Ideas That Work: When to Start the Last Case of the Day?

HOW LATE IS TOO LATE? Surgeons who book cases later in the day can put a strain on your staff.

When to Start the Last Case of the Day?

The young orthopods are bringing lots of complex cases to your facility, but they're booking them later in the day, sometimes not starting a 4-hour rotator cuff reconstruction, for example, until 3 p.m. This puts the patient in recovery until 8 p.m., and staff who clocked in at 6 a.m. — and haven't had any relief — aren't heading home until 9 p.m.

It's a good problem to have, says Michealena Grangruth, CASC, the administrator of the Blue Springs Surgery Center in Orange City, Fla., but it's putting a strain on her facility. "They're good cases and the patients have great outcomes," she says, "but do you really want to send your patient home in the dark?"

Bound by their morning clinic schedules and their overnight trauma call, orthopods are more likely than other surgeons to schedule longer and more complex cases later in the afternoon, says Ms. Grangruth. "We have tried to get them to start earlier, but they can't and we don't have 23-hour stay in Florida. The latest we would ever want to start a case is no later than 4 p.m., but we would prefer 3 p.m."

Her solutions: Offer the new "heavy hitters" earlier blocks and add PRN nurses to work some afternoon shifts to help cover the later cases so she doesn't overwhelm her small staff.

Other facility managers are facing the same dilemma, which begs the question: How late is too late to start the last case of the day? Some work backwards from the end time. At the Surgery Center of Fort Collins (Colo.), the last cases of the day must be scheduled to end at 5 p.m., says Susan Lewton, RN, CNOR, the quality coordinator. Kingsport (Tenn.) Day Surgery shoots for a 4 p.m. end time, but the cutoff's not set in stone. Jessica Rutters, MBA, Kingsport's administrator, allows for exceptions "when it makes sense," such as when she doesn't expect a discharge problem or it's a short, relatively routine case like a carpal tunnel release.

The Texas Orthopedics Surgery Center in Austin, Texas, staggers the start times for its OR teams, scheduling 3 teams at the start of the day and 1 team to start later to cover the later cases. If more than 1 of the 3 ORs is scheduled to run past 5 p.m., an agency team comes in.

"That being said, there are times that the schedule just blows up and all of our planning and good intentions get lost in the craziness," says Jennifer King, RN, BSN, of Texas Orthopedics. "If a patient requires a PACU stay past 2030 or so, we consider a transfer. We hate doing them, but if that's what it takes, then that's what we'll do." Ms. King tries to book the docs that tend to arrive late or run past their scheduled time earlier in the day. "If that's not possible," she says, "then we try to limit the number of cases they book for that day."

— Dan O'Connor