A Dedicated Orthopaedic Trauma Operating Room Improves Efficiency at a Pediatric Center

Brusalis, Christopher M. BA; Shah, Apurva S. MD, MBA; Luan, Xianqun MS; Lutts, Meaghan K. MBA; Sankar, Wudbhav N. MD

Journal of Bone & Joint Surgery - American Volume:
doi: 10.2106/JBJS.16.00640
Scientific Articles
Abstract

Background: Dedicated orthopaedic trauma operating rooms have improved operating room efficiency, physician schedules, and patient outcomes in adult populations. The purpose of this study was to determine if a dedicated orthopaedic trauma operating room was associated with improved patient flow and cost savings at a level-I pediatric trauma center.

Methods: A retrospective analysis was performed for two 3-year intervals before and after implementation of a weekday, unbooked operating room reserved for orthopaedic trauma cases. Index procedures for 5 common fractures were investigated, including supracondylar humeral fractures, both bone forearm fractures, lateral condylar fractures, tibial fractures, and femoral fractures. To provide a control group to account for potential extrinsic changes in hospital efficiency, laparoscopic appendectomies were also analyzed. For each procedure, efficiency parameters and surgical complications, defined as unplanned reoperations, were compared between time periods. The mean cost reduction per patient was calculated on the basis of the mean daily cost of an inpatient hospital bed.

Results: Of 1,469 orthopaedic procedures analyzed, 719 cases occurred before the implementation of the dedicated orthopaedic trauma operating room, and 750 cases were performed after the implementation. The frequency of after-hours procedures (5 P.M. to 7 A.M.) was reduced by 48% (p < 0.001). The mean wait time for the operating room decreased among supracondylar humeral fractures, lateral condylar fractures, and tibial fractures, whereas no significant decrease (p = 0.302) occurred among 2,076 laparoscopic appendectomy cases. The mean duration of the surgical procedure and the mean time in the operating room were not significantly affected. Across all orthopaedic procedures, the mean duration of inpatient hospitalization decreased by 5.6 hours (p < 0.001), but no significant difference occurred among appendectomies. Decreased length of stay resulted in a mean cost reduction of $1,251 per patient. Supracondylar humeral fracture cases performed after implementation of the dedicated orthopaedic trauma operating room had fewer surgical complications (p = 0.018). No difference in complication rate was detected among the other orthopaedic procedures.

Conclusions: A dedicated orthopaedic trauma operating room in a pediatric trauma center was associated with fewer after-hours procedures, decreased wait time to the surgical procedure, reduced length of hospitalization, and decreased cost.

Author Information

1Division of Orthopaedic Surgery (C.M.B., A.S.S., and W.N.S.), Office of Clinical Quality Improvement (X.L.), and Division of Corporate Finance (M.K.L.), The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania

E-mail address for W.N. Sankar: sankarw@email.chop.edu

Article Outline

Efficient treatment of urgent musculoskeletal trauma is critical to delivering high-value care in orthopaedic surgery. Traditionally, patients with musculoskeletal trauma injuries that do not warrant emergency surgical procedures are scheduled as add-on cases the next day, usually following the completion of elective orthopaedic procedures. This system results in suboptimal care; patients experience prolonged wait times for the operating room, staying nil per os (NPO) for long durations, and surgeons operate at late hours with fewer and often less experienced support staff1. In response, some adult trauma centers have established dedicated orthopaedic trauma operating rooms, in which an operating room is kept open (unbooked) and available to orthopaedic traumatologists for urgent procedures on a daily basis. Orthopaedic trauma operating rooms have been demonstrated to improve operating room efficiency, physician schedules, and patient outcomes in adult populations2-6. However, these improvements have been instituted at centers in which fracture care is provided by orthopaedic traumatologists, in part as a means to appeal to those in this subspecialty2. The impact of implementing an orthopaedic trauma operating room at a pediatric level-I trauma center, in which care is provided by pediatric orthopaedic surgeons with practices not exclusively devoted to orthopaedic trauma, is unknown. The purpose of this study was to evaluate the impact of an orthopaedic trauma operating room on hospital efficiency and surgical outcomes at a pediatric level-I trauma center.

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Materials and Methods

The Dedicated Pediatric Orthopaedic Trauma Operating Room

At our tertiary care pediatric hospital, all attending pediatric orthopaedic surgeons share the responsibility of orthopaedic trauma and fracture care. Beginning in 2012, an unbooked operating room reserved for orthopaedic trauma cases was established Monday through Friday, 7:30 A.M. to 5 P.M. In a system similar to those described previously2, a surgeon of the day is designated for each day of the week, rotating among the attending orthopaedic surgeons. Nighttime call is provided by the following day’s surgeon of the day, so that the surgeon making decisions overnight is responsible for those same decisions the following morning. Similarly, the Monday trauma room is covered by the staff surgeon who assumes on-call responsibilities Sunday at 6 P.M. This ensures that the surgeon taking weekend call is not also responsible for the orthopaedic trauma operating rooms to begin the week. This schedule is disseminated widely and is known by administrative and operating room staff, who coordinate with the surgeon of the day prior to the first start to determine the order of cases to be performed in the orthopaedic trauma operating room and to ensure that appropriate resources are available to perform the procedures. No elective cases can be scheduled in the orthopaedic trauma operating room, and the surgeon of the day is kept free from all other surgical responsibilities, thereby guaranteeing availability for the first start. Communication between orthopaedic surgeons and allied health personnel facilitates patient handoffs between days. Patients and their families are informed of our institution’s team approach to orthopaedic trauma care, in which the operating surgeon changes daily to ensure adequate rest and availability to handle our volume of pediatric orthopaedic trauma.

Similar to orthopaedic trauma operating rooms developed in adult trauma centers2, when no cases are scheduled in the orthopaedic trauma operating room, both the operating room and operating room staff are utilized to complete elective cases or urgent or emergency cases by other surgical services. At our center, general surgery does not have a similar dedicated trauma room. On weekdays, emergency general trauma is moved into the most immediately available operating room, bumping other elective cases. Urgent but non-emergency general surgical cases are absorbed into the daily schedule as add-ons. On nights and weekends, a clean operating room stands ready to assume emergency trauma and is not used for less urgent cases.

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Study Design

Approval for this investigation was granted by the institutional review board. A retrospective analysis was performed for two 3-year intervals before and after implementation of the dedicated orthopaedic trauma operating room. The interval prior to the orthopaedic trauma operating room was defined as calendar years 2009 to 2011, and the orthopaedic trauma operating room interval was defined as calendar years 2013 to 2015. Procedures performed during the 2012 calendar year were excluded from data analysis as the dedicated orthopaedic trauma operating room was phased in during the course of this calendar year and may therefore not be representative of either cohort. Index procedures for 5 archetypal closed fractures treated urgently in our center were retrieved from billing records by Current Procedural Terminology (CPT) code: (1) open reduction and internal fixation of radius and ulna fractures (25575); (2) closed reduction and percutaneous pinning of supracondylar humerus fracture (24538); (3) open reduction and internal fixation of humeral lateral condyle fracture (24579); (4) tibia fracture treated with intramedullary elastic nails (27759); and (5) femur fracture treated with intramedullary elastic nails (27506). Cases with multiple CPT codes, including patients with open fractures or polytraumatic injuries, were excluded as these cases often necessitate an immediate surgical procedure and are associated with variable lengths of hospital stay.

Although prior studies evaluating orthopaedic trauma operating rooms have focused exclusively on changes detected among orthopaedic trauma procedures2-4,6, their uncontrolled study designs could not account for potential extrinsic changes in hospital efficiency over the same time period. Therefore, it is possible that the demonstrated improvements in efficiency may be attributable to unrelated, concurrent changes in patient management including improved efficiency in the emergency department or global decreases in operating room turnover time, rather than the orthopaedic trauma operating room itself7-10. To account for these possibilities, we analyzed laparoscopic appendectomies over the same time intervals as a control group. Appendectomies are subject to hospital-wide changes in patient management or flow, but are not eligible for the orthopaedic trauma operating room. Therefore, benefits attributable to the orthopaedic trauma operating room should be identified in orthopaedic trauma procedures, but not appendectomies.

For each procedure, several parameters of hospital efficiency and patient flow were measured and were compared between time periods. Patient wait time to the operating room was calculated as the difference between the time of arrival in the emergency department triage unit and the surgical start time. The proportion of after-hours procedures, defined as cases with a surgical start time between 5 P.M. and 7 A.M., was calculated. Duration of the surgical procedures, duration of overall time in the operating room, and duration of inpatient hospital stay (in hours) were also measured. Unplanned reoperations within 90 days of the index case were used as a marker for surgical complications, as reported by Bhattacharyya et al.2. The mean cost reduction per patient was based on the mean daily cost of an inpatient hospital bed multiplied by the change in hospital length of stay (fiscal year 2015 dollars).

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Statistical Analysis

All statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) software (version 23.0; IBM). Differences in outcomes between patient cohorts were assessed using an independent sample t test. A chi-square test and analysis of variance (ANOVA) were used to determine the significance of categorical variables. Data that were not normally distributed were analyzed using a nonparametric Mann-Whitney U test. The level of significance was established at a 2-sided alpha level of p < 0.05.

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Results

Of the 1,469 orthopaedic trauma procedures analyzed, 719 cases were analyzed prior to implementation of the orthopaedic trauma operating room and 750 cases were analyzed following implementation (Table I). The distribution of the 5 orthopaedic procedures did not differ significantly (p > 0.05) between time intervals (Fig. 1). During the same time periods, 918 appendectomies were analyzed prior to implementation of the orthopaedic trauma operating room and 1,158 were analyzed following implementation.

The frequency of after-hours orthopaedic procedures (5 P.M. to 7 A.M.) was reduced by 48% (p < 0.001) (Fig. 2). The mean time from presentation to the operating room decreased among supracondylar humeral fractures, lateral condylar fractures, and tibial fractures, whereas no significant decrease (p = 0.302) occurred among laparoscopic appendectomy cases (Fig. 3). Across all included orthopaedic procedures, the mean duration of inpatient hospitalization decreased by 5.6 hours (p < 0.001), but no significant difference (p = 0.689) occurred among appendectomies (Fig. 4). A decreased length of stay resulted in a mean cost reduction per patient of $1,251. The mean duration of the surgical procedure (p = 0.990) and the mean time in the operating room (p = 0.225) were not significantly affected. Supracondylar humeral fracture cases performed after implementation of the dedicated orthopaedic trauma operating room had a 53% reduction in unplanned reoperations (p = 0.018). Although there was a lower rate of unplanned reoperations among appendectomies (p = 0.024), no difference in the rate of unplanned reoperations was detected among the other fracture procedures.

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Discussion

Dedicated orthopaedic trauma operating rooms offer numerous advantages to health-care systems, providers, and patients. They minimize disruption of elective case schedules and outpatient clinic office hours. More importantly, they allow for timely treatment of orthopaedic trauma patients during normal working hours, minimizing patient wait time while NPO. Shifting fracture care into normal working hours may improve care, as after-hours procedures are often associated with scheduling difficulties, physician fatigue, lack of equally skilled operating room personnel, and unavailability of appropriate equipment1. Ricci et al.11 noted that an after-hours surgical procedure was an independent predictor for unplanned reoperations in the surgical treatment of lower-extremity fractures. Conversely, the establishment of an orthopaedic trauma operating room has been associated with a decreased incidence of stroke, myocardial infarction, and in-hospital death in patients undergoing hip fracture surgical procedures11, as well as lower morbidity rates in patients treated for low-energy subcapital hip fractures12.

The results of our study demonstrate that the establishment of a dedicated orthopaedic trauma operating room in a pediatric level-I trauma center is associated with a significant reduction in after-hours procedures, shorter wait times to the operating room, and an overall decreased length of hospitalization for several representative pediatric fractures. These findings suggest that the benefits of the orthopaedic trauma operating room extend beyond adult trauma centers staffed by dedicated orthopaedic traumatologists. Reductions in wait time and length of hospitalization suggest that orthopaedic trauma operating rooms may be an appealing practice model for improving patient flow, optimizing use of hospital resources, and improving value delivery13,14. The clinical importance of reducing patient wait time by, for instance, 0.7 hour for operative fixation of a supracondylar humeral fracture may seem minimal. However, given the high volume of supracondylar humeral fractures performed at our institution, incremental improvements in individual patient flow can lead to larger-scale gains in hospital efficiency. When summated over all eligible patients undergoing a surgical procedure for a supracondylar humeral fracture during the orthopaedic trauma operating room study interval, 0.7 hour per patient translates to more than 400 hours of patient wait time saved for this fracture type alone. Although anecdotal, our experience is that reduced time spent NPO has also led to increased satisfaction among patients and their families. The significant decrease in reoperation rate identified after orthopaedic trauma operating room implementation may represent greater accuracy of fracture reduction and fixation achieved by shifting procedures into normal working hours. However, further direct investigation is needed before reaching definitive conclusions.

Perhaps counterintuitively, no difference was detected in mean duration of the surgical procedure or mean duration of overall operating room time for any procedure following orthopaedic trauma operating room implementation. Our findings suggest that shifting operating room cases into the normal workday does not necessarily lead to shorter operative times. A study by Ricci et al.11 supported this conclusion, demonstrating that mean operative times for fracture procedures performed during normal working hours were actually increased by 19% for femoral fracture procedures and by 23% for tibial fracture procedures compared with those performed after normal working hours. One potential explanation is that, in comparison with outcomes such as surgical start time and patient wait time for the operating room, duration of the surgical procedure is more dependent on the attending surgeon than on systemic processes. The duration of a surgical procedure is also often impacted by efforts to educate trainees that may be curtailed later in the day. Because the index procedures were performed by the same group of orthopaedic surgeons over both study intervals, it follows that operative times would be consistent. Additional studies in a variety of practice settings are needed to more fully evaluate the impact of the orthopaedic trauma operating room on operative time.

Improvements in patient flow through the hospital result in direct and indirect financial benefits for a health-care system. As demonstrated by the presence of an orthopaedic trauma operating room at our institution, the reduced mean length of hospital stay for a given procedure facilitates increased patient throughput and improved resource utilization without a requisite expansion of infrastructure. Moreover, a reduction in after-hours surgical procedures minimizes the utilization of more costly overtime or nighttime staffing. However, quantification of such cost savings is complicated by existing patterns in health-care reimbursement and limitations in current hospital cost accounting. For instance, the per-patient cost of an inpatient hospital bed is allotted on a daily, rather than hourly, basis. Therefore, reducing a patient’s hospital stay by 5 hours only translates into direct financial savings when this time savings crosses from 1 day into the previous day. Nonetheless, improvements in hospital efficiency parameters, such as those afforded by the orthopaedic trauma operating room, will remain valuable, as such metrics are increasingly tied to government-funded reimbursement systems.

Our study must be considered in the context of its limitations. As with prior studies evaluating the orthopaedic trauma operating room in adult orthopaedic trauma care, our retrospective, observational study was not designed to account for all potential extrinsic improvements in health-care delivery that may have contributed to improved efficiency parameters. However, unlike prior studies, one strength of this analysis was its inclusion of laparoscopic appendectomy data as a control group. The fact that improvements identified in orthopaedic data were not detected in an archetypal general surgical procedure provides stronger support that the detected improvements are directly attributable to the orthopaedic trauma operating room, rather than other hospital-wide initiatives. Notably, the mean wait time for appendectomies did not change significantly across the study intervals, suggesting that the presence of the orthopaedic trauma operating room did not negatively impact patient flow within other surgical services. Moreover, our findings may not be generalizable to all pediatric centers with different practice patterns. For instance, in some centers, patients with certain fractures (e.g., lateral condylar fractures) are discharged from the emergency department and are scheduled for a surgical procedure on an elective basis, rather than being admitted. However, at our institution, absorbing a high volume of fracture cases into elective scheduling would be challenging and would prevent close monitoring of neurovascular status, swelling, and other clinical signs that can be important in many cases.

Another limitation was that we did not exclude data from weekends during the orthopaedic trauma operating room interval, despite no dedicated weekend orthopaedic trauma operating room being available. Runner et al.6 demonstrated that a Saturday orthopaedic trauma operating room reduced the mean length of hospital stay while increasing case volume of patients admitted for tibial or femoral fractures. Inclusion of weekend data in our study only favors the null hypothesis and makes it more difficult to show a difference in the outcomes between the two time periods. Nevertheless, that we were able to show outcome improvements is a testament to the meaningful impact of an orthopaedic trauma operating room. In addition, we were unable to provide meaningful data on the utilization rate of the dedicated orthopaedic trauma operating room. To fully evaluate the cost implications of implementation of the orthopaedic trauma operating room, it is important to acknowledge that cost savings from decreased hospital length of stay would potentially be offset by the opportunity cost from underutilization of the orthopaedic trauma operating room. However, urgent or emergency cases from other surgical departments or remaining elective cases from the day’s schedule are typically moved into the orthopaedic trauma operating room after completion of orthopaedic trauma cases. As a result, calculating overall utilization is quite complex, and, therefore, a full cost-analysis of the orthopaedic trauma operating room was beyond the scope of the current investigation. Finally, from our experience, it is worth underscoring the value in clinical continuity achieved when the surgeon of the day responsible for operative care in the orthopaedic trauma operating room is the same surgeon making clinical decisions the night prior.

In conclusion, a dedicated orthopaedic trauma operating room in a pediatric trauma center was associated with fewer after-hours procedures, decreased wait time to the surgical procedure, reduced length of hospitalization, and decreased per-patient cost. Further studies are needed to optimize the role of orthopaedic trauma operating rooms in diverse health-care settings, to evaluate their cost-effectiveness, and to innovate additional strategies to streamline the care of patients with musculoskeletal trauma.

Investigation performed at The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania

Disclosure: No external funding was received for this study. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article.

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