Fiscally responsible OR expansion…

This post is in response to a question posted in the Yahoo group (hme) about ‘triggers’ for OR room/suite expansion.  As usual, in healthcare, nothing is easy:

The decision to increase the number of OR’s can’t be made solely on the basis of the number of cases or % utilization per room. First there are the difficulties with those definitions:

1. A room could have 13 cataracts procedures done in the same time it takes to do 1 craniotomy; 4 TAHs (Total Abdominal Hysterectomy) in the time it takes to do 1 craniotomy; 3 Total Hips in the time it takes to do 1 craniotomy…. etc. So how are you counting the cases?

2. It’s very common to have a differences in duration of the same procedure. A factor of 2 or 3 is common; a factor of 4 or 5 is not unusual. I used to work with OB-GYNs who did hysterectomies in 15 minutes, C- sections in 20 min. We could take a woman into an OR and be out in 30 minutes. I’ve also worked with OB-GYNs who’d take 3 hours to do the same. These are extremes, but the times were normal for each surgeon. The point is, if you’re considering OR utilization, you could dramatically alter that parameter by changing the surgeon who is working in the OR.

Neurosurgery and plastic surgery are two of the specialties that tend to have large variations in the average times (factors of 3 or 4) dependent on surgeon. I also worked with one opthalmologist who could do 6 cataracts by the time it took another to do 1.

3. If you do a lot of orthopedics with epidurals or blocks, much of the time for the case can be related to anesthesia. If the blocks are done in the preop holding area, instead of the OR, you’ve again dramatically reduced your OR utilization time (but might need a larger holding area). Drop by a military hospital to see the effective use of blocks. You can also significantly decrease the time in the OR used to sleep, prep, and wake up the patient with a block.

[Just to be clear, the use of the term ‘block’ for anesthesia is not the same as the use of the term ‘block’ for “block scheduling’ unless you’re talking about the room in which you do blocks.  In that case, you could ‘block schedule’ the block room.]  ::grin::

4. An OR can run 24 hours a day. By utilization, do you mean total time out of 24 hours? Or out of the normal (whatever normal is for your hospital) working hours — like between 8am and 3am? Associated with this is the mis-classification of OR procedures as emergencies and not scheduled during the regular hours. In this case, you might have surgeons misclassifying cases as emergencies because they can’t get the times they want during the normal work day. This will screw up your calculations, increase your expenses (non-standard work hours are usually incredibly expensive, inefficient, and much more risky).

Then there’s the question of flipping rooms:

Flipping rooms is a form of ‘block scheduling’. In this case, you use two or three different rooms for 1 surgeon so that he can quickly go from one case he has finished to start the next case. This time lag is what surgeon’s perceive as ‘turnover time’. The cumulative time to sleep and prep the patient before the surgeon is in the room, and the time to ‘dress’ the patient and wake the patient up after the surgeon has left, can be as long as the time the surgeon is needed. The net result for the surgeon is to finish 2 cases by the time he would normally do 1.— It’s a good way to get surgeons to start to use your facility, but you might need an extra OR for flipping if you’re not sure how to do it effectively.

Then there’s the question of trauma:

Do you leave an OR open for trauma? If you have a large facility, you may not need to designate a special room for trauma at any one time; one of the ORs will be finishing its current case and be available for use for the trauma in any 30 minute period.  I’ve only once see an OR that was notified of a trauma less than 30 minutes before its arrival in the OR.

Double usage:

I’ve worked at places that used the extra OR in the OB suite for overflow from the regular OR. In fact, in one place we were considering knocking out a wall so that the 2 rarely used OB ORs could expand the existing ‘normal’ ORs. This would have been an effective 50% increase in capacity. If there were a pending C-section, then of course one of the ORs would be reserved for that potential surgery.

And… there are more consideration, but you get the idea.


About Brian D Gregory

Board Certified Anesthesiologist for 20 years. MBA from U of Georgia '90: Finance, Data Management, Risk Management. Practiced in multiple US states and Saudi Arabia at KFSH&RC and KFMC Taught residents in two locations. Worked with CRNAs for 20 years.
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