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OR Optimization Initiatives​

 

Background

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For over a year now, the Performance Optimization Committee (POC) has been meeting on a monthly basis, bringing together the leaders from all peri-operative areas with the goal of improving OR efficiency.  This includes the COO, CMO, Chiefs in Surgery, Anesthesia, Scheduling, EVS, SPD, and Nursing from Pre-op, PACU, ACS, and the main OR.  We've been successful to some degree, but one of the key areas where there is room to improve is the Turn-Around Time (TAT) of the ORs between cases.  

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TAT (Turn Around Time) Initiative 

 

TAT is defined as the time between your patient exiting the room (Out of Room) and your next patient entering the room (In Room).  These times are logged by the circulating nurse as you exit and enter the room, respectively.  On your EPIC chart, if you go to the “Summary” Tab on the left and then click on “Case Tracking Events” up at the top, you will see these times.

 

The goal set by Providence for TAT is 30 minutes.  This is the goal for all hospitals in the Providence system (and actually most hospitals in every health system).  This is for all scheduled cases in the Main OR during the weekdays.  GI, Cath Lab, ASC, and OB cases are not being monitored.  There are also some criteria for a room to be EXCLUDED from TAT monitoring (in other words, the TAT is not being monitored in these rooms either):

1.    Any room where the surgeon has multiple rooms that day (Yun, McKenna, Snibbe, Ehrhart, Gerhardt, Bae are the most common)

2.    When there is a neurosurgery (brain case) or cardiac case is to follow

3.    If there is already a scheduled gap longer than 30min between cases

4.    The next case in an Add-On

 

Before the POC was created, St. John's was dead last among all the Providence hospitals of our size, with an average TAT of 50-55min.  Quite embarrassing to say the least.  Dana Gilette (OR Manager) and I have been heading up the efforts to decrease TAT, and that is how the original Turnaround Teams came about, as well as the notification “Monitoring Turnover” is now on the Daily Anesthesia Schedule that Dorothy email to us.   Our average TAT is now somewhere in the low 40min range, but we've been stagnant in our improvement for several months.  In response, Dana and I have created a TAT Committee that incorporates Circulating RNs, Clinical Techs, EVS, Surgical Techs, and myself to represent Anesthesia. These are the 5 key components of an efficient room turnover, because the moment a patient exits the room:

 

  1. EVS worker: must clean and sterilize the room/floor (this can take about 10-12min) and they can only begin once the patient exits the room

  2. Clinical Tech: Cleans anesthesia machine, changes anesthesia circuit, suction, cleans and changes OR table, gets equipment for next case, etc.

  3. Surgical Tech: must take out the previous case cart from the room, bring in the next case cart once EVS has cleaned the room, then set up and count instruments for the next case

  4. Circulating RN: must drop off the patient in the PACU, set up for the next case, assist the Surgical Tech in counting, interview the next patient, and bring the next patient back to the room.  Each day, one or more dedicated “TAT Nurse(s)” will help these rooms with turnover, in order to split the work of the circulating RN and thereby expedite the turnover.  These are additional staff St. John's has hired for the sole purpose of expediting turnover. 

  5. Anesthesiologist: must have everything set up for the following case, see the next patient, possibly pre-medicate the next patient, and (for some) help wheel the patient into the room

 

In surveying EVS, Clin Techs, Surgical Techs, and Circulating RNs about how anesthesia could make room turnover faster, these were the top recommendations:

  • Be self-sufficient in preparing for your cases if Edwin is not available to help you.  Asking the RN to get lines, equipment (Glidescopes, Double Lumen Tubes), meds, etc. delays them in getting all their tasks complete to expedite a turnover. 

  • Clean off your cart and machine of meds and trash before you exit the room.  Per JACHO it is supposed to be clear of all meds anyway.  EVS workers and Clin Techs are delayed in cleaning when they have to move meds (which they aren’t suppsed to touch) or clean up random trash all over the ground before they can start wiping down equipment and mopping floors.

  • Communicate to the RN your plan for getting the next patient into the room.  The circulating RNs are often delayed when they have to go looking for anesthesia to figure out if we've seen the patient, if we want to pre-medicate, or if we are ready in the room to receive the patient.  They should be able to go get the patient at 25min into the TAT, without anesthesia being a question. 

 

When our daily schedule comes out (the one that Dorothy emails us), you will notice "Monitoring TAT" will be labeled next to some rooms.  This is your first indicator that you have a TAT goal of 30min that day.  There will also be fluorescent pink signs hung on the inside of the OR door in the rooms being monitored that day.  Above these signs is a timer that is pre-set to 25:00min, and will be for the anesthesiologist to start upon exiting the room.  When this timer goes off, it will be a signal to the RN to go get the next patient. Please see attached pics of these signs and timers.

 

Here is what we need from all anesthesiologists:

  1. When you see your room TAT is being monitored on the schedule, give your best effort to adhere to the following workflow.  The fluorescent pink sign hung inside the OR door will be a visible reminder.

  2. Prepare for your next case while your current case is still going (most everyone does this already).

  3. Before you are about exit the room, clean off your cart of all meds (this is a JACHO issue anyway) and attempt to pick up the trash that inadvertently missed the trash can next to you.

  4. As you exit the room, press the start button on the timer above the pink sign (should start counting down from 25:00 minutes).  Pressing the start button should coincide with the RN logging the “Out of Room” time on the computer.  If for some reason the timer is not set at 25:00, adjust it yourself and press start.

  5. As you wheel your patient to PACU, discuss with the circulating RN what your plan is for seeing the next patient and bringing them back to the OR (for example, if you plan on meeting the RN in Pre-Op to help wheel the patient back, if you plan on seeing the next patient immediately after leaving PACU and the RN can bring the patient back and overhead page you when in the room, etc.).  Just make a plan and communicate with the RN so there is no delay because they are unsure of where you are/what your plan is.

  6. Do whatever you need to do (set a timer on your phone, wait in pre-op for the RN) in order to have the patient exiting Pre-Op before 30min has elapsed.  The "In Room" time can be the moment you cross the red line (through the double doors) into the ORs.

 

In Summary:

  1. Know if your room is being monitored for TAT (daily assignment sheet, pink sign inside door)

  2. Be self-sufficient and Prepare in advance for your case.

  3. Clean up after yourself before exiting room so EVS/Clin Techs don't have to

  4. Start the 25min timer when you are Out Of Room

  5. Communicate with the RN your plan for getting the next patient into the room within 30min

  6. Be cognizant of the time elapsed and get passed the OR red line within 30min

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