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.

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.