Cohort study of cases with prolonged tracheal extubation times to examine the relationship with duration of workday

Abstract

Purpose The economics of the use of an anesthetic drug or device that produces benefit through reduction in operating room (OR) time depends on the day of the week and the total hours of surgical cases in the OR in which they are performed. Principally, this has to do with different durations of the regularly scheduled workday in the ORs within and among hospitals. We tested hypotheses relevant to the economic benefit of avoiding prolonged tracheal extubation times. Methods Observational data were obtained from a multiple-specialty academic tertiary hospital that uses an anesthesia information management system. Prolonged tracheal extubation times were considered those with tracheal extubations occurring 15 min or more after the end of surgery. The assessment of prolonged tracheal extubation times was limited to cases for which the patient's trachea was intubated and extubated while physically in the OR. Percentages were calculated for each of n = 39 four-week periods. Results are reported as mean (standard error of the mean) of these percentages, and the phrases ''at most/least'' are used to refer to the corresponding 95% confidence limits.Results At most, 6.1% [mean 5.5 (0.3)%] of the prolonged tracheal extubation times were attributable to cases that did not end during regular workdays from 7:00 AM-10:59 PM. At least 55.6% of prolonged tracheal extubation times occurred during cases on regular workdays and in an OR with more than eight hours of cases and turnovers [mean 57.0 (0.9)%; P \ 0.0001]. This percentage was 23.8 (0.8)% larger than for all other cases. Conclusions In the absence of an accurate facilityspecific cost analysis, prolonged tracheal extubation times should not be treated as fixed costs but as resulting in proportionally increased OR variable costs. RésuméObjectif En anesthésie, les économies résultant de l'utilisation d'un médicament ou d'un dispositif qui entraîne des avantages en réduisant le temps en salle d'opération (SO) dépendent du jour de la semaine et du nombre total d'heures de cas chirurgicaux réalisés dans cette salle. Ces économies ont surtout à voir avec les différences de durée d'une journée de travail normale planifiée dans les SO à l'intérieur de chaque hô pital et entre les hô pitaux. Nous avons testé des hypothèses pertinentes aux avantages économiques liés à la prévention d'un délai d'extubation trachéale prolongés. Méthode Nous avons obtenu des données observationnelles d'un hô pital tertiaire, universitaire et pluri-spécialisé qui se sert d'un système de gestion de l'information en anesthésie. Nous avons défini qu'il y avait

Prolonged Operative Time to Extubation Is Not a Useful Metric for Comparing the Performance of Individual Anesthesia Providers

“…1 • Because most (P < 0.0001) cases with prolonged times to extubation occur during regular workdays and in ORs with greater than 8 h of cases and turnover times, the extra OR time that results can reasonably be treated as an expensive variable cost. 5 • The incidences of prolonged times to extubations are modifiable (e.g., from meta-analysis of randomized trials, 95% or greater reduction [lower confidence limit] with use of desflurane vs. isoflurane). 1,6 • When surgeons score the importance of anesthesiologists' attributes on a scale from 0, "no importance," to 4, "a factor that would make me switch groups/ hospitals," their average score is 3.9 for "patient quick to awaken."…”

Strategies for Net Cost Reductions with the Expanded Role and Expertise of Anesthesiologists in the Perioperative Surgical Home

“…Examples include not only having more (1) housekeeping teams to reduce turnover times, 92,93 but also more (2) postanesthesia care unit (PACU) nurses, 41,[94][95][96][97][98] (3) transporters to reduce delays in PACU exit when patients are ready for discharge, 99 and/or (4) nurses to setup, assist anesthesiologists, and monitor patients after peripheral nerve blocks. 100 More expensive anesthetic drugs can be used to reduce OR times 101,102 and staff waiting 103 by reducing 104,105 annoying 106 prolonged times to extubation (i.e., 15 minutes or longer from end of surgery). Finally, the OR Medical Director can provide leadership to ensure the availability of 1 extra staffed OR when a service with 3 or 4 surgeons each has scheduled at least 8 hours of cases.…”

“…[92][93][94][95][96][97][98][99][100][101][102][103][104][105][106][107][108][109][110] Potential to Achieve Net Cost Reduction Is Limited to ORs with More Than 8 Hours of Cases Another limitation to decreasing costs through a reduction in OR time is that it is rarely effective except when there are at least 8 hours of OR time consistently for the service on the day of the week. 42,45,66,101,111,112 Many hospitals do not satisfy this condition. 38,39 There are even fewer hospitals that have many individual surgeons consistently filling an OR with at least 8 hours of cases each workday that the surgeon is doing at least one case.…”

“…It is close to meaningless to read a statement 111 that reducing OR time by 10 minutes reduces costs by $33.50 (or some even larger value), because OR time is not simply a variable cost (see Section 2). 42,101,104 Suppose that reducing OR time can be achieved. When calculating the reduction in costs achieved through a decrease in the OR time of an OR with >8 hours of cases, 101,105,111 do not blindly use a value for the cost per minute of OR time derived from the hospital financial cost accounting system.…”

Observational study of prolonged times to tracheal extubation

“…3 Furthermore, prolonged (C 15 min) times for that period are associated with longer times to OR exit. [2][3][4][5][6] From Table 4 of reference 6 , among cases with prolonged times to tracheal extubation, the mean time from end of surgery to OR exit was 28 min. Therefore, among the authors' cases with tracheal intubation and extubation in the OR, what percentage of cases in the before and after periods had times C 28 min from the end of surgery to OR exit (i.e., as previously studied) or, alternatively, C 30 min (i.e., what an organization might monitor), and what was the corresponding relative risk and confidence interval?…”