High Performing
Operating Rooms
Robert B. Zann MD
FACS
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EFFICIENCY
HIGH PERFORMING OR
TEAM APPROACH
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Office Reimbursement
Description
Patients
Medicare
Total
Surgery
Total Hip Arthroplasty MD
1
$1486.73
Total Knee Arthroplasty MD
1
$1605.67
Office Visits 5Pt’s/hr
Est. Patient Level 3
New Patient Level 4
3
2
$53.16
$139.70
$159.48
$279.40
X-Rays
Pelvis, 2 views
Knee, 2 views
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3
$60.20
$60.20
$120.40
$180.60
$739.88/hr
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DRG 544
Major Joint Replacement or Reattachment
• DRG Reimbursement- $11,000.00
• OR Charges
– 1 Hour $4,125.00
• every minute thereafter $40.00
– Supplies that are built in to the First hour cost are:
 Room Equipment
 FTE’s
 Custom Packs
 Dressing, Suction, Bovie, extra gowns
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• Incremental Charges #315.00
– Items such as:
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Cement
Cement Mixing Supplies
Irrigation supplies
Kamvac suction
Stapler
• Extra Charges
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Stryker Pain Pumps $200.00
Intra Articular Injection $450.00
Implant Cost $ ??
Platelet Rich Plasma Spray $ 408.00
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• ACU Charges
– Per hour $ 478.50
• PACU
– First Half Hour $ 959.00
– Every minute thereafter $ 12.50
• Room Rates
– Private vs Semi-Private $$$
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TEAM APPROACH
• Surgical Team
– M.D., P.A., R.N., Surgical Coordinator
• ANESTHESIA
– MD, CRNA
• OR PERSONNEL
– Orthopedic OR Coordinator
• Stryker Representative
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PRE-OP
• Surgical Team
• Pre-op rounds (one week pre-op)
– H&P, Pre-op Orders - MD, & PA
– X-ray rounds – entire team
– Pre-op Labs- Medical Clearance
– Post-op Orders- Preliminary Completion
– Post-op note- Preliminary Completion
– Pre-Op Holding
 Consent and H&P signed
 Initial correct site on patient
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Pre-operative x-ray rounds (1 week prior to surgery)
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• Anesthesia
• Pre-op consultation
 Optimal
24-48 hours pre-op
• Regional Anesthesia Administration in Pre-Op
holding area
• OR Personnel
• Confirmation of Patient, Procedure & Site
• Confirmation of Consent
• Confirmation of Labs
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• Stryker Representative
• Pre-operative templating
• Proper Instrumentation
• Multiple instrument sets
• Turn over instrumentation as needed
• Correct Prosthesis
• Assist in room turnover
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Pre-op Orders
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PRE-OP ORDERS: KNEE
(Dr. Robert Zann #339)
DIAGNOSIS
REGULAR DIET
LAB WORK DONE AS OUTPATIENT BY Dr.
Results to O.R.
CHEST X-RAY
EKG
CBC, SMA 12, LYTES, PLATELET COUNT
ADDITIONAL LABS: PT, PTT
MEDICAL / CARDIAC CLEARANCE BY DR.
CLEAN CATCH U/A
TYPE AND SCREEN
UNITS
BLOOD
BILATERAL
BK
AE HOSE
RESERVE CPM MACHINE
RESERVE ELECTRIC COOL
NPO AFTER MIDNIGHT FOR SURGERY IN AM
CONSENT FOR
TOTAL KNEE ARTHROPLASTY
START IV IN OPPOSITE UPPER EXTREMITY AS OPERATIVE
KNEE
WITH 18 GA INTERCATH R/L @ __________cc/hr
PRE-OP ANTIBIOTIC: TO BE GIVEN PER O.R. PROTOCOL
ADDITIONAL
AGENT:_______________________________________
CELEBREX 200mg 1 PO 1 HOUR PRIOR TO SURGERY UNLESS
ALLERGIC
TO SULFA OR SULFONAMIDES
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M.D. Signature _____________________ M.D. # 339
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PRE-OP ORDERS: HIP
(Dr. Robert Zann #339)
DIAGNOSIS
REGULAR DIET
LAB WORK DONE AS OUTPATIENT BY Dr.
Results to O.R.
CHEST X-RAY
EKG
CBC, SMA 12, LYTES, PLATELET COUNT
ADDITIONAL LABS: PT, PTT
MEDICAL / CARDIAC CLEARANCE BY DR.
CLEAN CATCH U/A
TYPE AND SCREEN
UNITS
BLOOD
BILATERAL
BK
AE HOSE
NPO AFTER MIDNIGHT FOR SURGERY IN AM
CONSENT FOR
TOTAL HIP ARTHROPLASTY
START IV IN OPPOSITE UPPER EXTREMITY AS OPERATIVE
HIP
WITH 18 GA INTERCATH R/L @ __________cc/hr
PRE-OP ANTIBIOTIC: TO BE GIVEN PER O.R. PROTOCOL
ADDITIONAL
AGENT:_______________________________________
CELEBREX 200mg 1 PO 1 HOUR PRIOR TO SURGERY
UNLESS ALLERGIC
TO SULFA OR SULFONAMIDES
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M.D. Signature ____________________ M.D. # 339
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Post-op Orders
Dr. Robert Zann #339)
Pg. 1 of 4
1. Vital Signs: Q 4 hours
2. Diet as tolerated
( Dr. Robert Zann #339)
Pg. 2 of 4
• Reg
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13. Remove Hemovac in A.M. Post-op Day # 1
3. IV: D5 LR at 75 cc/hr until tolerating po fluids, then MAP
4. X-Rays in PACU
•Knee portable A/P and Lateral (long Cassette) • R
• L
•Hips portable A/P and Pelvis - see tip of prosthesis • R
L
14. Start daily dressing changes Post-op Day # 1 - Adaptic and
4x4’s
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5. LABORATORY
•H & H, BMP in PACU, H & H QAM x 3
If Hb is less than or equal to 8 grams, transfuse 1 unit
Blood(Autologous if available), repeat H/H post
transfusion
•If Potassium is below 3.5 in PACU, add 40 meq. to first IV
liter
•Creatinine with calculated clearance in PACU and Daily
notify M.D. if less than 30ml/min
6. If Temperature > 102o, get urine culture & blood cultures
x 2, then notify physician
7. If Temperature > 101o, give Tylenol as ordered & ecourage
incentive spirometer
8. Incentive Spirometry Q1H while awake
15. Neurovascular checks to lower extremities every 2 hours for
24 hours, then every 4 hours for 24 hours
16. Dress in regular clothes starting PO day #1
17. MEDICATIONS:
•Pre-op Meds per Medical Dr. Consultant
•TYLENOL 650mg. P.O. Q4H PRN Temp. > 101 F
•FEOSOL 325 ONE P.O. daily
•AMBIEN 5mg. P.O. nightly prn sleep, may repeat x 1
•DARVOCET N-100 1 TAB P.O. Q4H prn mild pain
•PERCOCET 5/325 1 TAB P.O. Q4H prn mild to moderate pain
•PERCOCET 5/325 2 TABS P.O. Q4H prn moderate pain
•MORPHINE SULFATE _____________ Q4H prn severe pain
•CELECOXIB (Celebrex) 200mg 1 orally daily
•COLACE One P.O. Daily until B.M., then discontinue
•LAX of choice
•ZOFRAN 4mg I.V. or P.O. Q6H prn for nausea
•ANTACID of choice 30cc orally every 4 hours as needed
•REGLAN 10mg IV IVP every 8 hours x 48 hours
•OXYCONTIN 20mg orally every 12 hours
9. Bilat. BK A-E hose for hips; contralateral for knees
10. Physical Therapy: OOB TODAY; • Crutches
11. Weight bearing:
• Full
• Partial
• Walker
• Toe Touch
12. Foley catheter PRN - If used, • discontinue Post-op Day #1, or
• Discontinue after the epidural catheter is
discontinued
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M.D. Signature _________________________ M.D. # 339
Post-Operative Orders
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19.
(Dr. Robert Zann #339)
Pg. 3 of 4
POST-OP ORDERS: HIP/KNEE
POST OP-ANTIBIOTICS:
•Cefazolin 1gm intravenously every 8 hours for 3 doses (24
hours)
•Clindamycin 600mg intravenously every 8 hours for 3 doses
(24 hours)
•Vancomycin 1 gm intravenously every 12 hours for 2 doses
(24 hours)
•Other
24.• TOTAL HIP OR KNEE CARE PLAN
Coumadin Per Protocol After Daily Pro Time ( ) Yes ( ) No
PT & PTT DAILY, ( ) YES
( ) NO
START: ______________
10mg P.O. first dose
Date:_______________ Time:_______________
then daily thereafter according to Scale / INR as follows:
> 2.0
= No Coumadin
1.51 - 2.0 sec
= 2.5mg.
1.21 - 1.5 sec
= 5mg.
< 1.2
= 7.5mg.
If NO, list directive:
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• ARIXTRA 2.5mg. subcutaneous q 24 hours, • Start @
PM
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• Lovenox 40mg subcutaneous q 24 hours, • Start @
AM
22.
• PCA Pump - discontinue POD #1 – for break through pain,
Toradol 15mg I.V. Q6H prn x 24 hours
23.
• Epidural Catheter - when discontinued – for break through
pain,
Toradol 15mg I.V. Q6H prn x 4 doses within 24 hours, then
discontinue
M.D. Signature _________________________ M.D. # 339
(Dr. Robert Zann #339)
Pg. 4 of 4
•TOTAL KNEE CARE
A. Apply Cool Ice Machine at 50o
B. CPM Machine for Total Knees; Range: 0-45
3 hours BID
Increase 5-20 daily
START: Post–op Day #2
C. Knee patients OOB after surgery and Flex Knees 900 as
tolerated
D. Knee Immobilizer for comfort and quadricep weakness
• TOTAL HIP CARE
A. Hip dislocation precautions and exercise
B. Special instructions for deviation from protocol:
25.
CONSULTS:
A. Medical Dr. __________________________
B. Rehabilation Facility
C. Social Service
D. Occupational Therapy - if patient is being discharged home
E. Radiation Oncology Prophylatic Radiation Therapy ( )Yes
( )No
26.
HOME HEALTH CARE:
• COMMUNITY HOME HEALTH
• MED-TECH
M.D. Signature _____________________ M.D. # 339
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POST-OPERATIVE NOTE: (Dr. Robert Zann #xxx)
#
Name of Operating Surgeon:
Dr. Zann
Name of Assistants:Tolson/ Veech / Fenton / Huffman
Findings- Osteoarthritis Left Hip
Pre-op Diagnosis- Osteoarthritis Left Hip
Post-op Diagnosis- same
Technical Procedures Used- Left Total Hip Arthroplasty
Implants:
FemurHeadAcetInsertAnesthesia
Blood Loss
cc
Drains
one medium hemovac
Specimens removed
Left femoral head
Complications
Comments Intra- Articular Injection
“ Incision
M.D. Signature ____________________ M.D.# xxx
POST-OPERATIVE NOTE: (Dr. Robert Zann #xxx)
Name of Operating Surgeon:
Dr. Zann
#
Name of Assistants:Tolson/ Veech / Fenton / Huffman
Findings- Osteoarthritis Left Knee
Pre-op Diagnosis-Osteoarthritis Left Knee
Post-op Diagnosis- same
Technical Procedures Used- Left Total Knee Arthroplasty
Implants:
Femur- #
Tibia- #
Tibial insert- #
/
Patellamm cemented
mm
Anesthesia
Blood Loss
cc
Drains
one medium hemovac
Specimens removed- distal femur, and proximal tibial and patella
Complications
Comments Intra- Articular Injection
M.D. Signature ____________________ M.D.# xxx
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COMPUTER DATA
–Average Time for Pre-Op Nursing Assessment
and preparation
–Average Time for Administration of Anesthesia
–Average Time for Operating Room Preparation
–Average Surgical Time
–Surgical Turnover Time
•Last Staple insertion to next case skin incision
–Operating Room Turnover Time
•Patient out of room to next patient in room
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Turnover Time Issues
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Surgical Turnover Time
– Defining Turnover Time- Last Staple to Incision
• Hospital Turnover Time
– Patient exiting room and next patient entering room
• Ways to alleviate or decrease the turnover time
– Anesthesia- Pre-op holding Area vs In room
• Anesthesia Administered in Prep-op Holding
– Patient in room and positioned immediately- no delays
• Anesthesia Administered in the OR
– 20 min for Hip
– 30 min for Knees
 Additional Time to the turnover $$$$
• Turnover Time :
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One Room/no Pre-op
One Room/Pre-op
Two Rooms/no Pre-op
Two Rooms/Pre-op
Hospital
Surgical
20 min
20 min
-20 min(pt already in 2nd room)
-30 min(pt. already in 2nd room)
1 hr
45 min
10-15 min
5-10 min
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My Average Operating Time
• Patient enters room to
Patient exiting room
– Total Hip
57 min
– Total Knee
70 min
– Bilateral Knees 120 min
• Time from Incision to Wound
Closure
– Total Hip
– Total Knee
– Bilateral Knee
34.5 min
49.9 min
96.5 min
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One Room Efficiency Model with no Pre-op Holding Area
6:30am
Hip
7:30
7:00am
1
Knee 9:00
Hip
7:30am
8:00am
3
4
1
8:30am
9:00am
9:30am
10:00am 10:30am 11:00am 11:30am 12:00pm 12:30pm 1:00 1:30pm
56
3
10:30
3
4
1
Knee 12:00
5 6
4
3
1
4
5 6
3
4
5 6
1 Admission to Pre-op
2 Pre-op holding Regional Anesthesia
Total Knee- Femoral/Sciatic Nerve Block with catheter & Spinal
Total Hip- Spinal
3 Admission to Operating Suite
4 Incision
5 Case Completed
6 Transferred to PACU
Huffman-Zann Timeline
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One Room Efficiency Model with a Pre-op Holding Area
6:30am 7:00am 7:30am 8:00am 8:30am 9:00am 9:30am 10:00am 10:30am 11:00am 11:30am 12:00pm 12:30pm 1:00pm
Hip
7:30
1
3
Knee 9:00
1
2
Hip
4
10:00
56
3
1
Knee 11:00
4
56
2
3
1
4
56
2
3
4
1 Admission to Pre-op
2 Pre-op holding Regional Anesthesia
Total Knee- Femoral/Sciatic Nerve Block with catheter & Spinal
Total Hip- Spinal
3 Admission to Operating Suite
4 Incision
5 Case Completed
6 Transferred to PACU
Huffman-Zann Timeline20
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Two Room Efficiency Model with no Pre-op Holding Area
6:30am 7:00am 7:30am 8:00am 8:30am 9:00am 9:30am 10:00am 10:30am 11:00am 11:30am 12:00pm 12:30pm 1:00pm
Hip
7:30
1
Knee 8:30
1
Hip
9:30
3
4
3
56
4
1
Knee 10:30
Hip
56
3
4
1
11:30
56
3
4
1
5
3
6
4
56
1 Admission to Pre-op
2 Pre-op holding Regional Anesthesia
Total Knee- Femoral/Sciatic Nerve Block with catheter & Spinal
Total Hip- Spinal
3 Admission to Operating Suite
4 Incision
5 Case Completed
6 Transferred to PACU
Huffman-Zann Timeline21
Two Room Efficiency Model with a Pre-op Holding Area
6:30am 7:00am 7:30am 8:00am 8:30am 9:00am 9:30am 10:00am 10:30am 11:00am 11:30am 12:00pm 12:30pm
Hip
7:30
1
3
Knee
8:30
1
2
Hip
9:30
56
3
1
Knee 10:00
Hip
4
4
56
2
3
1
10:30
2
1
4
56
3
2
4
56
3
4
56
1 Admission to Pre-op
2 Pre-op holding Regional Anesthesia
Total Knee- Femoral/Sciatic Nerve Block with catheter & Spinal
Total Hip- Spinal
3 Admission to Operating Suite
4 Incision
5 Case Completed
6 Transferred to PACU
Huffman-Zann Timeline
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Greeting patients in Pre-Op Admission @ 7:00am
Confirming laboratory results and signing operative consent
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1st Case Total Hip Arthroplasty in room @ 7:30am
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2nd Case- Total Knee Arthroplasty room setup @ 7:30am
2nd Case- TKA patient receiving Femoral Nerve
Block w/catheter @ 7:30am
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1st Case THA started @ 7:50am
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1st Case instruments removed
Prior to completion of procedure
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Immediate operative dictation
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Completion of operative note and post-op orders
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2nd Case-TKA in room @ 8:00am
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Post-operative discussion with family
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2nd case completed @ 9:15 am
2nd room cleaned by 9:25am
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2nd Case closingcompleted @ 9:15 am
3rd Case in room @
9:00am
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Case 3 following patient confirmation, correct side confirmation
And preliminary completion of post-operative orders
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Conclusions
The most efficient is two rooms with a pre-op holding area
The least efficient is one room without pre-op holding
Reduction in Turnover Time (surgical turnover time!)
– Early Admission for Same-Day Lab Work,
• i.e. PT/PTT, Bleeding time, Platelet count, EKG, etc..
– Pre-op Anesthesia Evaluation-24-48 hrs prior to admission
– First Case with shortest time for Anestetic Administration
• i.e. THA rather that TKA
– Use of Pre printed templates (orders, post-op notes)
– Immediate Post operative dictation
– Clearance of all instruments and trial component during
wound closure
– Availability of Multiple instrument sets
– Cooperation of OR personnel to initiate room cleaning as
patient is transported from room
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Thank You!
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