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11
High Performing
Operating Rooms
Robert B. Zann MD
FACS
22
EFFICIENCYEFFICIENCY
HIGH PERFORMING ORHIGH PERFORMING OR
TEAM APPROACHTEAM APPROACH
33
Office ReimbursementOffice Reimbursement
DescriptionDescription PatientsPatients MedicareMedicare TotalTotalSurgerySurgeryTotal Hip Arthroplasty MDTotal Hip Arthroplasty MD 1 1 $1486.73 $1486.73
Total Knee Arthroplasty MDTotal Knee Arthroplasty MD 1 1 $1605.67 $1605.67
Office Visits 5Pt’s/hrOffice Visits 5Pt’s/hrEst. Patient Level 3 Est. Patient Level 3 3 3 $53.16 $53.16 $159.48 $159.48New Patient Level 4 New Patient Level 4 2 2 $139.70 $139.70 $279.40
X-RaysX-RaysPelvis, 2 views 2 $60.20 $120.40Knee, 2 views 3 $60.20 $180.60
$739.88/hr
44
DRG 544DRG 544Major Joint Replacement or Major Joint Replacement or
ReattachmentReattachment• DRG Reimbursement- $11,000.00DRG Reimbursement- $11,000.00
• OR ChargesOR Charges– 1 Hour $4,125.001 Hour $4,125.00
•every minute thereafter $40.00every minute thereafter $40.00– Supplies that are built in to the First hour cost are:Supplies that are built in to the First hour cost are:
Room EquipmentRoom Equipment FTE’sFTE’s Custom PacksCustom Packs Dressing, Suction, Bovie, extra gownsDressing, Suction, Bovie, extra gowns
55
• Incremental Charges #315.00Incremental Charges #315.00– Items such as:Items such as:
• CementCement
• Cement Mixing SuppliesCement Mixing Supplies
• Irrigation suppliesIrrigation supplies
• Kamvac suctionKamvac suction
• StaplerStapler
• Extra Charges Extra Charges – Stryker Pain Pumps $200.00Stryker Pain Pumps $200.00– Intra Articular Injection $450.00Intra Articular Injection $450.00– Implant Cost $ ??Implant Cost $ ??– Platelet Rich Plasma Spray $ 408.00Platelet Rich Plasma Spray $ 408.00
66
• ACU ChargesACU Charges– Per hour $ 478.50Per hour $ 478.50
• PACU PACU – First Half Hour $ 959.00First Half Hour $ 959.00– Every minute thereafter $ 12.50Every minute thereafter $ 12.50
• Room RatesRoom Rates– Private vs Semi-Private $$$Private vs Semi-Private $$$
77
TEAM APPROACHTEAM APPROACH
•Surgical TeamSurgical Team– M.D., P.A., R.N., Surgical CoordinatorM.D., P.A., R.N., Surgical Coordinator
•ANESTHESIAANESTHESIA– MD, CRNAMD, CRNA
•OR PERSONNELOR PERSONNEL– Orthopedic OR CoordinatorOrthopedic OR Coordinator
•Stryker RepresentativeStryker Representative
88
PRE-OPPRE-OP
• Surgical TeamSurgical Team•Pre-op rounds (one week pre-op)Pre-op rounds (one week pre-op)
– H&P, Pre-op Orders - MD, & PAH&P, Pre-op Orders - MD, & PA– X-ray rounds – entire teamX-ray rounds – entire team– Pre-op Labs- Medical ClearancePre-op Labs- Medical Clearance– Post-op Orders- Preliminary CompletionPost-op Orders- Preliminary Completion– Post-op note- Preliminary CompletionPost-op note- Preliminary Completion– Pre-Op HoldingPre-Op Holding
Consent and H&P signedConsent and H&P signedInitial correct site on patientInitial correct site on patient
99
Pre-operative x-ray rounds (1 week prior to surgery)
1010
• AnesthesiaAnesthesia•Pre-op consultationPre-op consultation
Optimal 24-48 hours pre-opOptimal 24-48 hours pre-op
•Regional Anesthesia Administration in Pre-Op Regional Anesthesia Administration in Pre-Op holding areaholding area
• OR PersonnelOR Personnel•Confirmation of Patient, Procedure & SiteConfirmation of Patient, Procedure & Site
•Confirmation of ConsentConfirmation of Consent
•Confirmation of LabsConfirmation of Labs
1111
• Stryker RepresentativeStryker Representative
•Pre-operative templatingPre-operative templating
•Proper InstrumentationProper Instrumentation
•Multiple instrument setsMultiple instrument sets
•Turn over instrumentation as neededTurn over instrumentation as needed
•Correct ProsthesisCorrect Prosthesis
•Assist in room turnoverAssist in room turnover
1212
• PRE-OP ORDERS: KNEE (Dr. Robert Zann #339)
• DIAGNOSIS• REGULAR DIET• LAB WORK DONE AS OUTPATIENT BY Dr.
Results to O.R.• CHEST X-RAY• EKG• CBC, SMA 12, LYTES, PLATELET COUNT• ADDITIONAL LABS: PT, PTT• MEDICAL / CARDIAC CLEARANCE BY DR.• CLEAN CATCH U/A• TYPE AND SCREEN
UNITSBLOOD
• BILATERAL BK AE HOSE
• RESERVE CPM MACHINE• RESERVE ELECTRIC COOL• NPO AFTER MIDNIGHT FOR SURGERY IN AM• CONSENT FOR TOTAL KNEE ARTHROPLASTY• START IV IN OPPOSITE UPPER EXTREMITY AS
OPERATIVE KNEE• WITH 18 GA INTERCATH R/L @ __________cc/hr• PRE-OP ANTIBIOTIC: TO BE GIVEN PER O.R.
PROTOCOL• ADDITIONAL
AGENT:_______________________________________• CELEBREX 200mg 1 PO 1 HOUR PRIOR TO SURGERY
UNLESS ALLERGIC • TO SULFA OR SULFONAMIDES
• M.D. Signature _____________________ M.D. # 339
• PRE-OP ORDERS: HIP (Dr. Robert Zann #339)
• DIAGNOSIS• REGULAR DIET• LAB WORK DONE AS OUTPATIENT BY Dr.
Results to O.R.• CHEST X-RAY• EKG• CBC, SMA 12, LYTES, PLATELET COUNT• ADDITIONAL LABS: PT, PTT• MEDICAL / CARDIAC CLEARANCE BY DR.• CLEAN CATCH U/A• TYPE AND SCREEN
UNITSBLOOD
• BILATERAL BK AE HOSE
• NPO AFTER MIDNIGHT FOR SURGERY IN AM• CONSENT FOR TOTAL HIP ARTHROPLASTY• START IV IN OPPOSITE UPPER EXTREMITY AS
OPERATIVE HIP• WITH 18 GA INTERCATH R/L @ __________cc/hr• PRE-OP ANTIBIOTIC: TO BE GIVEN PER O.R.
PROTOCOL• ADDITIONAL
AGENT:_______________________________________• CELEBREX 200mg 1 PO 1 HOUR PRIOR TO SURGERY
UNLESS ALLERGIC• TO SULFA OR SULFONAMIDES
• M.D. Signature ____________________ M.D. # 339
Pre-op Orders
1313
Post-op OrdersDr. Robert Zann
#339) Pg. 1 of 4
1. Vital Signs: Q 4 hours
2. Diet as tolerated • Reg •
3. IV: D5 LR at 75 cc/hr until tolerating po fluids, then MAP
4. X-Rays in PACU •Knee portable A/P and Lateral (long Cassette) • R
• L •Hips portable A/P and Pelvis - see tip of prosthesis • R •
L
5. LABORATORY •H & H, BMP in PACU, H & H QAM x 3
If Hb is less than or equal to 8 grams, transfuse 1 unit Blood(Autologous if available), repeat H/H post
transfusion •If Potassium is below 3.5 in PACU, add 40 meq. to first IV
liter •Creatinine with calculated clearance in PACU and Daily
notify M.D. if less than 30ml/min
6. If Temperature > 102o, get urine culture & blood cultures
x 2, then notify physician
7. If Temperature > 101o, give Tylenol as ordered & ecourage incentive spirometer
8. Incentive Spirometry Q1H while awake
9. Bilat. BK A-E hose for hips; contralateral for knees
10. Physical Therapy: OOB TODAY; • Crutches • Walker
11. Weight bearing: • Full • Partial • Toe Touch
12. Foley catheter PRN - If used, • discontinue Post-op Day #1, or • Discontinue after the epidural catheter is
discontinued
M.D. Signature __________________________ M.D. # 339
( Dr. Robert Zann #339) Pg. 2 of 4
13. Remove Hemovac in A.M. Post-op Day # 1
14. Start daily dressing changes Post-op Day # 1 - Adaptic and 4x4’s
15. Neurovascular checks to lower extremities every 2 hours for 24 hours, then every 4 hours for 24 hours
16. Dress in regular clothes starting PO day #1
17. MEDICATIONS: •Pre-op Meds per Medical Dr. Consultant •TYLENOL 650mg. P.O. Q4H PRN Temp. > 101 F •FEOSOL 325 ONE P.O. daily •AMBIEN 5mg. P.O. nightly prn sleep, may repeat x 1 •DARVOCET N-100 1 TAB P.O. Q4H prn mild pain •PERCOCET 5/325 1 TAB P.O. Q4H prn mild to moderate
pain •PERCOCET 5/325 2 TABS P.O. Q4H prn moderate pain •MORPHINE SULFATE _____________ Q4H prn severe pain •CELECOXIB (Celebrex) 200mg 1 orally daily •COLACE One P.O. Daily until B.M., then discontinue •LAX of choice •ZOFRAN 4mg I.V. or P.O. Q6H prn for nausea •ANTACID of choice 30cc orally every 4 hours as needed •REGLAN 10mg IV IVP every 8 hours x 48 hours •OXYCONTIN 20mg orally every 12 hours
M.D. Signature _________________________ M.D. # 339
1414
(Dr. Robert Zann #339) Pg. 3 of 4
18. POST OP-ANTIBIOTICS:•Cefazolin 1gm intravenously every 8 hours for 3 doses (24 hours)•Clindamycin 600mg intravenously every 8 hours for 3 doses (24 hours)•Vancomycin 1 gm intravenously every 12 hours for 2 doses (24 hours)•Other
19. Coumadin Per Protocol After Daily Pro Time ( ) Yes ( ) NoPT & PTT DAILY, ( ) YES ( ) NO START: ______________ 10mg P.O. first dose Date:_______________ Time:_______________then daily thereafter according to Scale / INR as follows:> 2.0 = No Coumadin1.51 - 2.0 sec = 2.5mg.1.21 - 1.5 sec = 5mg.< 1.2 = 7.5mg.If NO, list directive:
20. • ARIXTRA 2.5mg. subcutaneous q 24 hours, - • Start @ PM
21. • Lovenox 40mg subcutaneous q 24 hours, - • Start @ AM
22. • PCA Pump - discontinue POD #1 – for break through pain,Toradol 15mg I.V. Q6H prn x 24 hours
23. • Epidural Catheter - when discontinued – for break through pain,Toradol 15mg I.V. Q6H prn x 4 doses within 24 hours, then discontinue
M.D. Signature _________________________ M.D. # 339
POST-OP ORDERS: HIP/KNEE (Dr. Robert Zann #339) Pg. 4 of 4
24.• TOTAL HIP OR KNEE CARE PLAN
•TOTAL KNEE CAREA. Apply Cool Ice Machine at 50oB. CPM Machine for Total Knees; Range: 0-45 3 hours BID Increase 5-20 daily
START: Post–op Day #2C. Knee patients OOB after surgery and Flex Knees 900 as toleratedD. Knee Immobilizer for comfort and quadricep weakness
• TOTAL HIP CAREA. Hip dislocation precautions and exerciseB. Special instructions for deviation from protocol:
25. CONSULTS:A. Medical Dr. __________________________B. Rehabilation FacilityC. Social ServiceD. Occupational Therapy - if patient is being discharged home E. Radiation Oncology Prophylatic Radiation Therapy ( )Yes ( )No
26. HOME HEALTH CARE:• COMMUNITY HOME HEALTH • MED-TECH
M.D. Signature _____________________ M.D. # 339
Post-Operative Orders
1515
POST-OPERATIVE NOTE: (Dr. Robert Zann #xxx)
#Name of Operating Surgeon: Dr. Zann
Name of Assistants:Tolson/ Veech / Fenton / Huffman
Findings- Osteoarthritis Left HipPre-op Diagnosis- Osteoarthritis Left HipPost-op Diagnosis- sameTechnical Procedures Used- Left Total Hip Arthroplasty
Implants:Femur-Head-Acet-Insert-
AnesthesiaBlood Loss ccDrains one medium hemovacSpecimens removed Left femoral headComplicationsComments Intra- Articular Injection
“ Incision
M.D. Signature ____________________ M.D.# xxx
POST-OPERATIVE NOTE: (Dr. Robert Zann #xxx)
#Name of Operating Surgeon: Dr. Zann
Name of Assistants:Tolson/ Veech / Fenton / Huffman
Findings- Osteoarthritis Left KneePre-op Diagnosis-Osteoarthritis Left KneePost-op Diagnosis- sameTechnical Procedures Used- Left Total Knee
Arthroplasty
Implants:Femur- #Tibia- #Tibial insert- # / mmPatella- mm cemented
AnesthesiaBlood Loss ccDrains one medium hemovacSpecimens removed- distal femur, and proximal tibial and
patella
ComplicationsComments Intra- Articular Injection
M.D. Signature ____________________ M.D.# xxx
1616
COMPUTER DATACOMPUTER DATA
–Average Time for Pre-Op Nursing Average Time for Pre-Op Nursing Assessment Assessment and preparationand preparation–Average Time for Administration of Average Time for Administration of AnesthesiaAnesthesia–Average Time for Operating Room Average Time for Operating Room PreparationPreparation–Average Surgical TimeAverage Surgical Time
–Surgical Turnover TimeSurgical Turnover Time•Last Staple insertion to next case skin Last Staple insertion to next case skin incisionincision
–Operating Room Turnover TimeOperating Room Turnover Time•Patient out of room to next patient in roomPatient out of room to next patient in room
1717
Turnover Time IssuesTurnover Time Issues• Surgical Turnover Time
– Defining Turnover Time- Last Staple to Incision• Hospital Turnover Time
– Patient exiting room and next patient entering room
• Ways to alleviate or decrease the turnover timeWays to alleviate or decrease the turnover time– Anesthesia- Pre-op holding Area vs In roomAnesthesia- Pre-op holding Area vs In room
• Anesthesia Administered in Prep-op HoldingAnesthesia Administered in Prep-op Holding– Patient in room and positioned immediately- no delaysPatient in room and positioned immediately- no delays
• Anesthesia Administered in the ORAnesthesia Administered in the OR– 20 min for Hip20 min for Hip– 30 min for Knees30 min for Knees
Additional Time to the turnover $$$$Additional Time to the turnover $$$$
• Turnover Time : Hospital Turnover Time : Hospital SurgicalSurgical– One Room/no Pre-opOne Room/no Pre-op 20 min20 min 1 hr 1 hr– One Room/Pre-opOne Room/Pre-op 20 min20 min 45 min 45 min– Two Rooms/no Pre-op -20 min(Two Rooms/no Pre-op -20 min(ptpt already inalready in 22ndnd room room) ) 10-15 10-15
min min – Two Rooms/Pre-opTwo Rooms/Pre-op -30 min( -30 min(pt. already in 2pt. already in 2ndnd room room)) 5-10 min 5-10 min
1818
My Average Operating TimeMy Average Operating Time
• Patient enters room to Patient enters room to Patient exiting room Patient exiting room
– Total Hip 57 minTotal Hip 57 min– Total Knee 70 minTotal Knee 70 min– Bilateral Knees 120 min Bilateral Knees 120 min
• Time from Incision to Wound Closure Time from Incision to Wound Closure
– Total Hip 34.5 minTotal Hip 34.5 min– Total Knee 49.9 minTotal Knee 49.9 min– Bilateral Knee 96.5 minBilateral Knee 96.5 min
1919
1:00
Hip 7:30 1 3 4 5 6
Knee 9:00 1 3 3 4 5 6
Hip 10:30 1 4 3 4 5 6
Knee 12:00 1 3 4 5 6
1 Admission to Pre-op
2 Pre-op holding Regional AnesthesiaTotal Knee- Femoral/Sciatic Nerve Block with catheter & SpinalTotal Hip- Spinal
3 Admission to Operating Suite
4 Incision
5 Case Completed
6 Transferred to PACU
10:30am 11:00am 11:30am 12:00pm 1:30pm6:30am 7:00am 7:30am 8:00am 8:30am 9:00am 9:30am 10:00am 12:30pm
One Room Efficiency Model with no Pre-op Holding Area
Huffman-Zann Timeline
2020
Hip 7:30 1 3 4 5 6
Knee 9:00 1 2 3 4 5 6
Hip 10:00 1 2 3 4 5 6
Knee 11:00 1 2 3 4 5 6
1 Admission to Pre-op
2 Pre-op holding Regional AnesthesiaTotal Knee- Femoral/Sciatic Nerve Block with catheter & SpinalTotal Hip- Spinal
3 Admission to Operating Suite
4 Incision
5 Case Completed
6 Transferred to PACU
6:30am 7:00am 7:30am 8:00am 8:30am 9:00am 9:30am 10:00am 12:30pm 1:00pm10:30am 11:00am 11:30am 12:00pm
One Room Efficiency Model with a Pre-op Holding Area
Huffman-Zann Timeline
2121
Hip 7:30 1 3 4 5 6
Knee 8:30 1 3 4 5 6
Hip 9:30 1 3 4 5 6
Knee 10:30 1 3 4 5 6
Hip 11:30 1 3 4 5 6
1 Admission to Pre-op
2 Pre-op holding Regional AnesthesiaTotal Knee- Femoral/Sciatic Nerve Block with catheter & SpinalTotal Hip- Spinal
3 Admission to Operating Suite
4 Incision
5 Case Completed
6 Transferred to PACU
Huffman-Zann Timeline
6:30am 7:00am 7:30am 8:00am 8:30am 9:00am 9:30am 10:00am 12:30pm 1:00pm10:30am 11:00am 11:30am 12:00pm
Two Room Efficiency Model with no Pre-op Holding Area
2222
Hip 7:30 1 3 4 5 6
Knee 8:30 1 2 3 4 5 6
Hip 9:30 1 2 3 4 5 6
Knee 10:00 1 2 3 4 5 6
Hip 10:30 1 2 3 4 5 6
1 Admission to Pre-op
2 Pre-op holding Regional AnesthesiaTotal Knee- Femoral/Sciatic Nerve Block with catheter & SpinalTotal Hip- Spinal
3 Admission to Operating Suite
4 Incision
5 Case Completed
6 Transferred to PACU
6:30am 7:00am 7:30am 8:00am 8:30am 9:00am 9:30am 10:00am 12:30pm10:30am 11:00am 11:30am 12:00pm
Two Room Efficiency Model with a Pre-op Holding Area
Huffman-Zann Timeline
2323
Greeting patients in Pre-Op Admission @ 7:00am
Confirming laboratory results and signing operative consent
2424
1st Case Total Hip Arthroplasty in room @ 7:30am
2525
2nd Case- Total Knee Arthroplasty room setup @ 7:30am
2nd Case- TKA patient receiving Femoral Nerve Block w/catheter @ 7:30am
2626
1st Case THA started @ 7:50am
2727
1st Case instruments removed
Prior to completion of procedure
2828
Immediate operative dictation
2929
Completion of operative note and post-op orders
3030
2nd Case-TKA in room @ 8:00am
3131
Post-operative discussion with family
3232
2nd case completed @ 9:15 am
2nd room cleaned by 9:25am
3333
2nd Case closing-completed @ 9:15
am
3rd Case in room @ 9:00am
3434
Case 3 following patient confirmation, correct side confirmation
And preliminary completion of post-operative orders
3535
ConclusionsConclusionsThe most efficient is two rooms with a pre-op holding areaThe most efficient is two rooms with a pre-op holding areaThe least efficient is one room without pre-op holdingThe least efficient is one room without pre-op holdingReduction in Turnover Time (surgical turnover time!)Reduction in Turnover Time (surgical turnover time!)
– Early Admission for Same-Day Lab Work,Early Admission for Same-Day Lab Work,• i.e. PT/PTT, Bleeding time, Platelet count, EKG, etc..i.e. PT/PTT, Bleeding time, Platelet count, EKG, etc..
– Pre-op Anesthesia Evaluation-24-48 hrs prior to Pre-op Anesthesia Evaluation-24-48 hrs prior to admissionadmission
– First Case with shortest time for Anestetic AdministrationFirst Case with shortest time for Anestetic Administration• i.e. THA rather that TKAi.e. THA rather that TKA
– Use of Pre printed templates (orders, post-op notes)Use of Pre printed templates (orders, post-op notes)– Immediate Post operative dictationImmediate Post operative dictation– Clearance of all instruments and trial component during Clearance of all instruments and trial component during
wound closurewound closure– Availability of Multiple instrument setsAvailability of Multiple instrument sets– Cooperation of OR personnel to initiate room cleaning as Cooperation of OR personnel to initiate room cleaning as
patient is transported from roompatient is transported from room
3636
Thank You!