Improving Your OR Efficiency

Is it politically correct to speak about the cost-effectiveness of an operating theater?

DIDIER DUCOURNAU, MD

When I told Carl Awh during an Italian dinner that I was performing 14 retina surgeries in a single operating room every operating morning and up to 24 surgeries per day, I saw in his eyes more than incredulity. It was as if he was thinking, "He forgot to take his medicine this morning." At the end of the dinner he told me, "You should publish your OR organization; this would interest a lot of people in the United States."

REASONS FOR IMPROVING THE MANAGEMENT OF THE OPERATING THEATER

In fact, many reasons inclined me to organize my operating theater in order to have better time effectiveness:

► Emergency acceptance: A retinal surgeon must be able to accept emergencies at all times (retinal detachments, macular hole, cataract surgery complication, endophthalmitis, etc.) for 2 reasons:

• The final functional success may be linked to the processing speed.

• A retinal surgeon is obliged to work in relation with referring ophthalmologists who need to immediately find a retina center to accept their patients and thus relieve their responsibility.

Avoiding a long waiting list is beneficial for the patient and, in the end, a secret for success for the retinal surgeon. However, this means that the OR must have the capacity, every day, to adapt and accept additional retinal surgeries.

► A need for general anesthesia with faster conditions:

• Since hyaluronidase use disappeared some years ago, quality and reliability of retro- and peribulbar anesthesia has decreased.

• In the meantime, the quality of our intraocular manipulations increased in precision, making our failure rate decrease considerably. In the past, we easily accepted being forced to limit the posterior hyaloid peeling (thus jeopardizing the final success), when local anesthesia rendered the eye immobile. Nowadays, with our improved peeling precision, this is no longer acceptable.

• New techniques of general anesthesiology with short-action drugs, without intubation, inclined me to reconsider a larger use of general anesthesia. However, in most operating theaters, patients are put to sleep and awakened within the OR, thus requiring more than 30 minutes between 2 operations. This is acceptable for those operations that may last 2 hours, but for operations that last a mere 5 or 10 minutes, this 30-minute break is unreasonable. In these ORs, only 2 epiretinal membrane and 2 macular hole surgeries are accomplished in a morning, even if the actual surgical time is only 60 minutes. The risk may be that the surgeon can pressure the anesthesiologist, clearly showing him a certain degree of impatience and resulting in an early extubation.

► Personal complete intolerance when it comes to waiting for an instrument or for the next patient without getting worked up:

• I am much more tired when I am waiting for nothing compared to when I am working. I think that irritation may be induced by a delay, agitation of the staff that wants to make up the time, noise, or improvisation. All are sources of fatigue and lack of concentration.

• On the contrary, if everybody does the job calmly, and if everything is calculated to avoid any delay, then a kind of operating rhythm is established and all the surgeon's brain cells are able to respond to a sudden unexpected circumstance.

RESULTS OF OUR APPROACH

Starting from that, with the clinic manager's help, we organized the operating theater (Figure 1), as every industry would do with its production unit, in order to obtain a more effective result. Our operating theater offers 4 operating rooms dedicated to open globe surgery (other rooms are dedicated for refractive and nonsterile surgery). In these 4 operating rooms, 17,000 open globe surgeries are accomplished per year, ie, an average number of 80 surgeries per day, 20 per room and per day, from 8:30 a.m. to 6:00 p.m. The most impressive thing noticed by visitors is the lack of noise and agitation, giving the illusion of a less busy, stress-free OR. This performance is the result of multiple additional details.

Figure 1. Operating theater arrangement.

Operating Theater Arrangement. To avoid any circuit congestion, our operating theater differs from most others. In having 2 very large areas of both pre- and postop anesthesia, we are able to admit 20 patients at the same time. The preoperating room is equipped with 8 anesthesia-equipped stations (2 patients in preparation for each OR); the postsurgery room is equipped with 12 (3 patients per OR) (Figures 2 and 3).

Figure 2. View of the preoperating room. Please note the video monitor that informs the anesthesiologist of the perfect timing for commencement of the anesthesia.

Figure 3. View of the postoperating room.

The air treatment of the whole theater obeys a simple rule: the farther from the entrance, the more sterile the area and the higher the air pressure. The sterile storage of the instruments is therefore located at the end of the fourth OR, far behind the surgeons. When an instrument is needed, the nurse can access it immediately by going through the door at the bottom of the OR.

Operating Tables. Our operating theater is equipped with 24 available operating tables (20 for the pre- and postop rooms, the other 4 being the 4 ORs), which are slightly modified running strikers. They are modified in the sense that we removed everything under the patient's head support to allow more space for the surgeon's leg movement. With these 2 large rooms and these running tables, we can then ask the anesthesiologists to carry out their pre- and postop duties outside of the operating room.

Patient Rotation. Upon arrival, the patient is placed on a running table where they will stay until they leave the operating theater. The patient is then conducted to the preop room where anesthesiologists will perform a first sterilization of the operating site.

A video monitor connected to the 4 microscope cameras informs them when they must begin the local or general anesthesia. They perform it without rushing, controlling the patient's data on their monitors. When the room is cleaned, the patient is taken to the OR. When general anesthesia is performed, the time during which the patient is disconnected is between 10 to 15 seconds. The running table is placed and blocked according to marks made on the floor, which obviates the need to move the surgeon's foot pedals. After a second sterilization of the site, the patient's head is immobilized with sandbags. When the operation is finished, the patient is taken to the postop room where he or she can wake up slowly under control, with an analgesic treatment if needed. So there is no rush to wake up the patient and also no risk of early extubation.

Between 2 Patients. When a surgery is finished, while the patient is taken to the postop room, 2 employees enter, remove everything from the previous patient, clean up the OR, and vaporize antiseptic solution. This takes 3 minutes, during which the assistant washes his/her hands and the surgeon fills out the report. Then, the assistant prepares the following table with the nurse while the surgeon prepares himself/herself; this takes 3 additional minutes. So the "lost time" between 2 operations is about 6 minutes. Many positive impacts result from this:

► There is no need to work in 2 different ORs in order to save time, as can be the case when anesthesia induction and wakeup are performed within the OR.

► The OR, the most crucial area of the unit, where the highest financial investment is done, uses better time management and is therefore made more profitable.

► The surgeon does not lose time in performing the local anesthesia himself, resulting in the following consequences:

• The surgeon remains concentrated on his or her job.

• The local anesthesia is performed at the perfect time by the anesthesiologist himself, allowing a higher control of the effectiveness of the anesthesia.

During Surgery. Surgery is not a race. There is no reason to go faster if that carries with it a decreased quality of the procedure. However, for the same quality of surgery, a faster procedure will induce a lower surgical trauma. In addition, there are choices that allow one to go faster while improving the control or reducing the trauma, for example:

► The use of the surgical slit lamp avoids performing a third sclerotomy and increases the precision (and then the speed) of the manipulations due to the capacity for the free left hand to stabilize the forceps, while decreasing the risk of phototoxicity.

► The use of a vitrectomy machine equipped with an aspiration flow control system allows the surgeon to perform a faster vitrectomy (using levels of vacuum too dangerous with a vacuum control system) while decreasing the risks of catching the retina.

► The use of Brillant Peel facilitates the ILM peeling time while avoiding any toxic effect or vitreous staining

► The choice of certain forceps with a higher grasping effect, allowing to remove a larger membrane surface while reducing the number of exits and entries.

Respecting these choices allows to decrease the trauma but also to decrease the surgical time. You can now easily understand how I regularly perform 14 surgeries in the morning.

CONCLUSION

We must not reproduce the mistake made by anterior-segment surgeons who, praising their surgical speed, let the patients understand that cataract surgery was riskless.

A retinal surgery is something serious that requires concentration and flexibility of the surgeon. This is why I am happy with this operating theater organization that allows me to work calmly (I am not tired when I come back home after 24 surgeries) and that gives me time to accept emergencies. On Monday morning, when I begin my consultations, I regularly have 14 patients for Tuesday's surgical program (most of them composed of epiretinal membranes and macular edemas). During my consultation day, I regularly admit 7 to 9 additional patients sent by referring ophthalmologists, who tell their patients to come with their luggage. I have no trouble accepting these patients, as I am able to perform up to 24 surgeries the following day. But sometimes, and this is the destiny of our job, there are only 2 emergencies instead of 7 to 9: This is no problem for me either, for the 14 cases of the morning will damp down the variations and I will finish my surgical day at 3 p.m. without the feeling of having not properly filling out my work day.

Of course, my operating theater organization presents advantages that take into consideration some specific characteristics of the French health system, as well as personal situations that perhaps cannot be transposed for the Carl Awh, or more generally, US environments. Let's consider this paper as simply an example of one way to accurately perform, not as a universal model for executing retinal procedures. RP