Category: Operating Room

Innovations in technology have given us better and more powerful medical equipment but have also increased the cost of those devices. A reader recently asked when is it better to purchase medical equipment outright as opposed to pay-per-use financing? As always, the answer is… it depends.

When purchasing a high-cost piece of equipment outright, the hospital (or medical practice) either pays for the entire cost upfront or pays for it in installments. It is like buying a new car – you can either pay cash at the time of purchase or you can finance it over a period of a few years. A second method of acquiring that same piece of high-cost medical equipment is by a pay-per-use contract. In this acquisition model, the manufacturer lends the hospital the equipment for free and instead charges the hospital each time that equipment is used. There are situations when outright purchase is better and there are other situations when pay-per-use is better. For this post, I’ll use the example of a surgical robot but the principles apply to any high-cost piece of medical equipment. The total cost of a surgical robot system varies depending on model, price negotiation, and types of robotic arms used. But we’ll assume a fairly typical $2 million purchase price, $2,000 per operation consumables (eg, robotic arms), and $180,000 annual service contract.

First, create a pro forma

In hospital financing, a pro forma is a document that projects the total costs and total revenue from a proposed new service or piece of equipment purchase over time. Because of the high cost of a surgical robot, no hospital will purchase one just because a surgeon goes to the CEO and says the justification is “Because I want one“. Instead, the hospital is going to want to know whether in the long run the hospital is going to make money or lose money on the surgical robot. However, when I look at a pro forma, it is not just the dollars and cents that are important. There can be non-monetary benefits that can justify purchase of a surgical robot, even if the hospital is not going to make money on the robotic procedures. For example, shortened time in the operating room per surgical procedure, shorter patient recovery vs. non-robotic surgery, fewer surgical complications, improved patient satisfaction, attraction of new patients who prefer to have robotic surgery, etc.

When drafting a pro forma for outright purchase of a medical device such as a surgical robot, you need to look at all of the costs. This includes the purchase price of the equipment, the cost of consumables (such as the surgical arms that can only be used for a fixed number of surgeries), the cost of a service contract, and the cost of personnel. When possible, convert non-monetary factors into dollar-equivalents – for example, determine the cost per hour of an operating room and then include cost savings of a shorter OR procedure time with a robotic versus non-robotic operation. Conversely, if the robotic surgery will take longer than a non-robotic surgery, include this as a cost rather than a cost savings. The type of physicians and the types of procedures will need to be estimated. For example, if the surgical robot will be used by general surgeons, colorectal surgeons, gynecologists, urologists, and ENT surgeons then the relative costs of each of these different types of robotic surgeries needs to be included. Other costs to be factored in can include the cost of any building renovation required to accommodate the new equipment, the cost of training personnel to use the new equipment, the cost of insuring the new equipment, the cost of advertising the availability of the new equipment, etc. The service contract costs must be factored in as well. If a surgical robot is used 18 times per year and the service contract is $180,00 per year, then that works out to an expense of $10,00 per case. On the other hand, if the surgical robot is used 500 times a year, the expense is only $360 per case.

The revenue from a surgical robot will require an estimation of the volume of surgeries performed each year and the expected reimbursement. Reimbursement needs to be stratified by all of the different procedures that will be performed, for example, a robotic cholecystectomy vs. a prostatectomy vs. a hysterectomy. This can be pretty complicated because the reimbursement for an operation such as a cholecystectomy can vary depending on whether it is being paid for by Medicare, commercial insurance, Medicaid, or self-pay (note: self-pay usually translates to no-pay).

Central to a pro forma is the concept of depreciation. This is the expected number of years of life of that piece of equipment before you have to buy a new one. Medical equipment is often depreciated over 5 years. For example, a surgical robot that costs $2 million to purchase and is expected to last 5 years can be depreciated over those 5 years at $400,000 per year. In this example, the pro forma should include tables for each of the 5 years of depreciation. If the hospital projects doing 500 robotic cases per year, then the capital equipment costs would be $800 per case ($400,000 per year ÷ 500 cases per year).

Once you create a pro forma for outright purchase, you then need to create a pro forma for pay-per-use financing. Include all of the costs and revenues you used with the outright purchase pro forma but instead of equipment cost depreciated over the depreciation period (eg, 5 years), include the total annual pay-per-use costs over those 5 years. It is essential to clarify whether servicing the equipment is included in the pay-per-use contract. Usually it is but if the hospital is required to purchase a separate $180,000 per year service contract, then the financial advantages of pay-per-use acquisition can disappear.

Hospitals are unique environments compared to business and manufacturing. Proposals for capital equipment purchases should not be finalized until they have been evaluated and approved by the biomedical engineering department, the infection control department, the staff responsible for structural engineering, radiation safety personnel, etc.

Variables affecting the decision to purchase outright vs. pay-per-use

The decision of whether to buy a piece of medical equipment or pay-per-use is much more complex for a hospital than the decision of whether to acquire a piece of manufacturing equipment by outright purchase or pay-per-use for a factory. There are variables that are inherent in healthcare that do not exist in manufacturing and these variables can have a profound effect on how to pay for a new medical device. Here are some of the variables that the hospital must factor in to the decision-making process.

1. The number of physicians who will use it. If only one surgeon or one physician group will use a piece of equipment, then there is the risk that if that surgeon or group leaves the hospital to practice elsewhere, then the hospital could be stuck with an expensive device that just gathers dust in a closet. Just like it is risky to put your entire retirement investment portfolio in a single stock (as opposed to a mutual fund), it is risky to base the entire pro forma on the equipment’s use by just one physician.
2. The number of specialties that will use it. In the example of a surgical robot, it is far better to buy a robot that will be used by general surgeons, cardiothoracic surgeons, urologists, ENT surgeons, and gynecologists rather than just one of these specialties alone. This ensures that the device can be used every day, Monday through Friday, all year. This overcomes specialist slow downs due to medical conferences, outpatient clinic days, procedure seasonality, etc.
3. The hospital’s cash flow and budget. A $2 million purchase for a surgical robot can wipe out most of a small hospital’s annual new equipment budget. If the hospital lacks sufficient cash to purchase an expensive piece of equipment, then a pay-per-use model may be preferable since there will be an immediate return on investment. Otherwise, it could take several years of use to generate enough revenue to cover the cost of outright purchase.
4. Anticipated volume. If you anticipate a relatively low procedure volume each year, then it could take many years before you recoup your return on investment for the purchase and you’d be better off with the pay-per-use model. The more procedures you can do, the more likely you will be better off purchasing equipment outright.
5. Expectation of a new model in the near future. Medical equipment manufacturers usually keep dates of release of new models of their equipment secret until the last minute (sort of like Apple staying mum about new iPhone models until they are ready to be released). Nevertheless, a little detective work can give you an idea of whether a new version is on the future horizon. If so, you are often better off with pay-per-use initially and holding off on purchasing until the new model comes out. This also holds if you would be happy with the older (current) model since manufacturers will generally discount them to clear out their inventory once a new model comes out. The surgical robot model costing $2 million this year might drop to $1.5 million next year when the next model is released.
6. Commitment by the physicians. I got burned several years ago when our gastroenterologists insisted that we needed to start doing endoscopic ultrasound pancreatic biopsies. We spent a half million dollars on new endoscopic equipment that could only be used for those procedures and also invested in cytology telemedicine so that cytopathologists at another hospital could read the needle aspirates real-time during the procedure. Five years later, the gastroenterologists had not done a single endoscopic ultrasound procedure at our hospital and we basically wasted the money. If there is any uncertainty about whether the doctors will use the equipment, then a per-use model (at least at first) is preferable until the doctors prove that they will actually use it.
7. Procedure payer mix. A manufacturing company can determine the price it will charge for a product and base it’s pro forma on just one sales price. In medicine, however, the hospital gets paid different amounts by different payers for doing any given procedure or service. This means that creation of an accurate pro forma requires the hospital to not only project the total annual volume of procedures to be performed with a new device but also the projected payer mix for those procedures and the financial margin for each payer. Reimbursement from Medicare and Medicaid is fairly easy to project since they are fixed by CMS. However, each commercial insurance company will reimburse different amounts for any given procedure, depending on the hospital’s negotiated contract with that insurance company. Imagine the complexity of a manufacturer who projects that by installing new factory equipment, it can make and sell widgets. But sales contracts dictate that 30% of customers pay $10 per widget, 15% of customers pay $5 per widget, 25% of customers pay $18 per widget, 15% of customers pay $27 per widget, and 15% of customers don’t pay anything and get their widgets for free. In general, per-procedure hospital reimbursement is highest for commercial insurance, a bit lower for Medicare, lower still for Medicaid, and negligible for self-pay. We once had a surgeon who specialized in surgically implanting very expensive medical devices. When we did the initial pro forma, it looked like the hospital would net a small profit each year on the procedures. But after a couple of years, we noticed we were losing tens of thousands of dollars. It turned out that the surgeon was performing implants on commercially insured patients at a private hospital in town and only operating on Medicaid and self-pay patients at our hospital.
8. Non-monetary benefits. The decision of whether to purchase a piece of equipment outright or utilize a pay-per-use financing should not depend solely on the expense vs revenue columns on a pro forma. There can be non-monetary benefits that the hospital may value, even if the new equipment does not increase revenue. These can include attraction of new patients, improved patient satisfaction scores, reduced mortality, reduced complication rates, shortened operative times, etc. It is also important to keep the doctors happy because if the physicians really want to use a new piece of medical equipment and the hospital won’t buy it, those physicians will leave to go practice at another hospital that will buy the equipment. In this case, a pay-per-use acquisition model may allow the hospital to keep the doctors happy while eliminating or at least minimizing financial loses.
9. Connectivity. In an increasingly electronically interconnected world, the ability of medical equipment to connect to the monitors, electronic medical record, scheduling software, and billing software is essential. If there is concern about electronic compatibility, then pay-per-use might be a better option until optimized connectivity issues can be resolved.

The bottom line: its complicated

All too often in hospitals, the person who is the most eloquent, loud, or otherwise persuasive is the one who most heavily influences purchasing decisions. And this person is usually a powerful, silver-tongued physician. The hospital’s best defense against undue influence is the requirement to create a pro forma. This can guide the hospital about whether it is better in both the short-term and the long-term to purchase an expensive piece of equipment outright or utilize a pay-per-use acquisition model. One hospital may find that outright purchase is preferable whereas another hospital in the same town may find that pay-per-use is preferable. An accurate and well thought out pro forma is like a vaccination against future regret. No big-ticket equipment purchase should be put on the hospital’s final annual budget without one.

March 12, 2024

I just watched the Netflix series Blue Zones that examined habits of societies of people who were most likely to live more than a century. While I agree with most of the conclusions, there is much left out. The problem with such observational studies is that they are subject to population shift bias, observer bias, and selection bias. Over the last 40 years, I’ve seen hundreds of people die. It is inevitable if you are a critical care physician and even more inevitable if you are also a pulmonary physician specializing in idiopathic pulmonary fibrosis, a terminal disease. So, I have my own thoughts on what it takes to live to be a hundred years old (and what it takes to not die in our ICU). But first, let’s take a look at the three forms of bias.

Population shift bias. On the surface, it would seem to be easy to estimate the life expectancy of a group of people. Just look at all of the death certificates and calculate the average age of death. However, human populations are dynamic, with people constantly moving in and out of a given area. Let’s use an example of a hypothetical group of people living on an island in the Mediterranean. You go to the public records department and pull all of the death certificates for the past 10 years and find that the average age of death is 88 years old. You might then assume that the life expectancy is 88 years. But what if there had been no good-paying jobs on that island for the past 10 years and most of the people under age 65 moved to the mainland to find work? In that case, people born on the island who died before age 65 died somewhere else and this makes the average age of people dying on the island look falsely high. Also, the percentage of people living on the island who are older than 100 (per capita rate of centenarians) will be falsely high.

Population shift bias can also occur if there is a change in the birth rate. Let’s say you are measuring longevity by the average age of people on the same island. Three generations ago, families had an average of 6 children but now, families only have an average of 2 children. As a result, the average age of people on the island at any given time is now higher because there are fewer children. But that doesn’t mean that people are really living long.

Observer bias is a problem with any observational study. Let’s say you find that Seventh Day Adventists have a high percentage of people who live past 100. So, you look at the habits of those people to try to determine why they lived as long as they do. There may be hundreds of variables that make them different than everyone else in the world but if you are trying to prove that it is because of diet, then you will have blinders on and only focus on the observation that Seventh Day Adventists eat a plant-based diet. So, you might conclude that the vegetarianism caused then to live so long while overlooking the fact that Seventh Day Adventists also don’t smoke cigarettes.

Selection bias occurs when you look at a small group of people who have a particularly good or bad outcome and then assume that the group of people is representative of the population as a whole. An example of a selection bias error that is frequently made is nursing homes. It is often said that as soon as a person enters a nursing home, it cuts 3 years off of their life. One might then assume that being admitted to a nursing home causes a shortened life expectancy. However, a 70-year-old who need nursing home care is by definition sick and debilitated. A healthy and active 70-year-old would not be admitted to a nursing home. Entering a nursing home doesn’t make you live shorter, being chronically ill and debilitated makes you live shorter. The same can be said of doctor visits – people who visit doctors ten times a year are more likely to die than people who only visit a doctor once a year. If you fall into the trap of selection bias, then you would assume that seeing a doctor causes you to have a shortened life expectancy whereas the truth is that people who see a doctor more frequently have more serious and complicated diseases than those who see a doctor rarely.

The scientist in me would say that the only sure way to know if a habit will make you live longer is to do a randomized controlled trial, preferably placebo-controlled. But this type of study is impossible when looking at people’s life-long habits. So, everything we hear about the habits of people who live beyond 100 years is affected by these forms of bias. And I freely admit that these biases affect my own thoughts on living to be 100. You’ll see that my list is a lot different than the Blue Zone’s list. But I think you’ll find that my list will give you a better chance of becoming a centenarian.  So, here goes:

• Be a non-smoker. It is almost unbelievable that it was less than 50 years since the U.S. Surgeon General first reported that smoking was bad for your health. A study in the New England Journal of Medicine in 2013 found that women who smoke a pack of cigarettes a day live 11 years less than women who do not smoke. For men, smoking reduces life expectancy by 12 years. If you do the math, that works out to 14 minutes of life lost on average for every cigarette smoked.
• Get rid of your gun. Most of the people who die of firearm injuries did so from their own gun or the gun belonging to someone else in the family. The CDC reports that in 2022, 48,117 Americans died from a gunshot – 58% of those were suicides. In other words, a good guy with a gun is more likely to kill himself than to kill a bad guy with a gun.
• Wear a seatbelt. In America, we kill almost as many people with cars as we do with guns. The National Highway Traffic Safety Administration reports that in 2022, 42,795 Americans died in a motor vehicle accident. More than half of the drivers and passengers who died in a car accident were not wearing a seatbelt. In 1984, New York became the first state to legally require people to wear seatbelts – the law was met with outrage by anti-belters who said that it was an encroachment on their personal freedom. Unfortunately, that argument does not fly with widows and orphans.
• Maintain a normal BMI. We define obesity as a body mass index (BMI) greater than 30. Overweight is a BMI between 25 – 30. The National Health and Nutrition Examination Survey (NHANES) found that the prevalence of obesity in the U.S. is now 42%. As Americans have become more obese, a cultural taboo on criticizing obesity has emerged with the result that those who say anything bad about obesity can be accused of “fat-shaming”. But the reality is that obesity is not healthy. It increases the risk for hypertension, diabetes, and sleep apnea all of which can shorten life expectancy. It can cause arthritis that reduces physical activity and increases the risk of falls. A 2014 study found that people with a BMI > 40 have a life expectancy 14 years less than those who with a normal BMI between 18.5 and 25. A 2019 study found that even those with a BMI between 30 – 40 had a reduced life expectancy of 5.5 to 7.5 years compared to normal weight individuals.
• Don’t use drugs. In 2022, 105,452 Americans died from a drug overdose. That’s one out of every 3,000 people and more than died by both guns and motor vehicle accidents combined. The drug that causes the most overdose deaths is fentanyl. Most drug users do not call their local drug dealer asking for fentanyl. Instead, it is mixed with other drugs to potentiate their effects at a low cost. However, street drugs are not mixed by compound pharmacies and instead are mixed in unpredictable amounts by dealers with the result that a drug user does not really know what he or she is getting in a dose from one day to the next. Consequently, dying from a drug overdose is now easier than ever before.
• Get vaccinated. In 2019, 2,854,838 Americans died; of those, 49,783 (2%) died of influenza and pneumonia. In 2021, 3,464,231 Americans died; of those, 416,893 (12%) died of COVID. Last week, for my 65th birthday, I got a flu shot and a pneumonia shot. When they become available later this month, I’ll get this season’s COVID booster. These are some of the best investments you can make in your health. Infections cause inflammation and prolonged inflammation is harmful to the body. Vaccinations also cause inflammation (its how they work) but in contrast, vaccination inflammation is mild and brief – vaccinations stimulate rather than stress the immune system. If you live on a remote island with few visitors, it is easy to avoid respiratory infections since those infections have to be brought to the island by someone who is already infected. But for the rest of us, exposure to infections that have the potential to kill us is unavoidable so our best defense is vaccination.
• Choose your parents carefully. Okay, I know that no one can choose their parents but it is true that the genes that we inherit from them have a big impact on our life expectancy. Evolution has genetically engineered us to be able to live long enough to have children and then raise them until they can be self-sufficient. The current average age of menopause is 51 but in ancient times, it was much earlier, around age 40. Allowing for 15-20 years to fully raise and protect a child, our genes needed to ideally get us to about age 55 or 60. There was no natural selection advantage to having genes that let a person live older than that because those genes did not give a greater survival advantage to one’s offspring.  Genes that resulted in high cholesterol or breast cancer didn’t really matter 200,000 years ago because people did not live long enough to get the diseases they cause. Consequently, many families carry genes that that result in fatal diseases that occur in the family members’ 60’s or 70’s.
• Exercise your body. Many studies have shown that people who exercise regularly live longer. There are a lot of reasons for this: lower risk of obesity; lower risk of dying of cardiovascular disease; lower risk of osteoporosis; and better strength and balance that can reduce the chance of falling. However, the most effective physical exercise is a life-long exercise lifestyle rather than a New Years resolution gym membership. Walking can be great exercise but we have unfortunately engineered our communities to encourage sitting in a car rather than walking to workplaces, stores, restaurants, and places of worship. Rather than retiring and moving to a gated community on the outskirts of town, consider moving to a walkable neighborhood – preferably one with a lot of hills.
• Exercise your mind. What allowed humans to become the apex predators on Earth? Some people would say it is the capacity of speech. Others would say the ability to make tools. Yet others would say the dexterity that resulted from opposable thumbs. The reality is that it is verbal communication, tool-making, and complex dexterity were all facilitated by the homo sapiens brain. Every successive branch of hominid evolution has been associated with a larger and larger brain, from homo habilis (640 cc) to homo erectus (1,029 cc) to homo sapiens (1,350 cc). Our brains are like any other organ in our body – they work best when we use them regularly. Ideally, we should be exercising all areas of our brains. Exercise the brain’s motor centers by activities requiring balance and dexterity, for example, tennis or dancing. Exercise the brain’s left cortical areas with reading, creative writing, and conversation. Exercise the brain’s right cortical areas with music and art.
• Be engaged with other people. About 400,000 years ago, human ancestors firs started using spears. Ever since then, humans who lived in communities had an enormous advantage over those who lived solitary lives. The more organized the community, the better it’s chance of survival. Communities have propelled humans to the top of the food chain. We need communities as much as communities need us. Social isolation is associated with a higher risk of depression, suicide, dementia, and early death. Keeping connected with other people helps keep us connected with life. There are endless ways to do it: volunteer, be active in your place of worship, speak with family and friends regularly, even use Facebook.
• Avoid excessive calorie-dense foods. Everyone has an opinion about the best diet for longevity. Vegetarian, vegan, low-carb, herbal supplemented, more olive oil, less nitrates – the list is endless. The reality is that humans are built to be omnivorous and consequently, there are a lot of ways to have a healthy diet, as long as they are nutritionally balanced. The antithesis of nutritionally balanced diets are those that are dominated by calorically dense foods. These include excessively sweetened foods, fast foods, and high fat “junk” foods. MacDonalds french fries, like heroin and Fox News, have been specifically engineered to be addictive after just one bite and make you want more. Daily calorie needs are determined by age and physical activity but 2,000 for women and 2,500 for men is a good average.  Why waste so much of that on a Wendy’s Frosty (393 calories), Burger King large fries (448 calories), and a Chic-fil-A wrap (660 calories)? The advantage of diets that are high in vegetables, beans, and whole grains is that you can eat a lot, feel full, and have balanced nutrition – all without breaking the calorie bank.
• Drink in moderation (or not at all). For some people, there is no “safe” amount of alcohol – they are wired for addiction. But one or two glasses of wine a day is OK for most people and may or may not actually be beneficial. However, drinking excessively can unquestionably kill you. Excessive alcohol is involved in one-third of gun-related homicides, one-half of gun-related suicides, and one-third of motor vehicle deaths. In addition, chronic excessive alcohol use can cause cirrhosis, pneumonia, various cancers, and dementia. Overall, alcohol is responsible for 140,000 deaths per year in the U.S.
• Avoid poverty. You don’t need to be extremely rich to live a long life but it is really hard to live a long life if you are extremely poor. Poverty is associated with higher rates of smoking, obesity, drug use, and higher death rates for all of the 14 leading causes of death. Poverty results in inability to afford healthcare, living in crowded and unhealthy conditions, and over-reliance on calorically dense foods. Owning a Tesla won’t make you live longer but having to do all your grocery shopping at the Dollar General and being unable to afford a pneumonia vaccine can make you live shorter. Also, it is a lot more expensive to live to age 100 than to live to age 70, simply because you have to pay for more years of living expenses. So, even a middle-income working couple needs to make careful financial planning to avoid poverty in retirement.
• See your doctor regularly. A good primary care provider is worth his/her weight in gold when it comes to staying healthy and living longer. Even if you walk 5 miles a day, eat a nutritionally balanced diet, and never smoke, there are still things that can happen that are outside of your control. We can’t always prevent high blood pressure, colon cancer, or high cholesterol, no matter how good our lifestyle is. Five hundred years ago, people rarely died of heart attacks, colon cancer, and dementia for the simple reason that they didn’t live long enough to get them. But these are conditions that early diagnosis by your PCP can result in effective treatment. See your doctor once a year for a routine visit and follow all of the recommendations for health screening and preventive care.

Blue Zones is worth a watch on Netflix. But its conclusions are susceptible to being affected by population shift bias, observer bias, and selection bias. My own personal conclusions about longevity are also affected by these same biases. So, take my recommendations with a grain of salt – just don’t overdue it with too much sodium.

September 8, 2023

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

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

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

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

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

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

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