Since patient flow problems in a hospital are never limited to one area or department, managing that patient flow has become an immense challenge among hospitals today. Any patient flow inefficiencies that are present within an operating room will cascade throughout each department it touches in the hospital — delaying processes, testing and procedures during the course of patients' stay in the hospital. In addition, patient flow in the OR affects surgeon and patient satisfaction, which can directly influence case volume and revenue.
"The operating room is part of the treatment path," says Timothy J. Dowd, MD, CEO and managing partner of North American Partners in Anesthesia. "If cases back up, they can back up all the way to the emergency room, as the ED sends many incoming cases to the OR and into the PACU, where patients go post-surgery. You see patients lying in hallways in the emergency rooms waiting to be admitted but they're not because there's no bed. And there's no bed because patients are not getting quickly through the operating room." To prevent this scenario, hospitals need to designate someone(s) — usually a physician and a nurse — to oversee the details of each stage of a surgery, from the time a patient is scheduled to when he or she is discharged.
From scheduling to arrival
Pre-surgery screening may be more difficult today than it was in the past, because historically patients stayed in the hospital longer and were thus easier to access, according to Dr. Dowd. Today, most patients do not come to the hospital until the day of the surgery, and by that time it is too late to do the necessary testing and complete a proper history and physical. Therefore, OR staff need to contact patients beforehand through in-person visits or phone interviews to prepare them for the day of surgery. Prior to a patient's arrival for his or her scheduled surgery, the OR needs to screen the patient and conduct other tests to identify any potential issues, such as reactions to anesthesia or heart problems. This preparation usually involves coordinating multiple departments, such as the laboratory for lab testing, anesthesia for a consult and any specialists that may be needed.
From arrival to surgery
When the patient arrives at the hospital, the OR needs to confirm the patient's identity as well as the type of surgery and the necessary preoperative medication. The OR should also have a holding area nearby where patients and their family can wait and where clinicians and staff can meet with patients before the surgery, Dr. Dowd says. For example, while patients usually speak with an anesthesiologist before arrival, they may not meet the specific physician who will be taking care of them until the day of surgery. "You need to find a place for a little bonding time," Dr. Dowd says.
Surgery
One of the most important factors that can affect patient flow during surgery is time. Each case needs to start on time and should follow the schedule for the day. For surgeons to be able to adhere to schedules, OR schedulers need to accurately predict how long cases will take for each procedure and for each physician. There should also be time left open for add-on cases.
Another key factor in surgery throughput is having the correct equipment sterilized and on hand for the start of the surgery. Dr. Dowd says for high-cost devices, such as knee replacement implants, hospitals may not keep a large inventory and thus may have a manufacturer send the implant as late as the day of the surgery. OR leaders need to ensure these implants are ready on time for the appropriate surgery, or the procedure could be delayed while nurses locate the necessary devices. In addition to equipment, the OR should ensure other materials, such as blood supply and medications, are in place for the day's cases.
Post-surgery to discharge
When the surgery is over, OR turnaround should be completed as efficiently as possible so the next patient can get in on time. The patient whose surgery was completed needs to be moved to a post-anesthesia area and a recovery room, which requires that a bed in those areas be open. Otherwise, patients could be forced to stay in the OR, causing the hospital to lose cases, which in turn means lost revenue.
Dr. Dowd says one hospital lost more than 85 operating hours in one month due to insufficient recovery room capacity for post-surgery patients. The recovery room was at capacity because all of the beds in the hospital were full — or at least perceived to be. In reality, some patients had been transferred or discharged, but this information was never relayed to the appropriate people. Dr. Dowd suggests assigning a point person to ensure there is an adequate number of beds for each patient coming out of surgery.
One hospital Dr. Dowd has worked with has a recovery room hold code. When a recovery room nurse sees that a bed is not available for a post-surgery patient, he or she notifies the critical care unit director and the director of nursing, who then look for open beds in the hospital. Dr. Dowd says there usually are open beds that have not been reported to central supply by that time.
At discharge, patients are typically prohibited from driving home alone. To facilitate patients getting discharged on time, the OR should confirm patients have appropriate transportation home. OR staff should help make arrangements so the patient's driver has a place to park and can come in easily and on time to take the patient home. "By implementing and managing this process, you are able to alleviate any confusion and ensure that there are open beds for the post-surgery patients," Dr. Dowd says.
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"The operating room is part of the treatment path," says Timothy J. Dowd, MD, CEO and managing partner of North American Partners in Anesthesia. "If cases back up, they can back up all the way to the emergency room, as the ED sends many incoming cases to the OR and into the PACU, where patients go post-surgery. You see patients lying in hallways in the emergency rooms waiting to be admitted but they're not because there's no bed. And there's no bed because patients are not getting quickly through the operating room." To prevent this scenario, hospitals need to designate someone(s) — usually a physician and a nurse — to oversee the details of each stage of a surgery, from the time a patient is scheduled to when he or she is discharged.
From scheduling to arrival
Pre-surgery screening may be more difficult today than it was in the past, because historically patients stayed in the hospital longer and were thus easier to access, according to Dr. Dowd. Today, most patients do not come to the hospital until the day of the surgery, and by that time it is too late to do the necessary testing and complete a proper history and physical. Therefore, OR staff need to contact patients beforehand through in-person visits or phone interviews to prepare them for the day of surgery. Prior to a patient's arrival for his or her scheduled surgery, the OR needs to screen the patient and conduct other tests to identify any potential issues, such as reactions to anesthesia or heart problems. This preparation usually involves coordinating multiple departments, such as the laboratory for lab testing, anesthesia for a consult and any specialists that may be needed.
From arrival to surgery
When the patient arrives at the hospital, the OR needs to confirm the patient's identity as well as the type of surgery and the necessary preoperative medication. The OR should also have a holding area nearby where patients and their family can wait and where clinicians and staff can meet with patients before the surgery, Dr. Dowd says. For example, while patients usually speak with an anesthesiologist before arrival, they may not meet the specific physician who will be taking care of them until the day of surgery. "You need to find a place for a little bonding time," Dr. Dowd says.
Surgery
One of the most important factors that can affect patient flow during surgery is time. Each case needs to start on time and should follow the schedule for the day. For surgeons to be able to adhere to schedules, OR schedulers need to accurately predict how long cases will take for each procedure and for each physician. There should also be time left open for add-on cases.
Another key factor in surgery throughput is having the correct equipment sterilized and on hand for the start of the surgery. Dr. Dowd says for high-cost devices, such as knee replacement implants, hospitals may not keep a large inventory and thus may have a manufacturer send the implant as late as the day of the surgery. OR leaders need to ensure these implants are ready on time for the appropriate surgery, or the procedure could be delayed while nurses locate the necessary devices. In addition to equipment, the OR should ensure other materials, such as blood supply and medications, are in place for the day's cases.
Post-surgery to discharge
When the surgery is over, OR turnaround should be completed as efficiently as possible so the next patient can get in on time. The patient whose surgery was completed needs to be moved to a post-anesthesia area and a recovery room, which requires that a bed in those areas be open. Otherwise, patients could be forced to stay in the OR, causing the hospital to lose cases, which in turn means lost revenue.
Dr. Dowd says one hospital lost more than 85 operating hours in one month due to insufficient recovery room capacity for post-surgery patients. The recovery room was at capacity because all of the beds in the hospital were full — or at least perceived to be. In reality, some patients had been transferred or discharged, but this information was never relayed to the appropriate people. Dr. Dowd suggests assigning a point person to ensure there is an adequate number of beds for each patient coming out of surgery.
One hospital Dr. Dowd has worked with has a recovery room hold code. When a recovery room nurse sees that a bed is not available for a post-surgery patient, he or she notifies the critical care unit director and the director of nursing, who then look for open beds in the hospital. Dr. Dowd says there usually are open beds that have not been reported to central supply by that time.
At discharge, patients are typically prohibited from driving home alone. To facilitate patients getting discharged on time, the OR should confirm patients have appropriate transportation home. OR staff should help make arrangements so the patient's driver has a place to park and can come in easily and on time to take the patient home. "By implementing and managing this process, you are able to alleviate any confusion and ensure that there are open beds for the post-surgery patients," Dr. Dowd says.
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