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Patient Safety Tip of the Week
March 28, 2023
Intraoperative Team
Continuity and OR Efficiency
Teamwork and team communication are critical for
success in the OR. In our several columns on “after hours” surgery we’ve noted
one of the likely contributing factors may be that you are often operating with
a team that is likely different from your daytime team. The same also likely
applies to surgery during daytime hours. In our December 13, 2022 Patient
Safety Tip of the Week “Surgical Teams – the ‘Consistency Score’” we highlighted a metric, the “consistency
score”, developed by researchers at the Hospital for Special Surgery in New
York (Kirksey
2022). Using that metric, the
researchers showed that for both THA’s and TKA’s better team consistency was
associated with improved OR efficiency without any increase in adverse events.
Cousins et al. (Cousins
2023) recently looked at the impact of intraoperative changes of
non-physician staff on measures of OR efficiency in hip and knee arthroplasty.
Turnover among circulating nurses was associated with a significant increase in
operative duration in both THA’s and TKA’s, with estimated differences of 19.6
minutes of room time in THA’s and 14.0 minutes of room time in TKA’s. The
presence of a surgeon-preferred vendor was associated with a significant
increase in operative duration in both THA’s (26.3 minutes) and TKA’s (29.6
minutes). On the other hand, the presence of a preferred anesthesiologist or
surgical technician was associated with significant decreases of 26.5
minutes of procedure time and 12.6 minutes of room time, respectively, in
TKA’s.
Interestingly, and perhaps unexpectedly, both the presence of anesthesia residents in THA’s and the presence of surgical residents
in TKA’ s was associated with significant decreases in operative
duration. In some cases those decreases were up to 21.8 minutes of
overall room time. The
authors note that involvement of residents in many previous studies tended to
increase case duration. But the data in the current study suggests that, in some settings, resident participation may constitute a net benefit to operative efficiency rather than being a costly educational investment. The
presence of nonresident trainees (eg, nursing
students, staff in training,
medical students, and surgical
fellows) was not associated with
significant increases in operative duration
for THA’s or TKA’s.
The authors feel that the fact that the presence of a preferred anesthesiologist was associated with a significant decrease in
procedure time in TKA highlights the critical importance of smooth communication between surgeon and anesthesiologist throughout the duration of a procedure, even
after induction.
And…vendors. We personally hate the idea of vendors in the
OR. But it seems to be a fact of life. The
presence of a preferred vendor was associated with an increase
in operative duration in both
THA’s and TKA’s, in some cases of up to 29.6 minutes of overall room time.
The authors suggest that vendors
play a multifaceted role in the operative team and that the qualities that surgeons prioritize in
vendors may detract from
intraoperative efficiency. We’d wonder if it does not simply mean that
surgeons may have been unfamiliar with nuances of some newer implants, thus
requiring more communication with the vendors.
Unfortunately, the researchers only assessed operative
duration as a marker of operative efficiency and therefore were not able to
quantify postoperative outcomes such as readmissions or surgical site infections.
In our many previous columns on surgical case duration, one
statistic we’ve often cited is that the infection rate increases as surgical
case duration increases. Procter et al. (Procter 2010) looked at a large database of general
surgical procedures and demonstrated a linear relationship between duration of
surgery and infectious complications. This relationship persisted even after
adjustment for a variety of other risk factors for perioperative infections.
The unadjusted infectious complication rate increased by 2.5% per half hour.
Hospital length of stay (LOS) also increased geometrically by 6% per half hour.
Logically, prolonged operative time would also be expected to increase
pressure-related complications, such as decubiti and perioperative
neuropathies. But longer duration also increases the likelihood of increased
foot traffic into and out of the OR and more door openings and closings. These
are risk factors for surgical infections and also the
potential for distractions and interruptions, potentially contributing to
errors.
In our January 2021 What's New in the Patient Safety World
column “Operative
Time and Postoperative TKA Complications” we cited another study (Chen
2020) that used data from the American College of Surgeons National
Surgical Quality Improvement Program database on almost 15,000 patients who had
undergone revision total knee arthroplasties (TKA’s) between 2007 and 2016.
After adjustment, each additional 15 minutes of operative time increased the
likelihood of wound complications (odds ratio 1.023), postoperative blood
transfusion (odds ratio 1.169), and extended hospital stay (odds ratio 1.060).
Of course, from such database statistics one cannot determine the reason for
the prolonged surgical durations. In some cases, whatever led to complications
may have also prolonged the surgery. But, undoubtedly, in many cases the
complications resulted from the long surgical durations.
Overall, the Cousins study clearly
demonstrates that continuity of the team is important in terms of OR
efficiency. Having a circulating nurse, surgical tech, and anesthesiologist who
regularly work with the surgeon are clearly important.
Our prior columns
focusing on surgical case duration:
· March 10, 2009 “Prolonged Surgical Duration and Time
Awareness”
· January
2010 “Operative Duration and Infection”
·
July 21,
2012 “Surgical Case Duration and Miscommunications”
· August 26, 2014 “Surgeons’ Perception of Intraoperative Time”
· December 30, 2014 “Data Accumulates on Impact of Long Surgical
Duration”
·
November 24, 2015 “Door
Opening and Foot Traffic in the OR”
· July 26, 2016
“Confirmed:
Keep Your OR Doors Closed”
·
November
7, 2017 “Perioperative
Neuropathies”
· December 2017 “A
Fix for OR Foot Traffic?”
· January 2021 “Operative
Time and Postoperative TKA Complications”
Our prior columns
focusing on surgical OR foot traffic and door opening:
· March 10, 2009 “Prolonged Surgical Duration and Time
Awareness”
· January
2010 “Operative Duration and Infection”
· August 26, 2014 “Surgeons’ Perception of Intraoperative Time”
· December 30, 2014 “Data Accumulates on Impact of Long Surgical
Duration”
·
November 24, 2015 “Door
Opening and Foot Traffic in the OR”
· July 26, 2016
“Confirmed:
Keep Your OR Doors Closed”
· December 2017 “A
Fix for OR Foot Traffic?”
· April 23, 2019 “In and Out the Door and
Other OR Flow Disruptions”
· June 8, 2021 “Cut OR Traffic to Cut
Surgical Site Infections”
· January 11, 2022 “Documenting Distractions in
the OR”
· October 4, 2022 “Successfully Reducing OR
Traffic”
Some of our previous
columns on “after-hours” surgery:
·
September 2009 “After-Hours
Surgery – Is There a Downside?”
· October 2014 “What Time of Day Do You Want Your Surgery?”
· January 2015 “Emergency Surgery Also Very Costly”
· September 2015 “Surgery Previous Night Does Not Impact
Attending Surgeon Next Day”
· October 4, 2016 “More
on After-Hours Surgery”
· August 15, 2017 “Delayed
Emergency Surgery and Mortality Risk”
· October 24, 2017 “Neurosurgery
and Time of Day”
· December 2019 “Surgeon
On-Call Shifts”
· October 13, 2020 “Night-Time Surgery”
· December 13, 2022 “Surgical Teams – the
“Consistency Score””
References:
Kirksey M, Sasaki M, Grace D, et al. A Novel Network-Based
Metric of Surgical Team Consistency Opens Opportunities to Improve Hospital
Performance and Care Value. NEJM Catalyst 2022; 3(12): December 2022
https://catalyst.nejm.org/doi/full/10.1056/CAT.22.0244
Cousins HC, Cahan EM, Steere JT, et al. Assessment of Team Dynamics and Operative
Efficiency in Hip and Knee Arthroplasty. JAMA Surg 2023; Published online March
22, 2023
https://jamanetwork.com/journals/jamasurgery/article-abstract/2802864
Procter LD, Davenport DL, Bernard AC, Zwischenberger
JB. General Surgical Operative Duration Is Associated With
Increased Risk-Adjusted Infectious Complication Rates and Length of Hospital
Stay, Journal of the American College of Surgeons 2010; 210: 60-65
Chen AZ, Gu, A, Wei C, et al. Increase in Operative Time Is
Associated With Postoperative Complications in
Revision Total Knee Arthroplasty. Orthopedics 2020; 44(1):18-22 Posted November
25, 2020
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