliminate postoperative pain, anesthesiologists are using peripheral nerve blocks that can enable patients to move quickly into physical therapy, with less need for to take narcotics and opioids, says De Ruyter of Kansas University Medical Center.

The process involves using peripheral nerve catheters to ease postoperative pain for patients following orthopedic surgery. The catheter is a threadlike tube that provides a continuous infusion of anesthesia for pain relief that lasts up to three days after procedures. Nerve-block anesthesia has been used to alleviate pain in breast cancer surgery as well as kidney stone and hernia removals.

In a study of 510 patients treated over a three-year period, De Ruyter says he found that a peripheral nerve block can provide satisfactory analgesia for several days after orthopedic procedures, particularly in outpatient settings. Of the outpatients studied, the average duration of the catheter infusion was 2.3 days, and "no patients reported falls or difficulty in removing their catheters at home," De Ruyter says. In addition, "they actually participate in physical therapy more quickly, and we have less [use of] narcotics and opioids," he notes. "There's a high degree of patient satisfaction: ‘Hey my leg doesn't hurt. This is great! Let's do it again.' And then they want the other leg [operated on]," De Ruyter explains.

While some hospitals have reported success with peripheral nerve blocks, they are less commonly used for outpatient surgical procedures because of potential catheter-related complications and patient difficulty in having access to a physician outside the hospital after being sent home.

Communication via the phone appeared to be enough to monitor the patients in De Ruyter's research. He studied patients who had undergone foot and ankle surgery between 2008 and 2009 who were offered at-home analgesic therapy. The anesthesiologist contacted each patient daily while the analgesic was in place to "assess the efficacy and safety of the block," De Ruyter says. 

"The once-daily telephone contact with patients was adequate. There was minimal impact on the anesthesiology care team, and patients or caregivers were able to reliably remove their catheters at home," he says.

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This article appears in the December 2012 issue of HealthLeaders magazine.