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PERIOPERATIVE: Enhanced recovery after surgery

Enhanced recovery after surgery (ERAS) refers to redesigned perioperative care, sometimes also referred to as fast-track recovery after surgery.  Among the objectives are to reduce readmissions and avoid opioid abuse.  Changes include early ambulation, multi-modal analgesia and careful attention to nutrition.  The Cleveland Clinic includes ERAS in a list of the top 10 medical innovations for 2018.  The Gramlich article describes how the ERAS guidelines for colorectal surgery were implemented in six Canadian hospitals by the Alberta Health Services.  More information can also be obtained from the ERAS Society.


Cleveland Clinic. Top 10 medical innovations.  Click here: http://innovations.clevelandclinic.org/Summit/Top-10-Medical-Innovations.aspx

Gramlich, L.M., and others. (2017). Implementation of enhanced recovery after surgery: A strategy to transform surgical care across a health system. Implementation Science. 12(67). Click here:  https://implementationscience.biomedcentral.com/track/pdf/10.1186/s13012-017-0597-5?site=implementationscience.biomedcentral.com

ERAS Society. Click here: http://erassociety.org/   Posted by AHA Resource Center (312) 422-2050, rc@aha.org

PATIENT SAFETY: Handoffs between ICU and OR

There is a lot of literature describing problems with, and best practices for, the transfer of care of post-surgical patients moving into the intensive care unit setting.  However, after conducting a comprehensive literature search, the authors of this brief commentary found no comparable literature about the reverse type of handoff – for patients going from the special care unit into surgery.  They suggest that a checklist be adopted and give an example of one such checklist.  They also recommend that a verbal handoff be required.

What do I like about this article?  The authors are authoritative (Mount Sinai and Johns Hopkins medical schools) and I like the actual example of the handoff checklist.  Also, I like it that they appear to be filling a gap in the medical literature – at least at the time that they wrote this commentary.

Source: Evans, A.S., Yee, M.S., and Hogue, C.W. (2014, Mar.). Often overlooked problems with handoffs: From the intensive care unit to the operating room.  Anesthesia & Analgesia, 118(3), 687-689.  Click here for free full text: http://journals.lww.com/anesthesia-analgesia/Fulltext/2014/03000/Often_Overlooked_Problems_with_Handoffs___From_the.31.aspx  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

OPERATING ROOMS: Cost benefit of synthetic gloves

Natural rubber latex gloves are less expensive to buy than synthetic latex surgical gloves but can cause allergic reactions in staff and patients.  This study conducted at Alta Bates Medical Center (Berkeley, CA) prepared a cost benefit analysis comparing the different types of gloves and including the cost of treating cases of allergy.  The hospital did already use a large number of synthetic gloves, but converting completely to the synthetic gloves was found to save nearly $75,000 or 25 percent of overall OR operating costs.

Source: Wharton, K.R., and others. (2016, June). Can converting to synthetic surgical gloves lower hospital operating room costs? OR Manager, 32(6), 22-23, 25-26.  Click here for the publisher’s website: http://www.ormanager.com/can-converting-synthetic-surgical-gloves-lower-hospital-operating-room-costs/   The article mentions that a full case study can be requested from one of the authors – Philippe Henderson – by emailing him at: philippe.henderson@kraton.com   Posted by AHA Resource Center (312) 422-2050, rc@aha.org

OPERATING ROOMS: 60 percent of margin comes from perioperative services at better performing hospitals

These statistics come from the consulting firm Surgical Directions:

  • Over 68 percent of revenue comes from perioperative services at better-performing hospitals
  • 60 percent of margin from perioperative services at these better-performing hospitals

Most of this article is about tackling the challenge of staffing the surgical suite.  The consultants recommend establishing a SURGICAL SERVICES EXECUTIVE COMMITTEE (SSEC), which should include surgeons, nurses, hospital executives, and anesthesia providers.  The specific responsibilities of the SSEC are itemized.  It is recommended that the SSEC have a huddle each day to plan for surgical cases scheduled to take place over the next 3 to 5 days.  The OR staffing tool developed by the firm is also described.

Source: Mathias, J.M. (2015, Aug.). Predictive modeling helps match resources with needs. OR Manager, 31(8), 1, 7-9. Retrieved from http://www.ormanager.com/predictive-modeling-helps-match-resources-with-needs/ Posted by AHA Resource Center (312) 422-2050, rc@aha.org


OPERATING ROOM IDEAS: Sequestration of bariatric cases

Ways that hospitals are analyzing operational and financial data related to the surgical suite are explored in this article.  One hospital discovered, as part of an analysis of turnover times, that bariatric surgery cases were associated with longer turnover times.  The hospital then experimented with grouping all bariatric cases into dedicated ORs — “a three-room wing of its own in the OR.”  This sequestration of bariatric cases caused an 8-minute improvement in turnover times for other cases.  Because support staff were now also dedicated to the bariatric service line, they were also able to decrease turnover times.  Another case described is of a hospital that found an effective way to communicate the results of data analysis in order to reduce costs associated with physician preference items.

Source: Rempfer, D. (2015, June). Using perioperative analytics to optimize OR performance. HFM. Healthcare Financial Management, 69(6), 82-85. Retrieved from http://www.hfma.org/Content.aspx?id=31004    Posted by AHA Resource Center (312) 422-2050, rc@aha.org

ACOs: Should you include a ‘surgical home’?

The American Society of Anesthesiologists (ASA) has proposed a coordinated perioperative, or surgical home, model which would give anesthesiologists a leadership role in the development of an important component of accountable care organizations (ACOs).  This is a counterpart to the medical home model (which focuses on primary care and patients with chronic disease).  ASA envisions that anesthesiologists would evolve into “perioperative physicians” in this model.

Interesting fact: An estimated 60 to 70 percent of hospital expenses are related to patients who have surgery or undergo procedures.

Sources:  American Society of Anesthesiologists.  The Perioperative or Surgical Home, Aug. 21, 2011.  Click here for full text: http://www.saaahq.org/ThePerioperative_orSurgicalHome.pdf;  Warner, M.A.  The surgical home.  Newsletter. American Society of Anesthesiologists;76(5):30-32, May 2012; and, ASA responds to accountable care organization proposed rule.  Press Release, June 3, 2011.  Click here for full text: http://www.asahq.org/For-Members/Advocacy/Washington-Alerts/ASA-Responds-to-Accountable-Care-Organization-Proposed-Rule.aspx  Posted by AHA Resource Center, (312) 422-2050, rc@aha.org

Salary surveys: Hospital OR managers average $114,000

The average annual salary for hospital OR managers in 2011 is $114,000; compared to $88,500 for nurse managers of ambulatory surgery centers, according to this survey of readers of the OR Manager magazine.  There are other interesting facts collected in this survey.  For instance, in the hospital setting, the most common title for the head of the OR is DIRECTOR.  As far as org charts, about two-thirds of the ORs report directly to nursing administration.  The average age of OR directors is 53, and trend statistics show a consistent upward trend in this metric over the past decade.  The span of control of the hospital OR director, which averages 102 clinical and 19 nonclinical FTEs.

Source: The weak economy challenges OR case volumes, directors’ raises; and, For ASC managers, it’s all about the economy.  OR Manager;27(10):1+, Oct. 2011.  Click here to go to the newsletter’s website: http://www.ormanager.com/newsletter/index.html  Posted by AHA Resource Center, (312) 422-2050, rc@aha.org

What factors affect surgical team performance?

This study, based on detailed observation of 10 complex surgical cases at an academic medical center hospital supplemented by interviews of surgeons, anesthesiologists, RNs, techs, and ancillary support personnel, took a look at the team dynamics in the operating room.  Role behaviors were perceived differently by different team members.  The authors were surprised by the degree to which the OR team environment can be characterized as dynamic, requiring team members to be able to make on-the-spot adaptations. 

Source: Leach, L.S., Myrtle, R.C., and, Weaver, F.A.  Surgical teams: role perspectives and role dynamics in the operating room.  Health Services Management Research;24:81-90, 2011.  Click here for more on this article: http://hsmr.rsmjournals.com/content/24/2/81.abstract  Posted by AHA Resource Center, (312) 422-2050, rc@aha.org

Retained surgical items: incidence and how to avoid

The national incidence rate for retained surgical items (RSIs) has been estimated to be 1 in every 8,000 to 18,000 inpatient surgical operations; or, 1 in every 1,000 to 1,500 abdominal operations.  A study (Cima et al., 2008) at only the Mayo Clinic (Rochester, MN), found the actual incidence of retained foreign objects (RFOs) to be 1 in 5,500 operations during the period 2003 to 2006.  About two-thirds of the items were sponges.  The authors concluded that counting is not reliable as the primary way to avoid RFOs.  In a follow-up study at the Mayo Clinic (Cima et al., 2011), a data-matrix-sponge system was introduced.  This technology was found to be easy to use and, in the course of an 18-month trial, was found to eliminate sponge-related RFOs.  The Veterans Health Administration has developed, and made available online, a policy to prevent retained surgical items.


 Cima, R.R., and others.  Incidence and characteristics of potential and actual retained foreign object events in surgical patients.  Journal of the American College of Surgeons;207(1):80-87, July 2008.  http://www.cardinalhealth.com/us/en/brands/presource/files/2008%20Incidence%20and%20Characteristics%20of%20Potential%20and%20Actual%20Retained%20Foreign%20Object%20Events%20in%20Surgical%20Patients%20-%20Cima.pdf

Cima, R.R., and others.  Using a data-matrix-coded sponge counting system across a surgical practice: impact after 18 monthsThe Joint Commission Journal on Quality and Patient Safety;37(2):51-58, Feb. 2011.

Prevention of Retained Surgical Items.  Washington, DC: Veterans Health Administration, Apr. 12, 2010.  [VHA Directive 2010-017]

OPERATING ROOMS: Should you flip your ORs?

Making multiple operating rooms available in a back-to-back fashion, so that a surgeon can move quickly from one case to the next, is known as flipping, or double teaming.  Advantages and disadvantages of flipping ORs, and suggestions for how to establish criteria to determine which surgeons are eligible to request flipping, are discussed in this article.

Source: Patterson, P. (2010, Dec.). Flipping ORs: Does this common practice make business sense? OR Manager, 26(12), 1, 6-8. Full text here: http://www.ormanager.com/wp-content/uploads/pdf/ORMVol26No12FlippingORs.pdf (last accessed 7/9/15).