Revolving Door in OR Makes Surgeries Less Efficient

When support personnel changed out in the middle of hip and knee arthroplasty procedures, operative times were significantly longer than when staffing didn't change, researchers found.

"Room time" was longer by 19.6 minutes for hip replacements, and by 14.0 minutes for knee arthroplasties, for each additional circulating nurse listed on operating room (OR) personnel rosters for a given case (P<0.001), according to Henry Cousins, MPhil, of Stanford University in California, and colleagues.

Other measures of operative duration, including incision and procedure times, were also significantly longer with increased turnover, the researchers reported in JAMA Surgery.

But efficiency was improved when surgeons were able to hand-pick staff for their operations, the group also found. Room times were shorter by approximately 7-13 minutes for each additional "preferred" nurse or surgical technician, depending on the procedure.

On the other hand, when "preferred" vendors were in the room, operative times ballooned by up to 30 minutes.

"As hospitals refine operating room guidelines and adopt technologies to reduce preventable errors, intentional and regimented management of surgical team dynamics and communication during turnover may represent a powerful and cost-effective tool for improving operative efficiency and patient safety simultaneously," Cousins and colleagues wrote.

An accompanying commentary by two physicians from the University of Texas in Austin emphasized the relationship between surgical team makeup and communication, which in turn helps dictate efficiency.

"This study highlights the complex nature of the academic surgical environment and the need to be intentional in efforts to improve team communication, efficiency, and safety," wrote Anthony E. Johnson, MD, and Benjamin McArthur, MD.

They were especially heartened by the study's finding that operative times were generally shorter when advanced trainees (surgical and anesthesiology residents) were present. Previously, the pair noted, studies yielded mixed results as to whether having trainees in the OR helps or hinders efficiency.

Cousins's group found that operative times were unaffected by having medical or nursing students in the OR. But the presence of anesthesia residents shortened room times by 29.6 minutes during hip procedures (P=0.004) and by 24.3 minutes for knee replacements (P=0.01). Surgical residents did not affect room times significantly for hip arthroplasties, but during knee procedures, their presence was associated with shortening by 21.8 minutes (P<0.001).

The findings were based on records of 641 procedures at Stanford led by five different surgeons during 2018 and interviews conducted subsequently with four of those surgeons.

"Staff turnover was defined based on the number of individuals listed under specific roles, including circulating nurse, surgical technician, physician assistant, vendor, and anesthesiologist," the researchers explained. "Since specific staffing roles are generally occupied by one team member at any given time at our institution, Stanford Health Care, the listing of multiple staffing members under a specific role for a case implies that personnel were exchanged intraoperatively."

The four surgeons interviewed were given lists of 265 individuals serving as support staff and asked to pick the ones they most liked to work with. Cousins and colleagues then went through the case records to determine when these individuals were in the OR with that surgeon, correlating that data with operative times.

Overall, only a minority of procedures included preferred staff: approximately one-third had a preferred surgical technician and one-quarter featured a preferred nurse. Preferred residents were present for less than 5% of cases, and rates were similarly low for anesthesiologists and vendors.

Surgical fellows were on hand for about 12% of hip and knee arthroplasties; approximately of 90% of cases included surgical and anesthesiology residents. Medical students were present for about 15% of procedures, and nursing students for around 10%.

Cousins and colleagues said the decreased efficiency with intraoperative turnover probably reflects "subtle artifacts" related to the change in personnel, including "communication requirements and familiarity with operating room layout." Similarly, the team suggested, improved communication likely explains the increased efficiency seen with the presence of surgeon-preferred staff.

The group explained the massive increase in operative time associated with preferred vendors as perhaps stemming from a "multifaceted role" during joint replacements. "[T]he qualities that surgeons prioritize in vendors may detract from intraoperative efficiency," Cousins and colleagues offered.

Limitations to the study included its single-center nature and the use of operative time measures as the principal outcomes; others of more importance to patients such as readmissions and complications were not considered. Also, the influence of unmeasured confounders cannot be excluded. The authors conceded, too, that their measure of intraoperative staff turnover might not have been perfect: it remains possible that multiple individuals assigned to a given role could have been present simultaneously in some cases.

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