Dr. Thomas Goetz, MD, FRCSC Clinical Assistant Professor, UBC

1. The “Swing-Room" Experience:Productivity Improvements in Elective Hand and Upper Extremity Surgery at St. Paul’s Hospital. Dr. Thomas Goetz, MD, FRCSC Clinical Assistant Professor, UBC

2. Disclosure • No industry conflicts with this presentation.

3. “Swing-Room” Concept Implementation • Opened January 31, 2008 • 1st two years of operations • Funded by the Lower Mainland Innovation and Integration Fund (LMIIF) • 3rd year • Funded by Procedural Care Funding PATIENT FOCUSSED FUNDING

4. The SPR – “Swing-Rooms”

5. The SPR – “Swing-Rooms”

6. Goals of the “Swing-Room” • Improve Quality of Care • Safer environment than minor procedure room • Expand scope of SPR outside of main OR • Decant main OR • Decreased post-op recovery time and post-op pain • Reduce Wait Times • Cost Savings or Increased Efficiencies

7. Current Study – Look at performance of swing rooms • Retrospective audit of data gathered from office and operating room data collectedat our institution (St. Paul’s Hospital). • Analysis of: • O.R. Operations Management Efficiencies: • Surgeon utilization • Surgical turnover time • Throughput • Operating room costs • Total and costs/case • Hand and Upper Extremity Waitlist Reduction

8. Our Data Set • Data collected from one SPH Hand and Upper Extremity surgeon • Pre-SPR • Feb. 2007 – Jan. 2009 (2 years) • 657 patients over 207 O.R. days • Post-SPR system • Feb. 2009 – Oct. 2011 (21 months) • 962 patients over 243 O. R. days • “Swing-Room” Patients • 320 patients over 46 O.R. days • Main O.R. Patients • 642 patients over 197 O.R. days

9. O.R. Times Scheduled Pre-op Setup Anesthesia Surgeon Cleanup PACU Office Times Date of Consultation Decision Date Data Available • Patient age, gender • Logged Procedure Codes • Times (start and end times)

10. Results Operations Management

11. Surgeon Utilization

12. Surgical Turnover Time Increased Regional Blocks?

13. Throughput

14. Total Cases per Year (assuming 1.5 OR days/week) 28% Increase in case throughput = 86 Additional Cases

15. Results Surgical Costs

16. O.R. Variable Cost Differences/Day

17. 63% Variable Cost Savings per Case Variable Cost/Case

18. Results Waitlists

19. Waitlist Reduction – H & UE • Prior to “Swing-Room” • Elective wait-times ~36 weeks (range 21-44 weeks) • Based on difference between surgical decision date and O.R. booking date • After “Swing-Room” • Elective Wait-times ~7 weeks (range 6-10)

20. Simple Waitlist Model • Assume 1.5 O.R. days/week. • 4 Main O.R. days/month • 3 cases/day • 2 Swing-Room days/month • 7 cases/day • Assume 5 new patients booked per week for surgery. • Assume patients are interchangeable between O.R. settings.

21. Waitlist Change over 1 year(starting with 144 on waitlist) At 1 Year: 170 patients At 1 Year: 68 patients

22. Conclusion The use of a “Swing-Room”concept can improveOR roomproductivity and efficiency while decreasing costs/case. Implementation of a “Swing-Room” concept can be used to decrease waitlists. • Shows how patient focused funding can be used in a government funded hospital to radically decrease waitlists.

23. Questions ?

24. Anesthesia Study A Study of General Anesthesia and Brachial Plexus Block for Outpatient Upper Limb Surgery Dr. Seib, Dr. Head, Dr. Schwarz

25. “Swing-Room” Background • In 2008, the Providence Health Care Health Authority obtained government funding  Capital Payback Fund • Funding used to: • Expand the surgicaloutpatient department • Build a “swing-room” operating theatre system. • Two (2) side by side procedure rooms • Performsurgeries under regional anesthetic blocks which could not otherwise occur outside of themain OR under local anesthetic.

26. How Much Funding?

27. Typical Orthopaedic Hand and Wrist O.R. Slate • Osteotomy left small metacarpal with possible joint release (30mins) • Left wrist scapho-trapezium-trapezoid fusion (90mins) • Left wrist arthroscopy with debridement (45mins) • Ulnar shortening osteotomy of left wrist for distal radius malunion (45mins) • Left EIP TO EPL transfer (60mins) • Resection soft issue mass dorsum left wrist (60 mins) • Right proximal row carpectomy possible scaphoidectomy and 4 corner partial wrist fusion(90mins)

28. Operations Management - Definitions • OR Utilization • % time that OR room occupied with nursing/physician activity • High percentage utilization reflects decreased room idle time • Surgeon Utilization • % time that surgeon is in O.R. room doing surgery • Excludes surgeon set-up time (time not recorded) • Generated from case start and end times • Analysis of Surgical Turnover Time • Time between the surgical end of a case to the surgical start of the next case • Throughput • Case output per day

29. O.R. Utilization Extra Reserve Capacity from 2 Room System

30. Waitlist Change over 1 Year

31. The SPR – “Swing-Rooms”

32. Surgical Turnover Time Negative Turnover Time

33. Upper Extremity Wait Times • Prior to the inception of the swing room, wait times for elective upper extremity surgery were slowly increasing over time. • By January 2009, • Wait time to surgery ~211 days • Calculated from booking date to date of surgery

35. Forecasting (Pre-Swing Room) • Extrapolating this increasing trend line • Wait times would be estimated to increase to~250 daysby December 2011

36. 250 Days

37. Waitlists After “Swing-Room” • Increased case output in the “Swing-Room” -> caused direct decreases in the senior author’s waitlist (for “Swing-Room” eligible cases).

39. Ripple Effects in the Main O.R. • Implementation of the “Swing-Room” -> Caused off-loading of the Main O.R. • As a result, • Wait times for cases not suitable for the “Swing-Room” that had to be done in the Main O.R. also decreased.