Is your operating room a finely tuned symphony orchestra or a jam session?
When the jobs of surgery and the people who perform them are well coordinated within a buttoned-down system then the patient—the ultimate focus of the healthcare system—benefits mightily.
And, says Adolph Lombardi, Jr. M.D., president of Joint Implant Surgeons in New Albany, Ohio, so does the system. Dr. Lombardi, an active advocate of efficiency in the OR, is working to streamline the pre-, intra-, and postoperative processes down to the minute.
“Why waste time and effort if things can be made more efficient?” asks Dr. Lombardi, who also operates at Mount Carmel New Albany Surgical Hospital. “My experience in optimizing our time in the OR has led me to believe that we are missing a vast number of opportunities to reduce wasted resources.”
“There is ongoing criticism about the cost of the products used in total joint replacement (TJR). During each such debate people say, ‘Such-and-such and implant shouldn’t cost so much!’”
But, says Dr. Lombardi, this focus is too narrow and bypasses a whole universe of things that are not being discussed.
“We have to examine the overall cost of doing business. If I can safely complete five procedures as opposed to three in the same amount of time, then I am utilizing the same amount of personnel, heat, electricity, etc., and have thus been more productive and more efficient.”
“In studying cost, we need to examine all different parts of the equation. When assessing cost, one must look at the way we practice, especially in larger facilities. You have to step through the day, in essence.”
Number one, says Dr. Lombardi, the surgeon sets the tone and mood with regard to expectations.
“Sit down with the administration and develop a detailed plan as to how you will optimize patient care. What can you do preoperatively to ensure things go smoothly? What can you agree on as far as time of patient arrival? Surgeon arrival? Will you allow fluids up to 4 hours before the procedure? What medications do patients need to halt before surgery? And so on.”
“It is particularly useful to develop educational materials regarding what happens before surgery, the day of surgery, what to expect in the hospital, and what patients need to go home. As for the staff, everyone understands that the goal is to get the patient up and walking the same day.”
A healthy patient with a joint problem…
It’s a triad of care, says Dr. Lombardi, with the hospitalist, orthopedic surgeon, and anesthesiologist coming together to coordinate the procedure. Citing a need for a philosophical shift, Dr. Lombardi notes, “We need everyone on the same page as far as understanding that we are not treating a sick patient, but instead are treating a healthy patient with a joint problem. Our job is to maintain this person’s health status and get him or her moving again.”
To that end, maintaining a positive attitude is critical. “Let’s say that when the patient is brought to the preop holding area the nurse says, ‘This operation involves a lot pain and pain medications and you won’t be able to move around easily for a while.’ That is in stark contrast to a nurse who says, ‘You have a painful hip, but the surgeon can fix it, and we will manage any pain the best we can. You will likely be up and walking later and then go home tomorrow.’ My mantra is that regarding outcomes, it can take one person on the team to knock things out of whack.”
How they do it…
While Dr. Lombardi isn’t standing around with a stopwatch, he is completely aware that every minute counts…and he knows how to count them.
“Diane Doucette, president and COO of our hospital, invented the concept of the time stamp as part of the surgical process. We track what time the patient arrives and every minute after that. If the first case is scheduled for 6:30 and he arrives at that time then it is noted, as is the time that he moves to anesthesia.
The surgeon’s arrival time is noted, the time the patient gets to the OR, etc. This way, we can readily identify where the problem/obstacle is. And if the patient is the problem we have to determine if there was an issue with communication on our end.”
To de-clutter the anesthesia process, Dr. Lombardi arranged for this to start during preop. “The patient is monitored by a nurse and a representative from anesthesia, who can do a block and a spinal at that point. That way, when you roll the patient into the OR there are not five or six people trying to get a spinal into the patient.”
