A recent study in the American Journal of Surgery identified these five factors as the most common causes of case hold-ups in the the OR:

• insufficient nursing personnel and/or anesthesia staff,
• cases that run past schedule and delay other procedures,
• inappropriately prepped patients,
• inability to transfer patients because of PACU congestions
• and unavailable surgeons.

Researchers defined OR "time-waste" as the time in which the scheduled OR was not busy with the scheduled patient. They found 79 wasted hours over the 30-day study period, or 15 percent of the total time the OR could have been in use. As you know, it doesn't take much to throw the surgical schedule off course. I'd like to share with you the approach to minimizing OR hold-ups we've devised here at Saratoga Hospital.

Department cooperation
A segregated OR is an inefficient OR. If the department of surgery, anesthesia staff and OR nursing staff each views itself separate from the others, there's no unified approach to efficiently doing cases in the OR.

Our solution is to have regular "surgery suite" meetings that involve all the departments involved in surgical care. In particular, the doc-to-doc communication between the surgery department and the anesthesia staff has had a significant impact on helping us keep the ORs moving. Anesthesia has taken a much more active role in tasks that not only improve our clinical performance (such as reducing PONV rates) but also for moving cases along more efficiently by their selection of anesthetic agents and techniques for working with each specialty. Meanwhile, our pre-op, OR and PACU nursing staff are on the same page in getting patients prepped and moved to and from the OR.

Our fast-tracking program for all monitored care anesthesia cases lets us successfully bypass Phase I PACU in about 70 percent of our outpatient cases. That is especially important because our PACU is quite small relative to the size of our seven-OR hospital.

Constant motion
Something should always be going on in each of your scheduled ORs; they should either be in use or in the process of being turned over and prepared for the next case. We assign two assistants to track each of our seven rooms. It is their duty to see where each room stands and to assist in getting the ball rolling to start the next case as soon as possible.

Our regular staff work eight-, 10- or 12-hour shifts. All ORs open at 7 a.m. Four operating rooms close at 3:30 p.m., one at 5:30 p.m. and two run through 7 p.m. This prevents "stacking" of cases (as does scheduling longer cases for earlier in the day). We've assembled a pool of flextime and per diem staff to cover as needed.

Managing materials
A major time- waster is using staff to pull supplies and assemble case trays for the cart. It's a lot more efficient and, ultimately, less costly to use customized case packs when possible. While material costs-per-case rise, just-in-time delivery has many benefits:

• It frees personnel to help out as needed with patient care and OR turnover.
• It's convenient. Everything you need for all of your cases is assembled and ready to go.
• It's not nearly as expensive as you may think. We get a very competitive price on our packs because we have such heavy case volume. Moreover, you make the money back in reduced staffing costs.

Automated scheduling
We use the Array system to generate utilization reports and determine our block times for our surgeons. Rather than guessing, we know exactly when every case begins and ends. When hold-ups arise, we can track the sources of the problem. We can tell a surgeon how often - and by how long - his cases go past his estimated times and delay other procedures. We know how many of his cases are delayed or cancelled because of issues that were not resolved with anesthesia. And we know when the case is prepped and the OR is ready but the surgeon is unavailable or vice versa.

We don't have to "get tough" with our docs and staff. The computer does it for us with the schedules we create. We can then confront them with the irrefutable evidence, if necessary, to remind them that our hospital is in the business of providing surgical care to as many patients as possible while our ORs are open. We run at more than 85 percent capacity in our ORs, so there is little time to lose.

All about costs and care
Today more than ever, facility managers need to control the high costs of running ORs while providing for timely patient care. There may be no greater way to do that than to use the strategies we've discussed to minimize time wasted in the OR.