Operating Room

A Safe Operating Room Is A Cold Operating Room

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

Temperature: 68-73° F

Humidity: 30-60%

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

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

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

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

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

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

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

December 21, 2016

Hospital Finances Operating Room

Thou Shalt Not Covet Thy Neighbor’s Surgeon

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

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

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

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

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

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

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

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

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

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

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

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

December 6, 2016

Operating Room

How Climate Change Affects The Operating Room

The climate scientists were all wrong when projecting future increases in the Earth’s temperature… it is happening much faster than they thought it would. These hotter temperatures turn out to have a big impact on hospital’s operating rooms. June 2016 was the 14th straight month that broke the monthly record for the hottest of those months on Earth ever recorded by NOAA. The average land temperature on Earth during June 2016 was 2.23° F higher than the 20th century average for June. In Central Ohio, not only are the temperatures higher this summer, but so is the humidity.

No matter what the outside weather, the inside of an operating room has to be in constant climate of 68-74° F and 30-60% humidity with up to 25 room changes of air per hour (that is a lot more room changes than your home central air conditioner has to do). Air handler units built into hospitals in the northern United States in the 1960’s and 1970’s were not built for the high temperatures and humidity that we are now experiencing. To understand why this is a problem, I had to take a crash course in HVAC systems from our director of facilities.

For air to get from the outside atmosphere into the operating room, it has to go through several steps. First, air is drawn into the HVAC system from intake vents. The air then passes through a heating coil (turned on in the winter) and a cooling coil (turned on in the summer). The cooling coil circulates a cooled liquid, in our hospital’s case, it is cooled water that comes from a refrigeration unit in our boiler room. The air then goes through a filter so that it is 99.997% pure. Next come additional heating and cooling coils to get the air to the proper temperature for any given location in the hospital.

If the room is too hot, then surgeons with gowns on and patients with drapes on can get overheated. Humidity comes into play also because if the humidity gets high, then the air will seem several degrees hotter even if the temperature doesn’t change (this is the difference between the actual temperature and the “heat index”).

In order to maintain constant temperature and humidity, it can require a lot of frequent adjustment in air handler controls. Recently, the temperatures and humidity in Columbus were really off the charts for long periods of time and we started seeing our operating rooms’ temperature and humidity rise excessively.

So here is what we had to do. The first cooling coils were set to 42° F. The air doesn’t get that cold but this does maximally reduce the humidity (i.e., dries the air out). The air gets down to about 56° F. Although that is plenty cold for operating room air, the air was still too humid so we next heat the air up to 68° F with the secondary heating coils in order to further reduce the humidity. So, in order to get it right, we had to supercool the air then warm it back up to get the humidity down.

This works OK for now but if  we continue to have heat record breaking months in the next few years, then hospitals in areas of the country where constant high heat and high humidity were not previously a problem are going to have to invest in expensive new HVAC systems in order to maintain the tightly controlled climates that our operating rooms require.

August 5, 2016

Operating Room

Does Your Operating Room Operate Efficiently?

A hospital’s operating room powers the hospital’s financial margin. But for the OR to be truly effective, it has to be efficient. In order to be efficient, you have to know what data to analyze and how to interpret that data. For this post, I want to focus on 2 metrics: (1) first case start times and (2) operating room turn over times.

At our hospital, we are very fortunate to have an outstanding Medical Director of Perioperative Services who understands efficiency and works well to build consensus among the surgeons, anesthesiologists and OR staff to create an efficient environment with a focus on optimizing the patient’s experience. One of the first areas he addressed was whether the first cases of the day started at the time that they were scheduled to start. The operating room schedule is just like an outpatient office schedule: if you start the first patient 30 minutes late, you are going to be late by 30 minutes for all of the rest of the patients for that day and then you are going to have to pay your staff overtime for 30 minutes when they finally finish up their day 30 minutes later than anticipated. In order to start on time, several things are required:

  1. The room has to be ready for the patient
  2. The patient has to be ready for the room
  3. The OR staff have to be in the room
  4. The anesthesiologist has to be in the room
  5. The surgeon has to be in the room.

If any one of these are not in place at the time of the first scheduled case, then everyone gets delayed for the rest of the day. If your operating room first cases are not starting on time, the next step is to drill down to determine which of these 5 variables is the culprit and then take steps to rectify the situation

Room turn over time is more complex. At our medical center, The Medical Director of Ambulatory Surgery, Associate Professor of Anesthesiology Dr. Mike Guertin, has done a very detailed analysis of room turn over and I’ll credit him with my understanding of room turn over.

The number of minutes it takes to turn an operating room over can vary depending on the surgical case. For example, surgeries that use a basic surgical instrument set and minimum number of OR staff (for example, cataract removal) can have short room turn-overs, say, 20 minutes. On the other hand, a surgery that uses a large number of specialized instrument sets plus a larger number OR staff (for example, hip replacements) will need a longer time to turn the room over, say 40 minutes. For a wide spectrum of different types of surgeries, a good average to shoot for is 80% of the room turnovers taking less than 30 minutes.

There are 4 key parts of an operating room turnover:

  1. The time from incision closure to the first patient leaving the room
  2. The time from when the first patient leaves the room until the room is ready for the second patient
  3. The time from when the room is ready until the second patient is ready in that room
  4. The time that the second patient is ready in the room until the the incision is made

Although on the surface, this sounds simple, in reality this is a supremely complex human behavioral engineering challenge. Here are some ways to address the common causes of delay in room turnover:

Standardize work flows. The staff should not have to be called to do routine parts of the room turnover, they should do it automatically. For example, cleaning the floor of the room in between cases should be hard-wired into the staffing and it should not require the OR charge nurse to page housekeeping.

Improve communication. The fewer phone calls and pages that the staff have to make, the fewer minutes it takes to turn the room over. The solution may be different for different hospitals and could involve an overhead paging system, an auto-page triggered electronically to staff pagers or cellphones, patient flow monitor screens placed throughout the OR area, or microphone headsets for use by the staff.

Optimize pre-admission evaluation processes. Dr. Guertin found that in nearly half of cases, patients are not ready to go back to the operating room when the operating room is ready for them. More effective pre-admission evaluation and testing was able to have patients better prepared for surgery and have all of the proper documentation in order with fewer “unexpected surprises” on the day of surgery in our ambulatory surgery center. Not only does this improve patient flow and reduce day-of-surgery cancellations but it also significantly improves patient satisfaction. Outpatient pre-admission testing programs that use healthcare professionals at the top of their license capabilities (office assistants, medical assistants, RNs, CNPs/PAs, and physicians) can improve throughput of patients later when at the arrive to the hospital for their surgery.

Avoid a culture of defeat. Improving operating room efficiency can seem like an insurmountable task for the OR staff, physicians, and hospital administration. By following regular report metrics on room turnover and first start times, it can be much easier to show the OR staff small incremental changes of just 1-2 minutes and this is sometimes the positive reinforcement that is needed to maintain the culture of optimization.

Operating room time is expensive, typically $18-19/minute so even shaving a few minutes off of room turn over time can result in dramatic financial rewards. Reducing room turnover time by 10-15 minutes can allow for an additional surgical case per room each day. Equally important, a maximally efficient operating room with on-time first-starts each morning and shorter room turnover time will improve the patient experience and improve patient satisfaction. In the spirit of the Ohio State University Wexner Medical Center, Dr. Guertin refers to the process as “OSUWMC2”: “Optimal Surgical Utilization With Minimal Complications & Cancellations”.

The key message is that operating room optimization starts not when the patient arrives in the hospital on the day of surgery but instead starts when the patient first decides to have a surgery. There are no losers with operating room optimization, only winners.

July 31, 2016