high performing operating rooms robert b. zann md facs

11

High Performing

Operating Rooms

Robert B. Zann MD

FACS

22

EFFICIENCYEFFICIENCY

HIGH PERFORMING ORHIGH PERFORMING OR

TEAM APPROACHTEAM APPROACH

33

Office ReimbursementOffice Reimbursement

DescriptionDescription PatientsPatients MedicareMedicare TotalTotalSurgerySurgeryTotal Hip Arthroplasty MDTotal Hip Arthroplasty MD 1 1 $1486.73 $1486.73

Total Knee Arthroplasty MDTotal Knee Arthroplasty MD 1 1 $1605.67 $1605.67

Office Visits 5Pt’s/hrOffice Visits 5Pt’s/hrEst. Patient Level 3 Est. Patient Level 3 3 3 $53.16 $53.16 $159.48 $159.48New Patient Level 4 New Patient Level 4 2 2 $139.70 $139.70 $279.40

X-RaysX-RaysPelvis, 2 views 2 $60.20 $120.40Knee, 2 views 3 $60.20 $180.60

$739.88/hr

44

DRG 544DRG 544Major Joint Replacement or Major Joint Replacement or

ReattachmentReattachment• DRG Reimbursement- $11,000.00DRG Reimbursement- $11,000.00

• OR ChargesOR Charges– 1 Hour $4,125.001 Hour $4,125.00

•every minute thereafter $40.00every minute thereafter $40.00– Supplies that are built in to the First hour cost are:Supplies that are built in to the First hour cost are:

Room EquipmentRoom Equipment FTE’sFTE’s Custom PacksCustom Packs Dressing, Suction, Bovie, extra gownsDressing, Suction, Bovie, extra gowns

55

• Incremental Charges #315.00Incremental Charges #315.00– Items such as:Items such as:

• CementCement

• Cement Mixing SuppliesCement Mixing Supplies

• Irrigation suppliesIrrigation supplies

• Kamvac suctionKamvac suction

• StaplerStapler

• Extra Charges Extra Charges – Stryker Pain Pumps $200.00Stryker Pain Pumps $200.00– Intra Articular Injection $450.00Intra Articular Injection $450.00– Implant Cost $ ??Implant Cost $ ??– Platelet Rich Plasma Spray $ 408.00Platelet Rich Plasma Spray $ 408.00

66

• ACU ChargesACU Charges– Per hour $ 478.50Per hour $ 478.50

• PACU PACU – First Half Hour $ 959.00First Half Hour $ 959.00– Every minute thereafter $ 12.50Every minute thereafter $ 12.50

• Room RatesRoom Rates– Private vs Semi-Private $$$Private vs Semi-Private $$$

77

TEAM APPROACHTEAM APPROACH

•Surgical TeamSurgical Team– M.D., P.A., R.N., Surgical CoordinatorM.D., P.A., R.N., Surgical Coordinator

•ANESTHESIAANESTHESIA– MD, CRNAMD, CRNA

•OR PERSONNELOR PERSONNEL– Orthopedic OR CoordinatorOrthopedic OR Coordinator

•Stryker RepresentativeStryker Representative

88

PRE-OPPRE-OP

• Surgical TeamSurgical Team•Pre-op rounds (one week pre-op)Pre-op rounds (one week pre-op)

– H&P, Pre-op Orders - MD, & PAH&P, Pre-op Orders - MD, & PA– X-ray rounds – entire teamX-ray rounds – entire team– Pre-op Labs- Medical ClearancePre-op Labs- Medical Clearance– Post-op Orders- Preliminary CompletionPost-op Orders- Preliminary Completion– Post-op note- Preliminary CompletionPost-op note- Preliminary Completion– Pre-Op HoldingPre-Op Holding

Consent and H&P signedConsent and H&P signedInitial correct site on patientInitial correct site on patient

99

Pre-operative x-ray rounds (1 week prior to surgery)

1010

• AnesthesiaAnesthesia•Pre-op consultationPre-op consultation

Optimal 24-48 hours pre-opOptimal 24-48 hours pre-op

•Regional Anesthesia Administration in Pre-Op Regional Anesthesia Administration in Pre-Op holding areaholding area

• OR PersonnelOR Personnel•Confirmation of Patient, Procedure & SiteConfirmation of Patient, Procedure & Site

•Confirmation of ConsentConfirmation of Consent

•Confirmation of LabsConfirmation of Labs

1111

• Stryker RepresentativeStryker Representative

•Pre-operative templatingPre-operative templating

•Proper InstrumentationProper Instrumentation

•Multiple instrument setsMultiple instrument sets

•Turn over instrumentation as neededTurn over instrumentation as needed

•Correct ProsthesisCorrect Prosthesis

•Assist in room turnoverAssist in room turnover

1212

• PRE-OP ORDERS: KNEE (Dr. Robert Zann #339)

• DIAGNOSIS• REGULAR DIET• LAB WORK DONE AS OUTPATIENT BY Dr.

Results to O.R.• CHEST X-RAY• EKG• CBC, SMA 12, LYTES, PLATELET COUNT• ADDITIONAL LABS: PT, PTT• MEDICAL / CARDIAC CLEARANCE BY DR.• CLEAN CATCH U/A• TYPE AND SCREEN

UNITSBLOOD

• BILATERAL BK AE HOSE

• RESERVE CPM MACHINE• RESERVE ELECTRIC COOL• NPO AFTER MIDNIGHT FOR SURGERY IN AM• CONSENT FOR TOTAL KNEE ARTHROPLASTY• START IV IN OPPOSITE UPPER EXTREMITY AS

OPERATIVE KNEE• WITH 18 GA INTERCATH R/L @ __________cc/hr• PRE-OP ANTIBIOTIC: TO BE GIVEN PER O.R.

PROTOCOL• ADDITIONAL

AGENT:_______________________________________• CELEBREX 200mg 1 PO 1 HOUR PRIOR TO SURGERY

UNLESS ALLERGIC • TO SULFA OR SULFONAMIDES

• M.D. Signature _____________________ M.D. # 339

• PRE-OP ORDERS: HIP (Dr. Robert Zann #339)

• DIAGNOSIS• REGULAR DIET• LAB WORK DONE AS OUTPATIENT BY Dr.

Results to O.R.• CHEST X-RAY• EKG• CBC, SMA 12, LYTES, PLATELET COUNT• ADDITIONAL LABS: PT, PTT• MEDICAL / CARDIAC CLEARANCE BY DR.• CLEAN CATCH U/A• TYPE AND SCREEN

UNITSBLOOD

• BILATERAL BK AE HOSE

• NPO AFTER MIDNIGHT FOR SURGERY IN AM• CONSENT FOR TOTAL HIP ARTHROPLASTY• START IV IN OPPOSITE UPPER EXTREMITY AS

OPERATIVE HIP• WITH 18 GA INTERCATH R/L @ __________cc/hr• PRE-OP ANTIBIOTIC: TO BE GIVEN PER O.R.

PROTOCOL• ADDITIONAL

AGENT:_______________________________________• CELEBREX 200mg 1 PO 1 HOUR PRIOR TO SURGERY

UNLESS ALLERGIC• TO SULFA OR SULFONAMIDES

• M.D. Signature ____________________ M.D. # 339

Pre-op Orders

1313

Post-op OrdersDr. Robert Zann

#339) Pg. 1 of 4

1. Vital Signs: Q 4 hours

2. Diet as tolerated • Reg •

3. IV: D5 LR at 75 cc/hr until tolerating po fluids, then MAP

4. X-Rays in PACU •Knee portable A/P and Lateral (long Cassette) • R

• L •Hips portable A/P and Pelvis - see tip of prosthesis • R •

L

5. LABORATORY •H & H, BMP in PACU, H & H QAM x 3

If Hb is less than or equal to 8 grams, transfuse 1 unit Blood(Autologous if available), repeat H/H post

transfusion •If Potassium is below 3.5 in PACU, add 40 meq. to first IV

liter •Creatinine with calculated clearance in PACU and Daily

notify M.D. if less than 30ml/min

6. If Temperature > 102o, get urine culture & blood cultures

x 2, then notify physician

7. If Temperature > 101o, give Tylenol as ordered & ecourage incentive spirometer

8. Incentive Spirometry Q1H while awake

9. Bilat. BK A-E hose for hips; contralateral for knees

10. Physical Therapy: OOB TODAY; • Crutches • Walker

11. Weight bearing: • Full • Partial • Toe Touch

12. Foley catheter PRN - If used, • discontinue Post-op Day #1, or • Discontinue after the epidural catheter is

discontinued

M.D. Signature __________________________ M.D. # 339

( Dr. Robert Zann #339) Pg. 2 of 4

13. Remove Hemovac in A.M. Post-op Day # 1

14. Start daily dressing changes Post-op Day # 1 - Adaptic and 4x4’s

15. Neurovascular checks to lower extremities every 2 hours for 24 hours, then every 4 hours for 24 hours

16. Dress in regular clothes starting PO day #1

17. MEDICATIONS: •Pre-op Meds per Medical Dr. Consultant •TYLENOL 650mg. P.O. Q4H PRN Temp. > 101 F •FEOSOL 325 ONE P.O. daily •AMBIEN 5mg. P.O. nightly prn sleep, may repeat x 1 •DARVOCET N-100 1 TAB P.O. Q4H prn mild pain •PERCOCET 5/325 1 TAB P.O. Q4H prn mild to moderate

pain •PERCOCET 5/325 2 TABS P.O. Q4H prn moderate pain •MORPHINE SULFATE _____________ Q4H prn severe pain •CELECOXIB (Celebrex) 200mg 1 orally daily •COLACE One P.O. Daily until B.M., then discontinue •LAX of choice •ZOFRAN 4mg I.V. or P.O. Q6H prn for nausea •ANTACID of choice 30cc orally every 4 hours as needed •REGLAN 10mg IV IVP every 8 hours x 48 hours •OXYCONTIN 20mg orally every 12 hours

M.D. Signature _________________________ M.D. # 339

1414

(Dr. Robert Zann #339) Pg. 3 of 4

18. POST OP-ANTIBIOTICS:•Cefazolin 1gm intravenously every 8 hours for 3 doses (24 hours)•Clindamycin 600mg intravenously every 8 hours for 3 doses (24 hours)•Vancomycin 1 gm intravenously every 12 hours for 2 doses (24 hours)•Other

19. Coumadin Per Protocol After Daily Pro Time ( ) Yes ( ) NoPT & PTT DAILY, ( ) YES ( ) NO START: ______________ 10mg P.O. first dose Date:_______________ Time:_______________then daily thereafter according to Scale / INR as follows:> 2.0 = No Coumadin1.51 - 2.0 sec = 2.5mg.1.21 - 1.5 sec = 5mg.< 1.2 = 7.5mg.If NO, list directive:

20. • ARIXTRA 2.5mg. subcutaneous q 24 hours, - • Start @ PM

21. • Lovenox 40mg subcutaneous q 24 hours, - • Start @ AM

22. • PCA Pump - discontinue POD #1 – for break through pain,Toradol 15mg I.V. Q6H prn x 24 hours

23. • Epidural Catheter - when discontinued – for break through pain,Toradol 15mg I.V. Q6H prn x 4 doses within 24 hours, then discontinue

M.D. Signature _________________________ M.D. # 339

POST-OP ORDERS: HIP/KNEE (Dr. Robert Zann #339) Pg. 4 of 4

24.• TOTAL HIP OR KNEE CARE PLAN

•TOTAL KNEE CAREA. Apply Cool Ice Machine at 50oB. CPM Machine for Total Knees; Range: 0-45 3 hours BID Increase 5-20 daily

START: Post–op Day #2C. Knee patients OOB after surgery and Flex Knees 900 as toleratedD. Knee Immobilizer for comfort and quadricep weakness

• TOTAL HIP CAREA. Hip dislocation precautions and exerciseB. Special instructions for deviation from protocol:

25. CONSULTS:A. Medical Dr. __________________________B. Rehabilation FacilityC. Social ServiceD. Occupational Therapy - if patient is being discharged home E. Radiation Oncology Prophylatic Radiation Therapy ( )Yes ( )No

26. HOME HEALTH CARE:• COMMUNITY HOME HEALTH • MED-TECH

M.D. Signature _____________________ M.D. # 339

Post-Operative Orders

1515

POST-OPERATIVE NOTE: (Dr. Robert Zann #xxx)

#Name of Operating Surgeon: Dr. Zann

Name of Assistants:Tolson/ Veech / Fenton / Huffman

Findings- Osteoarthritis Left HipPre-op Diagnosis- Osteoarthritis Left HipPost-op Diagnosis- sameTechnical Procedures Used- Left Total Hip Arthroplasty

Implants:Femur-Head-Acet-Insert-

AnesthesiaBlood Loss ccDrains one medium hemovacSpecimens removed Left femoral headComplicationsComments Intra- Articular Injection

“ Incision

M.D. Signature ____________________ M.D.# xxx

POST-OPERATIVE NOTE: (Dr. Robert Zann #xxx)

#Name of Operating Surgeon: Dr. Zann

Name of Assistants:Tolson/ Veech / Fenton / Huffman

Findings- Osteoarthritis Left KneePre-op Diagnosis-Osteoarthritis Left KneePost-op Diagnosis- sameTechnical Procedures Used- Left Total Knee

Arthroplasty

Implants:Femur- #Tibia- #Tibial insert- # / mmPatella- mm cemented

AnesthesiaBlood Loss ccDrains one medium hemovacSpecimens removed- distal femur, and proximal tibial and

patella

ComplicationsComments Intra- Articular Injection

M.D. Signature ____________________ M.D.# xxx

1616

COMPUTER DATACOMPUTER DATA

–Average Time for Pre-Op Nursing Average Time for Pre-Op Nursing Assessment Assessment and preparationand preparation–Average Time for Administration of Average Time for Administration of AnesthesiaAnesthesia–Average Time for Operating Room Average Time for Operating Room PreparationPreparation–Average Surgical TimeAverage Surgical Time

–Surgical Turnover TimeSurgical Turnover Time•Last Staple insertion to next case skin Last Staple insertion to next case skin incisionincision

–Operating Room Turnover TimeOperating Room Turnover Time•Patient out of room to next patient in roomPatient out of room to next patient in room

1717

Turnover Time IssuesTurnover Time Issues• Surgical Turnover Time

– Defining Turnover Time- Last Staple to Incision• Hospital Turnover Time

– Patient exiting room and next patient entering room

• Ways to alleviate or decrease the turnover timeWays to alleviate or decrease the turnover time– Anesthesia- Pre-op holding Area vs In roomAnesthesia- Pre-op holding Area vs In room

• Anesthesia Administered in Prep-op HoldingAnesthesia Administered in Prep-op Holding– Patient in room and positioned immediately- no delaysPatient in room and positioned immediately- no delays

• Anesthesia Administered in the ORAnesthesia Administered in the OR– 20 min for Hip20 min for Hip– 30 min for Knees30 min for Knees

Additional Time to the turnover $$$$Additional Time to the turnover $$$$

• Turnover Time : Hospital Turnover Time : Hospital SurgicalSurgical– One Room/no Pre-opOne Room/no Pre-op 20 min20 min 1 hr 1 hr– One Room/Pre-opOne Room/Pre-op 20 min20 min 45 min 45 min– Two Rooms/no Pre-op -20 min(Two Rooms/no Pre-op -20 min(ptpt already inalready in 22ndnd room room) ) 10-15 10-15

min min – Two Rooms/Pre-opTwo Rooms/Pre-op -30 min( -30 min(pt. already in 2pt. already in 2ndnd room room)) 5-10 min 5-10 min

1818

My Average Operating TimeMy Average Operating Time

• Patient enters room to Patient enters room to Patient exiting room Patient exiting room

– Total Hip 57 minTotal Hip 57 min– Total Knee 70 minTotal Knee 70 min– Bilateral Knees 120 min Bilateral Knees 120 min

• Time from Incision to Wound Closure Time from Incision to Wound Closure

– Total Hip 34.5 minTotal Hip 34.5 min– Total Knee 49.9 minTotal Knee 49.9 min– Bilateral Knee 96.5 minBilateral Knee 96.5 min

1919

1:00

Hip 7:30 1 3 4 5 6

Knee 9:00 1 3 3 4 5 6

Hip 10:30 1 4 3 4 5 6

Knee 12:00 1 3 4 5 6

1 Admission to Pre-op

2 Pre-op holding Regional AnesthesiaTotal Knee- Femoral/Sciatic Nerve Block with catheter & SpinalTotal Hip- Spinal

3 Admission to Operating Suite

4 Incision

5 Case Completed

6 Transferred to PACU

10:30am 11:00am 11:30am 12:00pm 1:30pm6:30am 7:00am 7:30am 8:00am 8:30am 9:00am 9:30am 10:00am 12:30pm

One Room Efficiency Model with no Pre-op Holding Area

Huffman-Zann Timeline

2020

Hip 7:30 1 3 4 5 6

Knee 9:00 1 2 3 4 5 6

Hip 10:00 1 2 3 4 5 6

Knee 11:00 1 2 3 4 5 6




4 Incision

5 Case Completed


6:30am 7:00am 7:30am 8:00am 8:30am 9:00am 9:30am 10:00am 12:30pm 1:00pm10:30am 11:00am 11:30am 12:00pm

One Room Efficiency Model with a Pre-op Holding Area


2121

Hip 7:30 1 3 4 5 6

Knee 8:30 1 3 4 5 6

Hip 9:30 1 3 4 5 6

Knee 10:30 1 3 4 5 6

Hip 11:30 1 3 4 5 6




4 Incision

5 Case Completed



6:30am 7:00am 7:30am 8:00am 8:30am 9:00am 9:30am 10:00am 12:30pm 1:00pm10:30am 11:00am 11:30am 12:00pm

Two Room Efficiency Model with no Pre-op Holding Area

2222

Hip 7:30 1 3 4 5 6

Knee 8:30 1 2 3 4 5 6

Hip 9:30 1 2 3 4 5 6

Knee 10:00 1 2 3 4 5 6

Hip 10:30 1 2 3 4 5 6




4 Incision

5 Case Completed


6:30am 7:00am 7:30am 8:00am 8:30am 9:00am 9:30am 10:00am 12:30pm10:30am 11:00am 11:30am 12:00pm

Two Room Efficiency Model with a Pre-op Holding Area


2323

Greeting patients in Pre-Op Admission @ 7:00am

Confirming laboratory results and signing operative consent

2424

1st Case Total Hip Arthroplasty in room @ 7:30am

2525

2nd Case- Total Knee Arthroplasty room setup @ 7:30am

2nd Case- TKA patient receiving Femoral Nerve Block w/catheter @ 7:30am

2626

1st Case THA started @ 7:50am

2727

1st Case instruments removed

Prior to completion of procedure

2828

Immediate operative dictation

2929

Completion of operative note and post-op orders

3030

2nd Case-TKA in room @ 8:00am

3131

Post-operative discussion with family

3232

2nd case completed @ 9:15 am

2nd room cleaned by 9:25am

3333

2nd Case closing-completed @ 9:15

am

3rd Case in room @ 9:00am

3434

Case 3 following patient confirmation, correct side confirmation

And preliminary completion of post-operative orders

3535

ConclusionsConclusionsThe most efficient is two rooms with a pre-op holding areaThe most efficient is two rooms with a pre-op holding areaThe least efficient is one room without pre-op holdingThe least efficient is one room without pre-op holdingReduction in Turnover Time (surgical turnover time!)Reduction in Turnover Time (surgical turnover time!)

– Early Admission for Same-Day Lab Work,Early Admission for Same-Day Lab Work,• i.e. PT/PTT, Bleeding time, Platelet count, EKG, etc..i.e. PT/PTT, Bleeding time, Platelet count, EKG, etc..

– Pre-op Anesthesia Evaluation-24-48 hrs prior to Pre-op Anesthesia Evaluation-24-48 hrs prior to admissionadmission

– First Case with shortest time for Anestetic AdministrationFirst Case with shortest time for Anestetic Administration• i.e. THA rather that TKAi.e. THA rather that TKA

– Use of Pre printed templates (orders, post-op notes)Use of Pre printed templates (orders, post-op notes)– Immediate Post operative dictationImmediate Post operative dictation– Clearance of all instruments and trial component during Clearance of all instruments and trial component during

wound closurewound closure– Availability of Multiple instrument setsAvailability of Multiple instrument sets– Cooperation of OR personnel to initiate room cleaning as Cooperation of OR personnel to initiate room cleaning as

patient is transported from roompatient is transported from room

3636

Thank You!

high performing operating rooms robert b. zann md facs

Documents

preop orders md

preopsurgical teampreop

cchrpreop antibiotic

operative knee

preoperative xray

operative hip

hour cost

week preophp