The Swing-Room" Experience: Productivity Improvements in Elective Hand and Upper Extremity Surgery at St. Pauls Hospital.

Dr. Thomas Goetz, MD, FRCSCClinical Assistant Professor, UBC

DisclosureNo industry conflicts with this presentation.

Swing-Room Concept ImplementationOpened January 31, 20081st two years of operations Funded by the Lower Mainland Innovation and Integration Fund (LMIIF)3rd yearFunded by Procedural Care FundingPATIENT FOCUSSED FUNDING

The SPR Swing-Rooms

The SPR Swing-Rooms

Goals of the Swing-RoomImprove Quality of CareSafer environment than minor procedure roomExpand scope of SPR outside of main ORDecant main OR Decreased post-op recovery time and post-op painReduce Wait TimesCost Savings or Increased Efficiencies

Current Study Look at performance of swing roomsRetrospective audit of data gathered from office and operating room data collected at our institution (St. Pauls Hospital). Analysis of:O.R. Operations Management Efficiencies:Surgeon utilizationSurgical turnover timeThroughput Operating room costsTotal and costs/caseHand and Upper Extremity Waitlist Reduction

Our Data SetData collected from one SPH Hand and Upper Extremity surgeonPre-SPRFeb. 2007 Jan. 2009 (2 years)657 patients over 207 O.R. daysPost-SPR systemFeb. 2009 Oct. 2011 (21 months)962 patients over 243 O. R. daysSwing-Room Patients320 patients over 46 O.R. daysMain O.R. Patients642 patients over 197 O.R. days

Data AvailableO.R. TimesScheduledPre-opSetupAnesthesia SurgeonCleanupPACUOffice TimesDate of ConsultationDecision Date

Patient age, genderLogged Procedure CodesTimes (start and end times)

ResultsOperations Management

Surgeon Utilization

Surgical Turnover TimeIncreased RegionalBlocks?

Before theSwing-RoomMain O.R.53m:25sAfter the Swing-RoomMain O.R.45m:54sSwing-Room10m:44s

Throughput

Before theSwing-RoomMain O.R.3 Cases/DayAfter the Swing-RoomMain O.R.3 Cases/DaySwing-Room7 Cases/Day

Total Cases per Year (assuming 1.5 OR days/week)28% Increase in case throughput= 86 Additional Cases

ResultsSurgical Costs

O.R. Variable Cost Differences/Day

Main O.R.Swing-RoomCost of LabourRNs @ 7.5 h/d @ $33/h + 18% relief & 22% benefits=6 RNs0.5 PWA0.5 AA$2,245.504 RNs0.5 PWA0.5 AA$1732.50Cost of Supplies(Differences in anesthetic costs, surgical sets and surgeon preference cards)Supplies @ $155/case3 cases/day

$465Supplies @ $90/case7 cases/day

$630

Total Variable Cost/Day$2710.50$2362.50

Variable Cost/Case63% Variable CostSavings per Case

Main O.R.Swing-RoomTotal Variable Cost/Day$2710.50$2362.50Cases per Day37Variable Cost per Case$903.50$337.50

ResultsWaitlists

Waitlist Reduction H & UEPrior to Swing-RoomElective wait-times ~36 weeks (range 21-44 weeks)Based on difference between surgical decision date and O.R. booking dateAfter Swing-RoomElective Wait-times ~7 weeks (range 6-10)

Simple Waitlist ModelAssume 1.5 O.R. days/week.4 Main O.R. days/month3 cases/day2 Swing-Room days/month7 cases/dayAssume 5 new patients booked per week for surgery.Assume patients are interchangeable between O.R. settings.

Waitlist Change over 1 year(starting with 144 on waitlist)At 1 Year:170 patients

At 1 Year:68 patients

Chart1

144144

144.5142.5

145141

145.5139.5

146138

146.5136.5

147135

147.5133.5

148132

148.5130.5

149129

149.5127.5

150126

150.5124.5

151123

151.5121.5

152120

152.5118.5

153117

153.5115.5

154114

154.5112.5

155111

155.5109.5

156108

156.5106.5

157105

157.5103.5

158102

158.5100.5

15999

159.597.5

16096

160.594.5

16193

161.591.5

16290

162.588.5

16387

163.585.5

16484

164.582.5

16581

165.579.5

16678

166.576.5

16775

167.573.5

16872

168.570.5

16969

169.567.5

Main O.R.

Swing and Main O.R.

Weeks

Patients on Surgical Waitlist

Sheet1

12345678910111213141516171819202122232425262728293031323334353637383940414243444546474849505152

Main O.R.144144.5145145.5146146.5147147.5148148.5149149.5150150.5151151.5152152.5153153.5154154.5155155.5156156.5157157.5158158.5159159.5160160.5161161.5162162.5163163.5164164.5165165.5166166.5167167.5168168.5169169.5

Swing and Main O.R.144142.5141139.5138136.5135133.5132130.5129127.5126124.5123121.5120118.5117115.5114112.5111109.5108106.5105103.5102100.59997.59694.59391.59088.58785.58482.58179.57876.57573.57270.56967.5

ConclusionThe use of a Swing-Room concept can improve OR room productivity and efficiency while decreasing costs/case.Implementation of a Swing-Room concept can be used to decrease waitlists.Shows how patient focused funding can be used in a government funded hospital to radically decrease waitlists.

Questions ?

Anesthesia StudyA Study of General Anesthesia and Brachial Plexus Block for Outpatient Upper Limb SurgeryDr. Seib, Dr. Head, Dr. Schwarz

Swing-Room BackgroundIn 2008, the Providence Health Care Health Authority obtained government funding Capital Payback Fund Funding used to:Expand the surgical outpatient departmentBuild a swing-room operating theatre system.Two (2) side by side procedure roomsPerform surgeries under regional anesthetic blocks which could not otherwise occur outside of the main OR under local anesthetic.

How Much Funding?

Typical Orthopaedic Hand and Wrist O.R. SlateOsteotomy left small metacarpal with possible joint release (30mins)Left wrist scapho-trapezium-trapezoid fusion (90mins)Left wrist arthroscopy with debridement (45mins) Ulnar shortening osteotomy of left wrist for distal radius malunion (45mins)Left EIP TO EPL transfer (60mins)Resection soft issue mass dorsum left wrist (60 mins) Right proximal row carpectomy possible scaphoidectomy and 4 corner partial wrist fusion (90mins)

Operations Management - DefinitionsOR Utilization% time that OR room occupied with nursing/physician activityHigh percentage utilization reflects decreased room idle time Surgeon Utilization% time that surgeon is in O.R. room doing surgeryExcludes surgeon set-up time (time not recorded)Generated from case start and end timesAnalysis of Surgical Turnover TimeTime between the surgical end of a case to the surgical start of the next caseThroughput Case output per day

O.R. UtilizationExtra Reserve Capacity from 2 Room System

Waitlist Change over 1 Year

The SPR Swing-Rooms

Surgical Turnover TimeNegative Turnover Time

Before theSwing-RoomMain O.R.53m:25sAfter the Swing-RoomMain O.R.45m:54sSwing-Room10m:44s

Upper Extremity Wait TimesPrior to the inception of the swing room, wait times for elective upper extremity surgery were slowly increasing over time.By January 2009,Wait time to surgery ~211 days Calculated from booking date to date of surgery

Forecasting (Pre-Swing Room)Extrapolating this increasing trend lineWait times would be estimated to increase to ~250 days by December 2011

250 Days

Waitlists After Swing-Room Increased case output in the Swing-Room -> caused direct decreases in the senior authors waitlist (for Swing-Room eligible cases).

Ripple Effects in the Main O.R.Implementation of the Swing-Room-> Caused off-loading of the Main O.R.

As a result,Wait times for cases not suitable for the Swing-Room that had to be done in the Main O.R. also decreased.

Build costs part of Capital Payback Fund used to revamp/renew and expand surgical outpatient facilities. Facilitated by head of surgical services Cheryl Bishop.Patient focussed funding vs block funding*Central core area. Room on each side*Clean supply closet for picked case carts, contaminated case cartoutflow closet.View from one OR across core to second OR*Only surgeon that fully utilized the time for cases that would require main OR. Eg no local cases.**International Statistical Classification of Diseases and Related Health Problems,

% time that surgeon actually working. If you want to improve health care delivery then make the surgeon work!**Likely due to increased use of regional blocks and less use of general anesthetics in general*Assuming 1.5 OR days per week. After Swing room is started assume allocated to swing and to the main ORSome estimates required. Savings in PACU space and nursing, Day care space and nursing.Anaesthesia assitant now full timeOCERALL TOTAL COST IS ABOUT EQUAL*Significant savings in cost/case**

After 21 months wait list to 7 weeks. But really after 8 months was a 2 monthsWhile maintaining total costs near level.***These are not simple trigger finger releases or carpal tunnels.Performed under regional blocks +/- sedation*This slide assume that a surgeon gets 6 O.R. days in a 4 week period of time*Likely due to increased use of regional blocks and less use of general anesthetics in general