Orthopedics

Feature Article 

Surgical Efficiency of Anterior Cruciate Ligament Reconstruction in Outpatient Surgical Center Versus Hospital Operating Room

Nathan C. Patrick, MD; Christopher A. Kowalski, MD; William L. Hennrikus, MD

Abstract

Anterior cruciate ligament (ACL) reconstructions are complex orthopedic procedures in which a proficient team is of vital importance. Outpatient surgical centers (OSCs) often provide orthopedic-specific teams; however, hospital operating rooms (ORs) commonly rotate staff. The purpose of this study was to compare the efficiency of pediatric ACL reconstructions between a surgical center and a hospital OR owned and directed by a single institution. Cases examined involved pediatric patients, aged 12 to 18 years (mean age, 15.9±1.5 years), who underwent ACL reconstructions by a single orthopedic surgeon from 2009 to 2014. Procedural efficiency was defined as shorter total OR time, less total staff, and fewer support staff changes. Total OR time was also broken into 3 distinct time periods: in-room to incision time, total procedure time, and stop time to out-of-room time. A total of 49 ACL reconstructions were performed in healthy athletes, with 28 surgeries at the OSC (mean age, 15.7±1.3 years) and 21 surgeries in the hospital OR (mean age, 16.1±1.8 years). Overall efficiency was higher at the OSC, with total OR time improved by 30 minutes on average (P=.0001) with less total staff (P=.0002). Surgical technician and nursing changes occurred 6 and 2.5 times more often in the hospital OR, respectively. Procedural efficiency was greater at the OSC. The provision of consistent and experienced orthopedicspecific teams allows for improvement in OR efficiency, cost, and value. [Orthopedics. 2017; 40(5):297–302.]

Abstract

Anterior cruciate ligament (ACL) reconstructions are complex orthopedic procedures in which a proficient team is of vital importance. Outpatient surgical centers (OSCs) often provide orthopedic-specific teams; however, hospital operating rooms (ORs) commonly rotate staff. The purpose of this study was to compare the efficiency of pediatric ACL reconstructions between a surgical center and a hospital OR owned and directed by a single institution. Cases examined involved pediatric patients, aged 12 to 18 years (mean age, 15.9±1.5 years), who underwent ACL reconstructions by a single orthopedic surgeon from 2009 to 2014. Procedural efficiency was defined as shorter total OR time, less total staff, and fewer support staff changes. Total OR time was also broken into 3 distinct time periods: in-room to incision time, total procedure time, and stop time to out-of-room time. A total of 49 ACL reconstructions were performed in healthy athletes, with 28 surgeries at the OSC (mean age, 15.7±1.3 years) and 21 surgeries in the hospital OR (mean age, 16.1±1.8 years). Overall efficiency was higher at the OSC, with total OR time improved by 30 minutes on average (P=.0001) with less total staff (P=.0002). Surgical technician and nursing changes occurred 6 and 2.5 times more often in the hospital OR, respectively. Procedural efficiency was greater at the OSC. The provision of consistent and experienced orthopedicspecific teams allows for improvement in OR efficiency, cost, and value. [Orthopedics. 2017; 40(5):297–302.]

As health care reimbursements decline and costs rise, efficiency in the health care setting becomes increasingly important. Surgical services account for a significant portion of a hospital system's overall revenue; therefore, enhancing and streamlining operating room (OR) efficiency is key.1–5 In broad terms, surgical services provide a certain value to the hospital system. Porter6 has defined value as outcomes/cost. Regarding surgical efficiency, cost in many ways is equivalent to time. As long as patient outcomes remain constant, an increase in the value of surgical procedures can be accomplished by a decrease in the amount of time per procedure, which can lead to an increase in the number of procedures performed in a given period. Therefore, value may also be defined as outcomes/time. Increased efficiency will maximize value.

Outpatient surgical centers (OSCs) are an effective, cost-reducing alternative to hospital ORs that have shown increased surgical efficiency without compromising patient safety.3,7–9 Although not suitable for all surgical procedures, OSCs are an excellent option for procedures that do not require an overnight hospital stay, such as anterior cruciate ligament (ACL) reconstruction in the pediatric population.

Anterior cruciate ligament reconstructions are complex orthopedic procedures in which a proficient team is of vital importance. Experienced surgical technicians and nurses play pivotal roles during these procedures. The practice of rotating surgical technicians and nurses is more common in the hospital OR compared with the OSC. Clearly, OSCs function in a different manner compared with their inpatient hospital counterparts, but what exactly are the key differences? The purpose of this study was to compare the efficiency of pediatric ACL reconstructions between an OSC and a main hospital OR owned and directed by a single institution. The authors' hypothesis was that OSCs would show increased procedural efficiency, as defined by shorter total OR time, less total staff, and fewer support staff changes.

Materials and Methods

Institutional review board approval was obtained. Cases examined involved pediatric patients, aged 12 to 18 years (mean age, 15.9±1.5 years), who underwent ACL reconstructions by a single orthopedic surgeon (W.L.H.) electively from 2009 to 2014 at either an OSC or a hospital OR. The 2 facilities are owned and operated by a single institution; however, there is no exchange of staff between the 2 sites. Additionally, there is no economic advantage to the surgeon to perform a procedure in one facility over the other. Procedural efficiency was defined as shorter total OR time, less total staff, and fewer support staff changes. Total OR time was also broken into 3 distinct time periods: in-room to incision time, total procedure time, and stop time to out-of-room time. These efficiency measures were controlled for age, sex, additional procedures, type of surgical preparation, and graft type (quadriceps tendon, iliotibial band, and bone–patella tendon–bone). All patients underwent reconstruction via a transphyseal or extraphyseal technique. An all-epiphyseal technique was not used in this study. Use of a regional nerve block was also reviewed but was found to have no effect on efficiency data because all blocks were performed in the preoperative holding area prior to arrival in the OR. Unpaired t tests were used to compare procedural variables between the outpatient and the inpatient facilities. Statistical significance was defined as P<.05.

Results

A total of 49 ACL reconstructions were performed in healthy athletes, with 28 surgeries at the OSC (mean age, 15.7±1.3 years) and 21 surgeries in the hospital OR (mean age, 16.1±1.8 years). The location of the surgery was determined by the next available OR of the surgeon. Overall efficiency was higher at the OSC, with total OR time improved by 30 minutes on average (P=.0001) with less total staff (P=.0002) (Tables 12). All 3 time components of the total OR time—total procedure time (P=.0440), in-room time to incision time (P=.0001), and stop time to out-of-room time (P=.0169)—were shorter for procedures performed at the OSC (Figure). Surgical technician and nursing changes occurred 6 and 2.5 times more often in the hospital OR, respectively (surgical technician, P=.0001; nurse, P=.0006) (Table 3). In total, more than 30 different nurses and 15 different surgical technicians assisted with procedures in the hospital OR, compared with 10 nurses and 5 surgical technicians in the OSC. Patient age, use of a nerve block, additional procedures performed, type of surgical preparation, and graft type did not have an effect on efficiency at either facility. No differences in complications or outcomes were appreciated between the facilities.

Procedural Variables Measured Between the Outpatient Surgical Center and the Hospital Operating Room

Table 1:

Procedural Variables Measured Between the Outpatient Surgical Center and the Hospital Operating Room

Outpatient Surgical Center and Hospital Operating Room Case DetailsOutpatient Surgical Center and Hospital Operating Room Case Details

Table 2:

Outpatient Surgical Center and Hospital Operating Room Case Details

Comparison of mean time components (minutes) between the outpatient surgical center (OSC) and the hospital operating room (OR). Total OR time was broken into 3 distinct time periods: in-room to incision time, total procedure time, and stop time to out-of-room time. All time components were found to be shorter at the OSC (P<.05).

Figure:

Comparison of mean time components (minutes) between the outpatient surgical center (OSC) and the hospital operating room (OR). Total OR time was broken into 3 distinct time periods: in-room to incision time, total procedure time, and stop time to out-of-room time. All time components were found to be shorter at the OSC (P<.05).

Number of Surgical Technician and Nursing Changes Occurring in Both the Outpatient Surgical Center and the Hospital Operating RoomNumber of Surgical Technician and Nursing Changes Occurring in Both the Outpatient Surgical Center and the Hospital Operating Room

Table 3:

Number of Surgical Technician and Nursing Changes Occurring in Both the Outpatient Surgical Center and the Hospital Operating Room

Discussion

Health care expenditures in the United States accounted for 17.8% of the gross domestic product in 2015—a total of $3.2 trillion, or $9990 per person. It is projected that the percentage of the gross domestic product occupied by health care–related expenses will grow to 19.9% by 2025.10 These numbers are, in part, related to the decisions physicians and other health care providers make on a daily basis. Apparent small or insignificant changes can yield dramatic results on the national and global levels. For example, OR income accounts for more than 30% of overall hospital income, but this may be an underestimation.1 Additionally, it is estimated to cost $6000 per hour to staff and use an OR.11 This suggests that improving OR efficiency by as little as 15 minutes per procedure could result in $1500 in savings. These data beg the question: What can be done? Multiple strategies to maximize OR use and efficiency have been described, ranging from specialty-specific OR teams to optimizing OR scheduling to lessen OR “downtime” and case delays or cancellations.2,4,5,12,13

The literature reveals that, compared with a hospital OR, OSCs show superior efficiency from the beginning of cases with shorter presurgery wait times.2,3 The current study reaffirms this. These improvements allow for procedures to consistently begin on time, which lessens delays throughout the day and permits add-on procedures to begin earlier. These differences may, in part, be due to a surgical team performing the same, or similar, surgeries on a regular basis.2 The current data show a 30-minute difference in total OR time between the 2 surgical facilities. At the OSC, a more consistent surgical team performs the operation.

Intraoperative time can be subdivided into in-room to incision time, total procedure time, and stop time to out-of-room time. These all represent areas in which efficiency can be increased. Induction rooms are one method allowing tasks to be carried out in parallel. While a surgeon is finishing an operation on one patient, the next patient can be induced in an induction room and then wheeled into another OR so the surgeon can arrive and promptly begin the next operation. Similarly, if regional blocks are used, a regional block room can be set aside to accomplish these tasks as quickly as possible to keep the OR on schedule.14,15 Induction rooms are not used at either facility; however, 30 of the current patients did undergo a regional block in the preoperative holding area. Nine of these regional blocks were performed for the hospital OR patients and 21 were performed for the OSC patients. Intraoperative time was not affected by the use of regional blocks at either facility, as these were performed prior to arrival in the OR.

This study revealed some important differences between the OSC and the main hospital OR of the same institution. Total procedure time, in-room time to incision time, and stop time to out-of-room time were all significantly less at the OSC compared with the main hospital OR for the same operation. Operating room staff changes throughout a procedure were also less at the OSC, which contributes to the growing body of evidence that specialty-specific OR teams are more efficient, likely because of procedural familiarity.2,4,5,12

This study had several limitations. The first was the assumption that the more consistent staff at the OSC implied greater experience and procedural familiarity. Given the retrospective design, neither surgical technicians nor nurses were asked about their prior experience and comfort with an ACL reconstruction in the pediatric population. However, with surgical technician and nursing changes occurring 6 and 2.5 times more often in the inpatient setting, respectively, a more consistent surgical team was encountered at the OSC. The second, again given the retrospective nature of the study, was the inability to objectively account for OR management and scheduling differences. A prospectively designed study would allow for these variables to be accounted for and possibly standardized.

Conclusion

Procedural efficiency was greater at the OSC compared with the hospital OR. The provision of consistent and experienced orthopedic-specific teams allows for improvement in OR efficiency, cost, and value.

References

  1. Weinbroum AA, Ekstein P, Ezri T. Efficiency of the operating room suite. Am J Surg. 2003; 185(3):244–250. doi:10.1016/S0002-9610(02)01362-4 [CrossRef]
  2. Kadhim M, Gans I, Baldwin K, Flynn J, Ganley T. Do surgical times and efficiency differ between inpatient and ambulatory surgery centers that are both hospital owned?J Pediatr Orthop. 2016; 36(4):423–428. doi:10.1097/BPO.0000000000000454 [CrossRef]
  3. Merrill DG, Laur JJ. Management by outcomes: efficiency and operational success in the ambulatory surgery center. Anesthesiol Clin. 2010; 28(2):329–351. doi:10.1016/j.anclin.2010.02.012 [CrossRef]
  4. Small TJ, Gad BV, Klika AK, Mounir-Soliman LS, Gerritsen RL, Barsoum WK. Dedicated orthopedic operating room unit improves operating room efficiency. J Arthroplasty. 2013; 28(7):1066–1071. doi:10.1016/j.arth.2013.01.033 [CrossRef]
  5. Xu R, Carty MJ, Orgill DP, Lipsitz SR, Duclos A. The teaming curve: a longitudinal study of the influence of surgical team familiarity on operative time. Ann Surg. 2013; 258(6):953–957. doi:10.1097/SLA.0b013e3182864ffe [CrossRef]
  6. Porter ME. What is value in health care?N Engl J Med. 2010; 363(26):2477–2481. doi:10.1056/NEJMp1011024 [CrossRef]
  7. Malek MM, DeLuca JV, Kunkle KL, Knable KR. Outpatient ACL surgery: a review of safety, practicality, and economy. Instr Course Lect. 1996; 45:281–286.
  8. Kim S, Bosque J, Meehan JP, Jamali A, Marder R. Increase in outpatient knee arthroscopy in the United States: a comparison of National Surveys of Ambulatory Surgery, 1996 and 2006. J Bone Joint Surg Am. 2011; 93(11):994–1000. doi:10.2106/JBJS.I.01618 [CrossRef]
  9. Kao JT, Giangarra CE, Singer G, Martin S. A comparison of outpatient and inpatient anterior cruciate ligament reconstruction surgery. Arthroscopy. 1995; 11(2):151–156. doi:10.1016/0749-8063(95)90060-8 [CrossRef]
  10. Centers for Medicare & Medicaid Services. NHE fact sheet. www.cms.gov/researchstatistics-data-and-systems/statistics-trendsand-reports/nationalhealthexpenddata/nhefact-sheet.html. Accessed April 9, 2017.
  11. Macario A. What does one minute of operating room time cost?J Clin Anesth. 2010; 22(4):233–236. doi:10.1016/j.jclinane.2010.02.003 [CrossRef]
  12. Stepaniak PS, Vrijland WW, de Quelerij M, de Vries G, Heij C. Working with a fixed operating room team on consecutive similar cases and the effect on case duration and turnover time. Arch Surg. 2010; 145(12):1165–1170. doi:10.1001/archsurg.2010.255 [CrossRef]
  13. Archer T, Macario A. The drive for operating room efficiency will increase quality of patient care. Curr Opin Anaesthesiol. 2006; 19(2):171–176. doi:10.1097/01.aco.0000192796.02797.82 [CrossRef]
  14. Strum DP, Sampson AR, May JH, Vargas LG. Surgeon and type of anesthesia predict variability in surgical procedure times. Anesthesiology. 2000; 92(5):1454–1466. doi:10.1097/00000542-200005000-00036 [CrossRef]
  15. Williams BA, Kentor ML, Williams JP, et al. Process analysis in outpatient knee surgery: effects of regional and general anesthesia on anesthesia-controlled time. Anesthesiology. 2000; 93(2):529–538. doi:10.1097/00000542-200008000-00033 [CrossRef]

Procedural Variables Measured Between the Outpatient Surgical Center and the Hospital Operating Room

VariableOutpatient Surgical CenterHospital Operating RoomPa
Patients, No.2821
Age at surgery, mean±SD, y15.7±1.316.1±1.8.3706
Total operating room time, mean±SD, min150±21180±28.0001
In-room to incision time, mean±SD, min26±640±13.0001
Total procedure time, mean±SD, min115±19129±25.0440
Stop time to out-of-room time, mean±SD, min7±611±5.0169
Tourniquet time, mean±SD, min86±2392±27.4008
Total staff, mean±SD, No.7.00±0.988.33±1.35.0002
Surgical technician changes per case, mean±SD, No.0.18±0.391.09±0.99.0001
Nursing changes per case, mean±SD, No.0.68±0.481.67±1.32.0006

Outpatient Surgical Center and Hospital Operating Room Case Details

Patient No.Age, yIn-Room to Incision Time, minTotal Procedure Time, minStop Time to Out-of-Room Time, minGraft TypeAdditional Procedures
Outpatient surgical center
  115.0451125QTNone
  215.5411433QTLM debridement
  315.1241325QTLM debridement
  414.9281175QTNone
  516.5221058QTNone
  615.7301468QTNone
  716.2281287QTMM debridement
  816.1221019QTLM debridement
  916.0231179QTLM debridement
  1016.5291307BPTBNone
  1114.1321502ITBLM debridement
  1213.9311347ITBLM debridement
  1315.9261405QTLM debridement
  1415.5251237BPTBNone
  1516.6241049BPTBNone
  1615.9231033BPTBMM debridement
  1717.3231035BPTBNone
  1816.1261166BPTBNone
  1917.023823BPTBNone
  2017.3231102BPTBNone
  2114.1281035BPTBNone
  2218.4221108BPTBLM debridement
  2316.920909BPTBLM debridement
  2417.2259711BPTBLM debridement
  2514.0278134ITBNone
  2615.1311429ITBLM debridement
  2712.42710313ITBNone
  2815.7261204BPTBMM debridement
Hospital operating room
  114.6459912QTNone
  215.74614013QTLM debridement
  318.04912915QTNone
  418.75313819QTLM debridement
  517.2361628QTNone
  616.94113610QTNone
  715.8301228QTNone
  817.93014022QTLM debridement
  914.63615811QTNone
  1017.23514915BPTBLM debridement
  1117.4371287BPTBNone
  1214.9871155BPTBNone
  1317.83410012BPTBNone
  1417.73613710BPTBNone
  1518.03313910BPTBNone
  1613.732499ITBNone
  1716.1261478ITBNone
  1813.63415413ITBNone
  1915.4341174ITBLM repair
  2012.54812311ITBLM debridement
  2114.24612421ITBNone

Number of Surgical Technician and Nursing Changes Occurring in Both the Outpatient Surgical Center and the Hospital Operating Room

Patient No.No.

Surgical Technician ChangesNursing Changes
Outpatient surgical center
  111
  201
  311
  401
  501
  611
  701
  811
  901
  1001
  1101
  1211
  1301
  1400
  1500
  1601
  1700
  1800
  1901
  2000
  2100
  2201
  2301
  2400
  2501
  2600
  2700
  2801
Hospital operating room
  102
  211
  323
  412
  504
  622
  722
  823
  913
  1010
  1112
  1212
  1301
  1422
  1510
  1600
  1700
  1811
  1901
  2020
  2112
Authors

The authors are from the Penn State Milton S. Hershey Medical Center, Bone & Joint Institute (NCP, CAK), and the Department of Orthopaedics, Penn State College of Medicine (WLH), Hershey, Pennsylvania.

The authors have no relevant financial relationships to disclose.

The authors thank Greg Lewis, PhD, for his statistical analysis.

Correspondence should be addressed to: William L. Hennrikus, MD, Department of Orthopaedics, Penn State College of Medicine, 30 Hope Dr, Hershey, PA 17033 ( wlh5k@hotmail.com).

Received: December 15, 2016
Accepted: May 24, 2017
Posted Online: June 30, 2017

10.3928/01477447-20170621-01

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