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Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
Address correspondence to Robert Udelsman, MD, MBA, FACS, Department of Surgery, Yale University School of Medicine, New Haven, CT. Address e-mail to robert.udelsman{at}yale.edu
The operating room is the functional location where a large group of individuals representing three diverse groups—nursing, anesthesia, and surgery—deliver care to the common, unifying, and key individual: the patient. These three disciplines have disparate training, goals, incentives, and cultures. The ideal operating room environment would enhance collegial interactions and reward efficiency. Unfortunately, this is rarely obtained or appreciated.
In this issue of Anesthesia & Analgesia, Dexter et al. (1) assert that reductions in turnover time would have minimal impact on operating room efficiency, resource utilization, and personnel satisfaction. The original data are limited to the measurement of average turnover times at four university hospitals over a 1-yr interval. The report can be challenged on several methodological issues including: 1) the selective exclusion of "slow-down days (e.g., during American Society of Anesthesiologists meeting)," 2) the apparent arbitrary application of cost analysis of an over-utilized hour (1.75 times the cost of an under-utilized hour), and 3) the fact that the only costs considered seem to be those related to the anesthesia and perhaps nursing staff. One could also suggest that this analysis by the Director of the Division of Management Consulting may represent less than clear objectivity. These arguments, however, would be counterproductive and detract from consideration of a much broader issue. The operating room, at least in some institutions, has become a battle zone where conflict revolves not around the patient’s disease, but rather over a fundamental misalignment of incentives among employee stakeholders.
Surgeons are functionally oriented to case completion and depend on talented anesthesia personnel and trained nursing staff to deliver analgesia, anesthesia, and equipment so that the procedure can be accomplished. Surgeons are most interested in predictable start and turnover times. This orientation is divergent from nursing, and in many cases, anesthesia staff who are not infrequently encouraged to work a shift. It is not uncommon during a single operation to experience multiple changes in both nursing and anesthesia personnel. Furthermore, the operating room represents only one of several locations where a surgeon works. The surgeon also runs an office, sees the patients in clinics that generate the referrals to the operating room, and in academic medical centers is likely to run a laboratory as well as assuming significant administrative, research, and educational activities. Many anesthesiologists share the dilemma of embracing multiple and at times competing responsibilities. Nursing personnel are far more oriented to the operating room as their dominant vocational location.
The operating room administrative structure tends to punish efficiency. It is quite common that if a room finishes early, it will be selected for add-on cases, notably trauma and emergencies including those outside the expertise of nurses assigned to the room (outside of the "cluster"). This punitive relationship results in predictable behavior. It is therefore not surprising that nursing staff learn to delay turnover times to avoid onerous tasks which are frequently associated with shift overruns and compulsory overtime.
Who can question the notion that efficiently run operating rooms make fiscal sense? It is certainly in the best interest of the hospital because the operating room and the cases it accommodates represent the margin by which hospitals survive.
The goal that leaders in anesthesia, surgery, and nursing must embrace is to determine how to align incentives among these three functional groups. We must reward efficiency both with favorable shift hours and financial incentives. The operating room is not, from a fiscal perspective, dissimilar to any business that employs both significant capital resources and highly skilled personnel. The operating room represents a location where creative administrators can align with leadership in nursing, anesthesia, and surgery to set clear rewards that encourage efficiency.
The era of unlimited time for educational activities has passed. This does not suggest that we abandon our academic missions; rather, we must accomplish them efficiently. Allowing 45 min to an hour for an anesthesia resident to insert an epidural catheter and then induce general anesthesia is no longer tolerable. Similarly, surgeons can no longer allow residents, interns, and even medical students to learn how to close the abdomen while the surgeon is off site dictating the operative note. Academic institutions must lead rather than follow. Examples of creative solutions to competing educational and clinical missions are operative and anesthesia simulators through which trainees can gain sophisticated skill sets before their operative experience.
Efficiency is also required for residency training. The 80-h resident work week is likely to represent an iteration of work hour restrictions and not a final destination. Surgical residents suffer severely from delayed turnovers as they are effectively tied to the location. Anesthesia residents would also benefit from increased case efficiency and case volumes.
What is clear is that the operating room represents a unique functional unit where anesthesiologists, surgeons, and nurses must develop synergistic relationships designed to deliver efficient, compassionate, cost-effective, and safe care to patients.
Reference
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