Operating Room Efficiency for Preparation, Drape, and Room Utilization With the Direct Anterior Approach

Kristoff Corten

Christophe Olyslaegers

Admir Hadzic

Introduction

Perioperative services have to strive for efficiency, optimal outcomes, and overall cost reduction in an economic environment of decreased reimbursement.¹^,²^,³^,⁴^,⁵^,⁶^,⁷ As a result, surgeons now have to pay more attention to the important challenges of resource utilization, with the goals of reducing overall cost while maintaining, or even improving, the quality of care delivered to the patient.

Approximately 70% of total joint arthroplasties performed are potential candidates for outpatient surgery at freestanding ambulatory surgery centers (ASCs). ASCs aim to improve value of care by delivering optimal outcomes at lower costs. Therefore, increased operative efficiency with a significant reduction in process costs and waste is imperative. Surgeons must lead the advancement and promotion in adopting these efficiency measures in order to get the entire surgical team fully on board. The direct anterior approach (DAA) bears many advantages for the ASC outpatient setting because it minimizes soft tissue damage and optimizes rehabilitation.

Achieving financial viability by efficient workflows is dependent on parameters such as operating room (OR) flow management, equipment inventory, and surgical team expertise.⁸ Similar to many other processes in the industry, efficient and standardized OR flows will lead to decreased process times and more reproducible results.⁹^,¹⁰^,¹¹ Bottom-up models for introducing high-efficiency OR flows have to integrate the efforts of all stakeholders. This will be critical for aligning surgeons, OR staffing, and hospitals in planning for future growth and the overall financial sustainability of the services. In an attempt to provide a solution to these challenges, we developed the ESY concept. The reduction of the ergonomic burden of the surgical staff is the starting point of the ESY concept. The reduction of OR equipment is a major driver in this lean process model.

The DAA bears advantages for enhanced OR efficiency because it offsets many variables, with minimum soft tissue damage being one of the most important factors. It allows the surgeon to create highly standardized and reproducible procedures with a minimum of OR staff and OR instrument equipment. In addition, patients placed in a supine position offsets the variability of pelvic rotation, which is often encountered in the lateral decubitus position. Thus, the OR setup is highly standardized and the procedure can even be conducted by one surgeon and one scrub nurse without the need for additional assistants. This allows for the reallocation of other staff members to other tasks and more productive and efficient allocation of the operating staff for additional responsibilities. Both the soft tissue aspects and the controlled pelvic position improve the 90-day outcome with reduced dislocation and infection rates.¹⁰

In this chapter, we describe how bottom-up efficiency measures of the ESY concept were introduced in our DAA total hip arthroplasty (THA) procedure. The EDA hip is a hyperefficient procedure that is conducted on a regular OR table with a team of one surgeon and one scrub nurse.

The Efficient SurgerY Concept

OR efficiency is most often related to “economic” incentives. Decreasing OR time and surgical tray use are frequently considered to be key factors in reducing hospital expenses.⁸^,¹²^,¹³^,¹⁴ OR costs can be evaluated through an “overall OR time per minute.” In the United States, each minute of OR time is estimated to be worth $22 to $80.¹⁵ In the United Kingdom, OR running costs are a median of £16/min (range, £12-£20/min).¹⁶ OR time/minute also can be useful to evaluate the cost of OR turnover delays. However, it is not useful when trying to modify and analyze the OR flow management process and associated costs. Models including Lean, Six Sigma, and PDSA (Plan-Do-Study-Act) have been implemented in health care to improve and measure the efficiency of processes. They involve continuous process improvement by means of changes centered on the elimination of variables, thereby reducing errors and maximizing value.¹⁷^,¹⁸

Sustainable and “bottom-up” OR efficiency methodologies should go further than only focusing on economics with only efforts to decrease costs and OR times. Improved physical and mental ergonomics for the surgical team create an important buy-in from all stakeholders because it minimizes fatigue and errors. This will positively influence outcomes and helps to mitigate
occupational hazards. With this philosophy in mind, we initiated the ESY concept for DAA THA.

The ESY concept is a bottom-up, multidisciplinary Lean Six Sigma methodology that reduces OR variables to optimize “ergonomics” and “parallel processing.” The ultimate goal of parallel processing is the creation of a positive “ESY OR pulse,” which indicates that none of the team members are delayed in their consecutive tasks. Furthermore, different tasks collide together at different time points of the OR flow. Thus, delays within the processes are minimized. The basis of the ESY concept is identifying and minimizing process variables to amplify the ability of the team. This requires dedicated hospital resources and modified physician behavior with an open mind for interdisciplinary assessment with anesthesiologists, nursing staff, support personnel, sterile processing, and hospital administrators. Efforts to reduce OR variables are focused on improving ergonomics for all team members in order to reallocate staff and reduce fatigue, inaccuracies, and potential hazards.

Factors that affect OR efficiency have been well addressed in the literature.¹⁹^,²⁰^,²¹^,²² We have identified five key parameters that allow for reproducibly creating a positive ESY OR pulse. Surgical tray reduction and use is the starting point of the ESY concept algorithm (Figure 45.1). This is frequently considered to be the key factor in reducing hospital expenses,⁸^,¹²^,¹³^,¹⁴ but there is more to it than just a reduction in sterilization costs. Minimizing tray use reduces the time to create a standardized OR setup, therefore minimizing the room turnover and preparation times. In addition, it also affects the tray weights with improved ergonomics for the nurse. Thus, both the decreased OR time and tray reduction will considerably affect the physical and mental fatigue of the team. In addition, tray reduction allows for reproducibly executing parallel processing because instrument tray variables are significantly reduced.

FIGURE 45.1 The ESY concept algorithm starts bottom-up from improved team ergonomics to achieve improved quality of care with economic benefits.

Parallel processing (Figure 45.2) is achieved at different levels of the overall OR flow management. It encompasses simultaneous workflows of different team members who collaborate in harmony. Prerequisites to achieve this are creating a standardized OR setup and draping and retractor placement. Introducing locoregional anesthesia allows for redesigning of the operative system including block rooms where the patient can be prepared.²³ Reducing OR variables with the standardized OR setup allows for more accurately and reproducibly achieving a positive ESY OR pulse without delays or gaps in overlapping rooms.²⁴

FIGURE 45.2 Parallel processing implies that multiple aspects of the OR flow process are being executed by different team members simultaneously.

In this example, patient preparation and instrument table setup are simultaneously executed (upper and lower dark blue bar). During the surgical approach and component insertion, the nurse and surgeon work together (orange bar). OR instrument breakdown (light blue, lower bar) is started by the nurse at the initiation of the closing of the wound (gray bar) and is finalized before breakdown of patient coverage (light blue, upper bar). In this case, a positive ESY OR pulse was achieved because none of the teams had to wait for each other to move forward in the process.

(Adapted with permission from DEO.)

The EDA hip is a standardized anterior approach procedure that features all parameters of the ESY concept with a goal to create a positive ESY OR pulse. The procedure can be conducted by one surgeon and one scrub nurse. The concept allows for reallocating other staff members such as surgical assistants to prepare for the next case, to finalize administrative work in time, and to setup and break down the OR. This staff reallocation substantially improves the ESY OR pulse and allows for safely overlapping two rooms, which improves the efficiency and productivity of the team.

Equipment Reduction

Streamlining the surgical instrumentation is commonly emphasized for improving OR efficiency. It would greatly support THA in the outpatient setting by reducing the need for handling, storage, and sterilization of instruments. Most importantly, it improves the mental and physical exhaustion of the surgical team. The EDA hip encompasses the reduction of “regular” instrument trays that are well structured into the ESY instrument kit. This reduces tray weights and the efforts to select instruments. Multiple drapes are replaced by one EsySuit (MedEnvision). Reallocating manpower and reducing OR time are achieved with standardized orthostatic retractor placement by means of the Gripper (MedEnvision).

Rationale

Instrument trays are rarely audited, leading to an increasing number of unused instruments on surgical trays over time.²⁵ Reducing and standardizing trays have been shown to cut costs, reduce related preparation times, and avoid unnecessary delays associated with incorrect postings or missing instrument sets.¹⁴^,²⁶ Cichos et al¹⁸ showed that the mean instrument use before and after Lean optimization increased from 23% to 54%.

Multiple studies have suggested that reusable instrumentation could become contaminated following resterilization and may be associated with surgical site infections.²⁷^,²⁸^,²⁹^,³⁰^,³¹ Therefore, solutions such as single-use instruments or minimizing the amount of reusable equipment have been shown to reduce the infection rate.¹⁰^,³² In addition, a difference of 20 minutes was observed in the OR preparation due to the reduction of four surgical trays.¹² Goldberg et al¹⁴ showed that the largest driver for cost savings in single-use instrumentation was a reduction of tray sterilization of $994 per case. Single-use instrumentation is a nice example on how time and cost efficiencies can be facilitated while bringing greater predictability to multiple steps in the global delivery of total joint arthroplasty.¹⁴

A standardized OR setup is more easily achieved with reduced instrument trays. Most orthopaedic departments have surgical staff who rotate in multiple services and cover many different kinds of procedures. Minimizing instrument tray content to only those instruments that are required to conduct the surgery minimizes the variabilities in OR setup between different nurses and allows them to be more reproducible in setting up the instrument table and creating a standardized OR (Figure 45.3).

In summary, there are many arguments that support the reduction of equipment inventory. Without any doubt, there is a significant impact on sterilization cost reduction. However, sustainable efficiency measures within the ESY concept go beyond these direct cost analyses and focus on mental and physical team ergonomics. These improved ergonomics ultimately lead to OR and turnover time reduction with a reduced risk of errors and complications.

FIGURE 45.3 OR overview showing the transition from (A) the traditional DAA to (B) the EDA hip.

A, Multiple trays and two nurses are required to conduct the procedure. Selecting the correct instruments and structuring all trays requires more time and skills, which leads to variability in OR setup. This leads to variations in OR execution and long turnover times. B, The reduction of instrument trays has led to reproducibly setting up a standardized OR. The EDA hip procedure can be conducted with one scrub nurse. This allows for reallocation of manpower.

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