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Biomedical subjects

A Macario

Publications and source records attributed to A Macario.

At least 19 recordsLinked to original sources
PubMed2000

Effect of compensation and patient scheduling on OR labor costs.

To determine whether to accept a contract to provide additional surgical cases, OR managers must determine the incremental costs of caring for the new patients. The expected profitability of the contract can be computed by subtracting the incremental costs from the revenue. For surgical procedures, the incremental costs of OR labor significantly depend on how employees are paid (e.g., part-time versus full-time). If a surgical suite employs full-time staff members, incremental labor costs also are affected by how the day and time of patients' cases are selected (e.g., whether new cases are scheduled weeks in advance by the surgeon and the patient, or are performed on short notice based on the discretion of the surgical suite). This article explains how to estimate the incremental costs of staffing an OR for a case and discusses the use of internet-based online exchanges to match demand for OR time for additional cases to available unused OR capacity in variety of surgical suites.

Appointments and Schedules↗
PubMed2000

Quantitative description of the workload associated with airway management procedures.

STUDY OBJECTIVES: To measure the workload associated with specific airway management tasks. SETTING AND INTERVENTION: Written survey instrument. PATIENTS: 166 Stanford University and 75 University of California, San Diego, anesthesia providers. MEASUREMENTS AND MAIN RESULTS: Subjects were asked to use a seven-point Likert-type scale to rate the level of perceived workload associated with different airway management tasks with respect to the physical effort, mental effort, and psychological stress they require to perform in the typical clinical setting. The 126 subjects completing questionnaires (overall 52% response rate) consisted of 43% faculty, 26% residents, 23% community practitioners, and 8% certified registered nurse-anesthetists (CRNAs). Faculty physicians generally scored lower workload measures than residents, whereas community practitioners had the highest workload scores. Overall, workload ratings were lowest for laryngeal mask airway (LMA) insertion and highest for awake fiberoptic intubation. Airway procedures performed on sleeping patients received lower workload ratings than comparable procedures performed on awake patients. Direct visualization procedures received lower workload ratings than fiberoptically guided procedures. CONCLUSIONS: These kinds of data may permit more objective consideration of the nonmonetary costs of technical anesthesia procedures. The potential clinical benefits of the use of more complex airway management techniques may be partially offset by the impact of increased workload on other clinical demands.

Adult↗
PubMed2000

Scheduling surgical cases into overflow block time- computer simulation of the effects of scheduling strategies on operating room labor costs.

UNLABELLED: "Overflow" block time is operating room (OR) time for a surgical group's cases that cannot be completed in the regular block time allocated to each surgeon in the surgical group. Having such overflow block time increases OR utilization. The optimal way to schedule patients into a surgical group's overflow block time is unknown. In this study, we developed a scheduling strategy that balances the OR manager's need to reduce staffing costs and the needs of patients and surgeons for flexibility in choosing the dates and times of cases. We used computer simulation to evaluate our scheduling strategy. Surgeons and patients (i) can schedule the case into any overflow block within 2 wk; (ii) can only schedule the case into a "first case of the day" start time more than 2 wk in the future if there is not enough open time for the case within 2 wk; (iii) must schedule the case to be done within 4 wk; and (iv) are encouraged to perform the case on the earliest possible date. Staffing costs were lowest when the OR manager did not incorporate surgeon and patient preferences when scheduling cases into overflow block time. The strategy we developed provides surgeons and patients with some flexibility in scheduling, while only increasing OR staffing costs slightly over the minimum achieved when the OR manager controls scheduling. IMPLICATIONS: The strategy we developed provides surgeons and patients with some flexibility in scheduling, while increasing OR staffing costs only slightly over the minimum achieved when the OR manager controls scheduling. Staffing costs were lowest when the operating room (OR) manager did not incorporate surgeon and patient preferences when scheduling cases into overflow block time.

Appointments and Schedules↗
PubMed2000

A retrospective examination of regional plus general anesthesia in children undergoing open heart surgery.

The use of regional anesthesia in combination with general anesthesia for children undergoing cardiac surgery is receiving increasing attention from clinicians. The addition of regional anesthesia may improve clinical outcomes and decrease costs as a result of the reduced need for postoperative mechanical ventilation. The goal of this retrospective chart review was to evaluate whether spinal anesthesia (SAB) or epidural anesthesia (EPID) in combination with general anesthesia was associated with circulatory stability, satisfactory postoperative sedation/analgesia, and a low incidence of adverse effects. The medical records of 50 consecutive children having open heart surgery with SAB or EPID and general anesthesia between September 1996 and December 1997 were reviewed. We found no significant differences in the incidence of clinically significant changes in vital signs, oxygen desaturation, hypercarbia, or vomiting. Patients in the SAB group received significantly more sedative/analgesic interventions than those in the EPID group.

Anesthesia, Conduction↗
PubMed2000

What is the relative frequency of uncommon ambulatory surgery procedures performed in the United States with an anesthesia provider?

UNLABELLED: Between 1994 and 1996, the National Center for Health Statistics used sophisticated sampling methods to measure the number and types of ambulatory surgery cases performed in the United States. We reanalyzed raw data obtained from this National Survey of Ambulatory Surgery to select cases with an anesthesia provider and here report characteristics of these 228,332 cases (e.g., patient age, anesthetic type). The goal of our study was to estimate what percentage of cases, of a specified surgical procedure or combination of procedures, may have been performed less than once per year per facility. Previous studies suggest the most important source of scheduling inaccuracy can be the absence of recently performed cases on which to base predictions of case duration. We found that 36% +/- 1% (SE) of all cases in the United States were a type of procedure or combination of procedures that occurred <6984 times per year (the number of surgery facilities performing ambulatory surgery in the United States). Approximately one third of all ambulatory cases were of a procedure or combination of procedures that may have been performed as infrequently as once per year per facility. This could impair the effectiveness of predicting the durations of ambulatory cases by using historical case-duration data. IMPLICATIONS: Approximately one third of all ambulatory cases were a procedure or combination of procedures possibly performed as infrequently as once per year per facility. This could impair the effectiveness of predicting the durations of ambulatory cases by using historical case-duration data.

Adolescent↗
PubMed2000

Analgesia for labor pain: a cost model.

BACKGROUND: Epidural analgesia and intravenous analgesia with opioids are two techniques for the relief of labor pain. The goal of this study was to develop a cost-identification model to quantify the costs (from society's perspective) of epidural analgesia compared with intravenous analgesia for labor pain. Because there is no valid method to assign a dollar value to differing levels of analgesia, the cost of each technique can be compared with the analgesic benefit (patient pain scores) of each technique. METHODS: The authors created a cost model for epidural and intravenous analgesia by reviewing the literature to determine the rates of associated clinical outcomes (benefit of each technique to produce analgesia) and complications (e.g., postdural puncture headache). The authors then analyzed data from their institution's cost-accounting system to determine the hospital cost for parturients admitted for delivery, estimated the cost of each complication, and performed a sensitivity analysis to evaluate the cost impact of changing key variables. A secondary analysis was performed assuming that the cost of nursing was fixed (did not change depending on the number of nursing interventions). RESULTS: If the cesarean section rate equals 20% for both intravenous and epidural analgesia, the additional expected cost per patient to society of epidural analgesia of labor pain ranges from $259 (assuming nursing costs in the labor and delivery suite do not vary with the number of nursing interventions) to $338 (assuming nursing costs do increase as the number of interventions increases) relative to the expected cost of intravenous analgesia for labor pain. This cost difference results from increased professional costs and complication costs associated with epidural analgesia. CONCLUSIONS: Epidural analgesia is more costly than intravenous analgesia. How the cost of the anesthesiologist and nursing care is calculated affects how much more costly epidural analgesia is relative to intravenous analgesia. Published studies have determined that epidural analgesia provides relief of labor pain superior to intravenous analgesia, quantified in one study as 40 mm better on a 100-mm scale during the first stage of labor and 29 mm better during the second stage of labor. Patients, physicians, and society need to weigh the value of improved pain relief from epidural analgesia versus the increased cost of epidural analgesia.

Adult↗
PubMed2000

Statistical method using operating room information system data to determine anesthetist weekend call requirements.

We present a statistical method that uses data from surgical services information systems to determine the minimum number of anesthetists to be scheduled for weekend call in an operating room suite. The staffing coverage is predicted that provides for sufficient anesthetists to cover each hour of a 24-hour weekend period, while satisfying a specified risk for being understaffed. The statistical method incorporates shifts of varying start times and durations, as well as historical weekend operating room caseload data. By using this method to schedule weekend staff, an anesthesia group can assure as few anesthetists are on call as possible, and for as few hours as possible, while maintaining the level of risk of understaffing that the anesthesia group is willing to accept. An anesthesia group also can use the method to calculate its risk of being understaffed in the surgical suite based on its existing weekend staffing plan.

Data Interpretation, Statistical↗
PubMed1999

Relying solely on historical surgical times to estimate accurately future surgical times is unlikely to reduce the average length of time cases finish late.

STUDY OBJECTIVE: To determine whether using only previous cases' surgical times for predicting accurately surgical times of future cases is likely to reduce the average length of time cases finish late (after their scheduled finish times). DESIGN: Computer simulation. MEASUREMENTS AND MAIN RESULTS: Data from an operating room (OR) information system for two surgical suites were analyzed. For each case performed in fiscal year 1996, we searched backward for 1 year and counted the number of previous cases that were the same type of procedure performed by the same surgeon. Then, for each suite, surgical times were fitted to a statistical model estimating the effect of the type of procedure and who the surgeon was on surgical time. The estimated "variance components" were used in Monte-Carlo computer simulations to evaluate whether a hypothetical increase in the number of previous cases available to estimate the next case's surgical time would improve scheduling accuracy. Predictions of how long newly scheduled cases should take were impaired because 36.5% +/- 0.4% (mean +/- SE) of cases at a tertiary surgical suite and 28.6% +/- 0.7% of cases at an ambulatory surgery center did not have any cases in the previous year with the same procedure type and surgeon. Computer simulation was used to generate additional hypothetical cases. Using this data, even having many previous cases on which to base predictions of future surgical times would only decrease the average length of time that cases finish late by a few minutes. CONCLUSION: An OR manager considering using only historical surgical times to estimate future surgical times should first investigate, using data from their own surgical suite, what percentage of cases do not have historical data. Even if there are sufficient historical data to estimate future surgical times accurately, relying solely on historical times is probably an ineffective strategy to have future cases finish on time.

Ambulatory Surgical Procedures↗
PubMed1999

What can the postanesthesia care unit manager do to decrease costs in the postanesthesia care unit?

The economic structure of the PACU dictates whether a cost-reducing intervention (e.g., reducing the length of time patients stay in the PACU) is likely to decrease hospital costs. Cost-reducing interventions, such as changes in medical practice patterns (e.g., to reduce PACU length of stay), only impact variable costs. How PACU nurses are paid (e.g., salaried v hourly) affects which strategies to decrease PACU staffing costs will actually save money. For example, decreases in PACU labor costs resulting from increases in the number of patients that bypass the PACU vary depending on how the staff is compensated. The choice of anesthetic drugs and the elimination of low morbidity side effects of anesthesia, such as postoperative nausea, are likely to have little effect on the peak numbers of patients in a PACU and PACU staffing costs. Because the major determinant of labor productivity in the PACU is hour-to-hour and day-to-day variability in the timing of admissions from the operating room, a more even inflow of patients into the PACU could be attained by appropriate sequencing of cases in the operating room suite (e.g., have long cases scheduled at the beginning of the day). However, this mathematically proven solution may not be desirable. Surgeons, for example, may not want to lose control over the order of their cases. Guidelines for analysis of past daily peak numbers of patients are provided that will provide data to predict the minimum adequate number of nurses needed. Though many managers already do this manually on an ad hoc basis statistical methods summarized in this article may increase the accuracy.

Cost Control↗
PubMed1999

Decrease in case duration required to complete an additional case during regularly scheduled hours in an operating room suite: a computer simulation study.

UNLABELLED: We used Monte-Carlo computer simulation to determine whether surgical or anesthetic interventions to achieve small decreases in case duration may create enough new open operating room (OR) time to permit an additional case to be scheduled for completion in an OR suite during regular working hours. We used rules for scheduling of cases assuming that OR personnel are compensated so that the OR suite can profit financially from decreasing case duration to complete an additional case during regularly scheduled hours. The decreases in each case's duration required to create enough new open OR time to reliably (> or =95%) schedule another case were 30-39 min, 79-110 min, and 105-206 min for OR suites with 1-15 ORs and mean case durations of 1, 2, or 3 h, respectively. IMPLICATIONS: Computer simulation shows decreasing case duration is unlikely to create sufficient operating room time to reliably permit an additional case to be scheduled for completion during working hours. Additional cases may best be added to the operating room suite schedule by optimizing case scheduling, not by decreasing the duration of all cases in the suite.

Anesthesia↗
PubMed1999

Computer simulation to determine how rapid anesthetic recovery protocols to decrease the time for emergence or increase the phase I postanesthesia care unit bypass rate affect staffing of an ambulatory surgery center.

UNLABELLED: Ambulatory surgery centers (ASC) are implementing new anesthetic techniques and rapid recovery protocols in the postanesthesia care unit (PACU) to achieve earlier discharge after general anesthesia. Using computer simulation, we addressed two questions. First, what is the decrease in an ASC's operating room (OR) staff if the time from which the surgery is finished to the time the patient leaves the OR is decreased? Second, what is the decrease in PACU nursing staffing if patients bypass phase I PACU (i.e., proceed from the OR directly to the phase II PACU)? The decrease in labor costs from rapid emergence or fast-tracking depends on how staff are compensated, how many ORs routinely run concurrently, and what percentage of patients undergo general anesthesia. The results show potential decreases in ASCs' labor costs ($7.39 per case) from technologies (e.g., new anesthetics or Bispectral Index [Aspect Medical Systems, Natick, MA] monitoring) to decrease emergence times or increase the phase I bypass rates. IMPLICATIONS: Decreases in operating room and postanesthesia care unit labor costs resulting from faster emergence and phase I postanesthesia care unit bypass vary depending on the amount of routine overtime, how the staff are compensated, and how many patients are routinely anesthetized each day.

Ambulatory Surgical Procedures↗
PubMed1999

Which clinical anesthesia outcomes are both common and important to avoid? The perspective of a panel of expert anesthesiologists.

UNLABELLED: Anesthesia groups may need to determine which clinical anesthesia outcomes to track as part of quality improvement efforts. The goal of this study was to poll a panel of expert anesthesiologists to determine which clinical anesthesia outcomes associated with routine outpatient surgery were judged to occur frequently and to be important to avoid. Outcomes scoring highly in both scales could then be prioritized for measurement and improvement in ambulatory clinical practice. A mailed survey instrument instructed panel members to rate 33 clinical anesthesia outcomes in two scales: how frequently they believe the outcomes occur and which outcomes they expect patients find important to avoid. A feedback process (Delphi process) was used to gain consensus rankings of the outcomes for each scale. Importance and frequency scores were then weighted equally to qualitatively rank order the outcomes. Of the 72 anesthesiologists, 56 (78%) completed the questionnaire. The five items with the highest combined score were (in order): incisional pain, nausea, vomiting, preoperative anxiety, and discomfort from IV insertion. To increase quality of care, reducing the incidence and severity of these outcomes should be prioritized. IMPLICATIONS: Expert anesthesiologists reached a consensus on which low-morbidity clinical outcomes are common and important to the patient. The outcomes identified may be reasonable choices to be monitored as part of ambulatory anesthesia clinical quality improvement efforts.

Adult↗
PubMed1999

An operating room scheduling strategy to maximize the use of operating room block time: computer simulation of patient scheduling and survey of patients' preferences for surgical waiting time.

UNLABELLED: Determining the appropriate amount of block time to allocate to surgeons and selecting the days on which to schedule elective cases can maximize operating room (OR) use. We used computer simulation to model OR scheduling. Inputs in the computer model included different methods to determine when a patient will have surgery (on-line bin-packing algorithms), case durations, lengths of time patients wait for surgery (2 wk is the median longest length of time that the outpatients [n = 367] surveyed considered acceptable), hours of block time each day, and number of blocks each week. For block time to be allocated to maximize OR utilization, two parameters must be specified: the method used to decide on what day a patient will have surgery and the average length of time patients wait to have surgery. OR utilization depends greatly on, and increases as, the average length of time patients wait for surgery increases. IMPLICATIONS: Operating room utilization can be maximized by allocating block time for the elective cases based on expected total hours of elective cases, scheduling patients into the first available date provided open block time is available within 4 wk, and otherwise scheduling patients in "overflow" time outside of the block time.

Anesthesia↗
PubMed1999

Which clinical anesthesia outcomes are important to avoid? The perspective of patients.

UNLABELLED: Healthcare quality can be improved by eliciting patient preferences and customizing care to meet the needs of the patient. The goal of this study was to quantify patients' preferences for postoperative anesthesia outcomes. One hundred one patients in the preoperative clinic completed a written survey. Patients were asked to rank (order) 10 possible postoperative outcomes from their most undesirable to their least undesirable outcome. Each outcome was described in simple language. Patients were also asked to distribute $100 among the 10 outcomes, proportionally more money being allocated to the more undesirable outcomes. The dollar allocations were used to determine the relative value of each outcome. Rankings and relative value scores correlated closely (r2 = 0.69). Patients rated from most undesirable to least undesirable (in order): vomiting, gagging on the tracheal tube, incisional pain, nausea, recall without pain, residual weakness, shivering, sore throat, and somnolence (F-test < 0.01). IMPLICATIONS: Although there is variability in how patients rated postoperative outcomes, avoiding nausea/vomiting, incisional pain, and gagging on the endotracheal tube was a high priority for most patients. Whether clinicians can improve the quality of anesthesia by designing anesthesia regimens that most closely meet each individual patient's preferences for clinical outcomes deserves further study.

Adult↗
PubMed1999

A strategy for deciding operating room assignments for second-shift anesthetists.

UNLABELLED: We developed a relief strategy for assigning second-shift anesthetists to late-running operating rooms. The strategy relies on a statistical method which analyzes historical case durations available from surgical services information systems to estimate the expected (mean) remaining hours in cases after they have begun. We tested our relief strategy by comparing the number of hours that first-shift anesthetists would work overtime if second-shift anesthetists were assigned using our strategy versus if the anesthesia coordinator knew in advance the exact amount of time remaining in each case. Our relief strategy resulted in 3.4% to 4.9% more overtime hours for first-shift anesthetists than the theoretical minimum, as would have been obtained had perfect retrospective knowledge been available. Few additional staff hours would have been saved by supplementing our relief strategy with other methods to monitor case durations (e.g., real-time patient tracking systems or closed circuit cameras in operating rooms). IMPLICATIONS: A relief strategy that relies only on analyzing historical case durations from an operating room information system to predict the time remaining in cases performs well at minimizing anesthetist staffing costs.

Algorithms↗