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Williams, BA MD, MBA; Alpers, J MD; Figallo, CM; Anders, J; DeRiso, BM MD; Watkins, WD MD, PhD

doi: 10.1097/00000539-199802001-00020
Abstracts of Posters Presented at the International Anesthesia Research Society; 72nd Clinical and Scientific Congress; Orlando, FL; March 7-11, 1998: Ambulatory Anesthesia

Department of Anesthesiology/CCM, University of Pittsburgh, Pittsburgh, PA.

Abstract S20

Increasing the number of anesthesia preparation activities may increase preoperative costs and time; however, if these activities add value to patient care, then downstream costs and time will be offset (if not fully overcome). We will examine the additional preoperative time taken by anesthesiologists to place regional anesthetics for patients undergoing anterior cruciate ligament (ACL) reconstruction of the knee following an anesthesia clinical pathway (CP). Turnover time (TOT) values will be compared with those from patients following a general anesthesia (GA) CP, and historical controls undergoing GA or regional anesthesia (RA). Managerial responses to these changes in TOT will be discussed.

Methods: After IRB approval, we reviewed medical records and hospital databases with time information from outpatients undergoing ACL reconstruction by one surgeon from July 1995 through June 1997. During academic year (AY) 1996-97, these outpatients selected either epidural anesthesia, (EA), GA, or GA with femoral nerve block (GFNB), consistent with an intraoperative CP established for these patients. AY 1995-96 patients were not subjected to any existing clinical pathways and were not prescribed specific anesthesia care plans other than those individually decided upon by varying staff anesthesiologists. CP patients selecting EA or GFNB had the regional techniques initiated and activated in the preoperative holding area (POHA) during the concurrent case in the OR. Using a computerized patient-tracking system, time stamps were recorded when the patients entered and exited the POHA and OR. TOT was calculated from the time stamps entered, and was consistent with the interval from "Patient-out-of room" (POR) to "Patient-in-room" (POR) described in the Association of Anesthesia Clinical Directors Procedural Times Glossary. [1] Pairwise comparisons of TOT values were analyzed using the independent-samples t-test. Values of P < 0.10 were noted as trends, P < 0.05 was considered statistically significant.

Results: For the patients of the one surgeon studied during AY 1995-96, 84% (143/170) underwent GA, whereas during AY 1996-97, 80% (110/137) underwent a preoperative epidural or femoral nerve block. TOT data from all 307 patients were examined, including TOT going into these patients' procedures (entering TOT), and TOT after these patients' procedures (exiting TOT). Entering TOT data were available for 213 patients, and exiting TOT data were available for 239 patients. The entering TOT significantly increased in AY 1996-97 (25 +/- 8 min, mean +/- SD) when compared with AY 1995-96 (21 +/- 7 min, P < 0.001). A trend towards increased exiting TOT was also seen when comparing AY 1996-97 (25 +/- 10 min) with AY 1995-96 (22 +/- 10 min, P < 0.08).

Discussion: An ill-conceived managerial response to increased TOT may include eliminating regional anesthesia as an anesthetic option. However, the prudent manager would direct attention to the preoperative processes which forbid the efficient performance of regional anesthetics. In our center, we now introduce to patients the benefits of regional anesthesia during the preoperative phone call, and by placing pamphlets introducing regional anesthesia in the surgeon's office. In addition, we now ask patients to report to the hospital earlier, call for their transport to the POHA sooner, have the OR pharmacy prepare labeled syringes of desired local anesthetics the evening before anticipated need, and have cross-trained all ambulatory anesthesia staff (and nurse anesthetists and post-anesthesia nurses) in the performance of (or assistance with) regional anesthesia.

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1. American Journal of Anesthesiology 23 (5S):3-12, 1996.
© 1998 International Anesthesia Research Society