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

Disclosure

• No industry conflicts with this presentation.

“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

The SPR – “Swing-Rooms”

The SPR – “Swing-Rooms”

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

Current Study – Look at performance of swing rooms

• Retrospective audit of data gathered from office and operating room data collected at 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

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

Data Available

– O.R. Times• Scheduled• Pre-op• Setup• Anesthesia • Surgeon• Cleanup• PACU

– Office Times• Date of Consultation• Decision Date

•Patient age, gender•Logged Procedure Codes•Times (start and end times)

Results

Operations Management

Surgeon Utilization

69.4

84.5

74.7

50.0

60.0

70.0

80.0

90.0

100.0

MainO.R.

Before"Swing-Room"

"Swing-Room"

MainO.R.After

"Swing-Room"

% SurgeonUtilization

Surgical Turnover Time

Before the

“Swing-Room”

Main O.R. 53m:25s

After the

“Swing-Room”

Main O.R. 45m:54s

“Swing-Room” 10m:44sIncreased RegionalBlocks?

Throughput

Before the

“Swing-Room”

Main O.R. 3 Cases/Day

After the

“Swing-Room”

Main O.R. 3 Cases/Day

“Swing-Room” 7 Cases/Day

Total Cases per Year (assuming 1.5 OR days/week)

216

0

216

144168

302

0

50

100

150

200

250

300

350

Before "Swing-Room" After "Swing Room"

Main O.R."Swing-Room"Total

28% Increase in case throughput

= 86 Additional Cases

Results

Surgical Costs

O.R. Variable Cost Differences/Day

Main O.R. “Swing-Room

Cost of Labour

RNs @ 7.5 h/d @ $33/h + 18% relief &

22% benefits=

6 RNs

0.5 PWA

0.5 AA

$2,245.50

4 RNs

0.5 PWA

0.5 AA

$1732.50

Cost of Supplies

(Differences in anesthetic costs, surgical sets and

surgeon preference cards)

Supplies @ $155/case

3 cases/day

$465

Supplies @ $90/case

7 cases/day

$630

Total Variable Cost/Day

$2710.50 $2362.50

Variable Cost/Case

Main O.R. “Swing-Room”

Total Variable Cost/Day

$2710.50 $2362.50

Cases per Day 3 7

Variable Cost per Case

$903.50 $337.50

63% Variable CostSavings per Case

Results

Waitlists

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)

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.

Waitlist Change over 1 year(starting with 144 on waitlist)At 1 Year:

170 patients

At 1 Year:68 patients

Conclusion

The use of a “Swing-Room” concept can improve OR room productivity 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.

Questions ?

Anesthesia Study

A Study of General Anesthesia and Brachial Plexus Block for Outpatient Upper Limb Surgery

Dr. Seib, Dr. Head, Dr. Schwarz

“Swing-Room” Background

• In 2008, the Providence Health Care Health Authority obtained government funding Capital Payback Fund

• Funding used to:1. Expand the surgical outpatient department

2. Build a “swing-room” operating theatre system.• Two (2) side by side procedure rooms• Perform surgeries under regional anesthetic blocks

which could not otherwise occur outside of the main OR under local anesthetic.

How Much Funding?

Typical Orthopaedic Hand and Wrist O.R. Slate

1. Osteotomy left small metacarpal with possible joint release (30mins)

2. Left wrist scapho-trapezium-trapezoid fusion (90mins)3. Left wrist arthroscopy with debridement (45mins) 4. Ulnar shortening osteotomy of left wrist for distal

radius malunion (45mins)5. Left EIP TO EPL transfer (60mins)6. Resection soft issue mass dorsum left wrist (60 mins) 7. Right proximal row carpectomy possible

scaphoidectomy and 4 corner partial wrist fusion (90mins) 

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

O.R. Utilization

82.3

75.1

83.1

66.0

70.0

74.0

78.0

82.0

86.0

MainO.R.

Before"Swing-Room"

"Swing-Room"

MainO.R.After

"Swing-Room"

% O.R.Utilization

Extra Reserve Capacity from 2 Room System

Waitlist Change over 1 Year

The SPR – “Swing-Rooms”

Surgical Turnover Time

Before the

“Swing-Room”

Main O.R. 53m:25s

After the

“Swing-Room”

Main O.R. 45m:54s

“Swing-Room” 10m:44s

Negative Turnover Time

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

Forecasting (Pre-Swing Room)

• Extrapolating this increasing trend line– Wait times would be estimated to increase

to ~250 days by December 2011

250 Days

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).

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.