Medical Education Operating Room

In The Future, Your Nurse Anesthetist Will Be A Doctor

Certified registered nurse anesthetists (CRNAs) are advanced practice nurses who deliver anesthesia. In 2025, the training requirements to become a CRNA will change and require that all new CRNAs have a doctorate degree. In the past, a 4-year bachelors degree followed by a 2-year masters degree in nurse anesthesia was required to become a CNRA. This is similar to other advanced practice providers such physician assistants, nurse midwives, and nurse practitioners. In 2009, the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) voted to require all nurse anesthesia educational programs to transition to 3-year doctoral programs. The deadline for conversion from masters to doctoral programs is 2025. Therefore, after 2025, all newly graduated nurse anesthetists will have doctorate degrees. In order to meet that deadline, beginning this year in 2023, all students enrolling in CRNA programs must enroll in a 3-year doctorate program.

There are six possible doctoral degrees that a nurse can pursue in becoming a CRNA:

  1. DNP (Doctor of Nurse Practice): a degree for a clinical career
  2. DNAP (Doctor of Nurse Anesthesia Practice): a degree for a clinical career
  3. PhD (Doctor of Philosophy): primarily a degree for a career in academics
  4. EdD (Doctor of Education: primarily a degree for a career in education
  5. DNS (Doctor of Nursing Science): primarily a degree for a career in research
  6. DMPNA (Doctor of Management Practice in Nurse Anesthesia): primarily a degree for a career in administration

The vast majority of new CRNAs will have either a DNP or DNAP degree. Both are 3-year programs that require a previous bachelors degree, usually a BSN (Bachelors of Science in Nursing). Both require one year of prior clinical work practice as an RN in a critical care setting but some individual programs may require 2-years of practice as an RN. Both have similar curricula but there are minor differences between the two types of doctorate degrees.

DNP versus DNAP

Doctor of Nurse Practice (DNP). This is a doctoral degree offered at a school of nursing that is accredited by the American Nurses Credentialing Center (ANCC) which is a subsidiary of the American Nurses Association. There are many specialty pathways within the DNP program and a student choosing to become a nurse anesthetist would enroll in the the CRNA pathway. A DNP is considered a “terminal degree”, meaning it is the highest degree that can be obtained in a field. Terminal degrees are usually required for university faculty members seeking tenure.

Doctor of Nurse Anesthesia Practice (DNAP). This is a doctoral degree specially designed for nurse anesthetist students at a training program approved by Nurse Anesthetists Council of Accreditation (NACA). Unlike the DNP, the DNAP is only for nurse anesthetists and not other nurse practitioner specialties. Some, but not all universities consider a DNAP to be a terminal degree; therefore it may not be appropriate for someone who plans to pursue an academic career at a university in order to ensure universal eligibility for faculty jobs.

For the hospital, both the DNP and DNAP programs can be considered equivalent from a training standpoint.

A certification exam is required after training

After graduating from an accredited nurse anesthetist program, individuals must then take the National Certification Exam (NCE) administered by the National Board Certification and Recertification for Nurse Anesthetists (NBCRNA). In 2022, the pass rate for first-time takers of the exam was 83.4%. After passing the certification exam, individuals must then apply for CRNA licensure in their state.

After initial certification, CRNAs are required to be re-certified every four years. Recertification involves having 100 hours of continuing education credits and completion of one core module from each of four core areas: airway management, pharmacology, human physiology & pathophysiology, and anesthesia technology (the core modules provide 60 of the required continuing education credits). CRNA licensure is state-specific and individual states can have additional requirements to practice as a CRNA.

Implications for hospitals

The result of the new requirements is that newly trained CRNAs will have one additional year of training than CRNAs trained in the past. However, because that one year will be nurse anesthetist-specific training, the net result will be a 50% longer training in anesthesia than previously. The additional training should result in greater anesthesia knowledge. The implication is that hospitals may change their utilization of CRNAs:

  • Ability to start cases independently at night. CRNAs are required to work under the supervision of a physician – in Ohio, the “supervising physician” does not have to be an anesthesiologist. The rules on CRNA scope of practice are state-specific but in most states, CRNAs can start surgical cases without a physician anesthesiologist present in the OR area. However, many individual hospitals have rules over and above state regulations and require the presence of an attending anesthesiologist for the CRNA to start a case. This has relevance to cases at night when there can be a delay starting emergency operations while waiting for the anesthesiologist to arrive. Hospitals may find that it is more practical to have in-house CRNAs at night to expedite cases. In this situation, the surgeon would become the CRNA’s supervising physician rather than the anesthesiologist. However, because emergency cases at night are often some of the most physiologically complicated and high-risk, hospitals may still want to have attending anesthesiologists on call from home at night for back-up purposes.
  • Endoscopy sedation. In the past, sedation for colonoscopies and other procedures performed in hospital endoscopy suites was administered by the gastroenterologist or surgeon performing the procedure. In recent years, procedural sedation has increasingly been administered by anesthesiologists. The new requirements may give hospitals more comfort in having CRNAs perform procedural sedation without the physical presence of a physician anesthesiologist in the endoscopy suite area. In this situation, the gastroenterologist or surgeon would become the “supervising physician”.
  • Emergency airway management. In the past, hospitalists were routinely trained in intubation and airway management, such as occurs in the intensive care unit or during cardiopulmonary resuscitation. Because intubation is no longer required during internal medicine or family medicine residency, many hospitalists no longer perform intubation, leaving airway management to critical care physicians, emergency medicine physicians, anesthesiologists, and respiratory therapists. The new training requirements may give hospitals more comfort in designating CRNAs to be responsible for emergency airway management, particularly at night.
  • But, be prepared to pay more. The U.S. Bureau of Labor Statistics reports that CRNAs have a median hourly wage of $97.64 per hour. This equates to an annual income of $203,090 per year. There is considerable variation between different states. For example, the median annual income for CRNAs in California is $246,510 whereas in Oklahoma, the median income is $168,470. Here in Ohio, CRNA income is at about the U.S. average with a median income of $197,630. In contrast, the MGMA reports that the average income for a physician anesthesiologist in academic practice is $407,681 and in private practice is $468,106. In other words, a CRNA costs half as much as an anesthesiologist. However, as the length of CRNA training increases, CNRA incomes are likely to rise in the future.

The trend throughout healthcare has been to increasingly utilize advance practice providers (such as nurse practitioners and physician assistants) to perform services historically performed by physicians. Because these advance practice providers are less expensive than corresponding physicians, they can reduce healthcare costs. The new requirement of a doctoral degree to become a CRNA will likely result in an expansion of the use of CRNAs for anesthesia, sedation, and airway management.

May 3, 2023

Operating Room

Operating Room Block Scheduling Versus Open Scheduling

There are some healthcare services that hospitals lose money on and some services that hospitals make money on. Hospitals tend to lose money on medical admissions and uninsured/Medicaid patients but make money on surgeries. Specialty hospitals, such as orthopedic surgical hospitals, take advantage of this and consequently can be quite profitable. However, for community hospitals to meet their obligation to align the healthcare resources of the hospital with the healthcare needs of the community, those community hospitals must maintain an adequate ratio of surgical to non-surgical services. But it also means that the hospital’s operating rooms must consistently function at maximum efficiency. And that is where OR scheduling can make or break a hospital’s financial bottom line.

In simplistic form, there are basically two ways to schedule surgeries: block scheduling and open scheduling. In block scheduling, a block of time is assigned to a specific surgeon or surgical group and no other surgeon can schedule cases in that particular operating room during that particular time and day. In open scheduling, surgical cases are booked in an operating room based on first-come, first-served and many surgeons may book cases in any given room in the OR area on any given day. As an analogy, block time is like a restaurant reservation – you reserve a table days in advance and you know when you walk in the restaurant that you are going to have a table at that particular time and day without having to wait. There are certain guiding principles to block time:

1. Block time belongs to the hospital

2. Block time is an extremely valuable asset

3. The hospital must designate a guardian of the block time

Block scheduling has certain advantages. It allows for specific operating rooms to be dedicated to specialized equipment (laparoscopic equipment, robotic equipment, fluoroscopy, etc.). It is allows the surgeon to make the most efficient use of his/her time by clustering cases at one time so that the surgeon does not need to be constantly racing between the office and the operating room. The surgeon can then schedule other times during the week to be seeing outpatients, thus making that surgeon’s office practice more efficient. It can allow the hospital to make most efficient use of a given operating room since the same surgeon will be physically present and ready to go as soon as the next patient is brought into the OR.

Similarly, open scheduling can have certain advantages. It allows accommodation of urgent or emergent cases. It can result in more consistent use of the operating room, nursing staff, and anesthesiology staff during regular work hours. It can result in less use of staff overtime. There is no need for a block time release policy or monitoring of block time utilization.

What really constitutes a block?

In order to maintain optimal utilization of the operating room, it is best to avoid half-day blocks and instead grant full-day blocks, whenever possible. It takes time to set up an operating room for a spine surgery case if that OR has been used for ENT surgeries all morning and therefore there is less down-time when reconfiguring a room for a second half-day block. Furthermore, no surgeon can predict with perfect accuracy how long it will take to do a particular surgery – there are inevitably unexpected delays or complications that can make a surgery go longer and there are inevitably last minute cancelations that can make the schedule shorter. If either of these happen during a morning half-day block, then it can result in either the OR going unused at the end of the morning or the surgeon with the afternoon half-day block having to wait to start her/his surgeries. It may be operationally most efficient to have some blocks end at 3:00 PM rather than at 5:00 PM.

Some surgeons may not need a full-day block each week. In these situations, scheduling an every-other-week block for that surgeon can make sense and be preferable to scheduling a weekly half-day block. Usually, you can find a second surgeon who also needs an every-other-week block to counter balance scheduling.

Surgeons frequently define their value by block time

When a hospital recruits a new surgeon, one of the first things that surgeon will ask for is block time. From the surgeon’s perspective, it is an indication of how much the hospital values her/him and the surgeon with block time will have a perception of having a greater chance of success. Indeed, to recruit the best surgeons, a hospital must be willing to offer block time. And if that surgeon can reliably fill their block time, then it is a win-win financially for both the surgeon and the hospital. However, the philosophical question will always remain: “Is block scheduling a right or a privilege?”. The bottom line is that a surgeon’s pride is often enhanced by having block time but the hospital’s financial viability is enhanced by the surgeon consistently filling that block time.

Some surgical specialties are better suited for block time

Surgeries that can be planned weeks in advance are the most efficient users of block time. For example, orthopedic joint replacements, spinal operations, and hernia repairs are elective surgeries and can be scheduled far in advance – these are best suited for block time scheduling. On the other hand, cholecystectomies, fracture repairs, and dilation & curettage procedures are often scheduled with only 24 – 48 hours notice – these are best suited for open scheduling. Sometimes, it is necessary to have a dedicated block that is not scheduled weeks in advance, for example, a trauma block. Although some trauma cases need to go to the OR emergently, most trauma cases can wait until the next morning. Having a dedicated block in the mornings for hip fracture repairs may be necessary for a hospital that is a designated trauma center.

Block vs. open scheduling is not an either/or proposition

A high-functioning hospital must use both block scheduling and open scheduling. The challenge is getting the right ratio of block to open scheduling in order to perform the maximum number of surgeries each week with the most efficient use of the surgeons’ time. To do this, there has to be rules for which surgeons get block time, how block time is released when the surgeon does not have cases to fill his/her block time, the amount of open scheduling necessary to meet the demands of urgent surgeries, and the amount of utilization that a surgeon must maintain in order to keep her/his block time. All of this means that the hospital must have good data including data on utilization, data on how accurately individual surgeons estimate it will take to do a given surgical procedure, and how often the operating room runs overtime. In order for the surgeons to believe the data, it has to be accurate, timely, and transparent.

So, what is the ideal ratio of block:open scheduling? As with most things in hospital management, it depends. For a hospital that does a lot of joint replacements and spine surgeries, a block ratio of 80% block time may be appropriate. For a hospital that depends on emergency department admissions to fill their operating rooms with trauma cases and appendectomies, then a ratio of 60% block time may be appropriate. For most hospitals, the maximum percentage of block time should not exceed 75-85%.

Not only is it necessary to have an optimal overall monthly block ratio, but it is necessary to have an optimal daily block time ratio. There are certain days of the week that are more desirable for surgeons to operate on than others. Surgeons who do inpatient surgeries tend to prefer Mondays, Tuesdays, and Wednesdays so that their patients can be discharged by Friday and so they do not have to round on the weekend. But Monday is also a day that typically has a high utilization of open schedule cases for all of the patients admitted over the weekends with fractures and acute cholecystitis. For the hospital to function at peak efficiency, it has to maintain a constant census throughout the week and so some surgeons will necessarily have to be assigned the less desirable Thursday and Friday blocks. This is often newer surgeons which allows the hospital to reward those surgeons with the highest block time utilization with the most desirable block times.

The importance of a block release policy

Sometimes, a surgeon does not need their block time. Maybe they have a planned vacation or will be attending a medical conference. Maybe they may just not have enough cases to do that week. In order to avoid the operating room being unused on those occasions, there must be a robust mechanism for releasing that surgeon’s block time so that other surgeons can schedule cases into that time. Vacation and time off for conferences needs to be communicated to the OR scheduling desk as soon as the surgeon knows she/he will be taking time off. If this is two or three months in advance, it allows another surgeon to pick up an extra day of block time that week. However, if this is only two or three days in advance, then no other surgeon will have enough notice to schedule a full block of elective cases and that OR will need to be filled by open scheduling.

Because individual operating rooms may have specialized equipment (robot, imaging capability, etc.), it may be preferable to have a staged block release policy in order to most efficiently use that operating room. So, for example, the orthopedic joint replacement surgeon’s block time gets first released to other orthopedic surgeons and then later gets released to all of the other surgeons if none of the orthopedic surgeons want that time.

Be prepared for concerns by your surgeons

  1. If I release my block months in advance of a conference I’ll be attending, will that be held against me?
  2. If a patient is unexpectedly sick or cancels an elective surgery at the last minute, will that be held against me?
  3. Am I going to be penalized if I operate faster than other surgeons and finish my block earlier in the day?
  4. Am I going to be penalized if the OR staff take excessively long to turn the room over between my surgeries so that I finish late?
  5. If I don’t have block time am I going to be stuck doing all of my elective cases at 4:00 in the afternoon?

Block time management requires resources

Perhaps nowhere else in the hospital does the adage “You have to spend money to make money” apply better than the OR scheduling desk. Optimized block time management requires the hospital to invest in a robust OR scheduling program, ideally one that is embedded in or communicates with the hospital’s electronic medical record. But the hospital cannot rely on a computer program alone – there has to be a human being who is overseeing the OR scheduling process. Block time optimization is a data-driven process and so there has to be a mechanism to have reliable information about individual surgeon first case start times, case duration times, block finish times, case cancelation rates, percent of blocks released, and room turnover times. There also has to be physician leadership intimately involved in block time management and data review. This will ideally involve a dedicated medical director of preoperative services but also a committee of involved surgeons in order to provide self-monitoring of block utilization. Ideally, block utilization data should be posted regularly (weekly or monthly) in a location that all of the surgeons can see.

Ideally, a given block should be utilized 80% of the time. If it is less than that, then the OR is likely to be frequently sitting idle in the afternoon. If it is more than that, then the OR is likely frequently running overtime into the evening and the surgeon may be developing a back-log of cases.

Block time management is complicated and can be costly. Within the hospital, it can be politically charged. But when done right, it can make the surgeons happy and the hospital profitable.

October 25, 2020

Emergency Department Inpatient Practice Medical Economics Operating Room

How Hospitals Get Blood For Transfusion

When the average person thinks of donating blood, the first words that come to mind are “Red Cross”. However, the American Red Cross only supplies about 40% of transfused blood in the United States. What most people don’t realize is that the U.S. uses a free-market approach to maintain its blood supply with the result that there are dozens of different blood suppliers for our nation’s hospitals and they compete with each other.

Every day, 35,000 units of packed red blood cells, 7,000 units of platelets, and 10,000 units of plasma are transfused in the United States. In order to meet the needs, there has to be a continuous flow of donated blood into the country’s blood banking system because blood has a short self-life: 42 days for red blood cells and 5 days for platelets. However, red blood cells can be frozen for up to 10 years.

Most countries use a single, government-directed supplier for the blood supply but the U.S. utilizes a network of non-profit blood services that are overseen by federal regulations. As of 2016, there were 786 registered blood establishments that collect blood plus 725 hospital and non-hospital blood banks. Blood centers account for 93% of all collected blood and hospital blood banks account for 7% of collected blood.

We do not transfuse as much blood as we used to. Lower transfusion thresholds (from previous thresholds of 8-9 g/dL hemoglobin to current thresholds of 7 g/dL), a trend toward less-invasive surgeries, the increased use of erythropoietin, hospital blood management programs, and improved medical technology have led to a reduced utilization of blood; the number of units transfused has dropped by 25% since 2008. As the demand for blood has fallen, there has been more competition between the various blood suppliers and many suppliers have gone out of business. So, who are all of these blood suppliers?

  • The American Red Cross. This is the most visible and publicly recognizable blood supplier and accounts for about 40% of the nation’s blood.
  • America’s Blood Centers. This is a network of more than 50 independent, local blood suppliers that supply about 50% of the nation’s blood. Its member organizations manage more than 600 donation sites in 45 states. Two of the largest members are Vitalant (western United States) and Versiti (midwestern United States).
  • The Armed Services Blood Program. This supports the military and their beneficiaries.

Blood is a unique commodity in that it is almost entirely donated for free by volunteers. The cost of blood is therefore primarily due to the expense of processing, storage, and distribution. Hospitals will typically contract with a particularly blood supplier based on (1) per-unit cost to the hospital and (2) quality of service from the blood supplier. Because of the declining demand for blood and because the U.S. has experienced a period of hospital consolidation into large hospital systems that can compete aggressively for blood pricing, the financial margin for most blood centers are razor thin and many operate at an annual financial loss.

Because 92-95% of blood is transfused into hospital inpatients, the cost of blood is absorbed into the hospital’s general expenses rather than being passed directly to the consumer (i.e., the patient). This is because hospitals are paid by a DRG price that is fixed based on an inpatient’s diagnosis and the hospital gets paid the same whether 1 unit of blood is transfused or 20 units of blood is transfused. Most blood is sold on a consignment model – the hospital stores blood but only charges the blood centers for the units actually transfused; therefore, the blood centers bear the cost of outdated units. The net result is that the blood suppliers are happy when more blood is transfused and the hospitals are happy when less blood is transfused. The average price paid from hospitals to blood centers in 2013 was $225 per unit.

About 38% of the U.S. population is eligible to donate blood but only a fraction of eligible persons actually donate. All blood is subject to testing for communicable diseases including:

  • Hepatitis B surface antigen (HBsAg)
  • Hepatitis B core antibody (anti-HBc)
  • Hepatitis C virus antibody (anti-HCV)
  • HIV-1 and HIV-2 antibody (anti-HIV-1 and anti-HIV-2)
  • HTLV-I and HTLV-II antibody (anti-HTLV-I and anti-HTLV-II)
  • Serologic test for syphilis
  • Nucleic acid amplification testing (NAT) for HIV-1 ribonucleic acid (RNA), HCV RNA and WNV RNA
  • Nucleic acid amplification testing (NAT) for HBV deoxyribonucleic acid
  • Antibody test for Trypanosoma cruzi, the agent of Chagas disease

The most common blood type is O+ followed by A+. People with type O- blood are known as universal donors because anyone can received type O- red blood cells. Persons with type AB+ are known as universal recipients because they can receive blood of any type. Like 9% of Americans, I’m B+ so I can receive blood from people with blood types B+, B-, O+, and O- (in other words, 59% of of the population); I can donate blood to people with blood types B+ and AB+ (in other words, 13% of the population). There are differences in blood types between countries and between racial/ethnic groups. For example, 11% of South Koreans are AB+ (universal recipients) whereas only 0.5% of Ecuadorians are AB+. On the other hand, only 0.1% of South Koreans are O- (universal donors) whereas 11% of people in the United Kingdom are O-.

On my 16th birthday, the first thing I did the day I got my driver’s license was to drive to the American Red Cross blood donation center to give blood. Except for a few years during residency and fellowship (when I was regularly exposed to HIV secretions and blood in the ICU), I gave blood every 2-4 months for the next 40 years. About 3 years ago, the Red Cross raised the minimum hemoglobin necessary to donate blood and I found myself too anemic to donate. After anemia tests showed iron deficiency and a work-up for GI bleeding was negative, the conclusion was that I donated too frequently and didn’t eat enough meat. So, I started taking iron supplements for a week before and after blood donations, cut back my donation frequency to every 4 months, and learned to love grilled ribeyes again.

The average donor is male, married, college-educated, with an above-average income, white, and between the ages of 30-50. However, 45% of donors are over age 50. So there is a great need to recruit younger people into the donation pool as the current donor pool ages out. In addition, given the ethnic and racial differences in blood types, there is a need to ensure that our nation’s blood donor demographics more closely represents the nation’s ethnic and racial demographics  so that tomorrow’s blood supply optimally meets tomorrow’s blood demands. We need to eliminate the current disparities that exist in blood donation.

Our nation’s blood supply is a business but a business that is a unique hybrid of volunteers and commercial enterprises that is like no other business in the world. The dynamics of our blood supply is changing based on changes in healthcare financing and some healthcare experts believe that the blood supply system as we currently know it is in peril. But regardless of the changes in economics, patients will still need blood and volunteer donors will still be the ultimate suppliers of that blood. So what am I going to do about it? I do what I’ve always done. I’ll take iron supplements for the next few days and then donate a pint.

May 8, 2019

Inpatient Practice Operating Room

Why Are Pulmonologists So Happy?

As an intern, the one specialty I was sure I did not want to go into was pulmonary. The inpatients all had either COPD or lung cancer brought on by the bad life choice of smoking, the sputum they brought up was gross, and there didn’t seem like there was anything we could do for them. So, back in 1987, I decided to do a critical care fellowship and pulmonary was just the necessary appendage to a critical care fellowship. I was a bit surprised when I read the 2018 Medscape Physician Compensation Report that reported that pulmonologists appear to be among the most satisfied of physicians. The report is the compilation of 20,239 physicians in 29 specialties who responded to the annual Medscape survey.

Although the main focus of the report is about monetary compensation, there are several other questions that to me are more interesting than salary One question asked is “If you were to do it all over, would you choose medicine again?” Pulmonologists were more likely than any other speciality to respond that yes, they would choose medicine again at 88% of respondents, with cardiologists a very close second. In a previous blog post, I have commented on the fact that fewer physicians are choosing infectious disease and nephrology and this is reflected by the the low percentage of nephrologists (66%) and infectious disease specialists (68%) who would choose medicine again.

So, could it be salary that makes pulmonologists so happy? Probably not. All physicians make an extraordinary income compare to the rest of Americans. But pulmonologists are in the middle of the pack when it comes to earnings and earnings do not correlate very well with whether or not a respondent would choose medicine again. In fact, physicians in the highest earning specialties were just about as likely as the lowest earning specialties to report that they would go into medicine again. Plastic surgeons at 80% choosing to go into medicine as a career and orthopedic surgeons at 75% are the highest earners (note that neurosurgeons were not reported in the Medscape survey) where as pediatricians (79%) and endocrinologists (78%) are the lowest earners. So, it does not appear that income determines career satisfaction. However, in the Medscape survey, a separate question asked “If you had to do it over again and went into medicine, would you pick the same specialty?” In this case, earnings correlated with whether the physician would choose the same specialty with 98% of orthopedic surgeons and 97% of plastic surgeons choosing the same specialty again.

What about how the physicians feel about their compensation? The pediatrician knows that he or she is going to make a lot less than an orthopedic surgeon before starting residency. But does career satisfaction correlate to how appropriately the doctor believes that he or she is compensated for the work he or she does? Maybe so. The Medscape survey indicated that 70% of pulmonologists reported that they felt fairly compensated. The only specialists who reported feeing more fairly compensated were emergency medicine physicians at 74%. Interestingly, some of the specialists who were least likely to feel that they were fairly compensated were also the specialists who had the highest incomes. Only 50% of plastic surgeons and 51% of orthopedic surgeons felt fairly compensated.

So why are pulmonologists so happy and willing to go into medicine again? No one knows for sure but I have my own opinions.

  1. Variation in practice location. It is said that variety is the spice of life and few other specialists practice in such a variety of locations. On any given week, a pulmonologist will see patients in the outpatient clinic, the intensive care unit, the bronchoscopy suite, a hospital nursing unit, or a long-term acute care hospital. It is hard to get bored when you have contact with so many other doctors, nurses, and respiratory therapists.
  2. Pulmonologists have a built-in mid-life crises solution. Very few physicians do a pure pulmonary or pure critical care medicine fellowship. Instead, most do a combined pulmonary-critical care fellowship. It takes about 14 years of college/medical school/residency/fellowship to finally become an attending pulmonary & critical care physician so most start their career about age 32 and then retire around age 66. Straight out of fellowship, most newly minted pulmonary/critical care physicians do mostly critical care. This is because in the ICU, the first day on the job, you have a full set of patients whereas it takes a few years to build up an outpatient pulmonary referral base. At the other end of one’s career, when a pulmonary/critical care physician gets closer to retirement, he or she has built up a nice outpatient practice and is tired of the emotional and physical demands of the ICU. For most, the pulmonary and the critical care curves cross at age 45; younger than that and they do mostly critical care, older than that and they do mostly pulmonary. So right when many professionals are getting tired of their job in their mid-40’s, the critical care physician is metamorphosing into a pulmonologist and gets to have a different job for the second half of his or her career. When I started my career, I identified mainly as a critical care physician. Now, I identify mainly as a pulmonologist. It was surprising to me that whereas 88% of pulmonologists would choose medicine again, only 75% of critical care physicians said they would choose medicine again as a career. This may relate more to age than career choice since self-identified pulmonologists are older than self-identified critical care physicians.
  3. They do procedures… in moderation. In the past month, I have done (or supervised fellows doing) central lines, arterial lines, chest tubes, bronchoscopies, thoracenteses, ventilator management, endotracheal intubations, pulmonary exercise tests, and PFT interpretations. But procedures are only a minor part of the pulmonologist’s workday. Nevertheless, that mix of both procedures and E/M (evaluation and management) services gives variety to the workday and keeps one from being stuck in a career rut.
  4. We are entering a golden era of pulmonary medicine. Pulmonary is about 20 years behind oncology and 30 years behind cardiology with regards to scientific breakthroughs. We as a society have invested enormous public and corporate research money into finding cures for cancer and cardiovascular disease in the past several decades and it has really paid off. Pulmonary diseases such as idiopathic pulmonary fibrosis, cystic fibrosis, and asthma are just now getting the major research breakthroughs that oncology and cardiology have already experienced and many of the previously untreatable pulmonary diseases are becoming not only treatable but sometimes even curable. That makes for it being a very exciting time to be a pulmonologist.

This is all just speculation of course. But it is comforting to know that the majority of doctors in all specialties would do it all over again if they could. Pulmonologists just want to do it all over again a little more.

April 28, 2019

Operating Room

Optimizing Surgical Block Time

It gives a sense of great accomplishment for a newly trained surgeon to be initially appointed to the medical staff of a hospital but surgeons really know when they have “arrived” when they are granted block time in the operating room. Block time is when a specific surgeon (or surgical group) is assigned an operating room for a half-day or full-day every week. That surgeon owns that particular operating room for that block of time and can schedule several surgical cases, one right after another.

Surgeons like block time because it is very efficient for them. They only have to go to the locker room to get changed into scrubs once and they can do a lot of surgeries without having to travel back and forth to the hospital. They can tell their patients with reasonable accuracy what time their operation will be starting and they can plan the rest of their week’s outpatient appointments, meetings, etc. without having a conflict. For a surgeon, it is easy to quantify their value and importance by block time. If the surgeons do not have block time and have to schedule cases in “open time”, then those surgeons often find themselves in the physician’s lounge waiting for the surgeons scheduled in that particular operating room for the hour before them to finish their cases. And a surgeon drinking coffee in the lounge instead of operating is not making money for him/herself or for the hospital. From the surgeon’s perspective, block time can be as important of an employment negotiation as vacation time and office space – if a surgeon wants block time and can’t get it at one hospital, then that surgeon will take his/her patients to another hospital that gives him/her block time.

But there is a down-side to block time. If the surgeon does not fill their block with cases, then the operating room loses money – some estimates put the cost of an OR at $15-20 per minute after factoring in staff time, equipment, administrative costs, etc. The hospital also loses money through opportunity margin, that is, the money that could have been made if some other surgeon was doing an operation in that empty room.

Another problem with block time is that if all of the operating rooms are “blocked out”, then there is no capacity for emergency cases, for example, the trauma patient who shows up in the emergency department or the patient in the ICU who needs an exploratory laparatomy. In order to accommodate these surgical cases that cannot be scheduled weeks or months in advance, there has to be sufficient “open time” when surgeons can add-on cases on relatively short notice.

Block times are not all the same duration. For example, an otolaryngologist who does a lot of tonsillectomies and septoplasties may be able to do a surgery every 30 minutes and so a 4-hour block may be appropriate. On the other hand, an otolaryngologist who does complex neck cancer surgeries with flap creation may be doing procedures that can take all day and so an 8-hour block may be appropriate. In addition, some surgeons can warrant having 2 OR rooms at a time blocked, such as the otolaryngologist doing tonsillectomies and septoplaties who can be doing a surgery in one room in about the time it takes to clean another room, allowing him/her to efficiently go back and forth between the two rooms. The otolaryngologist doing the major neck cancer surgery for 8 hours only needs one OR per block time.

Open time can be created by either purposefully keeping some operating rooms out of the block time schedule so that they are never blocked out or open time can be created by “releasing” block time when a surgeon does not have any cases scheduled for that particular day. For some specialties that normally schedule their cases electively weeks or months in the future, for example joint replacement surgery, it may be appropriate to release a surgeon’s block 4 weeks in advance if he/she has no cases on the schedule by that time. However, for other specialties, it may not be possible to release a block more than a day or two in the future, for example, neurosurgery, when once a brain tumor or aneurysm is diagnosed, it has to be operated on within a few days.

Therefore, the hospital has to have the right balance between block time and open time. Here are some of the tactics to optimize block time use:

  1. Develop an accurate way of measuring block time utilization for each surgeon. When a surgeon does not do any surgeries on a given block time day, it is pretty easy to define that block as unutilized. But what about the surgeon who only schedules two 1-hour surgeries in a 6-hour block? Or the surgeon who schedules six 1-hour surgeries in that same block but gets done faster than expected in only 3 hours? Distinguishing between unutilized versus underutilized blocks becomes important. It is important to get buy-in about how block time utilization will be defined from the surgeons and then to provide them with a scorecard so that there is objective data to justify any future changes to their block times. Ultimately, the goal is to identify “collectable time” which is the smallest quantum of time that another surgical case could be fit into – for a cataract surgeon, “collectable time” in a given block might be 30 minutes but for a thoracic surgeon doing coronary bypass surgeries, “collectable time may be more like 3 hours. 100% utilization is not obtainable; 75% utilization may be a more realistic goal.
  2. Give feedback to the surgeons regularly. Ideally, they should have a “report card” outlining their block utilization every month. If this information is only provided once or twice a year, it becomes more difficult for the surgeon to change their behavior and their practice patterns. Regular feedback brings results and makes adjusting surgeons’ block time easier. If a surgeon is consistently running over their block time, then that surgeon should reduce the number of cases scheduled in their blocks. On the other hand, if a surgeon is consistently finishing the last case long before the end of the block time, that surgeon should schedule more cases in the block.
  3. Know the economics of your community. The target for block time utilization will vary depending on profitability and competitiveness. For example, if your hospital is trying to attract more surgeons, you will have to accept a lower block time utilization percentage. Also, in a surgical market that is primarily affluent patients with commercial insurance, the hospital can afford to have a lower block time utilization and still be profitable whereas if most of the patients have Medicare or Medicaid (with lower reimbursement for any given surgery), the hospital will need to have a higher block time utilization to avoid losing money.
  4. Define the duration of one whole block. For an OR that normally runs 7:00 AM to 3:00 PM, a whole block would be 8 hours. However, if the OR has the ability to staff rooms for a longer period, a full block could be 12 hours. This would permit surgeons to schedule half blocks (e.g., 7:00 AM to 1:00 PM), 1/3 blocks (e.g., 7:00 AM to 11:00 AM), or 2/3 blocks (e.g. 11:00 AM to 7:00 PM). Blocks less than 4 hours in duration result in operating room inefficiency.
  5. Ensure that the first case starts on time each day. If the first case starts late then the surgeon will run past their block end time and that means that if there is another block scheduled for that operating room later in the day, the second block will not start on time.
  6. Control the operating room turn-over time. The faster the OR staff can clean the OR and get it ready for the next patient, the more cases you can schedule in a given block.
  7. Release blocks as far into the future as possible. If a surgeon has vacation or will be attending an out of town conference, that surgeon’s block time can be released many months before the scheduled vacation/conference time. It becomes much easier to reassign that block on that particular week to another surgeon who is looking to do extra cases that week. Set automatic block release times that are appropriate for how far in advance a specific surgeon typically books cases: for a joint replacement surgeon, it may be 2 weeks, for a neurosurgeon, it may be 3 days, for an orthopedic trauma surgeon, it may be 6:00 AM the day of the block. Try to average 3 weeks for block releases when including auto-released blocks plus electively released blocks.
  8. Develop an approach for reassigning released block time that the surgeons agree on. For example, if a gynecologist releases his/her OR block for a day 2 months in the future because of a planned vacation, will that block be up for grabs by any surgeon on a first-come, first-served basis? Or will the other gynecologists in the same practice be given the first choice about picking up the extra block?
  9. Develop a way of easily displaying block and open time so that a scheduler in the surgeon’s outpatient office can take a block that was released by another surgeon or schedule an individual case in an OR open time. A robust and simple to understand OR calendar that is integrated into the electronic medical record is ideal.
  10. Be willing to take away block time from surgeons who are not utilizing their blocks. This can be difficult when the surgeon is a senior member of the medical staff or someone who brings highly lucrative procedures to the hospital. As an example, if block time utilization falls below 65%, then the duration of that block or number of blocks could be reduced. If block utilization is > 80%, then that surgeon/service should be offered additional blocks. It is often more feasible to reduce the number of blocks rather than reduce the amount of time a surgeon has in their block since reducing the block duration means that you will have small increments of open OR time popping up during the week and it is often hard to find a surgeon to do a single short procedure in that time. As an example, reducing a surgeon’s block from 4 hours to 3 hours means that you are going to have a 1-hour time slot that you will need to find another surgeon to fill.
  11. Determine the correct ratio of block-to-open operating rooms that the hospital needs. If there is too little open OR time, then surgeons will hoard their block time since they know they can’t fit in extra cases on other days and the hospital can find itself with a low block utilization rate and surgeons who don’t want to give up their blocks. In this situation, new surgeons can’t get on the OR schedule. On the other hand, if there is plenty of open OR time so that surgeons can always find an acceptable time/day to put in their cases, then they will be more amenable to giving up underutilized block time. If the amount of block time is too low, then the surgeons will find themselves not being able to consistently work with the same anesthesiologists and OR staff and that can result in operational inefficiency and medical errors. Ideally, there should always be at least 2 ORs that are open and not blocked out and for most hospitals, an 80% block to 20% open time is a reasonable goal. However, that ratio will be different for different hospitals; for example, a hospital that is a trauma center and tends to do a lot of surgeries on patients admitted through the emergency department may need a ratio of 60% block to 40% open time.

Ultimately, what the surgeons want is a predictable time that they can do a lot of cases back to back. What the hospital wants is all of the operating rooms being used for surgeries as many minutes of the day as possible. Reconciling these two often conflicting goals can be challenging but successful reconciliation will ultimately lead to both surgeon satisfaction and hospital productivity.

October 5, 2018

Operating Room

Reducing Joint Replacement Surgery Infections

Joint replacement surgeons are coveted by hospitals because they bring in lucrative elective inpatient surgeries that can improve the hospital’s financial margin. Furthermore, patients who have successful joint replacements are some of the happiest patients in the hospital and they will often improve the hospital’s patient satisfaction scores. However, a post-operative infection of the newly implanted joint can mean a longer hospital stay, prolonged IV antibiotics, poor patient satisfaction, and financial loss to the hospital. Therefore, it is incumbent on us to keep the post-op infection rate as low as possible. There are a number of factors that can increase the risk of infection: patient risk factors, patient preparation factors, surgeon factors, and operating room environment factors. Here are some of the things that can keep your hospital’s joint replacement surgery infection rate down.

Patient Risk Factors

Not all patients have the same risk of getting a post-operative infection. Some patients are inherently more likely to get infected than others. Some of these risk factors are controllable and others are not. So, patient selection becomes critical when deciding whether the patient should or should not undergo an elective knee or hip replacement. Here are some of the factors to consider:

  1. Obesity. The incidence of arthritis, particularly knee arthritis, goes up in obese patients and so does the risk of post-operative infection. Obesity brings with it problems with wound healing and concurrent diseases such as diabetes. Patients at the highest risk are those with morbid obesity, that is, a body mass index > 40. Ideally, patients should lose weight prior to undergoing elective joint replacement surgery but the problem is that the patients’ joint disease often precludes them from meaningful exercise so weight loss can be very challenging. If your hospital has a joint replacement infection problem, consider limiting elective joint replacements to those patients with a BMI < 40 or even 35.
  2. Smoking. As a pulmonologist, I focus on the deleterious effects of cigarettes on the lungs and heart but smoking is also a risk for post-op infections. Patients should stop smoking 2 months before surgery. For those patients that I send for lung transplant evaluation, documentation of smoking cessation by doing urine cotinine levels is mandatory (patients must be tobacco-free for at least 6 months to be eligible for lung transplant) – if your hospital has a joint replacement infection problem, then consider mandatory urine cotinine testing pre-operatively to confirm smoking cessation.
  3. Diabetes. Because obesity is rampant in our country, so is diabetes. In fact, in one study, more than half of patients with diabetes who presented for joint replacement did not know they had diabetes until they were undergoing pre-op evaluation for the surgery. Patients with an excessively high hemoglobin A1C should have surgery deferred until their diabetes is better controlled.
  4. Malnutrition. The body mass index works both ways: too high and the risk of infection goes up and too low and the risk of infection goes up. Patients with a BMI of less than 20 are at increased risk.
  5. Alcohol abuse. 8.4% of adult men and 4.2% of adult women have an an alcohol abuse disorder. Therefore, statistically, 1 out of every 16 patients presenting for joint replacement have an alcohol abuse risk factor.
  6. Prior joint replacement infection.
  7. Immunosuppressant use. This is particularly an issue for patients with rheumatoid arthritis since not only do they often need a hip or knee replacement, but they are often taking medications to treat the rheumatoid arthritis that can delay wound healing and suppress the immune system.
  8. Anemia. Patients with anemia have more than twice the risk of infection as those without anemia. They also have a longer length of hospital stay, which adds additional expense to the hospital.
  9. Cancer.

Importantly, there are some patient factors that surprisingly do not have much effect on post-op infections including concurrent heart disease, pulmonary disease, or neurologic disease.

Having a good pre-admission testing process to risk-stratify patients is essential. Ideally, hospitals doing a lot of joint replacement surgeries should have a dedicated outpatient clinic where physicians, nurse practitioners, and/or physician assistants trained and experienced in surgical infection risk identification can assess patients and identify those who are at increased risk. Ideally, this should be coupled with risk factor reduction strategies to reduce the patients chances of getting a joint replacement infection. These could include endocrinology evaluation to reduce the hemoglobin A1C, hematology evaluation to determine the cause of anemia and correct anemia, smoking cessation programs, dietary consultation to reduce the BMI in obese patients and increase the BMI in malnourished patients, and rheumatology consultation to reduce or hold immunosuppressive medications (particularly in those patients with rheumatoid arthritis).

Patient Preparation Factors

Even those patients with minimal or no risk factors can get joint replacement infections if they are colonized with certain bacteria. Dental caries and gingivitis are often implicated, however, the data in the literature is sparse. Nevertheless, those patients with bad teeth or gums should have these addressed by a dentist in order to reduce their overall bacterial burden. The data is much stronger for Staphylococcus aureus colonization, particularly in the nose. Patients undergoing elective joint replacement surgery should have screening for nasal carriage of Staph aureus, including determination of whether the Staph is methicillin-sensitive (MSSA) or methicillin-resistant (MRSA). Those patients found to have either type of Staph in the nares should undergo Staph aureus decolonization. A commonly used strategy is to use 2% mupirocin ointment to the nares twice a day for 5 days plus 2% chlorhexidine gluconate wash daily for five days.

Antibiotic prophylaxis at the time of surgery can also reduce joint replacement infection rates but it is critical to chose the right antibiotic and to get the timing of antibiotic administration right. For uncomplicated patients, cefazolin, 2 gm IV over 30 minutes just prior to the start of surgery. If using a tourniquet, the entire dose must be infused before the tourniquet is placed. For obese patients weighing > 120 kg, a 3 gm dose of cefazolin should be given. If the surgery takes more than 4 hours, a second dose of cefazolin should be given. If the pre-operative nasal carriage screen is positive for MRSA, then patients should get a dose of vancomycin (1.5 gm over 2 hours) in addition to cefazolin. Patients with severe penicillin or cephalosporin allergy should get a combination of vancomycin and aztreonam (2 gm IV over 30 minutes).

Skin preparation is also important. Rather than shaving, use clippers for hairy skin. Adequate skin preparation with chlorhexidine and with povidone iodine is necessary.

Surgeon Factors

Not all surgeons are created equal – some are slower than others. The duration of surgery also affects the incidence of post-operative joint infection, the longer the surgery, the higher the risk of infection. In one study, patients undergoing knee replacement who did not get an infection had an average operative time of 94 minutes whereas those that did get an infection had an average operative time of 127 minutes. The experience of the surgeon also matters, those that do fewer than 20-50 joint replacements per year generally have higher rates of infection. These two surgeon factors are intertwined: a study showed that operative time decreases with increasing surgical experience and a surgeon’s operative time for knee replacement plateaus after 300 operations.

Ideally, your hospital will have a dedicated physician or group of physicians who do elective joint replacement surgeries. This can be a problem for smaller hospitals or those in rural areas that do not have sufficient annual volume to support a joint replacement surgeon. Additionally, the hospital should monitor operative time for joint replacement surgeries to identify surgeons who consistently have excessively long operative times.

Operating Room Environment Factors

There are a myriad number of ways that the OR environment can affect joint replacement surgical infections. Here are a few:

  1. Central sterile supply. Joint replacement instrument sets are notoriously large and complex. You have to have great people working in the central sterile supply (CSS) area to ensure that that all of the instruments are clean and sterilized and that all of the sets have the correct instruments. If there is “bioburden” (e.g., bone fragments, blood stains, hairs) on one of the instruments, then it has to go back, even if it was adequately sterilized. Not everyone can do this well, so many hospitals monitor the rates of bioburden and inclusion of correct instruments in sets by individual employee – those that have consistently high rates may need to be identified for remediation or reassignment to other duties.
  2. Hand hygiene. Every person going in and out of the OR needs to clean their hands every time they go through the door.
  3. Door openings. It is amazing how many times the door to the operating room is opened during a joint replacement surgery. Sometimes it is because a new piece of equipment is needed. Sometimes it is because these are long procedures and staff need a break. Sometimes it is because a vendor needs to bring in a joint prosthesis component. Each time that OR door opens, the risk of infection increases. Develop strategies to minimize the use of the door during surgery.
  4. Vendors. These are representatives of the manufacturers of the joint prostheses who are experienced in the technical aspects and sizing of different components of the artificial joints. They are essential to the proper selection and placement of the prostheses and also can provide essential advice to the surgeon during the operation. However, they are not hospital employees and as such, do not necessarily go through the same infection control training that all of the other operating room staff do. Processes should be in place to ensure that the vendors are well versed in basic infection control measures including OR attire, hand hygiene, etc.
  5. Cell phones. A study of hospital workers’ cell phones indicated that 100% were colonized by bacteria and 53% were colonized with MRSA. It doesn’t matter how long you scrub your hands prior to entering the OR, if you then handle your cell phone, your hands are no longer clean. Remove temptation of OR staff by having cell phones turned off or left outside of the OR.
  6. Operative field contamination risks. Having a fly in your soup is gross; having a fly in your surgical incision is life-threatening. Insect control is essential to maintaining good infection control. Also, take a look at the ceiling and fixtures to identify peeling paint, dust, or condensation that could fall into the operative field. Having adequate air exchanges in the operating room is also essential – there is always some degree of dust particles floating around in the air and all of the people in the OR are constantly shedding dander and hairs that can become dust components (the average person sheds about a billion skin cells per day). There should be at least 15 air exchanges per hour (> 20 is better) and the OR should be kept at a higher air pressure than the surrounding corridors and rooms so that dust and particulate matter does not get sucked into the operating room.
  7. Temperature and humidity. Operating rooms should be kept between 30-60% humidity and 68-73 degrees F. If the patient develops hypothermia during the procedure, the risk of infection increases so avoiding hypothermia (temperature < 96.8 degrees F [36 degrees C]) is desirable.
  8. Ergonomic design. Inside the OR, the tables and equipment should be located in ways to minimize staff movement, eliminate unnecessary human activities, and minimize transport distances for instruments. Also, minimize the number of people in the OR by using windows or cameras for teaching purposes rather than having trainees not participating in the procedure standing close to the operating field.

Reducing or eliminating surgical infections following joint replacement requires a concerted effort by the hospital that starts with the outpatient pre-operative assessment and continues through education of the patient at the time of discharge.

January 6, 2018

Emergency Department Operating Room

Timing Of Hip Fracture Surgery

How we practice medicine in the United States is often dictated by quality metrics established by Medicare and The Joint Commission. Our hospitals often focus on monitoring these publicly reported metrics but there are others that deserve equal attention, even though they are not publicly reported. One of these is the time between when a person presents to the emergency department with a hip fracture to when they have hip fracture surgery. If the hospital’s expectation is that surgery be done immediately, then there is a substantial expense in maintaining an open operating room and on-call pay for the surgeon, anesthesiologist, and OR staff to do emergency surgeries in the middle of the night. On the other hand, if there is an excessive delay, then the mortality rate goes up.

A 2016 study in the American Journal of Preventive Medicine examined 19.8 million EMS “events” (most of which were 911 calls). Of these, 4.3 million involved people over age 65 years old. 17.5% of all 911 calls in patients over age 65 were for falls, most of which (60%) were in the person’s home. There was a gender difference: 15.0% of 911 calls involving men were for falls but 19.1% of 911 calls involving women were for falls.  The older the person, the more likely a fall was the reason for the 911 call:

  • Age 65-74: 12.7%
  • Age 75-84: 17.4%
  • Age ≥ 85: 22.6%

One of the most important complications of falls in the elderly is hip fracture. Every year in the United States, there are about 250,000 admissions to the hospital for hip fractures and 90% of hip fractures result from falls. Over a lifetime, 6% of American men will sustain a hip fracture but 14% of post-menopausal women will have a hip fracture. Hip fracture is an important cause of death: when women have a hip fracture, 5% will die within 30 days and 20% will die within a year; when men have a hip fracture, 10% will die within 30 days and 30% will die within a year. About half of patients who have a hip fracture are unable to live independently after their fracture.

A study in last month’s JAMA gives us some direction regarding how hospitals should approach the timing of hip fracture repair. The authors examined 42,230 hip fracture patients treated by 522 orthopedic surgeons at 72 hospitals in Ontario from 2009 – 2014. The average age of the patients was 80 years old and 70% of the patients were women. One-third of the patients had surgery within 24 hours of admission and two-thirds had surgery later than 24 hours after admission. The key result was that the mortality rate went up for every hour that surgery was delayed beyond 24 hours from admission to the hospital. Shown in this graph is the 30-day mortality but the 1-year mortality graph had a similar shape (although higher overall mortality rates). The authors further analyzed various complications and found that the percentage of patients having pneumonia, myocardial infarction, deep venous thrombosis, and pulmonary embolism had similar-appearing graphs with the incidence of all of these complications increasing in patients whose surgeries were delayed beyond 24 hours.

So, it appears that there is a “sweet spot” in the timing of hip fracture repair. A wait time of up to 24 hours is acceptable but beyond 24 hours, the risk of complications and death steadily increase.

Because patients with hip fracture are elderly and often have serious medical co-morbidities, having at least a few hours to obtain medical consultation, correct major electrolyte abnormalities, identify and treat unstable angina, correct significant anemia, etc. can be useful to improve a patient’s ability to get through a major operation. On the other had, the sooner the patient has surgery, the sooner they can get out of bed to be started in physical therapy and the less likely they are to get complications of being bedridden such as pneumonia and pulmonary embolism.

So from the hospital’s perspective, what expectations should we be setting for the management of patients with hip fracture?

  • We need to monitor the time from ER presentation to surgery. The goal should be for most patients to be operated on within 24 hours of presentation. 
  • We need to ensure that we have surgeons, anesthesiologists, and OR staff to do hip fracture surgery seven days per week.
  • Most patients presenting with hip fracture at night can wait to have surgery until the next morning. 
  • We need to have availability of medical consultants who can evaluate patients with hip fracture in the first hours of their presentation.
  • We need to set expectations for medical consultants that their evaluation should not delay surgery except in patients with the most serious acute medical problems.
  • For patients with hip fracture and unstable medical problems such as active gastrointestinal bleeding or unstable angina, we need to have seven day per week availability of testing such as endoscopy and cardiac catheterization or have the ability to transfer patients needing these pre-op tests to another hospital that can do them. 
  • We need to have physical therapists available to get patients up and out of bed as soon as possible after surgery – preferably on the same day. This requires having physical therapists available seven days per week.

The good news is that the incidence of hip fracture appears to be decreasing. The best way to improve mortality from hip fractures is to prevent the fractures in the first place by reducing geriatric falls. Community programs designed to screen patients at risk for falls, to improve balance and gait by improving physical conditioning in the elderly, to correct vision impairment, to modify the living environment of the elderly, and to identify and eliminate medications contributing to falls are all effective measures to reduce the incidence of geriatric falls.

However, even though we may be able to reduce the number of hip fractures, we are not going to be able to eliminate them entirely. We should target a “door to OR time” of < 24 hours for hip fracture just like we target a “door to balloon time” of < 90 minutes for patients with acute myocardial infarction.

December 11, 2017

Operating Room

Robots In The Hospital – Its Not Like Robots In The Factory

There are a lot of signs that the “great recession” that began in 2008 is over. The unemployment rate is the lowest that it has been in 12 years. Manufacturing output is back to pre-recession 2008 levels and close to a record high. However, manufacturing jobs are not; in fact, America has lost 5 million manufacturing jobs since 2000. The reason isn’t that they’ve been stolen from low wage countries, the reason is robotics.

Over the past 25 years, advances in production robotics has resulted in many of the factory jobs once done by assembly line human workers now being done by robots. They are faster, they are more accurate, they don’t have expensive fringe benefits, they don’t go on strike, and they don’t call in sick. In other words, automation of U.S. factories has reduced production costs and eliminated an enormous number of manufacturing jobs. And those jobs are not coming back. In our factories, robots replace people.

The robots are gaining a foothold in our operating rooms, too. But in the OR, they are not replacing people. The most commonly used surgical robot is the da Vinci system. It runs about $2.5 million per robotic unit. Until last month, our hospital was the only hospital in town without a da Vinci robot but we recently purchased one in order to grow our hernia repair program and our gynecologic surgery program. You see, we compete with our neighboring hospitals to attract surgeons and younger surgeons want access to the robots that they used when they were training as residents and fellows. If you don’t have a robot, the top young surgical recruits are going to go across town to your competitor hospital. Moreover, many patients have a perception that surgeries done with a robot are better than those done solely by hand. Having a surgical robot is no longer a competitive advantage for a hospital, it is a competitive necessity.

You need just as many people in the operating room when you are doing a robotic surgery as you do without a robot. You see, unlike in the factory, where manufacturing robots replace people, in the operating rooms, surgical robots augment people. The surgical robot is not used for “automated surgery” but instead is controlled by the surgeon who sits in a console and controls the arms of the robot. Instead of the surgeons hand holding a scalpel, the robot’s arm holds the scalpel and the surgeon’s hand controls the robot’s arm. With cameras on the end of the robotic arms, this allows the surgeon to get into tight places and use smaller incisions than he/she could with  a regular open procedure. This translates to less post-operative pain and more rapid recovery. It doesn’t necessarily make the surgery faster or less expensive – it just makes the surgery better.

Automation, robotics, and computerization has had huge impact on U.S. manufacturing jobs. But that is just the beginning. The prototypic self-driving cars of today will give way to the self-driving trucks of tomorrow and in 15 years, we as a country will be lamenting the loss of transportation and trucking jobs just as today we lament the loss of manufacturing jobs.

But at least for the foreseeable future, the intrusion of robots into the operating room is not going to translate to a loss of OR jobs. So, if you are a teenager and your career goal was a  union job at the General Motors plant, you need a new goal. And if you think you can go to truck driving school and have a job to last a lifetime, think again. But for the next 15 years, a robot is not going to take your operating room job away.

January 20, 2017

Operating Room

A Safe Operating Room Is A Cold Operating Room

On Monday, I got a text message from our hospital’s Chief of General Surgery at 6:40 AM that the operating rooms were in excess of 100° F. When the air temperature in the OR is too high, it is not only uncomfortable for the surgeons and OR staff who are all wearing surgical gowns, it is unsafe for the patients because of the risk of infection. When temperatures are too high, microorganisms grow. When the humidity is too high, condensation can develop on the ceilings and equipment resulting in non-sterile indoor “rain” on patients or instruments. If either the temperature or the humidity is too high, then the surgeons start sweating which is not only a distraction but no one wants drops of sweat falling into a patient’s open incision. Too cold is also bad, hypothermic patients are more likely to get wound infections. Because both too hot and too cold is dangerous, the CDC adopts the American Institute of Architects parameters for operating room ventilation:

Temperature: 68-73° F

Humidity: 30-60%

Air changes: 15 total air changes per hour and minimum 3 air changes of outdoor air per hour

Keeping a relatively narrow temperature and humidity range turns out to be more difficult than it might seem because of the relationship between temperature and humidity. For example, if a room is 68° F with 60% relative humidity (within parameter range) and you drop the temperature to 64° F, the relative humidity will rise to 68% (out of parameter range).

Operating rooms have visual alerts in a central location when the OR air temperature or humidity is out of the parameter range but these alerts are on monitors and if no one happens to be looking at the monitors, then the alerts go unnoticed.

When a hospital goes through a JCAHO (Joint Commission) site survey, the surveyors will make a bee-line for refrigerators and freezers to be sure that there are temperature logs being kept and alarms when there is a loss of power or refrigeration. However, no one ever thinks to have logs or alarms for the air temperature in an operating room.

So, on Monday morning, we moved as many procedures from the overheated primary OR area to an unaffected secondary OR area. However, when temperatures get to 110° F, many disposable supplies can be damaged and have to be thrown out and sterilized instrument sets need to be re-processed. Therefore, a number of surgeries had to be canceled at the last minute. Fortunately, although there was inconvenience, no patients were placed in jeopardy.

The best way to avoid excessive heat in the OR is to have multiple, redundant alerts. So, make sure that you have both audible alerts as well as visual alerts on the temperature monitors.  Also, arrange that the alerts trigger auto-pages to hospital administrative staff when OR temperature or humidity parameters are out of range.

I must have missed the class on HVAC systems in medical school.

December 21, 2016

Hospital Finances Operating Room

Thou Shalt Not Covet Thy Neighbor’s Surgeon

penguin-rockIf you are addicted to the National Geographic Channel, like I am, then you’ve probably seen videos of Adelie penguins. The males build nests out of stones in frozen Antartica in order to attract female penguins. Instead of going out and collecting their own stones, some criminal male penguins will steal stones from one his neighbor’s nests when his neighbor is out stone-hunting. Hospitals do the same thing – except instead of stones, they steal surgeons.

Surgical admissions to the hospitals are more lucrative than medical admissions. Surgical admissions account for 29% of all hospital admissions but account for 48% of hospital costs. If you are paying out of pocket, the hospital expense of a heart valve surgery is about $117,000 and a hip replacement is $39,000. For most hospitals, surgeries are their lifeblood. And inpatient surgeries are far more valuable than outpatient surgeries. Consequently, hospitals are constantly on the prowl for surgeons, especially those surgeons who do big-ticket surgeries that bring patients into the hospital and who can do a large volume of surgeries with low complication rates.

There are two ways that you can get acquire a high-volume, low-complication surgeon. You can hire him or her straight out of residency and then develop him/her by careful mentoring. Or, you can recruit them from another hospital. Recruiting from an out-of-state hospital is usually seen as fair game. A hospital in Columbus, Ohio doesn’t really compete with a hospital in Tampa, Florida when it comes to doing hip replacement surgeries so leaving a hospital in Columbus for a hospital in Tampa is not seen as taking surgical market share to Tampa.

moses-10-commandmentsBut recruiting a surgeon from one hospital to a different hospital in the same city is typically seen as playing dirty. First, that surgeon likely has a large referral base of primary care physicians and those physicians will continue to refer their patients to the surgeon regardless of which hospital he/she is operating at. Second, the first hospital has invested several years developing that surgeon to get him or her to a point of efficiency and notoriety.

A great surgeon wasn’t a great surgeon the day he/she finished residency. It takes time after training to become really great. In his book Outliers: The Story of Success, Malcolm Gladwell proposed that to be really great at something, you need to spend 10,000 hours in meaningful practice of it. For example, Bill Gates spent about 10,000 hours programming before he came up with the foundations of Microsoft’s operating system. The Beatles practiced and played concerts together in Germany for 10,000 hours between 1960-1964 before they made music history. A surgeon can’t get 10,000 hours of operating room time during a 5-7 year residency. Most of their operating time during training is spent as an assistant rather than being the primary surgeon and even so, they’d have to spend 40 hours a week operating for 5 years to get to 10,000 operating hours. So it takes some time after residency to make a good surgeon a great surgeon – I think it is typically about 7 years. Those 7 years are kind of like the time the Beatles spent in Germany before they became famous.

Not only does it take time for a surgeon to hit peak surgical skill, but it also takes time for that surgeon to cultivate a referral base and to become efficient. That part typically takes about 5 years. Therefore, the hospital has to subsidize the surgeon for about 5 years during the surgeon’s start-up period. So, a typical start up funding package from the hospital for a newly trained surgeon might be $250,000 for year 1, $150,000 for year 2, $125,000 for year 3, $100,000 for year 4, and $50,000 for year 5. That’s a total of $675,000 that the hospital invested in that surgeon to get them to a level of self-sustaining practice.

Now, if you are a competing hospital in the same city, you can either spend $675,000 cultivating your own surgeon right out of residency or you can spend $675,000 recruiting another hospital’s surgeon who is at the end of their 5-year start up. And if you really want to come out ahead financially, you can give that surgeon an extra $150,000 per year for 4 years (total $600,000) and save yourself $75,000 that you would have spent cultivating a newly trained surgeon.

pattonWhen leaving Africa in 1943, General George S. Patton famously said “No dumb bastard ever won a war by going out and dying for his country. He won it by making some other dumb bastard die for his country.” Similarly, a hospital wins the surgery volume war not by paying to develop its own surgeons but by making some other hospital pay to develop the surgeon… and then stealing them.

Not all types of surgeons are equal in this regard. For example, a surgeon who is really good at something unique and cutting edge that brings in lots of new lucrative elective surgeries to the hospital, like robotic prostatectomy, makes for great stealing. On the other hand, a general surgeon in a city with 50 general surgeons may not be worth spending as much to steal.

Additionally, optimal efficiency is not just a function of the surgeon but it is the entire operating room team, including the physician assistant, nurses, and operating room technician. It is much harder to steal an entire team from a hospital so there is inevitably some lost efficiency from a newly stolen surgeon.

Hospitals create barriers to other hospitals absconding with their surgeons by implementing “non-compete” clauses in the surgeon’s contract. A typical non-compete clause will say that the surgeon cannot work at a hospital within 10 miles for a year after resigning. There are ways around the non-compete clauses, however. They can be contested in court and the surgeon may or may not win. Or the hospital stealing the surgeon can locate the surgeon in a branch hospital or surgical center just outside of the non-compete radius. This happened to us a couple of years ago when 2 plastic surgeons a few years out of residency were recruited by a competing hospital system in Columbus that then located them at one of their branch hospitals that is 10.5 miles away from the OSU Medical Center, a half mile beyond the non-compete radius.

So in deciding whether to grow your own surgeon or steal someone else’s, it all comes down to financial strategy. Either approach can be cost effective and it is ultimately finances and not morality that guides behavior.

December 6, 2016