Dear All-

Mike has asked me to moderate the section on 'OR of the Future'.  Early in my involvement with the OR of the Future project at MGH, we realized that what hospitals really need to pay attention to is 'Perioperative Systems Design', optimizing the performance of the entire patient, materiel and personnel flow from one end to the other.  Simply put, Perioperative Systems Design is a rational approach to managing the convergent flow of patients having procedures from disparate physical and temporal starting points, through the operating room and then to such a place and time (e.g., home or hospital bed) where future events pertaining to the patient have no further impact on OR operations.  Perioperative Systems Design attends to both throughput and efficiency.  Optimizing throughput is not necessarily the same as optimizing efficiency, although the two are intrinsically linked.  Improvements in efficiency match resources and demand, while enhanced throughput might require application of extra resources to accommodate demand.  Effective Perioperative Systems Design impacts the ability of hospitals to accommodate their patients’ needs, as well as hospital finances.

We started our Perioperative Systems Design effort in the OR of the Future, a project sponsored by the Center for Integration of Medicine and Innovative Technology (CIMIT) and Massachusetts General Hospital.

In the OR of the Future we've built a working induction room for a single OR and done a financial and operational analysis of using it with truly luxurious staffing:  1-1 anesthesia coverage plus an additional nurse.  The most jaundiced view of the impact is that we complete one additional case 4 days out of 5, the anesthesia department loses money, the hospital breaks even and we get more cases done in limited OR space.  This was published in Anesthesiology.  Since then we have scaled back on resources, lowering costs, and throughput has actually increased.  The POTENTIAL throughput improvement is easily 2 cases per day in regular hours, but we have allowed the room to be under-scheduled (hence the 0.8 case per day additional throughput initially reported).

There are several other analyses of 'induction rooms', cited in the Krupka and Sandberg review referenced below.  In each case, the significant factor is not the induction room per se, but rather, the use of EXTRA resources, be they induction rooms, other spaces, extra equipment , extra personnel, etc., to achieve PARALLEL processing (i.e., two parts of the team working independently on subtasks at the same time rather than doing those subtasks sequentially).

Our parallel processing experiments have been so successful that we're about to embark on a project wherein we retire ORs to make new PACU space near ORs that will be converted to parallel processing (in this instance, via working induction rooms), with the expectation, supported by mathmatical modelling, that our NET throughput will go up.

The reports from all of the other respondents indicate that many groups have recognized the value of parallel processing (at least for blocks & lines) and found ways to implement parallel workflows, often without dedicated rooms / physical resources to do so.  Curiously, none of the major architectural firms have discovered the notion of parallel processing to the extent of creating physical spaces to support it.  However, with the right infrustructure and systems, the time savings is sufficient to do extra cases regardless of the type of anesthesia.  In our reported results, the vast majority of patients were gen-surg, gyn and urology patients receiving general anesthesia, and we still realized extra throughput almost every day.

We've moved on to begin directly discharging one surgeon's laparoscopic cholecystectomy patients FROM THE PACU.  Here are the results in summary:  PACU LOS, unchanged (direct DC vs DC to hospital bed).  Hospital net margin: unchanged.  One intrahospital transfer, one surgical floor bed admission eliminated for every patient directly discharged.  We now discharge about 80% of the 'test surgeon's' patients directly from PACU, which translates 1% - 3% of the total surgical volume on his OR days.  Our hospital is jammed, so these new 'ddLCs' translate into the ability to do additional cases that we would not have otherwise had beds for.  This will appear in the September issue of Surgery.

Bibliography below:

1.   Krupka DC, Sandberg WS. Operating room design and its impact on operating room economics. Curr Opin Anaesthesiol 2006;19:185-91.
2.   Sandberg WS, Canty T, Sokal SM, Daily B, Berger D. Financial and Operational Impact of a Direct-From-PACU Discharge Pathway for Laparoscopic Cholecystectomy Patients. Surgery 2006:(in press).
3.   Sandberg WS, Daily B, Egan M, Stahl JE, Goldman JM, Wiklund RA, Rattner D. Deliberate Perioperative Systems Design Improves Operating Room Throughput. Anesthesiology 2005;103:406-18.
4.   Sandberg WS, Ganous TJ, Steiner C. Setting a research agenda for perioperative systems design. Semin Laparosc Surg 2003;10:57-70.
5.   Seim AR, Andersen B, Sandberg WS. Statistical Process Control as a Tool for Monitoring Non-Operative Time. Anesthesiology 2006;105:370-80.
6.   Cendan JC, Good M. Interdisciplinary work flow assessment and redesign decreases operating room turnover time and allows for additional caseload. Arch Surg 2006;141:65-9; discussion 70.
7.   Hanss R, Buttgereit B, Tonner PH, Bein B, Schleppers A, Steinfath M, Scholz J, Bauer M. Overlapping induction of anesthesia: an analysis of benefits and costs. Anesthesiology 2005;103:391-400.
8.   Sokal SM, Craft DL, Chang Y, Sandberg WS, Berger DL. Maximizing operating room and recovery room capacity in an era of constrained resources. Arch Surg 2006;141:389-93; discussion 93-5.
9.   Stahl JE, Sandberg WS, Daily B, Wiklund RA, Egan MT, Goldman JM, Isaacson KB, Gazelle S, Rattner DW. Reorganizing Patient Care and Workflow in the Operating Room: A Cost-Effectiveness Study. Surgery 2006;139:717-28.
10.   Torkki PM, Marjamaa RA, Torkki MI, Kallio PE, Kirvela OA. Use of anesthesia induction rooms can increase the number of urgent orthopedic cases completed within 7 hours. Anesthesiology 2005;103:401-5.

Good luck; happy to share further experiences,

Warren Sandberg