World Record Turnover Time

Started by jetproppilot
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jetproppilot

jetproppilot

Turboprop Driver
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15+ Year Member
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We were busy today.

One of our orthopedists had 5 total joints, all in the same room...couldn't flip him because of the busy schedule.

Epidural and foley are placed in the pre-op area so essentially all we have to do is wheel the patient back to the OR, put 'em on the table, and prep and drape.

Combine that with a really efficient circulator and scrub tech

and everyone on the same page from pre op area into the OR to the PACU

average turnover time between these total joints was

SEVENTEEN MINUTES.😱

Put that in your pipe and smoke it.:meanie:

Why yes.

Yes you can,

ladies and gentlemen.
 
jetproppilot said:
We were busy today.

One of our orthopedists had 5 total joints, all in the same room...couldn't flip him because of the busy schedule.

Epidural and foley are placed in the pre-op area so essentially all we have to do is wheel the patient back to the OR, put 'em on the table, and prep and drape.

Combine that with a really efficient circulator and scrub tech

and everyone on the same page from pre op area into the OR to the PACU

average turnover time between these total joints was

SEVENTEEN MINUTES.😱

Put that in your pipe and smoke it.:meanie:

Why yes.

Yes you can,

ladies and gentlemen.
Click to expand...

I hope he/she bought you lunch. Nice.
 
epidural? Your Orthopod doesn't use bid lovenox? It also sounds like you are bolusing your epidural in a preop area so they can tolerate a foley? That's a pretty darn good average turnover time. Geez five cases and you kept it up. Nice.
 
Oggg said:
epidural? Your Orthopod doesn't use bid lovenox? It also sounds like you are bolusing your epidural in a preop area so they can tolerate a foley? That's a pretty darn good average turnover time. Geez five cases and you kept it up. Nice.
Click to expand...

Lovenox started the next morning after epidural DCed.

We do

combined spinal epidurals

in the pre op area..

15mg hyperbaric bupivicaine thru the spinal needle then catheter threaded,

foley immediately follows.

Doing the foley in the pre op area probably saves 5-10 minutes per case...

so with 5-6 back to back total joints

you're shaving 30-60 minutes off your day.
 
We can get to 20 minute turn over times for shoulders and that includes my ISB. Too bad it's not consistent. If you're doing 4 cases/day and you can save 15 mins/case that's a solid hour you're gonna go home earlier
 
For you guys out there in PP, can you describe your consenting process for those of us biding our time in the halls of academia? Are you doing the consents yourself prior to the blocks? Are they done in a preop clinic? It seems like in my quest to reduce my own turnover time, the rate limiting step is always the consent.
 
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Hawaiian Bruin said:
For you guys out there in PP, can you describe your consenting process for those of us biding our time in the halls of academia? Are you doing the consents yourself prior to the blocks? Are they done in a preop clinic? It seems like in my quest to reduce my own turnover time, the rate limiting step is always the consent.
Click to expand...

We have the same problem. We have to hassle one of the ortho floor residents for consent, many times they're in another OR, or in the ED seeing a consult, etc.
 
PMPMD said:
We have the same problem. We have to hassle one of the ortho floor residents for consent, many times they're in another OR, or in the ED seeing a consult, etc.
Click to expand...

My record time so far was 11 minutes ;-) (from out of the OR door to in the room with the next patient) We have a time limit of 20 minutes turn over time in ortho. PNC blocks are done by a separate regional team in pre-op. We transport the patient on our own, so the turn over time is primary dependent on us.

What worked for me: prepping everything for the next case during the current case, prep as much as you can in the morning, good professional friendly relationship/communication skill with scrub nurse/tech/orderly + helping them with their tasks to make their day easier, minimizing all of my physical movements i.e. combining 3 tasks into one, making each task more efficient, & walking fast (built-in exercise 🙂 )

In general, I am ready to go in 7 minutes, but confounding factors are: room being clean, scrub techs prepping the instruments, need to change the OR bed for different procedures, consents, etc etc etc...

Been setting a timer for my daily tasks from breaks, lunch, procedures, changing in locker room...if I can be speedy in other areas, I find that I can improve my total efficiency.
 
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Hawaiian Bruin said:
For you guys out there in PP, can you describe your consenting process for those of us biding our time in the halls of academia? Are you doing the consents yourself prior to the blocks? Are they done in a preop clinic? It seems like in my quest to reduce my own turnover time, the rate limiting step is always the consent.
Click to expand...

Ortho surgeon comes out of the OR, consents pt for surgery. I drop my last pt off, go see the next pt. 5 minutes later preop and consent done (remember we're talking about generally healthy pts). Block and sedation already drawn up during last case, pt already hooked up to monitors by preop nursing staff. US @ bedside, I grab a couple of items from my block cart and the block goes in by minute 15. 5 more minutes for the circulator to say hi to the pt and take the pt into the room and you've got 20 minutes pt out to pt in
 
jetproppilot said:
Lovenox started the next morning after epidural DCed.

We do

combined spinal epidurals

in the pre op area..

15mg hyperbaric bupivicaine thru the spinal needle then catheter threaded,

foley immediately follows.

Doing the foley in the pre op area probably saves 5-10 minutes per case...

so with 5-6 back to back total joints

you're shaving 30-60 minutes off your day.
Click to expand...


same guy/gal doing everything? ie dropping last pt off, running to preop do CSE? or do you have a second (ie board runner) who drops the CSE for the next case? if so how do you divide the units?

i won't place a spinal in preop - this has been covered ad nauseum before, but a fresh spinal needs to be closely monitored, and we don't have the setup/staff for it... only in the OR for our current system.

sounds like you have a smoothly running machine there, on that day.
 
slavin said:
same guy/gal doing everything? ie dropping last pt off, running to preop do CSE? or do you have a second (ie board runner) who drops the CSE for the next case? if so how do you divide the units?

i won't place a spinal in preop - this has been covered ad nauseum before, but a fresh spinal needs to be closely monitored, and we don't have the setup/staff for it... only in the OR for our current system.
Click to expand...

That would be our problem as well. Once you start the spinal, that time is continuous until the patient goes to the PACU. That means someone has to stay with that patient and cannot be involved with (or bill for) any other patient. Do you have an anesthetist that stays with that patient and either moves with them or hands them off to an anesthetist in the OR? How do you handle the logistics of this?
 
jwk said:
That would be our problem as well. Once you start the spinal, that time is continuous until the patient goes to the PACU. That means someone has to stay with that patient and cannot be involved with (or bill for) any other patient. Do you have an anesthetist that stays with that patient and either moves with them or hands them off to an anesthetist in the OR? How do you handle the logistics of this?
Click to expand...

We bill

interrupted time.

We made a line on our billing sheet for it.

Say we have a 7am total knee.

My partner and I get there at 6am.

Pre op nurse has everything ready for us....IV started, everything is pulled and waiting for us... versed, spinal bupivicaine, CSE kit, gloves, etc.

I'll start the process of placement at say 0612. Placement occurs, tape it up, lay pt down, finish paperwork, etc etc. Say I finish everything at 0627.

We bill interrupted time of 0612-0627

then start rebilling when we hit the room, say at 0650.

Same concept for our ultrasound guided peripheral nerve blocks which are done prior to surgery as well.

Interrupted Time is well within industry standard.

DON'T LET BEAUROCRACY AFFECT EFFICIENCY.
 
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jetproppilot said:
We bill

interrupted time.

We made a line on our billing sheet for it.

Say we have a 7am total knee.

My partner and I get there at 6am.

Pre op nurse has everything ready for us....IV started, everything is pulled and waiting for us... versed, spinal bupivicaine, CSE kit, gloves, etc.

I'll start the process of placement at say 0612. Placement occurs, tape it up, lay pt down, finish paperwork, etc etc. Say I finish everything at 0627.

We bill interrupted time of 0612-0627

then start rebilling when we hit the room, say at 0650.

Same concept for our ultrasound guided peripheral nerve blocks which are done prior to surgery as well.

Interrupted Time is well within industry standard.

DON'T LET BEAUROCRACY AFFECT EFFICIENCY.
Click to expand...

Looks like you're there for 5-10 minutes after dosing doing your paperwork. I'm assuming someone else monitors the patient after you go elsewhere. Does a nurse sit with them, or is another anesthesiologist floating around?
 
pgg said:
Looks like you're there for 5-10 minutes after dosing doing your paperwork. I'm assuming someone else monitors the patient after you go elsewhere. Does a nurse sit with them, or is another anesthesiologist floating around?
Click to expand...

You say that with a

PUNITIVE TONE.

Like a Nurse Administrator.

Why is that?
 
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jetproppilot said:
You say that with a

PUNITIVE TONE.

Like a Nurse Administrator.

Why is that?
Click to expand...

Jet, get over it.

The efficiency of doing spinals in holding appeals to me. Since you said you billed interrupted care, I was curious how you had things set up to do so safely. We will occasionally place blocks or epidurals in holding for providers who are in rooms, but haven't done spinals, mainly because none of us are willing to trust the patients to our preop nurses, who are both very busy and unfortunately not always on the ball.

Your current gig sounds like an efficiency dream.

I wasn't implying that you were doing anything shady or unsafe. There was nothing accusatory or "punitive" (wtf?) in what I wrote. It was a simple question.
 
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Twice-daily dosing. This dosage regimen is associated with an increased risk of spinal hematoma. The first dose of LMWH should be administered no earlier than 24 hrs postoperatively, regardless of anesthetic technique, and only in the presence of adequate (surgical) hemostasis. Indwelling catheters should be removed before initiation of LMWH thromboprophylaxis. If a continuous technique is selected, the epidural catheter may be left indwelling overnight, but must be removed before the first dose of LMWH. Administration of LMWH should be delayed for 2 hrs after catheter removal.

ASRA 2010
http://www.asra.com/publications-anticoagulation-3rd-edition-2010.php
 
The last 2 hospitals where I have worked have had multiple wrong sided blocks, which get reported to the state. The corrective action plan includes the surgeon marking the site of surgery and a block time out with 2 anesthesia attending and a nurse. With these requirements there is no way regional speeds up the day as claimed by regional zealots.
 
I trained at the usual slow turnover academic place with many less than efficient staff. We had one attending who was not usually efficient but was great at regional and loved doing as much as possible. We had a block resident that would cover all of the regional stuff for the day. One nice trick I learned from this attending was a 3-for-1 regional trifecta for total knees. When the OR was almost ready (cleaned and tech's opening) we would place an U/S guided femoral catheter, turn pt. lateral, do a classic approach single shot sciatic followed immediately by a spinal and then roll straight to the OR. Great approach that saved time and impressed the orthopods. Seems like this would be feasible if you were doing everything yourself and had cooperative pre-op nursing staff that would have everything ready at the bedside after you dropped your last pt. off in PACU.
 
BUMP.

This is the kinda s h it that should be

RELEVANT here.

Not your match list.

You aspiring anesthesiologist ROKKSTARRS out there

DO YOU WANNA MAKE THIS SITE IMPORTANT?

Then make it,

UM KAY?

Jesus.
 
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jetproppilot said:
BUMP.

This is the kinda s h it that should be

RELEVANT here.

Not your match list.

You aspiring anesthesiologist ROKKSTARRS out there

DO YOU WANNA MAKE THIS SITE IMPORTANT?

Then make it,

UM KAY?

Jesus.
Click to expand...

Welcome back, post a case, or post in a clinical or anesthesia business thread. There are 5 or 6 on page 1 right now, and any one of them would've benefited from experienced opinions or information.
 
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Thanks pgg
but that's not the point.
The Point is that.....uhhhhh
there's noone
WALKING POINT
here.
Why is that?
This forum is current day like the
REPUBLICAN PARTY.
Stratified.
No navigational tools.
 
I see your 17 minutes and I'll raise you a 4 min spine turnover. Same circulator, scrub and anesthesiologist. Different room which was set up by different crew but the pt was interviewed and pushed back by the same team as the first case.
 
Noyac said:
I see your 17 minutes and I'll raise you a 4 min spine turnover. Same circulator, scrub and anesthesiologist. Different room which was set up by different crew but the pt was interviewed and pushed back by the same team as the first case.
Click to expand...


Can you guys tell me the names of these circulators? Had a 30 min turn over at a surgery center the other day. It was a shoulder, but come on. Guess who they blamed it on when the surgeon complained? Even with me pushing the pt to the or myself, and asking multiple times to bring the pt back. I did do a block that took three minutes and would have been happy to do this before hand but we have limited monitoring capability in the preop area at this place. Jet or noy, can I send you my cv?
 
dhb said:
:corny: :laugh:
I was actually thinking the same thing but it all depends on when you start counting: skin closed to skin opened or patient in to patient out...
Click to expand...

If you were

thinking the same thing

than you are another

LIAR.

Since there are....hmmmmm...about

Five

no that's an exaggeration......

There are about

Six

institutions in this country out of thousands that can

TURN OVER A TOTAL JOINT ROOM IN SEVENTEEN MINUTES.

Take your

snake oil

speech elsewhere,

Slim.
 
jetproppilot said:
There are about

Six

institutions in this country out of thousands that can

TURN OVER A TOTAL JOINT ROOM IN SEVENTEEN MINUTES.
Click to expand...

I think how you count the turnover time is relevant. One of our total joint rooms always have a out-of-room to in-room time of <15 minutes, with a CA1 no less. And the last thing I would associate with my institution is efficiency. Now the spinal in the room may take another 20 minutes, but who's counting. Turnover is easy if you got a separate team for the blocks.
 
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Patient out to patient in = turnover.

Our inpatient turnover needs to be less than 20 min. for us to get our bonus (which we are always in the gold) Outpatient is15 min. (also in the gold)

Spine, ortho and robot cases always take the longest... but 20 min. turnover is nearly always possible... although sometimes you have to light a firecracker under some less motivated players in the OR (very rare over here). $$$ incentives really motivates OR staff. It is the way to go to get the slugs moving.

4min... is insanely fast Noy. I'm not sure Flash could get it done any quicker. He must work for you guys. 😉

flash.jpg
 
Noyac said:
But like I said, different room with different team setup. Teh rest of the crew was the same.
Click to expand...

We get negative-minute turnovers 🙂 some days in the joint rooms, because each orthopod gets two rooms and two crews. His PA is closing the last layers in room A while Dr Orthomoneymaker strolls into room B where the patient is ready to be cut. When it's smooth, they operate continuously and literally won't sit down all day, and one guy can bang out 7 or 8 total joints by CRNA-relieving time.

Unfortunately, it seems just as often something gets in the way and the 2nd crew has 1-2 hours of idle time while they look under chairs for missing implants, or an emergent lap chole comes in stat from the ER and an irate general surgeon steals a room and crew ... and then that smooth and beautiful eight-banger total joint schedule ends up running really, really late.


Still quite the change from the total hips I did as a resident with tetracaine/epi combined spinal epidurals where sometimes the epidural would get dosed intraop ...
 
fakin' the funk said:
Really? Because the last time I checked, this site is still called the STUDENT Doctor Forums...not the Arrogant Doctor Forums.
Click to expand...

Ever since I've "known" you
which is quite a long time now,
you've always had a chip on your shoulder.
Which says a lot.
Not quite sure why you incessantly present yourself like you do.
I find you quite irritating.
I'll bet you hear that a lot.
That you're irritating.
 
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Cases at our ASC are scheduled to start 15min after the previous case rolls out, and it's usually not a problem. Resident or fellow will do the block in pre-op, you just have to pick them up, wheel them back, start the prop and abx.

Even at the big house, the ortho rooms routinely have 20min turnover times, though again with a dedicated block resident (and you have to push the OR staff a little more because I believe there are less incentives).

Just in general, delays at my institution rarely seem to be anesthesia-driven, and if it is, it's usually for educational reasons. That extra 15 min to let a resident do X, Y, or Z is a fraction of the time they'll let the surgery resident dick around lysing adhesions or closing the fascia.
 
Hey buddy,

17 minutes is fine for a solo doc with the EXACT same OR crew and housekeeping each case. It's actually pretty average. But it's not ideal. Otherwise, if you have a separate OR team and anesthesia crew, it's actually pretty terrible because an orthopod should be able to scrub out and (having signed and marked the site beforehand) then be able to immediately roll into his next room and start cutting. This is nothing special or unique among places where we flip orthopods.

Long story short, good for you! Keep motivating the youngsters and talkin nonsense about bein a "ROKKSTAR". But i wouldn't be braggin about it on an anonymous forum bc it ain't **** son.

Peace.
 
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