Abstract
According to Webster's Dictionary, efficiency is defined as the capacity to produce desired results with a minimal expenditure of energy, money, time, and materials. For a surgeon performing an operative procedure this would mean “skillfulness in avoiding wasted time and effort.” (www.webster-dictionary.org) The essential ingredient to becoming efficient is to promote a culture of efficiency. There are 10 elements: 1) proactive surgeon perspective; 2) effective utilization of preoperative holding area; 3) preoperative planning / templating; 4) development of preference cards; 5) operating room set-up protocols; 6) operating room team concept; 7) streamlined instrument sets; 8) consistent operative workflow; 9) standardised closure / dressings; and 10) prompt and meticulous room turnover. Efficient performance of an operative procedure requires skillfulness in avoiding wasted time and effort. Perioperative efficiencies are optimised by development of “swing,” “flip,” or “double occupancy” criteria, understanding of timing of when to initiate the anesthetic block for the next case, skin closure routine by physician assistant/nurse practitioner/private scrub, and marking the operative site of your first two patients upon arrival to the hospital or surgery center. Utilise a pro-active approach to prepare case carts the day before surgery. The operating room team turns over their own rooms, with a “clean as you go” mentality. Develop a formalised communication process for patient flow issues, such as real-time push-to-talk group calling phones. Determine in advance the number of instrument sets required for the day's caseload to mitigate flash sterilization and decrease room turnover time. The goal of the surgeon is to be out of the operating room for 5 minutes in between cases before the next incision, utilizing that time to enter orders, communicate with the family, dictate, and mark the operative site of the patient who will follow the one in the case about to start. Implant selection can help if consistent. Everyone must know the instrument trays including surgeon, scrubs, and nurses. Minimise both the number of trays and the redundancy of instrumentation. Templating should be done in advance of the day of surgery. Keep your surgery consistent and always deliver your best product. The workflow for inpatient and outpatient surgeries should be the same: same implant, same approach, and same closure.
The culture of efficiency requires buy-in by all involved in the operative procedure. Every one entering the operating theatre should have proper body coverage – no hair visible, no nose visible. There should be a strict limit to needless activity: minimum opening of doors, no changing of personnel during an operation, and use of intercom/telephone to request equipment. As the surgeon and the team begin to embrace efficiency, surgical times will decrease. Multiple studies have demonstrated that increased surgical time is associated with a higher incidence of infection. This is secondary to time-dependent contamination of the surgical wound and field.
The take home message is to develop and embrace efficiency. Operating room efficiency is the product of multiple factors including preoperative preparation, skilled anesthesia team, motivated operating room staff, choreographed surgery, and well-designed instrumentation. The surgeon is the captain of the ship and the staff follows his or her lead. Your operating room days will flow smoothly. Your operations will proceed with minimal stress. You will spend less time drinking coffee between cases and have more free time at the end of the day. However, most importantly, you will deliver a quality product to your patient.
