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PubMed1999

A multidisciplinary process to improve the efficiency of cardiac operating rooms.

OBJECTIVE: To alter the approach to cardiac operating room services in an attempt to remain competitive in a cost-driven market. DESIGN: Study of processes and strategies for tracking and decreasing the times required for the multiple components of the operating room period. SETTING: Cardiac operating rooms in a tertiary care, university-affiliated hospital. PARTICIPANTS: All patients undergoing primary coronary artery bypass grafting during December 1996 (baseline) and the following year (1997). INTERVENTIONS: After participation in cost-containment meetings, site visits, and development of a working group, data collection was begun detailing the times of the various components of the operating room period. Changes of process were made to reduce operating room times. Most of these changes involved multitasking care: multiple people performing various tasks at the same time. All measured operating room intervals were decreased. There was no difference in morbidity and mortality over this time period. CONCLUSION: Development of a working group, with support from the hospital administration, can significantly decrease the time of tasks in a cardiac surgery operating room without adversely affecting morbidity and mortality.

Cardiac Surgical Procedures↗
PubMed2003

The addition of a mobile ultra-clean exponential laminar airflow screen to conventional operating room ventilation reduces bacterial contamination to operating box levels.

A mobile screen producing ultra-clean exponential laminar airflow (LAF) was investigated as an addition to conventional turbulent/mixing operating room (OR) ventilation (16 air changes/h). The evaluation was performed in a small OR (50 m(3)) during 60 standardized operations for groin hernia including mesh implantation. The additional ventilation was used in 50 of the operations. The LAF passed from the foot-end of the OR table over the instrument and surgical area. Strict hygiene OR procedures including tightly woven and non-woven OR clothing were used. Sedimentation rates were recorded at the level of the patients' chests (N=60) (i.e. the air had passed the surgical team) and in the periphery of the OR. In addition bacterial air contamination was studied above the patients' chests in all 10 operations without the additional LAF and in 12 with the LAF. The screen reduced the mean counts of sedimenting bacteria (cfu/m(2)/h) on the patients' chests from 775 without the screen to 355 (P=0.0003). The screen also reduced the mean air counts of bacteria (cfu/m(3)) above the patients' chests from 27 to 9 (P=0.0001). No significant differences in mean sedimentation rates (cfu/m(2)/h) existed in the periphery of the OR where 628 without and 574 with screen were recorded. During the follow-up period of six months no surgical site infections were detected. In conclusion when the mobile LAF screen was added to conventional OR ventilation the counts of aerobic airborne and sedimenting bacteria-carrying particles downstream of the surgical team were reduced to the levels achieved with complete ultra-clean LAF OR ventilation (operating box).

Bacteria↗
PubMed1985

[Bacterial contamination of the air in different operating rooms].

Bacteria air samples were taken in the operating rooms, with no people present, to specify the level of air contamination and suggest bacteriological standards for different operating rooms. In the first step of this study, for 5 months the air contamination mean value of operating rooms, ventilated at 15 changes/hour was 18.5 Cfu/m3 +/- 1.9. In the second part of the study, during two years, 1 381 air samples were taken in 8 different operating rooms. The mean values of air contamination range from 1.4 Cfu/m3 in a Charnley isolator system to 121 Cfu/m3 in an operating room ventilated at 7.5 changes per hour. As a general rule, the airborne contamination is more significant in the oldest operating rooms than in the new one with filtrated air. The variations observed between 1981 and 1982 are explained by technical modifications of the system or progress in control of operating room conditions. Measurements of the bacterial contamination of the air give useful informations, but it is however better to ensure that the specifications for volume air supply and positive air pressure in the operating theatres are being fulfilled. The airborne bacterial concentration in a modern ventilated operating room should not exceed 30 Cfu/m3.

Air Microbiology↗
PubMedDate not supplied

Operating room management: the role of the anesthesiologist.

Operating room management structures and interrelationships both within the operating suite and with other departments in the hospital can be extremely complex. Several different professional and support groups are represented that often have infrastructures of their own that may compete or conflict with the operating room's management hierarchy. Often, there really is little actual management of the operating suite as an entity. Because the units must interact effectively to provide a high level of patient care, it is important that areas of conflict be resolved. Many problems can be averted by implementation of specific policies and procedures, after appropriate action by the medical staff outlining operating room goals and objectives, and the establishment of realistic lines of authority and communication. More important than the actual structure of the management components in developing an efficient and successful operating room is the ability of key management personnel to understand the dynamics of people and situations as they evolve. Management must also continually monitor and objectively evaluate the system so that areas of deficiency of conflict may be identified and policies or procedures adapted to adequately meet the changing needs of staff and patients. Anesthesiologists are in unique positions to deal with many of these problems and should play an active role in their resolution. As physicians and consultants, we have an understanding of the burden faced by surgeons relative to patient care. Because the majority of our working time is spent in the operating room, we have an opportunity to develop an effective working relationship with nursing staff.(ABSTRACT TRUNCATED AT 250 WORDS)

Anesthesiology↗
PubMed1985

Control and accountability of controlled substance administration in the operating room.

Personnel working in the operating room complex may be at increased risk for chemical impairment. It has been proposed that this predisposition may be related to the frequency of use of controlled substances and the inadequate control over distribution of these medications, which frequently exists in the operating room. A system utilizing a pharmacy satellite in the operating room has increased the control and accountability of drug administration practices. Several other alternative systems are also reviewed. Emphasis is placed on the establishment of a quality assurance program to monitor compliance routinely.

Anesthesiology↗
PubMed1991

Manipulators don't last in the operating room.

Certain characteristics of the operating room are not conductive to successful manipulation. Given these characteristics, individuals who relate to others in a manipulative style are less likely to be found the operating room, but instead will choose a setting where there is more opportunity to meet needs in a manipulative manner. Nevertheless, it is important for the manager to be aware of manipulative behavior and to respond appropriately when it does occur. A manager who can handle manipulation can ensure that manipulators do not last long in the operating room.

Humans↗
PubMed1996

A comparison of operating room crowding between open and laparoscopic operations.

BACKGROUND: The clutter of equipment and lines in today's operating room (O.R.) is increasing. Endoscopic surgical procedures are particularly afflicted by this problem because they require additional equipment. Increasing O.R. crowding may present unnecessary hazards to traffic and adversely affect the performance of the surgical team. The purpose of this study is to provide a quantitative summary of the furniture, equipment, cables, and tubes present during open and laparoscopic operations. METHODS: We prospectively studied an unselected series of general surgical open (OP, n = 10) and laparoscopic (LAP, n = 10) operations performed at a major university teaching hospital. We recorded the location of all furniture and equipment as well as the source, course, and destination of all cables and tubes in the O.R. Cables and tubes touching the surgeon or the assistant were particularly noted. Results are expressed as median values for each group. RESULTS: The percent of O.R. space occupied increased from OP = 36% to LAP = 41% (p < 0.002). The median number of cables and tubes present increased from OP = 27 to LAP = 34 (p < 0.0002), with the number of these lines touching a member of the surgical team increasing from OP = 2 to LAP = 6 (p < 0.0003). CONCLUSIONS: We conclude that there is a significant trend toward increasing O.R. crowding during laparoscopic surgery. Innovative designs will be needed to reduce clutter in the O.R. of the future.

Crowding↗
PubMed2001

Fiberoptic orotracheal intubation on anesthetized patients: do manipulation skills learned on a simple model transfer into the operating room?

BACKGROUND: With increasing pressure to use operating room time efficiently, opportunities for residents to learn fiberoptic orotracheal intubation in the operating room have declined. The purpose of this study was to determine whether fiberoptic orotracheal intubation skills learned outside the operating room on a simple model could be transferred into the clinical setting. METHODS: First-year anesthesiology residents and first- and second-year internal medicine residents were recruited. Subjects were randomized to a didactic-teaching-only group (n = 12) or a model-training group (n = 12). The didactic-teaching group received a detailed lecture from an expert bronchoscopist. The model-training group was guided, by experts, through tasks performed on a simple model designed to refine fiberoptic manipulation skills. After the training session, subjects performed a fiberoptic orotracheal intubation on healthy, consenting, anesthetized, paralyzed female patients undergoing elective surgery with predicted "easy" laryngoscopic intubations. Two blinded anesthesiologists evaluated each subject. RESULTS: After the training session, the model group significantly outperformed the didactic group in the operating room when evaluated with a global rating scale (P < 0.01)and checklist (P0.05). Model-trained subjects completed the fiberoptic orotracheal intubation significantly faster than didactic-trained subjects (P < 0.01). Model-trained subjects were also more successful at achieving tracheal intubation than the didactic group (P < 0.005). CONCLUSION: Fiberoptic orotracheal intubation skills training on a simple model is more effective than conventional didactic instruction for transfer to the clinical setting. Incorporating an extraoperative model into the training of fiberoptic orotracheal intubation may greatly reduce the time and pressures that accompany teaching this skill in the operating room.

Adult↗
PubMed1991

Blood exposure in the operating room: reducing the risk.

Blood must be considered a toxic substance in the operating room. Members of the operating room team must exercise greater caution to prevent blood contact. Increased attention to the adequacy of barriers and avoidance of certain operating room behavior is important. All surgical team members must be vaccinated against hepatitis B. The frequency of operating room transmission of HIV infection is clearly less than has been the case with hepatitis B. Because of documented cases of occupationally acquired HIV following hollow needle exposures, it is clear that the risk is not zero. While no case of operating room transmission of HIV has yet been documented, it has no doubt occurred and will certainly be documented in the future. It is the responsibility of each member of the surgical team to be an advocate for his or her own protection in the operating room. A heightened awareness of our general behavior and particular attention to our use of sharp instruments and needles in the operating room will be our best line of defense.

Acquired Immunodeficiency Syndrome↗
PubMed2000

Determining staffing requirements for a second shift of anesthetists by graphical analysis of data from operating room information systems.

Some operating room (OR) managers face the dilemma whereby all cases in a surgical suite are not completed during a regularly scheduled (e.g., 8-hour) day. If the anesthesia group at the surgical suite plans for its employed anesthetists to work a fixed number of hours each day, then more than 1 shift of anesthetists may be needed to care for the patients in the ORs. We developed a graphical statistical method that anesthetists and anesthesiologists can use to determine how many anesthesia providers are required on the second shift to minimize labor costs. The method uses data from surgical services information systems or hospital information systems to compensate for seasonality or seasonal variation in the number of ORs running at different times of the day. We also consider application of our method to scheduling surgical nurses with multiple overlapping shifts throughout the day.

Computer Graphics↗
PubMed2005

[Supplemental survey in 2003 concerning life-threatening hemorrhagic events in the operating room].

BACKGROUND: We previously showed that pre-operative hemorrhagic shock and surgical hemorrhage were the major causes of life-threatening events in the operating room and subsequent fatality. We investigated the background of these events. METHODS: The Subcommittee on Surveillance of Anesthesia-Related Critical Incidents, Japanese Society of Anesthesiologist (JSA) sent confidential questionnaires to all JSA-certified training hospitals (n=862). The questionnaires were composed of two parts: one for examining all life-threatening events in the operating room and the other for examining the background of massive hemorrhage in the operating room. The number of patients registered between January 1, 2003 and December 31, 2003 was 1,367,790 from 782 hospitals. Life-threatening hemorrhagic events were reported in 1,011 patients, of whom 876 patients were available for further analysis of the background of the events. Fatality within 7 postoperative days following these events was 45.4%. RESULTS: In patients who developed life-threatening events due to hemorrhage, 35.2% had blood loss of more than 12 l x 60 kg(-1) of body weight, 44.9% had a maximal hemorrhagic speed of more than 240 ml x min(-1) x 60 kg(-1) of body weight, and 39.1% had a minimal hemoglobin concentration of less than 5 g x dl(-1). The main sources of hemorrhage were as follows: the abdominal aorta, 15.4%; the thoracic aorta, 14.0%; the liver, 12.6%; intra-cranium, 8.2%; the pelvic organs, 8.0%; celiac or mesenteric artery, 7.8%; the lung, 7.1%. Of patients who developed life-threatening events due to preoperative hemorrhagic shock, 18.3% underwent cardiac massage preoperatively, 50.0% lost consciousness, 58.5% were intubated, and 16.4% were retrospectively judged to have had no operative indications. Human factors also affected the life-threatening events due to preoperative hemorrhagic shock: delayed decision making concerning indications for surgical treatment, 15.6%; delayed admission to the operating room, 16.6%; delayed supply of blood products, 25.5%; problems in surgical management, 16.3%; problems in anesthetic management, 28.1%. These problems in anesthetic management included shortage of supportive anesthesiologists. This was partly explained by the time of their admission to the operating room: 67.0% of the patients admitted during the week end or at night. Of the patients who developed life-threatening events due to surgical hemorrhage, 58.0% were predicted preoperatively to develop massive hemorrhage by anesthesiologists, and 66.7% were informed of the risks of massive hemorrhage and associated complications. The main causes of surgical hemorrhage were as follows: adhesion or invasion, 44.7%; and problems in surgical judgments or techniques, 43.7%. Anesthetic management affected the development of life-threatening events in these patients: lack of infusion prior to hemorrhage, shortage of supportive anesthesiologists, delay in ordering additional blood products, delayed judgment to start blood transfusion, and shortage of rapid infusion/transfusion apparatus. Delay for hospitals in obtaining blood supply from blood banks was reported in 13.0% of cases, and delayed supply from inhospital blood transfusion service to the operating room in 16.0%. Despite massive hemorrhage, ABO cross-matching was omitted only in 13.4% of patients, and transfusion of ABO-compatible, instead of ABO-identical red blood cells, was performed only in 1.3%. CONCLUSIONS: To reduce life-threatening hemorrhagic events in the operating theater, reorganization of emergency medical service and blood supply, improvement of surgical techniques, improved triage of patients with hemorrhagic shock, flexible application of compatible blood products in emergency situations, and improvement of the quality and number of anesthesiologists should be considered.

Anesthesiology↗
PubMed2003

Early complications of tracheostomy performed in the operating room.

Tracheostomy is one of the oldest operations in medicine. The intraoperative and postoperative complications associated with this procedure are well established. Recently, percutaneous and open bedside tracheostomy in the intensive care unit has been reported as an alternative to tracheostomies performed in the operating room. We investigated the early complications in 70 consecutive tracheostomies performed in the operating room in Bnai Zion Medical Center in Haifa, Israel. The study revealed no complications related to patient transportation to and from the operating room. The complication rate of standard surgical tracheostomy performed in the operating room was very low.

Aged↗
PubMed2002

Operating room management and strategies in Switzerland: results of a survey.

BACKGROUND AND OBJECTIVE: Operating room management structures and interrelationships both within the operating suite and with other departments in the hospital can be very complex. Several different professional and support groups are represented that often have infrastructures of their own that may compete or conflict with the management hierarchy in the operating room. Today, there is often little actual management of the operating suite as an entity. We surveyed current operating room management in Switzerland. METHODS: A questionnaire was sent to the chief anaesthesiologists of all public hospitals in Switzerland. It asked for information about the structure, organization and management of operating rooms as well as respondents' opinions and expectations about management. Derived from both the literature and the results of the survey, a 'stages of excellence' model of best practice was developed. RESULTS: The overall response rate was 70%. Most anaesthesiologists were unsatisfied with current management policies and structures in their operating rooms. Of the hospitals questioned, 40% did not have an information system at all for the operating rooms. The remaining 60% had an information system that allowed rough scheduling in 71%, but only a few had more sophisticated systems that enabled dynamic scheduling (19%), user-defined conflict checking (5%), administration of a subsequent patient transfer station (postanaesthesia care units, intensive medical care, intensive care units) (10%) or other more advanced uses. All hospitals questioned offered some type of ambulatory surgery in a 'hospital-integrated' manner (i.e. use of the same operating room for both in- and outpatient surgery), but none had implemented a more efficient system where outpatient surgery was performed in separate facilities. CONCLUSIONS: Current management of the operating room in Switzerland is far from best-practice standards.

Anesthesiology↗
PubMed2006

Governing time in operating rooms.

AIM: This paper examines how time is controlled and governed in operating rooms through interpersonal communication between nurses and doctors. BACKGROUND: Time is a valuable commodity in organizations with improvements often directed towards maximizing efficiencies. As a consequence, time can be a source of tension and interpersonal conflict as individuals compete for control of its use. METHODS: The data in this paper emanate from an ethnographic study that explored a range of communication practices in operating room nursing. Participants comprised 11 operating room nurses. Data were collected over two years in three different institutional settings and involved participant observation, interviews and the keeping of a personal diary. A deconstructive analysis of the data was undertaken. RESULTS: Results are discussed in terms of the practices, in which clinicians are engaged in, to govern and control their use of time. The four practices presented in this paper include; questioning judgment and timing, controlling speed, estimating surgeons' use of time and coping with different perceptions of time. CONCLUSIONS: Time and speed were hotly contested by nurses. They used their personal knowledge of individual surgeon's habits of time to govern and control practice. Nurses thought about surgeons in terms of time and developed commonly accepted understandings about the length of surgical procedures. They used this knowledge to manage the scheduling of operations in the departments and to control the workflow in individual operating rooms. Knowledge of individual surgeons was a source of power for operating room nurses. RELEVANCE TO CLINICAL PRACTICE: Nurses have more power in the operating room than might be imagined but they exercise this power in subtle ways. If operating rooms are to work effectively, the operating room team must understand each others' work better.

Adaptation, Psychological↗
PubMed1999

The operating room of the future.

The operating room of the future will be designed to have peri-operative integration of all imaging capabilities. Pre-operative planning will become increasingly important, as will integrated intra-operative neuro-navigation. The operative work space will be redesigned to have robotic capabilities. Operating rooms will be isolated. Self-contained modular and robotic monitoring will become remote through improved sensors. The operating microscope will disappear. Light and magnification will be supplied by means other than optical microscopes.

Biomedical Engineering↗
PubMed2006

A prospective study of patient safety in the operating room.

BACKGROUND: To better understand the operating room as a system and to identify system features that influence patient safety, we performed an analysis of operating room patient care using a prospective observational technique. METHODS: A multidisciplinary team comprised of human factors experts and surgeons conducted prospective observations of 10 complex general surgery cases in an academic hospital. Minute-to-minute observations were recorded in the field, and later coded and analyzed. A qualitative analysis first identified major system features that influenced team performance and patient safety. A quantitative analysis of factors related to these systems features followed. In addition, safety-compromising events were identified and analyzed for contributing and compensatory factors. RESULTS: Problems in communication and information flow, and workload and competing tasks were found to have measurable negative impact on team performance and patient safety in all 10 cases. In particular, the counting protocol was found to significantly compromise case progression and patient safety. We identified 11 events that potentially compromised patient safety, allowing us to identify recurring factors that contributed to or mitigated the overall effect on the patient's outcome. CONCLUSIONS: This study demonstrates the role of prospective observational methods in exposing critical system features that influence patient safety and that can be the targets for patient safety initiatives. Communication breakdown and information loss, as well as increased workload and competing tasks, pose the greatest threats to patient safety in the operating room.

Communication↗
PubMed2001

Game theory in the operating room environment.

To optimize the functioning of an operating room the interactions of the staff (physicians and nurses) and other stakeholders (administrators) must be understood. Game theory provides a representation of the interactions that typically take place in the operating room environment. By understanding the types of games/interactions that occur the participants can better predict outcome and adapt their own behavior to optimize that outcome. Types of games seen in the operating room include fixed-sum, zero-sum, and non-zero-sum games. The Prisoner's Dilemma game and some of its variations are used to illustrate common interactions in the operating room. Examples of strategies for typical scenarios are discussed as well as ways to improve the outcome of the games. A better understanding of human behavior can improve the functioning of complex systems such as that found in the operating room.

Game Theory↗