John Di Capua, MD, is deputy CEO and chief medical officer of North American Partners in Anesthesia Corp.; vice president of anesthesia services of North Shore-Long Island Jewish Health System; and chairman and the Peter Walker Professor of Anesthesiology in the department of anesthesiology of Hofstra University-North Shore LIJ School of Medicine.
Q: Is there currently a standard amount of time that hospitals should target for the time one patient is wheeled out and the time the next surgery is ready to begin?
Dr. John Di Capua: While the data for a specific benchmark time is published, it depends highly on the type of surgery you're doing. Universally, in my experience, throughout all of the hospitals I've ever consulted on or that we've managed, there's always room for improvement in turnover time. It's been a problem that's plagued perioperative services for quite some time.
Q: What are your recommendations to improve turnover time (besides ensuring the surgeon is present and prepared on time)?
JD: To do it well and to have an impact on turnover time you need to have, first, a designated leadership team. That's where anesthesiology can make a big difference. The surgeons are certainly critically important to the OR but they come and go. Anesthesia, on the other hand, is present in the OR every single day. Working in concert with nursing leadership, anesthesia should take the leadership position in trying to improve patient flow.
There are many studies that have been done that show reducing turnover time rarely gets you to the point where you can add another case. These studies demonstrate if you shave 10 minutes off of turnover time from four cases in a day, you save 40 minutes. That's not enough time to do an additional case. What improving turnover time does is have a positive impact on both the surgeon and patient experience. In respect to the surgeons, it assures them of the commitment of the OR team in getting those cases done safely and efficiently. And the impact on patient satisfaction is significant when their cases are actually on time.
While anesthesia should take a key leadership role in improving turnover time, it's a multidisciplinary problem — it involves maintenance, nursing, anesthesia, transport, floor nursing. Anesthesia leadership must recognize that part of being a leader in a process is to build consensus and lead by example. It's a large metric and all members of the perioperative team need to be committed and involved.
Q: Why is turnover time a critical metric to focus on?
JD: I think it's critical but for different reasons [than most people think]. Most people think of focusing on turnover time as just trying to add more volume. As we discussed before, it's unlikely that simply improving turnover time will enable you to add additional cases in any given day. Where it can significantly increase volume is if you're able to increase the number of surgeons that use your hospital. Establishing a safe, welcoming and efficient environment in an OR suite is going to entice surgeons to bring cases to your hospital, and that's probably the principal reason to go ahead and do it.
You want to work with data to help facilitate change and enable a culture of constant improvement. In our organization, NAPA, we look at data to make decisions. One of the reports we typically use is a time study of every single case we do — we break it into 15 minute intervals. It gives us a very high resolution focused view on every single operating room in an institution and it allows us to actually come to the table and say, "this is what is actually happening in our OR, this is how many rooms we have going on at the same time, this is what turnover time is." Instead of working based on anecdote, you're sitting there having a conversation using high resolution data.
I think the future of the OR and all hospital management is becoming hinged both on a quality and on an operational flow perspective with the use of data.
Q: Has insufficient preoperative holding space been an issue with turnaround time?
JD: The truth about preoperative holding space is that given the quality metrics that have arisen, its impact on case turnover time has become overstated. The ability to use the holding area the way it was traditionally used— such as starting the anesthetic process -has changed in the last decade. With the requirement to obtain consent long before you begin a procedure, and safety checks that need to be done [in advance], the holding area is now more of a place for a comfortable and patient-protected discussion with patients and their family.
In reality, very often surgeons are leaving one case to get consent or evaluate a patient pretty close to the time begin their next case in the OR, so it limits the impact of a holding area on turnaround time.
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