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PEDIATRIC ANESTHESIA

Scheduling Elective Pediatric Procedures That Require Anesthesia: The Perspective of Parents

Edward R. Mariano, MD^*, Larry F. Chu, MD, MS (Biochemistry), MS (Epidemiology), Chandra Ramamoorthy, MBBS, and Alex Macario, MD, MBA

From the *Department of Anesthesia, University of California, San Diego School of Medicine, San Diego; and Departments of Anesthesia, Health Research and Policy, Stanford University School of Medicine, Stanford, California.

Address correspondence and reprint requests to Edward R. Mariano, MD, Department of Anesthesia, University of California at San Diego Medical Center, 200 West Arbor Drive, San Diego, CA 92103-8770 (619) 543-5720. Address e-mail to ermariano{at}ucsd.edu.

	Abstract

Top Abstract Introduction METHODS RESULTS DISCUSSION Appendix 1 REFERENCES

 
Daily variability in volume of elective pediatric procedures that require anesthesia may lead to an imbalance between available operating room resources and case load. Longer intervals between scheduling and the surgical date generally result in higher operating room utilization. In this study, we sought to determine which factors influence when parents schedule their children for procedures. We also aimed to identify parents’ ideal and longest acceptable waiting intervals and determine whether type of procedure, for example, affects scheduling. From a convenience sample of 250 randomly selected parents of children presenting for elective surgery, 236 completed surveys were analyzed. The remaining 14 surveys were not returned. Overall, parents scheduled their child’s procedure a median of 4.3 wk (interquartile range 2.0–8.6) in advance and reported an ideal waiting interval of 3 wk (interquartile range 2–4), and longest acceptable interval of 6 wk (interquartile range 4–10). Parents were willing to wait longer to schedule cardiac (4 wk, P = 0.004) and plastic (3.5 wk, P = 0.024) surgery when compared with general surgical procedures. Overall, parents ranked severity of the child’s illness, earliest available time, and surgeon’s suggested date as the three most important factors influencing when their child’s surgery is scheduled. The timetable for scheduling procedures was highly correlated with both mother and father having available time off work (_b = 0.72, P < 0.0001). Surprisingly, parents did not show a preference for scheduling cases during vacation or summer months.

	Introduction

Top Abstract Introduction METHODS RESULTS DISCUSSION Appendix 1 REFERENCES

 
Operating room (OR) procedures as well as diagnostic (e.g., magnetic resonance imaging suite) and other out of OR cases are commonly allocated nursing staff and anesthesia coverage in the form of "blocks" (1). This allocation may be based on historical use by surgeons and computer-based projections to minimize the amount of under- or over-utilized time (1). Fluctuations in daily surgical case load may make it difficult to anticipate the volume of scheduled cases in advance and assign OR staff appropriately (2). Ideally, demand for resources (staffing) is optimally matched with supply. Improving the OR scheduling process permits earlier identification of either fully used or open allocated OR time. Additional cases can then be readily placed into future open time in the OR or in out of OR locations (3).

For most hospitals and surgery centers, the chosen date for elective surgery is agreed upon by patients and surgeons in advance during the preoperative visit (4). For pediatric patients, diagnostic as well as surgical procedures require anesthesia services. These patients do not make decisions regarding their care themselves and rely on parents or guardians instead. While parental preferences for decision-making in other areas of perioperative care have been studied (5), parental preferences regarding the actual scheduling of their child’s procedure have not been measured. The goal of this study was to determine which factors influence when parents schedule their children for procedures. We also designed this study to identify parents’ ideal and longest acceptable waiting intervals to determine whether type of procedure, for example, affects the scheduling decision.

	METHODS

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The Stanford University Medical Center Human Subjects Committee approved this study.

Survey Development
To create a list of factors that might impact when elective cases are scheduled, we searched electronically for articles by using MEDLINE, limiting consideration to English-language journals published between 1986 and 2004 with studies conducted on human subjects. "Case scheduling" was entered separately, both as a Medical Subject Heading and as text words.

"Content validity" refers to the capacity of a questionnaire to measure all the dimensions of the phenomenon under investigation. The 11 full-text articles obtained from our literature search were read in detail (a sample of these studies is included in References) to identify factors related to case scheduling. In addition, a manual search of screening citation lists yielded another five articles.

During a pretest phase, the list was examined by four senior, board-certified pediatric anesthesiologists in the Department of Anesthesia, Stanford University School of Medicine/Lucile Packard Children’s Hospital, as well as by a convenience sample of five sets of parents, five pediatric surgeons, and three nurses involved with surgical scheduling. This pretest focus group testing phase helped to ensure that the items were properly worded, that significant factors were not excluded, and that the survey could be completed within 10 min.

In the final survey (Appendix), parents were asked to rate 15 potential influencing factors such as "when my child had vacation" using a 5-point Likert scale of "1 = not important at all" to "5 = extremely important." An open-ended question asking parents whether there were any other influential factors not listed were included at the end of the survey to ensure that important items were not missing. Parents were also asked when they scheduled their child’s procedure, if this interval was acceptable, and what they thought were the ideal and longest acceptable waiting intervals.

"Reliability" refers to the extent to which a scale produces consistent results if repeated measurements are made. We used the test-retest approach for assessing reliability. In test-retest reliability, respondents are administered identical sets of scale items at two different times under as nearly equivalent conditions as possible. We asked seven respondents to complete an identical questionnaire a second time 2 wk after the original questionnaire to check the reliability of the survey instrument. There were 119 eligible responses (No. of questions x No. of respondents). Open-ended questions and items referring to demographics were excluded. All items were answered by all respondents on both survey administrations: 50% of items were answered identically; 85% were answered within one option on either side of the original; and 98% were answered within two options.

Survey Distribution
English-speaking parents of 250 children scheduled for elective surgery and diagnostic testing (requiring anesthesia) at a tertiary care pediatric hospital between September 1, 2003 and September 1, 2004 were asked to complete the survey. Two hundred and fifty was chosen as a convenience sample of subjects whose children were undergoing a variety of procedures. On randomly selected days, surveys were distributed in person by a research assistant to all eligible parents in the designated surgical waiting area for that OR day. The surveys were returned anonymously to a drop box at the surgical admissions desk.

Statistical Analysis
Descriptive statistics were used to summarize demographic and survey response data. Normal distribution was determined using QQ plots and the Kolmogorov–Smirnov test. Descriptive statistics for non-normally distributed data are presented as median (interquartile range). Continuous normally-distributed variables and continuous variables transformed to normal distribution through log transformation were compared using Student’s t-test for independent samples and analysis of variance (ANOVA) as appropriate. Ideal waiting time was not normally distributed and this was not corrected by log transformation. Accordingly, hypothesis testing was performed using the Kruskal– Wallis test and post hoc testing using one-way ANOVA on the ranks of the observations with Tukey–Kramer correction for multiple comparisons.

The effects of various covariates as predictors of ideal waiting time were explored using polychotomous logistic regression by polychotomizing waiting times into discrete time intervals (<3, 3–6, and >6 wk) and treating them as ordinal data. Correlations between ordinal survey response variables were computed using the Kendall-Tau rank correlation. The value of the coefficient (_b) ranges from –1 to 1. A value of zero indicates no correlation; values near 1 indicate a strong direct correlation, and values near –1 indicate a strong inverse correlation. Values for moderate (0.4–0.7) and high (0.7–0.9) correlations were reported.

² and Fisher’s exact test were used to analyze discrete data when appropriate. Analysis was performed using SAS 9.1 (Cary, NC) with P < 0.05 considered statistically significant.

	RESULTS

Top Abstract Introduction METHODS RESULTS DISCUSSION Appendix 1 REFERENCES

 
Of the 250 surveys distributed, 236 (94%) were completed and returned. Demographic information is presented as Table 1. The mean age of patients scheduled for surgery was 82 mo, and most were male (57%) and Caucasian (52%). The majority of parents were college educated (74%) and earned a gross household income more than $90,000 per year (48%).

Severity of the child’s illness, earliest available time, and surgeon’s suggested date were the three highest-rated factors influencing parental scheduling (Table 2).

Only 7% of survey respondents answered the open-ended question on other factors influencing scheduling preferences. A sample of the responses included: "convenience," "needed to save his life," extreme pain, "health of another child," "short life expectancy," and "sports schedule. " None of these answers was reported on more than one survey.

Analysis of correlations between factors influencing parental scheduling showed high correlation for both mother and father having available time off work (_b = 0.72, P < 0.0001) and moderate correlation for distance traveled and availability of transportation (_b = 0.56, P < 0.0001), sufficient funds to afford medical care (_b = 0.52, P < 0.0001) and child-care help at home (_b = 0.46, P < 0.0001) (Table 3). Parents surveyed did not show a particular preference for scheduling procedures during vacation or summer months.

View this table: [in this window] [in a new window]   Table 3. Kendall b Correlation Coefficients for Ranked Importance of Ordinal Response Variable When Deciding When to Schedule Child’s Surgery, Where H0:b = 0

Parents scheduled procedures a median of 4.3 wk (2.0–8.6) in advance of the actual operation. Ninety-three percent of respondents reported that their waiting time was acceptable, and this did not change significantly among parents who had longer waiting times (Table 4). Most parents (78%) took the first date offered to them. Parents’ overall ideal waiting interval was a median of 3 wk (interquartile range 2–4), and the median longest acceptable interval was 6 wk (interquartile range 4–10) (Fig. 1). Analysis of ideal waiting time by type of procedure showed that parents were willing to wait longer for cardiac surgery (median 4 wk, P = 0.004) and plastic surgery (median 3.5 wk, P = 0.024) procedures when compared with general surgical procedures (Table 5). A stratified Kendall-Tau correlation analysis by type of surgical procedure showed a significant correlation between surgeon’s availability and earliest available time for patients scheduled for cardiac surgery (_b = 0.63, P < 0.001).

View larger version (9K): [in this window] [in a new window]   Figure 1. Parent-reported overall "ideal" and "longest acceptable" waiting intervals (wk) between scheduling and the actual procedure presented as median (interquartile range).

Analysis of factors influencing the reported ideal waiting time showed that gross annual household income of $30,000–$60,000 (OR 4.1, P = 0.05) and income more than $90,000 (OR 3.4, P = 0.04) significantly increased the odds of desiring shorter ideal waiting times when compared with households with an income less than $30,000 per year. Parents who rated earliest available time as extremely important in deciding when to schedule surgery also had increased odds of desiring shorter ideal waiting times (OR 3.7, P = 0.0004) which provides construct validity. The few parents who rated season of the year as extremely important in deciding when to have surgery had significantly lower odds of desiring shorter waiting times (OR 0.03, P = 0.009).

	DISCUSSION

Top Abstract Introduction METHODS RESULTS DISCUSSION Appendix 1 REFERENCES

 
Child’s severity of illness, earliest available OR time, and surgeon’s suggested date appear to be the three principal factors that influence pediatric case scheduling. In addition, convenience factors, such as time off from work, distance from the hospital, and availability of child care at home, contribute to parents’ scheduling decision.

Parents are willing to accept longer waiting intervals for pediatric cardiac and plastic/reconstructive surgery compared to general surgery. One explanation may be the limited availability and high demand for surgical expertise in these specific fields creating a backlog of cases. This is supported by our observation of longer ideal waiting times and markedly high correlation between surgeon’s availability and earliest available surgery date for these specialty procedures. For interventional cardiac procedures, potential causes for variability in waiting intervals between scheduling and actual procedures included the availability of required resources and services as well as the perceived urgency of the procedure (6).

Increasing the average waiting interval from 1 to 2 wk has been shown to improve OR utilization by 13% (3). However, the incremental benefit of further increases in the duration of this waiting interval was found to be small. Based on computer modeling, OR utilization rates over 90% cannot be achieved unless scheduling takes place at an average of at least 2 wk before the procedure (3). The ability to increase OR utilization by increasing waiting times beyond this period may be limited by patient dissatisfaction (7).

Ideally, maximal OR efficiency can be accomplished without sacrificing convenience (access to OR time and resources), but these two aspects are inseparable in reality. In fact, greater efficiency requires a decrease in access (ability to book cases whenever desired) and satisfaction as defined by surgeons and patients. Making it too easy to schedule elective cases (increasing access) decreases efficiency because of the need for extra open OR capacity and potential for overtime. The results of our study suggest an overall high rate of parental satisfaction with the scheduling process (93%), with parents reporting their actual waiting times as "acceptable " up to 21 wk for certain procedures, although the reported median "ideal " waiting interval was 4 wk.

Surprisingly, parents surveyed did not show a preference for scheduling procedures during vacation or summer months. Predictable month-to-month variation was not observed in ambulatory surgery case load for 5,252 hospitals and 1,732 freestanding surgery centers in the United States (8). Although certain procedures (e.g., myringotomy tube insertion) have known seasonality with more cases booked in the winter months coinciding with the seasonality of ear infections, other procedures do not (8). Our study results suggest that parents do not rank their child’s vacation schedule or season of the year higher than other important factors (e.g., availability of a particular surgeon).

As with any survey-based study, there are several limitations that may affect the ability to apply the results to the general population. Bias in the selection of subjects should be considered, as only parents waiting in designated areas were administered in the survey (convenience sampling). Parents who preferred not to wait in these areas were not included. This procedure may possibly have selected against parents with excessive anxiety, dissatisfaction, or frustration who could not tolerate the waiting room atmosphere. Furthermore, our sample was limited to English speakers with particular demographic features (mostly college educated with a household income over $60,000 USD). Nonresponse was kept to a minimum (overall response rate of 94%), in part, because our research assistant monitored compliance. Respondents were asked to list other factors affecting the scheduling which should be included and that were not on the original questionnaire to verify content validity. Few responded (7%), and no one factor was listed by more than two respondents. Thus, we believe that our survey did not miss any important factors affecting parental scheduling.

Overall, parents reported an ideal waiting interval of 3 wk and longest acceptable interval of 6 wk. Parents ranked severity of the child’s illness, earliest available time, and surgeon’s suggested date as the three most important factors when scheduling their child’s surgery. Although the timetable for scheduling procedures was highly correlated with both mother and father having available time off work, parents did not indicate a preference for scheduling cases during vacation or summer months.

	ACKNOWLEDGMENTS

 
The authors would like to thank Pam Bustamante for her tireless effort and selfless contribution to this study. Dr. Chu’s work is supported by a career development award from the National Institute of General Medical Sciences of the National Institutes of Health (5K23GM071400-02).

	Appendix 1

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	Footnotes

 
Accepted for publication August 25, 2006.

Supported by National Institute of General Medical Sciences of the National Institutes of Health Grant 5K23GM071400-02.

	REFERENCES

Top Abstract Introduction METHODS RESULTS DISCUSSION Appendix 1 REFERENCES

 

1. Strum DP, Vargas LG, May JH. Surgical subspecialty block utilization and capacity planning: a minimal cost analysis model. Anesthesiology 1999;90:1176–85.[Web of Science][Medline]
2. McManus ML, Long MC, Cooper A, et al. Variability in surgical case load and access to intensive care services. Anesthesiology 2003;98:1491–6.[Web of Science][Medline]
3. Dexter F, Macario A, Traub RD, et al. 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. Anesth Analg 1999;89:7–20.[Abstract/Free Full Text]
4. Dexter F, Traub RD. How to schedule elective surgical cases into specific operating rooms to maximize the efficiency of use of operating room time. Anesth Analg 2002;94:933–42.[Abstract/Free Full Text]
5. Tait AR, Voepel-Lewis T, Munro HM, Malviya S. Parents’ preferences for participation in decisions made regarding their child’s anaesthetic care. Paediatr Anaesth 2001;11:283–90.[Web of Science][Medline]
6. Carroll RJ, Horn SD, Soderfeldt B, et al. International comparison of waiting times for selected cardiovascular procedures. J Am Coll Cardiol 1995;25:557–63.[Abstract]
7. Tyler DC, Pasquariello CA, Chen CH. Determining optimum operating room utilization. Anesth Analg 2003;96:1114–21.[Abstract/Free Full Text]
8. Dexter F, Traub RD. The lack of systematic month-to-month variation over one-year periods in ambulatory surgery case load—application to anesthesia staffing. Anesth Analg 2000; 91:1426–30.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (3) Citing Articles via Google Scholar Google Scholar Articles by Mariano, E. R. Articles by Macario, A. Search for Related Content PubMed PubMed Citation Articles by Mariano, E. R. Articles by Macario, A. Related Collections Economics and Health Care Research Pediatrics