All Branch Topic (ABT) Surgical Services Service Line 3SL

[Monty Python]

Anybody seen any real impact, good or bad, from this latest DoD management system which purports to improve OR value and associated metrics?

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[psychbender]

Nope. But I'm sure implementing it looks good on OERs.

 

[HighPriest]

There are a lot more meetings. Everyone likes meetings.

 

[HighPriest]

So, here's a good example that is unfortunately far too frequent: Our OR has been "running" for 2 1/2 hours now and I've done two cases, both ear tubes (5 minutes or less), both with gas (no intubation) and my third patient isn't even in the room yet. 2 1/2 hours. The problem isn't meeting our metrics, the problem is the metrics we have don't lead to functional ORs. The utilization will be good, because it took them 30 minutes on each side of the case to put down and wake up these otherwise healthy patients. But our throughput sucks. I haven't seen any difference whatsoever in this since 3SL became a thing. Oh, and I had two broken instruments and one set with gross bio-burden. So that hasn't changed either. When I work offsite through an ERSA agreement, I'll do 10 cases before 10 o'clock. literally. When I work at the MTF I have to remind our scheduler that I can't have more than 3-4 turnovers all day or we won't finish on time. I can't schedule complex cases after 12:00, otherwise I risk having the "D" team in my room, which is so bad that I honestly think it's dangerous for the patient in many cases. 3SL or not - we're not interested in running a modern OR. OR time is just something we offer because we have to do it.

 

[Neogenesis]

Real impact? Absolutely. My email count is up, clip board carrying nurses are continually spouting "utilization" and overbooking is encouraged by those that don't actually work in the OR because it makes things look better

 

[Monty Python]

I'm also hard-pressed to see how the new FTEs hired to oversee/manage 3SL can be justified, unless .mil OR value skyrockets. Where is the return on investment? (I know, rhetorical question).

 

[Monty Python]

So, here's a good example that is unfortunately far too frequent: Our OR has been "running" for 2 1/2 hours now and I've done two cases, both ear tubes (5 minutes or less), both with gas (no intubation) and my third patient isn't even in the room yet. 2 1/2 hours. The problem isn't meeting our metrics, the problem is the metrics we have don't lead to functional ORs. The utilization will be good, because it took them 30 minutes on each side of the case to put down and wake up these otherwise healthy patients. But our throughput sucks. I haven't seen any difference whatsoever in this since 3SL became a thing. Oh, and I had two broken instruments and one set with gross bio-burden. So that hasn't changed either. When I work offsite through an ERSA agreement, I'll do 10 cases before 10 o'clock. literally. When I work at the MTF I have to remind our scheduler that I can't have more than 3-4 turnovers all day or we won't finish on time. I can't schedule complex cases after 12:00, otherwise I risk having the "D" team in my room, which is so bad that I honestly think it's dangerous for the patient in many cases. 3SL or not - we're not interested in running a modern OR. OR time is just something we offer because we have to do it.

You can run an anesthesia turnover-to-surgeon time report in S3 for trend analysis. You can also run a wheels-in to wheels-out report. Both of those reports in your PE tube scenario should be red flags for someone to start digging for the baseline cause. Absent something really bizarre, 30 minutes to mask down a kiddo for PE tubes is ???? Even PR Tylenol and/or intranasal fentanyl takes, oh, 3 seconds. And I'm assuming there's no IV start post-mask induction, so "no veins" can't be blamed for the 30 minutes. That's really mind-boggling, unless you have first-day anesthesia trainees in the OR.

 

[McCheese]

So, here's a good example that is unfortunately far too frequent: Our OR has been "running" for 2 1/2 hours now and I've done two cases, both ear tubes (5 minutes or less), both with gas (no intubation) and my third patient isn't even in the room yet. 2 1/2 hours. The problem isn't meeting our metrics, the problem is the metrics we have don't lead to functional ORs. The utilization will be good, because it took them 30 minutes on each side of the case to put down and wake up these otherwise healthy patients. But our throughput sucks. I haven't seen any difference whatsoever in this since 3SL became a thing. Oh, and I had two broken instruments and one set with gross bio-burden. So that hasn't changed either. When I work offsite through an ERSA agreement, I'll do 10 cases before 10 o'clock. literally. When I work at the MTF I have to remind our scheduler that I can't have more than 3-4 turnovers all day or we won't finish on time. I can't schedule complex cases after 12:00, otherwise I risk having the "D" team in my room, which is so bad that I honestly think it's dangerous for the patient in many cases. 3SL or not - we're not interested in running a modern OR. OR time is just something we offer because we have to do it.

...This. Exactly the same in our facility. Anesthesia time (and anesthesia turnover time) is seemingly untouchable and non-negotiable within the process. I asked an anesthesiology colleague - within this last month- why it took an hour of total room time to do a 5 minute ear tube case. Reply was pretty much "that's my time".
I don't trust S3 to give me any accurate info either; cut times and turnover times are often doctored by OR nurses. I resorted to tracking my own times for a bit some time ago to figure it out. O f course nothing happened when I pointed this out... they don't miss a beat to document "surgeon delay" whenever they can, though.

 

[Monty Python]

...This. Exactly the same in our facility. Anesthesia time (and anesthesia turnover time) is seemingly untouchable and non-negotiable within the process. I asked an anesthesiology colleague - within this last month- why it took an hour of total room time to do a 5 minute ear tube case. Reply was pretty much "that's my time".
I don't trust S3 to give me any accurate info either; cut times and turnover times are often doctored by OR nurses. I resorted to tracking my own times for a bit some time ago to figure it out. O f course nothing happened when I pointed this out... they don't miss a beat to document "surgeon delay" whenever they can, though.

Yeah, the OR "buck slip" (i.e., pass the buck) is paper and pen based off of (what, anesthesia's Innovian electronic clock, the clock on the wall, someone's wristwatch ... there's calibrated standardization for you), then is manually entered into S3. All sorts of opportunities for accidental or intentional hidden-agenda entry errors. At times, I wish all the ORs were constantly videotaped and time-stamped. It would be interesting to corroborate the tape with S3 time entries.

At a nearby private ambulatory surgery center, any turnover time except for total joints >20 minutes gets a raised eyebrow from the OR supervisor. Anything >25 minutes gets officially researched by the DON, who is tasked to fix it.

 

[HighPriest]

You can run an anesthesia turnover-to-surgeon time report in S3 for trend analysis. You can also run a wheels-in to wheels-out report. Both of those reports in your PE tube scenario should be red flags for someone to start digging for the baseline cause. Absent something really bizarre, 30 minutes to mask down a kiddo for PE tubes is ???? Even PR Tylenol and/or intranasal fentanyl takes, oh, 3 seconds. And I'm assuming there's no IV start post-mask induction, so "no veins" can't be blamed for the 30 minutes. That's really mind-boggling, unless you have first-day anesthesia trainees in the OR.

I hear everything you're saying. I've brought it up for longer than 3SL has been around. Nothing changes. Or, if it does change it changes for a few weeks or maybe a couple months and then it slowly devolves into this kind of thing again. Believe it or not my biggest beef isn't the long turnover, it's the unpredictability. It makes it ludicrously difficult to schedule a full day because I never know if I'm going to have an hour long turnover or a 20 minute turnover. It all depends upon who shows up for work that day. If I was doing three long cases, we could adjust fire on any given day and eat that time difference - or at least buffer it a little. But when you're talking 7-9 cases/day it's an insane difference.

So as soon as I have a day like this, I bring it up, someone looks back in the record and they see that maybe things have been slowly declining, but last month I had some good turnovers, so maybe this is a fluke and sure: we'll look into it. Then I have a couple of decent days - or maybe I schedule a couple/few longer cases and the turnover's don't matter. But then the same thing happens again. And yeah - no reason for it. We're talking about (today) masking down two healthy 9 year olds with no iv for a case time of 5 minutes or less. It shouldn't take 1/2 hour on each side.

 

[pgg]

When I was doing ear tubes at a MTF my anesthesia time was far longer than when I did them moonlighting ... because I couldn't trust the PACU to emerge a kid. I felt I had to wake them in the OR.

Still didn't take an hour. That's ridiculous.