Surgery end time

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Neogenesis

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What do you mark for surgery end time? Last suture, dressings/cast on, staff surgeon scrub out, etc?

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I wish there was a universal consensus on this... Especially considering they are so gung-ho on tracking times nowadays.

It's especially frustrating with posterior spine fusions or any procedure where the surgeon wants imaging in the OR. Some of the surgeons here want the patients to do a dance from the West Side Story before they feel comfortable in letting us take the ETT out. I know, ridiculous... like we don't know when the patient is able to be extubated. Has anyone extubated a patient and then had to immediately re-intubate so the surgeon could go back in to explore while still in the OR? I'm sure it happens, but the rate is probably really low.

And with posterior spine fusions (at least at my pediatric hospital) the surgeons always get films right after flipping. So I tend to hit surgery ends after the x-ray tech is done. The problem is if I hit surgery end on dressing application. Then I have to wait 5 minutes (if I'm lucky...) for everyone to stop gabbing so someone can grab the bed, then sometimes we have to wait for an extra flipper, then we have to wait for the x-ray tech... Sometimes this is 10 minutes, which makes it look bad when you have this long delay after surgery end times which makes it look like my wakeup took forever. Cause even though I document the flip, and the final imaging, that probably isn't captured when they analyze the data picking up the time stamps for specific events.

All this being said, being at an academic hospital, it seems nobody gives an F... What's an extra 5, 10, 15 minutes here or there...? OR staff is getting relieved at 3pm no matter what! Very annoying.
 
When I can wake them up.
That's pretty much what I do to. If they're still messing around putting on dressings/braces/etc, I don't mark surgery end. But I was doing some locums at a place and the circulator asked me what end time was and I replied, "I'll let you when they're done". And they all looked at me indignantly and said ," the surgeon is done. They're just doing dressings". So I just figured I'd ask what other people put.
 
That's pretty much what I do to. If they're still messing around putting on dressings/braces/etc, I don't mark surgery end. But I was doing some locums at a place and the circulator asked me what end time was and I replied, "I'll let you when they're done". And they all looked at me indignantly and said ," the surgeon is done. They're just doing dressings". So I just figured I'd ask what other people put.

Yup... sometimes the time between attending scrubbing out and the resident/intern/fellow/MS closing can be 30+ minutes. The key ninja quality is to document awake extubation before surgical end time.

Another favorite of mine is when the nurse calls in report to the MICU/NICU/SICU/PICU/ICU and starts asking you every detail about the patient. Then they ask you what the I/Os are and there still a good 30-60 minutes left until closing but they're through the big stuff. I either just approximate what I think it will be by then, or I just tell them I'll give report when I drop the patient off.

Finally, and completely off topic, is it just me or maybe it's jsut the few institutions I've worked at, but are there a disproportionate amount of people standing in the halls by white boards all day...?! I'm amazed anything gets done.
 
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I mark surgical end time when the surgical team (surgeon, resident, scrub tech, nurse) are done messing with the patient. It annoys our cardiac surgeons, who consider surgical end time to be when the last suture is in, and they break to write the op report. They want the 15 minutes that everyone else takes to apply dressings, wrap the leg, secure drains for transport, etc to come out of anesthesia time (because everything not surgical must be our time, right?).
 
When the drapes are down.
 
Some of the surgeons here want the patients to do a dance from the West Side Story before they feel comfortable in letting us take the ETT out

Let you take the tube out? o_O
 
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Yea, ridiculous. They want them to wiggle their toes or hands or do some sort of bogus "Neuro" exam to make sure that despite normal OR course and stable neuromonitoring they didn't somehow jack up their cord...
 
That's pretty much what I do to. If they're still messing around putting on dressings/braces/etc, I don't mark surgery end. But I was doing some locums at a place and the circulator asked me what end time was and I replied, "I'll let you when they're done". And they all looked at me indignantly and said ," the surgeon is done. They're just doing dressings". So I just figured I'd ask what other people put.

Easy. Next time time your extubation for when the last suture goes in. If they complain about the patient moving while they're putting dressings on, just tell them, sorry, according to them, the surgery's already over.

I don't hit surgery end until the dressing are on, drapes are down, patient is supine. I.e, ready to extubate, as narcus said.
 
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I can't stand that I'm being asked to
document this. Who cares? The circulator documents it anyways.
 
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What's with the fixation on extubation? That's not the end of surgery OR anesthesia time.

If I'm feeling particularly jaunty and the patient is right, I'll sometimes extubate before they're done with sutures or a dressing.

But that doesn't mean the surgery end time changes. When the surgery team is DONE, the surgery is over. That means when the dressing is on, and we're back in the supine position with the bed turned toward me. Surgeon wants the Foley out at the end of surgery? That's surgery time too, even if the surgeon is drinking coffee two floors away while the periop RN pulls the Foley.

To take it further ... neurosurgeon wants a neuro exam before we leave the room? That's still his time. Patient extubated, awake ... when he's done with his neuro exam and decides he's happy (or not) ... THEN surgery is over.
 
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I would think this might become critically important from a legal perspective if there is a question of surgeon presence/availability at the end of a surgery. Our time documentations become the de facto time stamp for things in the OR
 
Still using paper records. I don't document a surgery end time, just a anesthesia end time. I let
The nurses document out of room etc. Any reason this surgery end time stamp actually matters?


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Still using paper records. I don't document a surgery end time, just a anesthesia end time. I let
The nurses document out of room etc. Any reason this surgery end time stamp actually matters?

It matters now when it comes to case scheduling, because it helps us tell a slow surgeon he can't book 4 cases that our data proves routinely takes him 3 1/2 hours each, even if he pinky-swears he can do them in 2. This, more than anything else, is why I make sure the surgeon's time is documented in the computer as the surgeon's time.

It'll probably matter when anesthesia quality metrics start mining EMRs to look at things like
1) room time --> turnover to surgeon time
2) surgery end --> out of room time
Fraught with peril this line of thinking is, but it's coming. I'd rather have bad data used badly in a way that favors me instead of the surgeon.
 
Incoming medical student with no clue if this is correct, but at the ambulatory surgery centers where I have worked, the anesthesiologist and circulator agree on the end time as when dressings are on and the patient is awake.
 
It matters now when it comes to case scheduling, because it helps us tell a slow surgeon he can't book 4 cases that our data proves routinely takes him 3 1/2 hours each, even if he pinky-swears he can do them in 2. This, more than anything else, is why I make sure the surgeon's time is documented in the computer as the surgeon's time.

It'll probably matter when anesthesia quality metrics start mining EMRs to look at things like
1) room time --> turnover to surgeon time
2) surgery end --> out of room time
Fraught with peril this line of thinking is, but it's coming. I'd rather have bad data used badly in a way that favors me instead of the surgeon.
This makes sense and it's how we determine case booking times as well, however shouldn't the actual bookings be based on the average time it takes to complete the whole procedure and anesthetic (in room to out of room)? It's not like most places have a dedicated team consisting of the same anesthesiologist, circulator, surgeon and tech? That would take into account the variation in induction and wake up times and would lead to more accurate case times.
It seems to me that having these time stamps in place just incentivizes rushing and worsens patient care. I'm all for efficiency but focusing on these times seems like bad medicine.


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You have to consider practice environment. PGG practices in a place where slow surgeons are the norm. Most of the anesthesia start stop times are generally very fixed. Turn over to surgeon is also a fixed timestamp in our anesthesia log. In environments where efficiency is paramount you might count into and out of the OR as time for procedure and to determine operative times. Here we have to justify our reasoning about booking a surgeon for 2 cases versus 3 and those times are determined by turnover to surgeon to end of surgery.
 
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Door to door times have non-surgeon confounders, slow vs fast anesthesia, RN time, PACU gridlock, and other issues. Using this time makes it harder to refute an orthopod's claims that his 4 hour total joint averages aren't his fault, and if we just let him schedule 4 per day it'll be OK if the non-surgeons in the room try harder.

Surgeon brains aren't like ours. They see (or selectively remember/imagine) that a certain case takes 45 minutes skin to skin and think 45 plus 30 min for turnover means each case takes 1:15. If you don't have their times on hand to hold under their noses, they'll conjure all manner of reasons why that case took forever but the next one won't.

I think this time warp cognitive dissonance is a core competency of all ACGME approved surgical residencies.

I used to have this conversation with them almost daily. Part of the reason I'm so picky about surgery time is political. When the surgeon comes and whines about not being allowed to book 14 hours of surgery in a 10 hour block, they ALWAYS dispute the times we quote, saying the reason their last 5 lap choles took 2:30 apiece was because the room wasn't ready, or the RN prepped slow, or anesthesia took 15 min to wake up, or, or, or.
 
We have tried both ways. The anesthesia department and nursing staff gets consistently screwed when using "surgeon time" for the case length rather than in room to out of room or "room time". You are expected to perform all the operating time and not given any in and out time, so basically every case over-runs into another. Then the surgeon sits there pissed about how they are not in the room yet for next case which was scheduled at XX:XX. This has been the source of a lot of political discord about our staffing model and abilities, which largely went away when we switched to "room time" for scheduling.
With "room time" scheduling I can consistently call surgeons and ask them if they would like to go early rather than always be last minute getting to the cases. It makes people happier all over (in my environment) and I would recommend if you are ever asked for input that you suggest that way over the other.
I personally owned the mistake at my hospital we made initially when going to epic as I thought they were discussing room set up time when showing me the break down and said we didnt need to include that. I was thinking that they meant time prior to patient in room, when really they meant after patient is in room, setting up for cutting.

Agree with the above comment regarding needing accurate surgeon time to show for political reasons, I find our biggest issue is that surgeons dont realize how freaking slowly some of their PAs close wounds. "Yes, that knee took you 35 minutes, but your PA took 25 minutes to close it, thus surgery time is 1 hour."

Looking at efficiency and case volumes scheduled, it is too early to say for sure being only 6 months in, but so far there is no major trend towards less cases scheduled and performed. I can update after a full year if someone bumps the thread.


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We have tried both ways. The anesthesia department and nursing staff gets consistently screwed when using "surgeon time" for the case length rather than in room to out of room or "room time". You are expected to perform all the operating time and not given any in and out time, so basically every case over-runs into another. Then the surgeon sits there pissed about how they are not in the room yet for next case which was scheduled at XX:XX. This has been the source of a lot of political discord about our staffing model and abilities, which largely went away when we switched to "room time" for scheduling.
With "room time" scheduling I can consistently call surgeons and ask them if they would like to go early rather than always be last minute getting to the cases. It makes people happier all over (in my environment) and I would recommend if you are ever asked for input that you suggest that way over the other.
I personally owned the mistake at my hospital we made initially when going to epic as I thought they were discussing room set up time when showing me the break down and said we didnt need to include that. I was thinking that they meant time prior to patient in room, when really they meant after patient is in room, setting up for cutting.

Agree with the above comment regarding needing accurate surgeon time to show for political reasons, I find our biggest issue is that surgeons dont realize how freaking slowly some of their PAs close wounds. "Yes, that knee took you 35 minutes, but your PA took 25 minutes to close it, thus surgery time is 1 hour."

Looking at efficiency and case volumes scheduled, it is too early to say for sure being only 6 months in, but so far there is no major trend towards less cases scheduled and performed. I can update after a full year if someone bumps the thread.


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The problem with going early is that the OR staff gets all hissy pissy if you even attempt to bring the patient back before they're ready. Cause them counting the closing sutures on a 4 hour case make sit impossible for us to get the patient in the room, moved over, monitored and induced and intubated (or whatever the anesthesia plan is). So frustrating when you've been ready and the scrub/circulator need "another 5 minutes" to get ready. You've had 30 minutes... the equipment for next case is waiting outside. Yet I can drop the patient off in PACU, give report, finish documenting, turnover my workstation and machine, draw up needed drugs (if I didn't at the end of the last case), talk to patient, get consent and place at least one IV (sometimes an a-line if needed) in that same time.

Where I trained we had anesthesia techs who turned over the machines 90% of the time, but occasionally they'd be busy with other room turnovers or assisting in major cases. Same thing with the attendings. 75% of the time they'd talk and get consent for the 2nd case and on, and maybe 50% of the time put in an IV. But sometimes they were busy (or lazy... and I knew which ones) So I always assumed that it was MY job to get everything done in that 30 minutes. My goal for every case was to never be "That guy", you know the one that holds everything up. So yeah occasionally you get a tough IV/a-line stick, but very rarely. Yet sometimes it seems like the rest of the OR staff has this "What me worry?" attitude. Yet, if we bring a patient back a minute late, they're trying to pin it on an anesthesia delay. I guess when you know you're getting out at a set time no matter what, there's no incentive to work harder and faster. Is this the case with anyone else? MAybe it was just the hospital where I trained. Fellowship hospital isn't nearly as bad, but the turnover times can be ridiculous some days........
 
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