PROJECT NAME: Sustaining Low Turnaround Times
(TAT) of Intraoperative Imaging and Interpretation of
Potentially Retained Foreign Objects (RFO)
Institution: UT MD Anderson Cancer Center
Primary Author: Joseph R. Steele, MD MMM
Secondary Author: Terrell Evans BS (RT)
Project Category: Sustained CS&E Projects
,
,
Overview:
This project is a continuation of an ongoing effort between the Division of
Surgery, Perioperative Enterprise and the Division of Diagnostic Imaging at the
University of Texas MD Anderson Cancer Center.
Standard procedure for an unmatched count in the OR following surgery is
an intraoperative radiograph. This imaging is used to identify a potential RFO. This
process is disruptive to the OR workflow and often results in delays. A CS&E
project in 2010 addressed this and successfully decreased the TAT from over 60
minutes to approximately 45 minutes. The current project evaluates whether the
gains were sustained and what further improvements (if any) were made.
Aim Statement (max points 150):
To sustain the gains of the previous 2010 CS&E project, by continuing a
mean TAT of 45 minutes or less for all potential RFO imaging at UTMDACC.
Measures of Success:
Success was measured by comparing the current TAT with that obtained
immediately after the successful completion of the CS&E project in September of
2010. The TAT is defined as the time (in minutes) from when imaging is ordered
(OR call to radiology) to when the verbal report is called to the OR by the
radiologist.
Use of Quality Tools (max points 250):
The two primary quality tools used in this sustainability project were 1)
Control Chart and 2) Flowchart.
The TAT was charted on a control chart that was regularly reviewed by the
Division Quality Officer and the Radiology Manager.
I-MR Chart of TAT by Stage
Individual Value
300
1
3
4
5
6
7
8
9
10
1 1
1
11
200
100
1
1
1
1
1
1
1
1
1
_ C L=52.9
U
X=34.3
LC L=15.7
0
04/16/10
300
M oving Range
2
1
07/29/10
11/03/10
03/03/11
07/13/11
1
10/13/11
Date
2
12/05/11
3
4
02/09/12
04/03/12
05/31/12
5
7
9
6
8
10
11
1
1
200
11
1
100
11
11
11
1
1
1
11
1
1
1
11
1
0
04/16/10
07/29/10
11/03/10
03/03/11
07/13/11
10/13/11
Date
12/05/11
02/09/12
04/03/12
__
U C L=22.9
M
LCR=7.0
L=0
05/31/12
The Flowchart was used when 1) any changes were made to the process
2) educating technologists and staff about the RFO process.
Retained Foreign Objects or Incorrect Counts – Routine Hours
Revision
5. CT DI Service
Coordinator
receives call from
OR.
(Manual time
collection).
Operating Room
Radiologic
Technologist
CT DI Service
Coordinator
Radiologist
Routine Hours: Monday-Friday 06:00 – 23:00
10. Radiologist is
made aware of
RFO or incorrect
count in OR
16. Radiologist
reviews images
15. CT DI Service
Coordinator notifies
Radiologist images
are complete.
(Manual time
collection)
6. CT DI Services
Coordinator calls
713 794-1178 to
request technologist
dispatch
8. CT DI Service
Coordinator enters
requisition into
CARE.
9. CT DI Service
Coordinator calls
Radiologist using
call tree
7. Technologist is
dispatched to OR.
11. Rad Tech
arrives in OR with
x-ray unit
(Begin procedure
time is collected)
12. Tech obtain
images with Digital
carestream portable
13 Rad Tech
uploads images
via wirelessly
into PACS from
OR room and
verifies images
in Clinicstation.
2. OR calls CT DI
Service Coordinator at
713 745-5449.
18. DI CT Service
Coordinator contacts
OR with Radiologist on
the phone at the phone
number provided
earlier.
14. Rad Tech calls CT
DI Service Coordinator
at 713 745-5449 and
informs procedure is
complete
19. Report
communicated to OR
* Standard Read
Back
(Manual time
Collection)
4. Provides patient
name, MRN, md code,
svc code, type of exam
and OR room number
1. OR discovers a
RFO or incorrect
count
17. Radiologist
instructs CT DI
Service
Coordinator to
contact OR
3. Prepares patient
and room for
X-ray
Orange indcates
revision.
Also Tech does not
leave OR room
Yellow fill
indicates time
information
collection.
Bolded lines
indicate new
or revised
process
Interventions (max points 150 includes points for innovation):
Since completion of the initial CS&E project additional OR imaging
equipment was purchased to help improve the mean TAT.
One source of significant delay identified on the initial study was due to the
technologist not “covering” the entire area of interest and having to return to the
OR to acquire more images. This typically occurred with obese patients. A new xray machine was purchased and used starting early 2011. This particular machine
had a ‘heads up display’ screen that provided the technologist immediate feedback
by showing the image they just acquired, therefore, making it much more obvious if
they needed to obtain additional imaging. This was integrated into our post CS&E
(2010) workflow.
Results (max points 250):
At the end of the initial CS&E project (September 2010) the average TAT
had decreased to 45 minutes. Our most recent data (September 2011-July 2012)
demonstrates continued improvement with a mean TAT of 37 minutes.
We have, however, struggled with variation and “out of control” events. Analysis
has shown these to be the result of three causes:
1. The OR calls too early for the tech and when the tech arrives to obtain the
image the OR is not ready.
2. The OR calls the incorrect number leading to delays as phone calls are
rerouted.
3. The tech doesn’t use the equipment correctly and does not obtain the
complete exam (full field of view) on the initial attempt—forcing them to
return to the OR to obtain additional imaging.
Revenue Enhancement /Cost Avoidance / Generalizability (max
points 200):
A retained foreign object (RFO) is a significant event. High quality imaging
to avoid such an event in almost priceless. However, wasted time to obtain such
imaging is not.
Additional technical charge for OR time/case
Additional anesthesia charge/case
Additional professional anesthesia charge/case
140.00
39.90
75.60
Total annual savings= 255.50 per case X 280 (est.) = $71,540.00
OR time is quantified in the following method:
Additional technical charge for OR -- $1200/hr
Additional anesthesia charge-- $342/hr
Additional professional anesthesia charge-- $648/hr
saved
saved
saved
Conclusions and Next Steps:
Although the original CS&E project resulted in sustained gains and continued
improvement, our analysis uncovered multiple opportunities for additional
improvement. Specifically:
1. Regular education with the OR staff. Like many healthcare institutions we
have turnover among the OR personnel, surgical residents/fellows and even
faculty. It has been two years since the previous CS&E project was
completed and we must initiate regular (quarterly or at least semi-annually)
education for the OR staff on the RFO process.
2. Continued technologist education. The imaging equipment used in the OR
for RFO studies is like no other in the Department. New technologists must
be trained and refresher training available for those who have been
previously trained.
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