Economic, Educational, and Policy Perspectives on the Preincision Operating Room Period

Abstract

When renaming this section of Anesthesia & Analgesia “Economics, Education, and Policy,” we were not aware of four papers (1–4) being handled by the former Section Editor and Editor-in-Chief, Ronald D. Miller, MD. Acceptance of these papers has provided a welcome opportunity to highlight the interrelationship of economics, education, and policy. The authors examined the preincision operating room (OR) time, which includes the anesthesia release time (ART), defined as “the time at which the patient had a sufficient level of anesthesia established to begin the surgical preparation of the patient and the remaining anesthesia tasks did not preclude positioning and surgical preparation of the patient” (1). The ART differed significantly depending on the anesthetic technique and monitoring used (e.g., whether a pulmonary artery catheter was placed) (1). The attending anesthesiologists were, on average, quite good at forecasting ART (Spearman correlation coefficient 0.77) (4). The implication is that once the anesthetic plan is known, ART can be estimated and used to improve the prediction of case duration. One of the two questions that we address is how to quantify and achieve an economic benefit from estimating ART. Teaching resulted in a mean increase of time to incision of 4.5 min (2). This statistically significant, but small, value was similar to that obtained using a different methodology at another academic hospital (5). Cases with new residents had induction times that averaged 3.5 min longer than those done solo by anesthesiologists (5). The second question we answer is how to quantify the OR cost of teaching and how to expand teaching without increasing OR costs. More accurate estimation of ART, or longer times to incision due to education, are unlikely to affect the choice of the OR in which each case is performed. Alterations of 5 min to 15 min per case are rarely long enough to affect such decisions (6–8). Thus, the discussion can focus on understanding the importance of the relationship between small changes in case durations and variability in the length of the workday in a given OR. Suppose that three hip replacements are performed in the same OR every Monday. Each procedure takes exactly 2 h 20 min of OR time. A turnover robot cleans and sets up for the next case in precisely 30 min. Staffing should then be planned for exactly 8 h, where 8 h = 3 × (2 h 20 min) + 2 × (30 min). The OR nurses and anesthesia provider could expect to finish after precisely 8 h without any under- or overutilized OR time. They could schedule revenue-producing activities (e.g., seeing patients in a clinic) or personal activities (e.g., picking up their children) based on finishing at precisely 8 h. On one Monday, the absence of a technician causes a 5 min increase in ART for each case, resulting in a 15 min increase in OR time (i.e., 15 min of overutilized OR time). What is the incremental cost of the increase in ART? The increase of 5 min per case might be considered minimal, because it is only a 3.6% increase, where 3.6% = 5 min ÷ (2 h 20 min). However, this percentage approach ignores the fact that the OR has run 15 minutes longer than the length of the workday. Nurses would have to be paid overtime wages. Children would be picked up 15 min late. Patients in clinics would wait for 15 min. Instead, the analysis could be based on multiplying 5 min per case by the cost per minute of OR time (e.g., $15 per minute). Such an analysis would be valid, based on each hip replacement taking precisely 2 h 25 min instead of 2 h 20 min. However, the scenario is unrealistic. Every hip replacement does not take exactly the same amount of time. When case durations cannot be predicted with certainty, a different analysis is required. The incremental cost of finishing an OR day 15 min late cannot be estimated accurately by assuming a fixed cost per minute of OR time. Actual surgical times often differ from scheduled surgical times (9,10). Because of that u