ON-TIME STARTS
Starting the first procedure of the day on time is crucial to
setting the tone for how an OR functions. If there is a delay in getting the first
case started, it often affects the overall mood and support for performing all the
cases in the room efficiently. It is important for everyone to agree what start
time means. Surgeons have historically believed that start time is when they make
the first incision. Anesthesiologists believe that they have started on time if
they have completed induction at the prescribed time. Nurses believe that if the
room is prepared and ready, they have done all they can for the start. Obviously,
when no one agrees on what constitutes start time, misunderstandings and dissatisfaction
with room starts will occur.
In 1996, a group in the AACD published a procedure times glossary
that for the first time sought to create a standard for all OR events and time periods.
[25]
This glossary has now been accepted by the
American Society of Anesthesiologists, AORN, and the American College of Surgeons
and serves as the standard for descriptive terms in the OR. An excerpt of the glossary
may be found in Appendix 2
.
The glossary describes start time as the time that the patient enters the OR. Surgeons
may complain that if the patient enters the room at the posted start time, they have
no idea when the patient will actually be ready for the incision. At our institution
we reviewed times from the patient entering the OR to completion of preparation.
In uncomplicated cases (patient supine with no invasive monitoring lines), preparation
could be completed in 15 minutes in 78% of cases. If the case was complicated (position
other than supine, invasive monitors), the duration from start time to completion
of preparation averaged 30 minutes. These data were shared with surgeons so that
they could anticipate the time from room start (patient in room) until preparation
completed.
On-time starts depend on many factors. Patients must arrive at
the facility early enough to complete preoperative preparations and to have complied
with all preoperative instructions (NPO, medications, laboratory tests). The preoperative/admitting
process must be organized and allow sufficient personnel and space to process patients
and make them available to surgeons and anesthesiologists. Operating room nurses
must have the operating room and equipment ready. Anesthesia personnel must have
the equipment in the room checked, drugs
TABLE 86-4 -- Room block guarantees
|
Operating Room No. |
|
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
11 |
12 |
14 |
15 |
16 |
17 |
18 |
19 |
20 |
21 |
22 |
23 |
|
Monday |
Uro |
|
Ort |
Uro |
CTS |
Ort |
Neu |
Ort |
Gen |
Gen |
Gen |
Ped |
|
Pla |
Ort |
Gyn |
Ent |
Ent |
|
CTS |
CTS |
|
Tuesday |
Uro |
|
Ort |
Uro |
CTS |
Ort |
Neu |
Ort |
Neu |
Gen |
Gen |
|
Opt |
Pla |
Gyn |
Gyn |
Ent |
Ent |
Gen |
CTS |
CTS |
|
Wednesday |
Uro |
|
Ort |
Uro |
CTS |
Ort |
Neu |
Ort |
Neu |
Gen |
Gen |
Ort |
|
Pla |
Ent |
Gyn |
Ent |
Ent |
Gen |
CTS |
CTS |
|
Thursday |
Uro |
|
Ort |
Uro |
CTS |
Ort |
Neu |
Ort |
Neu |
Gen |
Gen |
Ped |
Ent |
Pla |
Pla |
Gyn |
Ent |
Ent |
Gen |
CTS |
CTS |
|
Friday |
Uro |
|
Ort |
Uro |
CTS |
Ort |
Neu |
Ort |
Neu |
Gen |
Gen |
|
Opt |
Pla |
Gen |
Gyn |
Ent |
Ent |
Gen |
CTS |
CTS |
|
CTS, cardiothoracic surgery; Ent, otolaryngology; Gen, general
surgery; Gyn, gynecology; Neu, neurosurgery; Opt, ophthalmology; Ort, orthopedics;
Pla, plastic surgery; Ped, pediatric surgery; Uro, urology. |
TABLE 86-5 -- Suggested block release times
|
Service |
Release Time |
|
Cardiothoracic |
1 day |
|
Vascular surgery |
2 days |
|
Orthopedics |
3 days |
|
Neurosurgery |
4 days |
|
Pediatric surgery |
1 wk |
|
General surgery |
1 wk |
|
Gynecology |
1 wk |
|
Ophthalmology |
1 wk |
|
Otolaryngology |
1 wk |
|
Plastic surgery |
2 wk |
prepared, paperwork completed, and intravenous lines or special needs addressed.
Surgeons must be available and have consent, history, and physical examination and
any patient questions or needs addressed. All these factors must be completed before
the room start can occur. A common misconception by many surgeons is that if a room
start is delayed, it is due to anesthesia factors. Many anecdotal reports by OR
clinical directors do not support this concept. We recently studied reasons for
all delayed room starts and grouped delays into factors controlled by patients, surgeons,
anesthesiologists, and nurses. The results ( Table
86-6
) demonstrate that surgeons controlled the largest number of delays
in first starts. Some of the most common reasons for surgeon-controlled delays are
listed in Table 86-7
.
Reports of success in starting first cases on time demonstrate
that this complex process is a challenge. If the definition of an on-time start
is that the patient is in the room by the start time, delays occur in 40% to 90%
of first starts.[26]
[27]
If an on-time start is categorized as the patient in the room within 10 minutes
of the scheduled start time, delays still occur in 5% to 50% of cases. Identifying
causes of delays, focusing efforts to removing barriers to smooth patient flow, improving
communications between preoperative personnel, patients, surgeons, nurses, and anesthesiologists,
and creating an atmosphere (culture) of shared ownership in starting on time will
improve on-time starts. Other keys for increasing on-time starts are listed in Table
86-8
.
