“Moving smoothly through the list” Maximising Operating Room Efficiency “Moving smoothly through the list” prepared by: Glenn Powers

Overview The importance of anaesthesia onset/offset Improving OR efficiency Time saving measures Overlapping induction Conscious monitoring Quick drugs Discussion points References Introducing the importance of the anaesthetist role in the operation of an efficient OR.

Importance of Anaesthesia Offset Increased patient demand for surgery and growing elective surgery lists are increasing the pressure for increased patient throughput in hospital Operating Theatres Anaethestists are therefore under every increasing pressure to optimize recovery times, decrease the incidence of post-operative complications and improve patient satisfaction with anaethesia care. Due to the high cost of the operating unit of a hospital also contributes to he need to optimization patient throughput. The speed of the induction of and recovery time from anaesthesia has been studied in an attempt to find measures to optimise the efficiency of the operating theatre. Introducing the importance of the anaesthetist role in the operation of an efficient OR.

Improving OR Efficiency Anaesthesiologists can substantially contribute to the efficient functioning of an operating theatre by calling for the next patient at the appropriate time and inducing anaesthesia in a timely fashion. Improving productivity involves reducing unnecessary delay and the effective deployment of high cost staff. Many delays are out of the anaesthetist’s control. These include that: Patients arrive late Patients are unprepared, (they eat or drank), Transportation delays, System issues e.g. equipment availability, staff allocation issues Over-viewing the basic areas that are under the control of the anaesthetist and those that are out of their hands

Time Saving Measures Many processes can be optimised to reduce the time a patient spends in the OR. Some of the most important are: Intubation time Turnover time Recovery from anaesthesia Numerous studies have been conducted to provide techniques to increase the efficiency of the OR such as: Overlapping Induction (OI). Bispectral Index (BSI). Fast acting, non-accumulating drugs. A basic overview of the main factors that can influence the time a patient spends in the OR that are a result of the practice of the anaesthetist. This slide introduces the three major factors that will be the focus of this presentation and expanded on in the subsequent slides.

Overlapping Induction (OI) Overlapping induction (OI) of anaesthesia is done by inducing anaesthesia in one patient with an additional team while the previous patient is still in the operating room. The study was conducted over 3 operating theatres. Patients are anaesthetised in an induction area and not the OR. A pre-anaesthesia and a PACU room is used so patients do not emerge from anaesthesia in the operating room. This slide details the study where overlapping Induction was used to increase patient turnover. It informs the anaesthetist of a technique that can be employed to reduce the time a patient spends in the OR.

Benefits of OI Using overlapping induction 33 more cases were performed over a 60 day study than when using conventional processes. 1.1 additional cases were performed each day, increasing cases from 151 using conventional processes to 184 when using OI. On average non-surgical time decreased from 68mins to 57mins and turnover time decreased from 38mins to 25mins. The benefits of OI are explained to get the anaesthetist thinking of how their procedures compare to OI and if it would be worth investigation the technique for implementation in their OR’s.

Conscious Monitoring Every 1000 anaesthetics given produce 1-2 cases of awareness. Strategies to avoid psychological injury have now been well described. Consequently the ASA (US) has recently recommended that anaesthetists use a combination of clinical signs, conventional cardiovascular and respiratory monitoring as well as brain function monitoring (on a case by case basis) to reduce the incidence of awareness (downloaded from www.asahq.org 30 April 2006). Electroencephalogram monitoring is a valuable method to determine the depth of anaesthesia. Conscious sedation relies on subjective clinical assessment and is often unreliable. Electroencephalogram monitoring provides a reliable indication of anaethetic depth.

Bispectral Index Monitoring Bispectral Index (BSI) guided anaesthesia has been thoroughly investigated as a possible time saving method to reduce the recovery time from anaesthesia(1,2) . Bispectral index (BIS) monitoring allows lower doses of midazolam and lower target concentrations of propofol. Thus avoiding excessively deep anaesthesia and leading to faster recovery time (2). Bispectral index titrated anaesthesia led to a significant reduction in the anesthetic requirement. It seems that BSI is a common practice and this slide gives an overview of its benefits for those who may not be familiar with the technique.

Benefits of BIS The anesthetic-sparing effect of cerebral monitoring resulted in a shorter PACU stay and improved quality of recovery from the patient’s perspective (2). Time to eye-opening and PACU discharge time reduced for BSI monitoring (2). BSI monitoring in conscious sedation is a valuable tool and can be used to augment clinical assesment (1). The benefits of BSI are explained so that any OR not using this technique can see the benefits and may be prompted to investigate the worth of this system.

Anaesthetic Drug Choice The choice of anaesthetics can have a significant effect on the quality of and recovery time from anaesthesia as well as the reduction of unwanted side effects. Here two drug regimes have been detailed. Midazolam vs Remifentanil Desflurane vs sevoflurane This information should get the audience thinking about what drugs they use for anaesthesia and whether alternate drugs may be more efficient. It just highlights that there are options avaliable.

Remifentanil and Fentanyl Patients receiving remifentanil required 33% less propofol to achieve loss of eyelash reflex and needed infusion rate of 46µg/kg/min vs 131µg/kg/min in control group. Time to eye opening was reduce from 10mins to 4mins using remifentanil and the deviation was reduced from +/- 6mins to +/- 3mins for better prediction of waking time. Recovery of protective reflexes and motor function was reduced from 13mins to 6mins and intermediate recovery based on PADSS was reduced from 19mins to 11mins. This information should get the audience thinking about what drugs they use for anaesthesia and whether alternate drugs may be more efficient. It just highlights that there are options avaliable.

Desflurane vs Sevoflurane A study on early recovery times of elderly patients undergoing a wide range of surgical procedures requiring two or more hours of anaesthesia is significantly faster after desflurane. The average times to extubation for desflurane vs sevoflurane was 5mins vs 9min, time to eye opening 5mins vs 11mins, to squeezing fingers on command 7mins vs 12mins and orientation 7mins vs 16mins. Intermediate recovery, as measured by the DSST and time to ready for discharge from the PACU was on average 56mins for desflurane and 71mins for sevoflurane. Again a drug comparison to enforce that alternate drugs are avaliable and may be utilised.

Conclusions Bispectral Index (BIS) is a commonly used technique to monitor anaesthetic depth and leads to a reduction in the anaesthetic requirement and recovery time of patients. Overlapping Induction (OI) shows promising results but would take substantial organisation and co-operation between staff and administration. The time-saving impact of several drugs has been studied and the correct choice of anaesthetic drugs can substantially reduce recovery times and reduce consumption. A summary of the major points to reiterate the importance of many areas on patient recovery.

Questions to Discuss Can anaesthetists really make a difference in improving OR efficiency? Can you see other additional opportunities where anaesthetists can make a difference? What are the barriers preventing anaesthetists from improving theatre efficiency? Of the strategies included in this presentation, what do you see as the pros and cons of each? If you were to choose just one change to make in your practice from the suggestions made, which would you choose? Why? Would these strategies increase or decrease your current workload? If so, in what ways would they change your workload? What kinds of medical/anaesthetic/organisational issues would you need to address if you were going to adopt one or more of these strategies? If you were going to adopt a strategy to improve efficiency, who would you need to tell and what would you say to ensure it worked?

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