1. The “Swing-Room" Experience: Productivity Improvements in Elective Hand and Upper Extremity Surgery at St. Paul’s Hospital. Dr. Thomas Goetz, MD, FRCSC Clinical Assistant Professor, UBC

2. Disclosure No industry conflicts with this presentation.

3. “Swing-Room” Concept Implementation Opened January 31, 2008 –1 st two years of operations Funded by the Lower Mainland Innovation and Integration Fund (LMIIF) –3 rd year Funded by Procedural Care Funding PATIENT FOCUSSED FUNDING

4. The SPR – “Swing-Rooms”

6. Goals of the “Swing-Room” Improve Quality of Care –Safer environment than minor procedure room –Expand scope of SPR outside of main OR –Decant main OR –Decreased post-op recovery time and post- op pain Reduce Wait Times Cost Savings or Increased Efficiencies

7. Current Study – Look at performance of swing rooms Retrospective audit of data gathered from office and operating room data collected at our institution (St. Paul’s Hospital). Analysis of: –O.R. Operations Management Efficiencies: Surgeon utilization Surgical turnover time Throughput –Operating room costs Total and costs/case –Hand and Upper Extremity Waitlist Reduction

8. Our Data Set Data collected from one SPH Hand and Upper Extremity surgeon Pre-SPR –Feb. 2007 – Jan. 2009 (2 years) 657 patients over 207 O.R. days Post-SPR system –Feb. 2009 – Oct. 2011 (21 months) 962 patients over 243 O. R. days –“Swing-Room” Patients »320 patients over 46 O.R. days –Main O.R. Patients »642 patients over 197 O.R. days

9. Data Available –O.R. Times Scheduled Pre-op Setup Anesthesia Surgeon Cleanup PACU –Office Times Date of Consultation Decision Date Patient age, gender Logged Procedure Codes Times (start and end times)

10. Results Operations Management

11. Surgeon Utilization

12. Surgical Turnover Time Before the “Swing-Room” Main O.R.53m:25s After the “Swing-Room” Main O.R.45m:54s “Swing-Room”10m:44s Increased Regional Blocks?

13. Throughput Before the “Swing-Room” Main O.R.3 Cases/Day After the “Swing-Room” Main O.R.3 Cases/Day “Swing-Room”7 Cases/Day

14. Total Cases per Year ( assuming 1.5 OR days/week) 28% Increase in case throughput = 86 Additional Cases

15. Results Surgical Costs

16. O.R. Variable Cost Differences/Day Main O.R.“Swing-Room Cost of Labour RNs @ 7.5 h/d @ $33/h + 18% relief & 22% benefits= 6 RNs 0.5 PWA 0.5 AA $2,245.50 4 RNs 0.5 PWA 0.5 AA $1732.50 Cost of Supplies (Differences in anesthetic costs, surgical sets and surgeon preference cards) Supplies @ $155/case 3 cases/day $465 Supplies @ $90/case 7 cases/day $630 Total Variable Cost/Day $2710.50$2362.50

17. Variable Cost/Case Main O.R.“Swing-Room” Total Variable Cost/Day $2710.50$2362.50 Cases per Day37 Variable Cost per Case $903.50$337.50 63% Variable Cost Savings per Case

18. Results Waitlists

19. Waitlist Reduction – H & UE Prior to “Swing-Room” –Elective wait-times ~36 weeks (range 21- 44 weeks) Based on difference between surgical decision date and O.R. booking date After “Swing-Room” –Elective Wait-times ~7 weeks (range 6-10)

20. Simple Waitlist Model Assume 1.5 O.R. days/week. –4 Main O.R. days/month 3 cases/day –2 Swing-Room days/month 7 cases/day Assume 5 new patients booked per week for surgery. Assume patients are interchangeable between O.R. settings.

21. Waitlist Change over 1 year (starting with 144 on waitlist) At 1 Year: 170 patients At 1 Year: 68 patients

22. Conclusion The use of a “Swing-Room” concept can improve OR room productivity and efficiency while decreasing costs/case. Implementation of a “Swing-Room” concept can be used to decrease waitlists. –Shows how patient focused funding can be used in a government funded hospital to radically decrease waitlists.

23. Questions ?

24. Anesthesia Study A Study of General Anesthesia and Brachial Plexus Block for Outpatient Upper Limb Surgery Dr. Seib, Dr. Head, Dr. Schwarz

25. “Swing-Room” Background In 2008, the Providence Health Care Health Authority obtained government funding  Capital Payback Fund Funding used to: 1.Expand the surgical outpatient department 2.Build a “swing-room” operating theatre system. Two (2) side by side procedure rooms Perform surgeries under regional anesthetic blocks which could not otherwise occur outside of the main OR under local anesthetic.

26. How Much Funding?

27. Typical Orthopaedic Hand and Wrist O.R. Slate 1.Osteotomy left small metacarpal with possible joint release (30mins) 2.Left wrist scapho-trapezium-trapezoid fusion (90mins) 3.Left wrist arthroscopy with debridement (45mins) 4.Ulnar shortening osteotomy of left wrist for distal radius malunion (45mins) 5.Left EIP TO EPL transfer (60mins) 6.Resection soft issue mass dorsum left wrist (60 mins) 7.Right proximal row carpectomy possible scaphoidectomy and 4 corner partial wrist fusion (90mins)

28. Operations Management - Definitions –OR Utilization % time that OR room occupied with nursing/physician activity –High percentage utilization reflects decreased room idle time –Surgeon Utilization % time that surgeon is in O.R. room doing surgery Excludes surgeon set-up time (time not recorded) –Generated from case start and end times –Analysis of Surgical Turnover Time Time between the surgical end of a case to the surgical start of the next case –Throughput Case output per day

29. O.R. Utilization Extra Reserve Capacity from 2 Room System

30. Waitlist Change over 1 Year

31. The SPR – “Swing-Rooms”

32. Surgical Turnover Time Before the “Swing-Room” Main O.R.53m:25s After the “Swing-Room” Main O.R.45m:54s “Swing-Room”10m:44s Negative Turnover Time

33. Upper Extremity Wait Times Prior to the inception of the swing room, wait times for elective upper extremity surgery were slowly increasing over time. By January 2009, –Wait time to surgery ~211 days Calculated from booking date to date of surgery

35. Forecasting (Pre-Swing Room) Extrapolating this increasing trend line –Wait times would be estimated to increase to ~250 days by December 2011

36. 250 Days

37. Waitlists After “Swing-Room” Increased case output in the “Swing-Room” -> caused direct decreases in the senior author’s waitlist (for “Swing-Room” eligible cases).

39. Ripple Effects in the Main O.R. Implementation of the “Swing-Room” -> Caused off-loading of the Main O.R. As a result, –Wait times for cases not suitable for the “Swing-Room” that had to be done in the Main O.R. also decreased.