Academic vs surgical centers

[Dusn]

I'm not an anesthesiologist; I'm actually in ophtho. But I have a question regarding why the turn-over is so much slower at academic centers than at surgical centers and I was hoping you guys might be able to provide some insight.

The reason for the slow turn-over in academic centers, according to my attendings, is that academic centers pay their anesthesiologist and OR/Pre-op staff by salary and not by patient, and so they have no incentive to work faster. (And of course I realize that the surgical residents slow things down as well, if we're doing the operation). As a result many surgical attendings are flocking to surgical centers for their elective procedures, whenever possible. This would seem to result in a huge loss of procedures and revenue for the hospital (and can negatively impact training for the surgical residencies).

So I can't understand why hospitals aren't changing anything to make their ORs operate similarly to the outpatient surgical centers? The first logical step would be to pay the OR staff, CRNAs and anesthesiology the same way that the surgical centers do. So why doesn't this happen -- what am I missing?

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[michigangirl]

Not sure I completely understand your question-- are you talking solely about ambulatory surgery? If that is the case, one of the biggest slow downs is trainees. Surgical trainees, anesthesia trainees-- a huge hit to efficiency, but necessary for education.

Inpatient/same-day admit surgery-- whole other ballgame. Trainees, acuity, complexity-- too many variables.

 

[Dusn]

Yes. Only ambulatory surgery. I may have a biased perspective but I think ambulatory surgeries are the majority of surgical cases and would represent a large source of potential surgical income for hospitals - one that I think they should be concerned about losing to outpatient surgical centers.

The turn-over is slow even for the attending-only cases, where the surgical resident does nothing. And honestly it doesn't seem like the anesthesia resident is slowing things down that much. Usually, for the ophtho cases, it's just a CRNA there most of the time and no resident at all

 

[imfrankie]

Obviously I cannot fathom why turnover is slow in your facility, but like many generalizations, the one you ascribe to your attending(s) is wrong. For one, there are numerous compensation models--productivity-based, salaried, hybrid--for all facilities you can imagine.

This may not seem on point, but since I can't answer your question, and because I know you mean well, let me share with you an observation that surgeons and their trainees often don't seem to appreciate: the case doesn't end when they walk away from the OR table.

 

[IlDestriero]

Some things the ASCs have going for them, at least where I am:
-no trainees
-only experienced staff, at all levels. This is huge.
-the nurses that work there all want to work there, and it's better than the big house, so they have incentive to stay, many are waiting for a coveted opening.
-limited volume, with appropriate staffing for the volume.
-accountability of staff. If the premed isn't given, nursing pre op not done on time, consent not checked and/or completed you know exactly who didn't do it. You can ask WTF happened?
-healthy patients make for quicker pre ops, more routine plans, etc.
-predictability of cases, times, etc.
-the surgeons book case time correctly. If you know that your 45 min hernia will only take 15 min because of something with this particular patient, that's how it's booked. The reverse is also true.
-predictable proper scheduling has all the patients coming in at the correct times.
-when we're done, we leave. No add ons, etc. The nurses may have to stay until 4, but the sooner I'm done, I'm done. That makes the surgeon and I want to move things along and be as efficient as possible.
-nobody's coming to relieve me, see above.

Add it all up and you're moving through the cases like a hot knife through butter.
BTW, I'm an academic faculty and get a bonus tied to productivity, among other things.

 

[climbingak]

The answer is it has nothing to do with anesthesia, but should have everything to do with anesthesia. To explain, I have been in many different places and anesthesia (prepping the patient for surgery, getting the room ready) is NOT slowing you down. The problem, in my opinion only, is that we have turned over the OR's to the nurses. There is no incentive to get cases in and out quickly. There is no incentive to please the surgeon or help get him out of there faster so he can get to clinic, etc. They could care less about delaying a surgeon because "Henry the OR tech needs lunch, he hasn't had lunch".

So why are most surgery centers different? Its because usually the anesthesiologist is RUNNING the show. Many times he is an owner. Even its not the anesthesiologist running it, whoever is knows that usually the surgeon is an owner and we do need to treat the surgeon as a customer. In my surgery center our anesthesia team has a motto, "Physician owned, physician run". There is no way I am going to buy into a surgery center with a bunch of surgeons and then turn it over to some NWC.

To me if all anesthesia groups could gain this control and push the OR's, you would see the same things in the hospitals, and the surgeons would no longer hate going there. Its a total mindset thing. Academics is a little different with all the training going on, but we all know it could still be faster even with all the training. Its tough for anesthesia to gain this control because the NWC is backed by the admin. If admin was smart, they would get behind a motivated anesthesia group and bring the surgeons back to the hospital more.

There are several smaller reasons as well. Hospitals have a little more unpredictability and a little more red tape.

Next time you get a motivated anesthesiologist in your room who can kindly help push the room along, I bet you will have a much more pleasant, more efficient day. The answer to a lot of the OR's problems lie in the anesthesia team, their support, and their motivation.

 

[jwk]

It's a facility-dependent problem, not simply a hospital vs ASC issue. In my own hospital system, which runs both hospitals and ASC's, turnover times vary tremendously. For GI and cataract cases, at one hospital, the patient may leave the room at 9:01 and the next patient roll into the room at 9:02, yet at an ASC in the same system, the time might be 9:01 and 9:11. That one minute vs 10 minute turnover difference is huge when multiplied x15-20 procedures per day. It makes no sense at all.

In hospitals that have shifts (7-3, 3-11, etc) where someone else is always coming in "later", I think things tend to be slower. If they don't get finished by 3pm, no problem, the evening crew will be here to finish the cases. In hospitals where the OR is primarily a 7-3 or 7-5 kinda place, similar to ASC's, and the staff doesn't go home until the work is done, things will generally get done a lot faster. Staff attitudes are probably the single biggest determinant.

 

[Dusn]

Thanks. This all made a lot of sense and helped clarify why things are the way they are. The nursing staff at my hospital will actually ask me to slow down during my surgical cases so that they don't have to scrub into another case near the end of their shift -- so I'm pretty sure I know where we fall on this spectrum.

 

[Brunette1981]

Also, a lot of turnover time depends on how the infrastructure and staffing is set up aside from physicians to make things more efficient.

I am an anesthesia resident and when I work at our main university hospital OR, I am personally setup for my next case before I leave the room with the patient. However these are some of the steps before the next case rolls in the door:

*wait for overhead page for moving help to get patient onto the hospital bed
*push (with the surgeons) the patient down 3-4 long corridors in a Big Boy bed to the PACU
*help PACU nurse put monitors on patient and wait while he/she gets an oral temperature and listens to patient's breathing before he/she'll take report
*give report
*walk to preop to get new patient
*next patient often wants to pee/say prayer/check on belongings before going back to surgery
*push stretcher 3-4 corridors to OR
*get moving help again for patient to get onto OR table

Even if I don't go back to my room at all, this ends up being a 20 min process largely out of my control.

In contrast, when we rotate in the Eye Center doing procedures, OR staff wheel the patients into and out of the room. I give PACU report by phone as the drapes are coming down. All I do in between cases is slap monitors on the patient and wipe down my machine and pull the particular patient's drugs (pre-drawn up) from the drawer. Turnover time = 2 min.

 

[Mman]

Thanks. This all made a lot of sense and helped clarify why things are the way they are. The nursing staff at my hospital will actually ask me to slow down during my surgical cases so that they don't have to scrub into another case near the end of their shift -- so I'm pretty sure I know where we fall on this spectrum.

In our main hospital, the OR staff (circulators, scrub techs, etc) are all there to work their shift. Whether their room cranks through 2 cases for the day or 10 cases for the day, they get paid the same and they go home at the same time. No incentive to move fast. So it's 30-40 minute room turnover all the time.

At our outpatient surgery center (same surgeons, same anesthesiologists, same CRNAs, same residents, same med students, etc) the OR staff goes home when their room is done. The faster it gets done, the sooner they go home. And they are salaried so they aren't paid per hour. Room turnover averages 10-15 minutes.


It's all about providing an incentive to the people turning the room over, either money or time. In the big hospital they know if they get their room done early, cases will spill over from some other room and they will just have to do more work because there is always a never ending list of add-on cases (that's what happens at a 1000 bed level 1 trauma center). Outpatient surgical facilities almost never have add on cases.

 

[cchoukal]

in our main hospital, the or staff (circulators, scrub techs, etc) are all there to work their shift. Whether their room cranks through 2 cases for the day or 10 cases for the day, they get paid the same and they go home at the same time. No incentive to move fast. So it's 30-40 minute room turnover all the time.

At our outpatient surgery center (same surgeons, same anesthesiologists, same crnas, same residents, same med students, etc) the or staff goes home when their room is done. The faster it gets done, the sooner they go home. And they are salaried so they aren't paid per hour. Room turnover averages 10-15 minutes.


It's all about providing an incentive to the people turning the room over, either money or time. In the big hospital they know if they get their room done early, cases will spill over from some other room and they will just have to do more work because there is always a never ending list of add-on cases (that's what happens at a 1000 bed level 1 trauma center). Outpatient surgical facilities almost never have add on cases.

+1.

 

[jd1572]

If your room turnover (time from when one patient leaves the OR to when the next patient arrives in the OR) is less than 5 minutes, is the room being cleaned appropriately? Is someone wiping down the monitors, EKG cables, pulse ox, anesthesia machine, etc.? Is someone cleaning the operating room table, arm boards, etc?

 

[chemlover]

It's all about providing an incentive to the people turning the room over, either money or time. In the big hospital they know if they get their room done early, cases will spill over from some other room and they will just have to do more work because there is always a never ending list of add-on cases (that's what happens at a 1000 bed level 1 trauma center). Outpatient surgical facilities almost never have add on cases.

So true! I wish the hospital administrators would see the light, and change this shift work setup for RNs. But I think the nurses would be initially against it, and they are unionized here.