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.
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.
1. Min W, Wolinsky PR. The dedicated orthopedic trauma operating room. J Trauma. 2011 ;71(2):513–5.
2. Bhattacharyya T, Vrahas MS, Morrison SM, Kim E, Wiklund RA, Smith RM, Rubash HE. The value of the dedicated orthopaedic trauma operating room. J Trauma. 2006 ;60(6):1336–40; discussion 1340-1.
3. Lemos D, Nilssen E, Khatiwada B, Elder GM, Reindl R, Berry GK, Harvey EJ. Dedicated orthopedic trauma theatres: effect on morbidity and mortality in a single trauma centre. Can J Surg. 2009 ;52(2):87–91.
4. Wixted JJ, Reed M, Eskander MS, Millar B, Anderson RC, Bagchi K, Kaur S, Franklin P, Leclair W. The effect of an orthopedic trauma room on after-hours surgery at a level one trauma center. J Orthop Trauma. 2008 ;22(4):234–6.
5. Roberts TT, Vanushkina M, Khasnavis S, Snyder J, Papaliodis DN, Rosenbaum AJ, Uhl RL, Roberts JT, Bagchi K. Dedicated orthopaedic operating rooms: beneficial to patients and providers alike. J Orthop Trauma. 2015 ;29(1):e18–23.
6. Runner R, Moore T Jr, Reisman W. Value of a dedicated Saturday orthopaedic trauma operating room. J Orthop Trauma. 2016 :30(1):e24–9.
7. Weld LR, Stringer MT, Ebertowski JS, Baumgartner TS, Kasprenski MC, Kelley JC, Cho DS, Tieva EA, Novak TE. TeamSTEPPS improves operating room efficiency and patient safety. Am J Med Qual. 2015 . Epub 2015 Apr 17.
8. Attarian DE, Wahl JE, Wellman SS, Bolognesi MP. Developing a high-efficiency operating room for total joint arthroplasty in an academic setting. Clin Orthop Relat Res. 2013 ;471(6):1832–6.
9. Haydar SA, Strout TD, Baumann MR. Sustainable mechanism to reduce emergency department (ED) length of stay: the use of ED holding (ED transition) orders to reduce ED length of stay. Acad Emerg Med. 2016 ;23(7):776–85. Epub 2016 Jul 1.
10. Bhatt AS, Carlson GW, Deckers PJ. Improving operating room turnover time: a systems based approach. J Med Syst. 2014 ;38(12):148. Epub 2014 Nov 8.
11. Ricci WM, Gallagher B, Brandt A, Schwappach J, Tucker M, Leighton R. Is after-hours orthopaedic surgery associated with adverse outcomes? A prospective comparative study. J Bone Joint Surg Am. 2009 ;91(9):2067–72.
12. Elder GM, Harvey EJ, Vaidya R, Guy P, Meek RN, Aebi M. The effectiveness of orthopaedic trauma theatres in decreasing morbidity and mortality: a study of 701 displaced subcapital hip fractures in two trauma centres. Injury. 2005 ;36(9):1060–6.
13. Zenteno AC, Carnes T, Levi R, Daily BJ, Price D, Moss SC, Dunn PF. Pooled open blocks shorten wait times for nonelective surgical cases. Ann Surg. 2015 ;262(1):60–7.
Copyright 2017 by The Journal of Bone and Joint Surgery, Incorporated
14. Porter ME. What is value in health care? N Engl J Med. 2010 ;363(26):2477–81. Epub 2010 Dec 8.