Tiered Outpatient OR Strategy Increases Efficiency, Reduces Costs Tiered Outpatient OR Strategy Increases Efficiency, Reduces Costs

A redesign of outpatient orthopedic operating room services increased efficiency and reduced costs at a tertiary care academic hospital in Ontario, Canada, according to a new report.

The new strategy, based on tiered grouping of surgical cases, reduced costs by about 60% and was associated with similar patient outcomes, as compared with a conventional operating room strategy.

Dr Abdel-Rahman Lawendy

“Despite the astonishing advances and innovations made in surgical care over the last five decades, service delivery remains an exceptional challenge. Wide-scale structural inefficiencies render surgical care largely ineffective for many Canadians,” Abdel-Rahman Lawendy, MD, PhD, associate professor of orthopedic surgery at Western University and medical director of the London Health Sciences Centre’s Surgi-Centre, told Medscape Medical News.

“We imagined and designed a public system that provides high-quality surgical care that is more cost-effective, more convenient, and more empowering to healthcare teams,” he said. “By applying a tiered framework to assess the operating room flow-through, our team was able to develop an understanding of the costs incurred as related to our administrative processes, which allowed for an intervention to decrease cost and increase output in the public system.”

The study was published November 8 in the Canadian Journal of Surgery.

Testing a New Model

Under the traditional surgical workflow at London Health Sciences Centre, all patients pass through the same operating room process regardless of their health status, the anesthesia method, or the surgical procedure. The process includes pre-admit, the operating room, the postanesthesia care unit (PACU), and post-recovery.

Lawendy and colleagues developed a streamlined form of outpatient operating room services with a tiered grouping of surgical cases, with the goal of improving wait times, reducing costs, and freeing up the standard operating room for more complex cases.

Under the tiered operating room strategy, patient intake didn’t involve a pre-admit clinic, or it was from the emergency department with ambulatory intake only. Anesthesia was limited to local, nerve block, and conscious sedation, and general anesthetic was used only if necessary. In addition, a scrub nurse wasn’t used, and instrumentation was limited to 25 instruments on a surgical tray. Patients were then discharged directly to postoperative care, and the PACU was only used if the patient was given a general anesthetic.

The prospective cohort study included 200 adult patients who were seeking an elective unilateral lower limb orthopedic procedure that didn’t require hospital admission and had a low requirement for surgical resources at London Health Sciences Centre in Ontario. The patients had no substantial or life-threatening comorbidities, which was defined as an American Society of Anesthesiologists score of 3 or less. Low requirement for surgical resources included optimizing and standardizing surgical trays, as well as plate and screw systems, which were customized to minimize equipment, setup, and sterile processing.

Patients were randomly assigned to the conventional operating room or the tiered “high-efficiency” operating room. The tier was allocated by matching the intensity of surgical resources to the health status of each patient. The procedures included forefoot and midfoot corrective surgery, foot and ankle fracture fixation, deformity correction, fusions, instability surgery, irrigation and debridement, tendon transfers, excision, and hardware removal.

The primary outcomes were costs associated with surgical and patient care, as well as levels of patient health. The expenses included the cost of equipment, supplies, medications, and salaries for allied health care staff, including nurses. Surgeons’ salaries were not included. Secondary outcomes included patient and staff satisfaction.

Overall, there were no major differences in patient age or overall health status between the conventional and tiered operating room groups. Patients in the tiered group had a symptomatic orthopedic condition for a longer duration, but they reported having a higher level of function and were more active.

With the tiered operating room strategy, the expenses associated with patient surgical care were 60% lower than in the conventional operating room, including both the labor and material costs. The turnover time per case fell from an average of 23.5 minutes in the conventional group to 8.75 minutes in the high-efficiency group.

The most substantial savings were associated with bypassing the PACU and decreasing operating room-associated labor and materials costs. Time to patient discharge was also significantly lower, and there were fewer reported adverse effects from anesthesia.

“With wait times increasing post-pandemic, a radical shift toward innovative ideas like this must be strongly considered,” Danny Goel, MD, clinical professor of orthopedic surgery at the University of British Columbia, told Medscape Medical News.

Dr Danny Goel

Goel, who wasn’t involved with this study, researches surgical education and skill acquisition, including virtual and augmented reality for surgical training and simulation. He is also CEO of PrecisionOS, a software company focused on immersive experiential, virtual reality-based medical education.

“This is a very promising study where the authors have demonstrated an economically sound model of surgical care in a no-hospital setting,” he said. “The focus on particular surgical procedures opens the potential for broader applications in not only orthopedics, but across disciplines.”

Measuring Satisfaction

Lawendy and colleagues found no differences in patient physical and mental health outcomes or pain interference scores between the two groups. The patients also had equivalent levels of overall health during their follow-up period of up to 6 months.

Patient satisfaction with preoperative or postoperative experience was equivalent for the two operating room strategies. Staff job satisfaction was similar for both groups as well.

The tiered setup was accepted by the three main professions assessed — anesthesiologists, surgeons, and nurses. Surgeons appeared to be the most satisfied with the new setup, even though they had fewer instruments and no scrub nurse, the study authors wrote.

The results were foundational for creating the London Health Sciences Centre’s Surgi-Centre, a stand-alone surgical center, which has been operational for a year, the study authors said. The center serves multiple surgical disciplines and is now expanding to three operating rooms, with plans to eventually include six operating rooms.

“With a reduction in nursing work capacity, in the absence of efficient knowledge acquisition, a potential for wait times to worsen in traditional hospitals does pose a potential risk that can be addressed with the approach highlighted in this paper,” Goel said. “A key message is that through appropriate patient selection, risk stratification, and a personalized care model, a time and cost-efficient model within Canada in not only within reach, but achievable when it’s needed the most.”

The study was supported by internal research funds from the London Health Sciences Centre. The authors and Goel report no relevant financial relationships.

Can J Surg. Published November 8, 2022. Full text

Carolyn Crist is a health and medical journalist who reports on the latest studies for Medscape, MDedge, and WebMD.

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