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Letters to the Editor: Letter to the Editor

In Response

Dexter, Franklin MD, PhD; Epstein, Richard H. MD

Author Information
doi: 10.1213/ANE.0000000000001354
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In Brief

Operating Rooms Averaging at Least 8 Hours of Cases and Turnovers

We thank Dr. Kaufman for his interest in our article.1 He describes 4 general situations in which the surgeon may be a constraint on decisions that can be made on the day of surgery.2 He writes: “the model advocated by the authors seems to assume that cases can transfer among surgeons in a group for maximum efficiency.”

No, it is the opposite of what Dr. Kaufman writes. Our model generally assumes that cases cannot transfer, even when, in practice, it might be a possibility. The assumption is that completing the case is a greater priority than what might result in overutilized operating room (OR) time because of a late surgeon (see page 833 of our article). Decisions are made subject to constraints such as surgeon availability and equipment availability.

In retrospect, it is rarely possible from information system data to know which cases could have been moved among surgeons. Thus, it would be assumed on the day of surgery that it would be unsafe to do the case without the listed surgeon. Consequently, the analysis and forecast would consider there to be no change made in the start time of the case to reduce overutilized OR time.3,4 The fact that sometimes (rarely) the case could be done by another surgeon in the group would ideally be considered on the day of surgery, if best for the patient. However, since, in our experience, rarely would computerized forecasts or software for the day of surgery know that, we did not consider that eventuality.

Our article is about ways to reduce the hours that anesthesia providers and nursing staff work late.1 The article is a Special Article because it answered one single question: whether decisions can be made both rationally and consistently, based on being down to a certain number of ORs at a certain time of the day. We showed that, indeed, this cannot be accomplished. Rather, decisions should be made based on the set of ordered priorities that we reviewed in 2004.5 The first is to maximize patient safety. The second is not cancelling a case other than for safety considerations. The third is to reduce overutilized OR time. The fourth is to reduce patient and surgeon waiting. These are precisely as pointed out by Dr. Kaufman. His examples highlight that “being down to a certain number of rooms at a certain time of day” violates the set of ordered priorities for rational decision making. There is not a way to incorporate knowledge, of whether there is >1 surgeon who may be available, into being down to a certain number of ORs at a certain time of the day. Conceptually, though, when an OR director has that knowledge, it can be taken into account, following the ordered priorities that we review. For example, if Dr. Smith, whose case is running late, informs the OR director that his partner, Dr. Jones, can cover his to-follow case, then that case might be moved into an available OR and started earlier, thus reducing overutilized time.

Dr. Kaufman may be considering a facility with multiple ORs that have cases in the morning, gaps >90 minutes in the middle of the day, and then another surgeon comes from clinic to do a short list of cases. If so, our article would not apply. From its first page and column: “we consider surgical suites for which each OR averages at least 8 hours of cases and turnover times on each regular workday.”1 Delays are excluded from turnover time calculations.3,4 We showed in our recent study with US national data that our article applies typically to university and large community hospitals.6 At those hospitals with at least 8 hours of cases and turnovers, at least two-thirds of the ORs generally are filled for at least 8 hours with 1 surgeon (see Figure 1 in the article reported by Sulecki et al7). Consequently, there would then be multiple ORs with the finishing first surgeon and available late afternoon time to accommodate each of Dr. Kaufman’s surgeons coming from clinics. Thus, our article would be fully considering the situations that he describes.

Franklin Dexter, MD, PhD
Division of Management Consulting
Department of Anesthesia
University of Iowa
Iowa City, Iowa
[email protected]

Richard H. Epstein, MD
Department of Anesthesiology
University of Miami
Miller School of Medicine
Miami, Florida


1. Dexter F, Wachtel RE, Epstein RH. Decreasing the hours that anesthesiologists and nurse anesthetists work late by making decisions to reduce the hours of over-utilized operating room time. Anesth Analg 2016;122:83142.
2. Kaufman JL. Decreasing the hours that anesthesiologists and nurse anesthetists work late. Anesth Analg 2016; 123:791.
3. Dexter F, Epstein RH, Marcon E, Ledolter J. Estimating the incidence of prolonged turnover times and delays by time of day. Anesthesiology 2005;102:12428.
4. McIntosh C, Dexter F, Epstein RH. The impact of service-specific staffing, case scheduling, turnovers, and first-case starts on anesthesia group and operating room productivity: a tutorial using data from an Australian hospital. Anesth Analg 2006;103:1499516.
5. Dexter F, Epstein RH, Traub RD, Xiao Y. Making management decisions on the day of surgery based on operating room efficiency and patient waiting times. Anesthesiology 2004;101:144453.
6. Dexter F, Dutton RP, Kordylewski H, Epstein RH. Anesthesia workload nationally during regular workdays and weekends. Anesth Analg 2015;121:16003.
7. Sulecki L, Dexter F, Zura A, Saager L, Epstein RH. Lack of value of scheduling processes to move cases from a heavily used main campus to other facilities within a health care system. Anesth Analg 2012;115:395401.
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