A Novel Emergency Operating Room Scheduling Software Promotes Efficiency and Cost-Effectiveness
James Leea* BEng, MD, CM, MSc, FRCSC | Ahmed Aoudea BEng, MEng, MD, CM, FRCSC | Becher Alhalabia MD, MHPE, PhD, FRCSC | Ayden Wattb BSc | Lucie Lessarda MD, FRCSC, FRCSC, FACS
ABSTRACT
Background: Operating room efficiency is invaluable for all medical systems across the globe. Particularly important for public systems, such as the one in Canada, the efficient management of operating room scheduling is crucial to managing large patient loads with limited resources. Methods: A new online scheduling software ORNET.CA was created and installed in a level one trauma centre. All staff were then trained for its use. The pilot for the software was launched in October 2015. Results: ORnet can improve OR efficiency by up to 10% by improving communication. For a single hospital center in Quebec, this represents an average annual cost saving of $267,325.99. Discussion: We present the results of launching a new real-time OR scheduling software at a Level 1 Trauma Center to improve communication between nurses and physicians during emergency surgeries in the OR on weeknights and weekends. Improved efficiency through real-time OR scheduling carries real benefits in improving access to quality patient care. Conclusion: We demonstrate that ORnet improves communication between hospital staff and physicians, reduces workflow interruption, and improves the quality of the working environment. These benefits have significant implications for the delivery of timely care in emergent cases for public health systems.
AUTHOR AFFILIATIONS: a Department of Surgery, McGill University Health Centre, Montreal; b Department of Experimental Surgery, McGill University, Montreal.
SUBMISSION DATE: July 1, 2021 | PUBLICATION DATE: August 3, 2021
DISCLOSURES: No funds were received in support of this study. The authors report no conflicts of interest.
ACKNOWLEDGEMENTS: The authors acknowledge Amir Al-Shourbaji who was involved in the programming and implementation of the ORnet software, and parts of data acquisition for the web-based survey sent to residents, physicians and nurses.
CITATION: James Lee et al (2021). A Novel Emergency Operating Room Scheduling Software Promotes Efficiency and Cost-Effectiveness. Canadian Health Policy, August 2021. ISSN 2562-9492 www.canadianhealthpolicy.com
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Introduction
Operating room efficiency is invaluable for all medical systems across the globe but is especially important for public systems such as the one in Canada where resources are limited with long waitlists and many patients requiring care. Delays affect all hospital staff involved in the system but also affect patients; peri-operative delays have been linked to adverse events and outcomes for patients (Eldar et al, 1997; Kassell et al, 1985; Moran et al, 2005; Shiga et al, 2008). Wong et al (2010) introduced the following seven error classifications that cause operating delays: technical, nursing, delays, communication, contamination, anesthesia and other. Addressing any one or more of these classes of error will lead to improved operating room efficiencies and allow for better patient care.
The first step in finding solutions and improving operating room efficiency is to identify when delays occur and the underlying cause. Wong et al (2010) state that hospital medical records can be used to monitor the prevalence of operating room delays. In this paper, we present an online solution to improve operating room efficiency and improve hospital staff’s quality of life. This online application is used in a university health care center in Canada and is hypothesized to decrease delays in the operating room by improving communication between hospital staff involved in the operating room.
Methods
A new online scheduling software ORNET.CA was created and installed in a Level 1 Trauma Center (Test Site). All nursing staff were trained for the use of the software and physicians were sent an email with instructions on its use. The pilot project for the software was launched in October 2015. The software depicts the OR schedule on weeknights or evenings (non-elective operating room time). The nursing team would input the list of cases for the day for the non-elective operating room (OR) on a real-time basis with standards established by the hospital using it. On-call physicians would log in to the web-based real-time scheduling software and view when their case would start and if the start time has been advanced or delayed due to other, more urgent, cases. In a situation where an OR is delayed due to an emergency, the physicians on-call would be notified immediately via e-mail or text notification or the web-based scheduling software directly. The schedule, flow of cases and equipment needed were accessible to all healthcare givers to ensure adequate communication through all parties involved. Information about cases, start time, equipment needed was visible to the healthcare givers in real-time.
Institutional Review Board approval was not required for this study. To ensure patient privacy, no patient information was present on the scheduling software; only procedure, expected surgical time and the department were shown on the scheduling software. This allowed for communication of start times, surgical equipment requirements for each case, and allowed for real-time case flow management without compromising patient information.
This study analyzes and presents data acquired from the software from January 2016 to May 2017. October 2015 to January 2016 was used as a trial period of the online scheduling software for hospital staff to become familiar with its use. All non-elective (or emergency) case data from our institution completed from July 2009 to June 2016 was analyzed to estimate the number of cases, hours in the operating room and determine higher volume months in terms of emergency cases. This data was then used to estimate cost savings associated with the software.
A survey was sent to all users to determine quality-of-life measures and impressions of the software by its users. The number of logins, cases and survey results were analyzed. Descriptive statistics were used to present these results. A cost analysis was conducted to determine the cost-effectiveness such a software program can have on healthcare centres based on average provincial salaries of health care workers.
Results
Survey Data: Nurses
A total of 13 nurses who were familiar with the software for at least one year were asked to complete a multiple-choice survey on the use of ORNET.CA. Only one nurse answered that she never used ORNET.CA; the remaining 12 either used the program very often (6-10 times per month) or often (3-5 times per month). The majority of nurses also responded that the software reduced the number of phone calls into the main OR by 25-50% and allowed them to focus on their tasks on-call. Over 70% of nurses responded positively to the statement “ORNET.CA has improved nursing workflow during evenings/weekends by reducing incoming calls” by responding that they strongly agreed or agree. Additionally, over 70% of nurses agree or strongly agreed that ORNET.CA has improved their quality of life. The majority of nurses also believe that ORNET.CA has improved communication between nurses and physicians during on-call shifts. One of the main comments by nurses at the end of the survey stated that ORNET.CA should be accessible to nursing units on the wards as well to reduce calls from ward nursing staff trying to get updates on the OR emergency list schedule.
Survey Data: Physicians
An email link to the survey was sent to all attending staff and residents in orthopaedic surgery, general surgery, and plastic surgery (58 attending staff and 75 residents). Sixty-eight physicians responded to the survey representing a 51% response rate. 20 of those had not completed the survey in its entirety and thus were excluded from our analysis. A total of 48 physicians from general surgery, plastic surgery or orthopedics completed all questions on the online multiple-choice questionnaire. The majority (67%) of physicians responded that they use ORNET.CA very often or often (more than 6 times/month) during their on-call shifts. The remainder of physicians responded that they sometimes (3-5 times/month) use the software. Given that physicians have 3-4 calls on average per month, these results point to routine use of the software when on-call.
When asked if ORNET.CA helped reduced the number of calls made into the OR for updates, the majority (90%) of responders said the number of calls had reduced by more than 25%. The majority of physician responders (64%) also believed the software improves communication between nurses and doctors. Also, more than 80% of responders said that they strongly agree that ORNET.CA has improved their time management during on-call shifts and allowed them to engage in wellness activities and complete their basic errands. Interestingly, more than half the physicians (55%) believe that ORNET.CA helps improve their quality of life while on-call.
Emergency (non-elective) case data at the site
To estimate cost savings with the use of ORNET.CA, data from our institution between 2009-2017 was analyzed. The number of cases by specialty done over each year and the number of hours in the OR on an emergency non-elective basis was determined (TABLE 1). The data showed that an average of 1642 emergency cases were performed annually at our institution. This corresponded to an average of 3954 hours of operating room time per year. To estimate turnover time, an average of 30 minutes between cases was used. Thus, it was estimated that an average of 821 hours was used for turnover annually. This represented 21% of the actual OR time used to perform surgery on those cases. Similarly, if we assumed 15 minutes per case of phone interruptions related to communication between nurses and physician concerning the OR scheduling and time management of physicians, then 410.5 hours could be attributed to communication on an annual basis; this represents approximately 10% of the annual OR time used to perform surgeries during emergencies.
Software data
The login information from the backend of the online software was reviewed. The number of logins per month, the number of physician logins, and the number of nurse logins were tabulated from January 2016 until May 2017 (FIGURES 1-4). On average there were 2450 logins per month for all users combined. Of these, an average of 1750 were physician logins per month. The orthopedic surgery department had the largest proportion of logins followed by general surgery and then plastic surgery; this correlated directly with the number of cases completed by each specialty on-call. From this data, it was assumed that for every three logins to the software the physician had the necessary information required about scheduling to avoid the need to phone the OR nurse in-charge, thereby avoiding a workflow interruption and saving the nurse’s time improving OR flow and efficiency. A factor of three logins per phone call was chosen since it was assumed that logging in to the software to get an update on the schedule is much simpler and quicker than having to phone the OR nurse; thus, the phone calls were assumed to not happen as often as each login. The time saving per three logins, i.e., time interruption/delay for one phone call into the OR, was assumed to be 5 minutes. Therefore, this corresponds to an annual saving of 583 hours of phone calls annually which is similar to the estimate made above based on the number of annual cases. Again, this represented more than a 10% time saving of OR time annually.
The estimate of cost savings
The average cost of health care providers in Quebec can be estimated to be $676.09 per hour in the operating room. This can be broken down to an average surgeon cost of $336.59/hour, anesthesiologist cost of $254.66/hour, and nursing cost of $84.84/hour. This excludes case costs of equipment, cleaning products, drapes, and instrument sterilization. With an average of 3954 hours of emergency OR at the test site per year, this totals an annual cost of over $2,600,000.00 of personnel cost per year. If ORNET saves 10% of this time by improving communication and therefore improving OR efficiency, this can represent an average annual provincial cost saving of $267,325.99 for a single busy Level 1 Trauma Center.
Limitations
This paper is limited to data acquired by one center for its pilot project. Although it is a tertiary academic center, it is not clear if the same effect would be seen in a smaller center where potentially fewer emergency cases are performed. In addition, the center was mainly paper-based prior to the implementation of this software and can have different effects on medical personnel in a center where they have already implemented a paperless system. The estimates used in the cost analysis were averages and may differ from the true cost savings of such a software.
Discussion
In this paper, we present the results obtained after launching a new real-time OR scheduling software at a Level 1 Trauma Center in Quebec, Canada. The purpose of this software was to improve communication between nurses and physicians during emergency non-elective surgeries in the OR on weeknights and weekends. At this center in Canada, there is typically only one operating room available for emergencies on a given weekend or evening and another reserved for only life-threatening emergencies. This means that all patients with acute surgical needs have to be scheduled with case priority in mind with many surgical subspecialties requesting for OR time simultaneously. The software presented in this paper allows for automated prioritization of cases based on surgical priority classification and surgery booking time. The program also allows all surgeons and nurses access to the on-call OR schedule at their convenience and avoiding to repeatedly phone the OR head nurse for updates on the OR schedule and start time of a corresponding case. Therefore, the software is used as a communication tool and an organizational tool for the operating room which in turn improves efficiency and allows for better time management.
Increasing efficiency and decreasing mistakes in the OR is an important research focus. It has been demonstrated that improving OR efficiency directly increased the number of cases being performed, improved patient care, and increased profitability for a tertiary academic establishment (Kaye et al, 2015; Macario, 2010). We demonstrated that the scheduling software ORNET.CA helped improve OR efficiency by 10%. This can be extrapolated to allow for 10% more cases to be done annually or an average of 164 more cases annually at our center. This improvement can have a major impact on health care in a public system that is becoming more and more burdened by a growing number of patients to be served while trying to utilize limited resources.
The efficiency of the OR and minimizing workflow interruption have been linked to better patient outcomes in the literature (Arora et al, 2010; Eldar et al, 1997; Kassell et al, 1985; Moran et al, 2005; Shiga et al, 2008; Wiegmann et al, 2007). Guedon et al (2016) state that the lack of reliable predictability of OR length for a given case or lack of a method to adapt the OR schedule as the day progresses affects the overall OR efficiency. This becomes more important for emergency non-elective cases where many unpredictable events can occur. Therefore, a real-time scheduling software accessible to the entire medical team allows for real-time adaptation to unexpected events while improving communication between OR personnel. This improved communication channel obviates the need for frequent phone calls to inquire about the continuously changing OR schedule and thus limits OR workflow interruptions. Limiting interruptions in turn has been demonstrated to limit medical errors and avoids situations that may compromise patient safety as shown in several studies (Arora et al, 2010; Wiegmann et al, 2007).
Operating room efficiency has not only been linked to patient care but a reduction in medical errors. With the OR being the costliest department in a hospital (Guedon et al, 2016; Kaye et al, 2015), improving its efficiency and decreasing errors becomes increasingly important. Guedon et al (2016) state that OR efficiency depends on many factors including availability of personnel, unpredictable emergency surgeries, and complexity of cases. The scheduling software presented in this paper allows personnel to be more prepared for cases by removing some of the unpredictability and interruptions related to an emergency OR and allowing all personnel to see the anticipated sequence of cases that will be performed. In addition, surgeons are better able to predict when they will be needed in the operating room, eliminating delays associated with personnel arrival and phone calls to surgeons. In the study by Nagy et al (2008), a software was used to estimate and identify sources of delay in the OR. They demonstrated that approximately 15% of delays can be associated to staff delays such as waiting for the surgeon to arrive for a case (Nagy et al, 2008). In addition, they show that as much as 42% of delays to the OR are related to scheduling related issues. Although scheduling delays do not apply directly to emergency cases, the software presented in this paper has the potential to address close to half of the potential causes for delays in the OR. In another paper, the most frequent reason for OR interruption was people entering the OR, phone calls, and pagers (Antoniadis et al, 2014). Antoniadis et al (2014) showed that an average of 9.82 interruptions occurred per hour in the OR. Thus, a software like ORNET.CA can be very valuable to the OR if it reduces phone calls and OR interruptions. Our results demonstrate that ORNET.CA does in fact reduce phone calls as shown by the OR nursing staff and physician survey responses; physicians indicate that they call less (by at least 25-50% or more), and nurses indicated that they receive less calls since the software was implemented.
Operating room interruptions not only decrease efficiency but also cause stress to the medical team. In a paper by Arora et al (2010), OR interruptions were shown to be the most frequent cause of stress to OR personnel. Therefore, reducing the number of interruptions by software such as ORNET.CA can also have a positive effect on reducing stress for the OR staff. This is also depicted in our results which show that the majority of nurses and physicians using ORNET.CA seem to think that the implementation of the software program has had a positive impact on the quality of life at work.
We present an estimate of personnel cost and the potential decrease in cost from an OR scheduling software for emergency non-elective cases. In our calculations we estimate an hourly OR rate of approximately $676.09 which includes surgeons, anesthesia, and nursing. This hourly cost varies depending on the complexity of surgery being performed, the number of surgeons required for the case (ex. A poly trauma, requiring orthopedics, plastics, vascular and general surgery) and so on, however, this hourly figure gives an estimate of costs associated with running an operating room. In addition, this estimate does not include additional costs such as disposables, drapes, instruments, and equipment being used. OR costs vary in the literature; the average OR cost was estimated to be 62$/min with a range from 22$/min to 133$/min (Macario, 2010). This would equate to 3,720$/hour on average or 1,320$/hours at the lowest quoted end. Therefore, we are likely underestimating the true cost, yet are still able to demonstrate significant cost saving (approximately 10%) for the emergency OR directly linked to the use a real-time scheduling software such as ORNET.CA. These savings can then be used to improve the quality of care in a Canadian public health care system where resources are limited.
Conclusion
In this paper we present a new online scheduling software for the emergency operating room at a tertiary university center. We demonstrate that this software improves communication between hospital staff and physicians, reduces workflow interruption, and improves the quality of the working environment. We also demonstrate that the software improves OR efficiency, potentially reducing personnel cost by approximately 10% annually. We believe that such a real-time online scheduling software should be used to improve operating room workflow in many centers where a similar software program has not been implemented. Future studies include implementation of the software at smaller centers or community hospitals to determine if similar results would be found.
Implications
Improved efficiency through real-time OR scheduling carries real benefits in improving access to patient care and decreasing wait times for emergency surgery. Further institutional benefits, particularly important for public health care systems such as Canada’s, arise from cost savings and a reduction in OR delays, potentially leading to a larger annual surgical case capacity. Additional studies will examine if the implementation of such a scheduling software could have other benefits; a future study will examine the effect of ORnet on improving resident time-management and quality of life while on-call, which has the potential to lower burnout rates and surgical resident attrition rates.
APPENDIX
TABLE 1.
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REFERENCES
Antoniadis, S., Passauer-Baierl, S., Baschnegger, H., & Weigl, M. (2014, May 1). Identification and interference of intraoperative distractions and interruptions in operating rooms. J Surg Res, 188(1), 21-29. https://doi.org/10.1016/j.jss.2013.12.002
Arora, S., Hull, L., Sevdalis, N., Tierney, T., Nestel, D., Woloshynowych, M., Darzi, A., & Kneebone, R. (2010, Jan). Factors compromising safety in surgery: stressful events in the operating room. Am J Surg, 199(1), 60-65. https://doi.org/10.1016/j.amjsurg.2009.07.036
Eldar, S., Nash, E., Sabo, E., Matter, I., Kunin, J., Mogilner, J. G., & Abrahamson, J. (1997, Mar). Delay of surgery in acute appendicitis. Am J Surg, 173(3), 194-198. https://doi.org/10.1016/s0002-9610(96)00011-6
Guedon, A. C., Paalvast, M., Meeuwsen, F. C., Tax, D. M., van Dijke, A. P., Wauben, L. S., van der Elst, M., Dankelman, J., & van den Dobbelsteen, J. J. (2016, Dec). ‘It is Time to Prepare the Next patient’ Real-Time Prediction of Procedure Duration in Laparoscopic Cholecystectomies. J Med Syst, 40(12), 271. https://doi.org/10.1007/s10916-016-0631-1
Kassell, N. F., Kongable, G. L., Torner, J. C., Adams, H. P., Jr., & Mazuz, H. (1985, Jul-Aug). Delay in referral of patients with ruptured aneurysms to neurosurgical attention. Stroke, 16(4), 587-590. https://doi.org/10.1161/01.str.16.4.587
Kaye, A. D., McDowell, J. L., Diaz, J. H., Buras, J. A., Young, A. E., & Urman, R. D. (2015, Mar-Apr). Effective strategies in improving operating room case delays and cancellations at an academic medical center. J Med Pract Manage, 30(6 Spec No), 24-29. https://www.ncbi.nlm.nih.gov/pubmed/26062313
Macario, A. (2010, Jun). What does one minute of operating room time cost? J Clin Anesth, 22(4), 233-236. https://doi.org/10.1016/j.jclinane.2010.02.003
Moran, C. G., Wenn, R. T., Sikand, M., & Taylor, A. M. (2005, Mar). Early mortality after hip fracture: is delay before surgery important? J Bone Joint Surg Am, 87(3), 483-489. https://doi.org/10.2106/JBJS.D.01796
Nagy, P. G., Konewko, R., Warnock, M., Bernstein, W., Seagull, J., Xiao, Y., George, I., & Park, A. (2008, Mar). Novel, Web-based, information-exploration approach for improving operating room logistics and system processes. Surg Innov, 15(1), 7-16. https://doi.org/10.1177/1553350608316573
Shiga, T., Wajima, Z., & Ohe, Y. (2008, Mar). Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression. Can J Anaesth, 55(3), 146-154. https://doi.org/10.1007/BF03016088
Wiegmann, D. A., ElBardissi, A. W., Dearani, J. A., Daly, R. C., & Sundt, T. M., 3rd. (2007, Nov). Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery, 142(5), 658-665. https://doi.org/10.1016/j.surg.2007.07.034
Wong, J., Khu, K. J., Kaderali, Z., & Bernstein, M. (2010, Jun). Delays in the operating room: signs of an imperfect system. Can J Surg, 53(3), 189-195. https://www.ncbi.nlm.nih.gov/pubmed/20507792
About the Authors
Dr. James Lee (MD, CM, FRCSC, M.Sc., B.Eng.) is a Board-Certified Plastic Surgeon recognized by the Royal College of Physicians and Surgeons of Canada. He is an Assistant Professor of Surgery at McGill University (Montreal, QC, Canada) and an attending Plastic Surgeon at the McGill University Health Center. Email: [email protected]
Dr. Ahmed Aoude (MD, FRCSC, M.Eng., B.Eng.) is a Board-Certified Orthopedic Surgeon recognized by the Royal College of Physicians and Surgeons of Canada. He is an Assistant Professor of surgery at McGill University (Montreal, QC, Canada) and holds further appointment as a staff orthopedic surgeon, MSK oncology surgeon, and Orthopedic spine surgeon at the McGill University Health Center. Dr. Aoude is additionally the Director of the Orthopaedic Research Laboratory at McGill University. Email: [email protected]
Dr. Alhalabi (MD, FRCS, MHPE, PhD) is a board-certified plastic surgeon recognized by the Royal College of Physicians and Surgeons of Canada. He is an Assistant Professor of Surgery at McGill University (Montreal, QC, Canada) with an interest in surgical education and peripheral nerve surgery. His research in surgical education focuses on cognitive competencies and the development of simulators. Dr. Alhalabi is pursuing further training in pediatric care. Email: [email protected]
Mr. Ayden Watt (B.Sc.) is a Graduate Student at McGill University in the Department of Experimental Surgery, Faculty of Medicine (Montreal, QC, Canada). He has experience in visual neuroscience research and surgical innovation, and his current research focuses on surgical simulation and pediatric craniofacial surgery. Email: [email protected]
Dr. Lucie Lessard (MD, FRCSC, FRCSC, FACS) is Board certified in both Plastic and Ear Nose Throat Surgery and recognized by the Royal College of Physicians and Surgeons of Canada. She is an Assistant Professor of Surgery at McGill University (Montreal, QC, Canada) and an attending Plastic Surgeon at McGill University Health Center. Additionally, Dr. Lessard is the head of BAHA/Ear Reconstruction for Congenital Problems at the Shriners Hospital where she is the main Plastic Surgeon. Email: [email protected]
