Inefficiencies in the operating room (OR) can occur before, during, and between cases and lead to multiple problems, including delays in the delivery of patient care. They also have a negative financial impact for the institution and cause frustration for surgeons, anesthesiologists, and other OR staff. Ultimately, delays lead to dissatisfaction among patients and health care providers. Operating room efficiency increasingly is becoming a marker of the quality of surgical care.
The Institute of Medicine (IOM) identified timeliness and efficiency as 2 of 6 areas for improvement for U.S. hospitals.1 Organizations such as the Centers for Medicare and Medicaid Services, Agency for Healthcare Research and Quality, IOM, Institute for Healthcare Improvement, The Joint Commission, Leapfrog Group, and National Quality Forum are beginning to monitor patient care workflow in order to improve quality while reducing costs.2
About 187 million Americans take at least 1 prescription drug.3 An estimated 20% to 50% of patients do not take their medications as prescribed and are said to be nonadherent with therapy.4,5 Nonadherence to medication also has been shown to result in increased health risks and costs of up to $290 billion.6 Patients who receive pharmacist services achieve better clinical outcomes for chronic diseases than national standards.7
Among patients with a chronic disease, poor adherence tends to result in poor outcomes and increased medical costs. Yet these are the patients who face the most risks in surgery and require the most preoperative care. Several studies have evaluated the frequency of medication nonadherence prior to surgery and its effect on surgery cancellations. These studies have examined a variety of factors related to patient preoperative education, medications, food intake, bowel prep, etc.
In a VA Puget Sound Health Care System study, 23% of patients undergoing ambulatory surgery were nonadherent to preoperative medication instructions.8 Studies have found that up to 7% of cancellations were impacted by medication nonadherence and preoperative education.9-13 Furthermore, studies using large-scale databases have found medically treatable conditions as a significant source of surgical delay.14 Had these conditions been treated a priori, delay in surgery would not have occurred. Unfortunately, it is not clear whether the delays were the result of missed preoperative checks or medication nonadherence.
Ensuring patient safety, including reducing medical errors and adverse events (AEs), is imperative in the surgical workflow. In 1999, the IOM estimated that medical error was a leading cause of death in the U.S. and resulted in up to 100,000 deaths annually.15
In a retrospective study of 15,000 cases, Gawande and colleagues found that 66% of all AEs were surgical and 54% of these were preventable.16 In addition to improving reporting systems, creating a culture of safety with all members of the health care team and building a partnership with patients during preoperative visits can ensure increased adherence and reduced medication AEs. In a neurosurgical cohort of patients, Bernstein and colleagues found that 85% of patients were subjected to at least 1 error; 10% of the errors were major, and 65% were deemed preventable.17
The purpose of this study is to evaluate whether redundancy built into the patient care protocols prior to surgery helps catch errors as demonstrated in time-out analyses.18 Decreasing these errors would lead to fewer surgical cancellations and medical workup delays. The authors hypothesize that a structured preoperative pharmacologic workup would result in decreased preoperative delay in the surgical workflow.
Methods
The study protocol was reviewed and determined to be a quality improvement/quality assurance initiative, which exempted it from institutional review board or other oversight committee review, at the Minneapolis VA Health Care System. The VA OR Efficiency Task Force identified medication adherence as a possible source of delay. A study therefore was undertaken to determine the adherence rate and how it impacted operative delays. Data were extracted from this study to test the stated hypothesis and compare with historic data.
Fifty consecutive patients undergoing neurosurgical procedures from May 2010 through July 2010 were retrospectively reviewed and evaluated. All patients had a preoperative consultation with a pharmacist and the neurosurgery coordinator who reviewed all medications with the patient and gave specific instructions on which medications should be continued or discontinued prior to the surgery date. This information was documented on the OR Medication Compliance Worksheet and included in the patient’s preoperative chart by the neurosurgery coordinator. On the day of surgery, all active medications on this chart were reviewed with the patient by the anesthesiologist and documented on the OR Medication Compliance Worksheet. The worksheet was then sent to the neurosurgery coordinator for secondary review and analysis.
To evaluate delays, the authors reviewed the patient anesthesiology records. Delays were defined as either cancellations of the case due to medication nonadherence, which would make it unsafe to proceed with surgery, or minor delays due to medication nonadherence, which required further preoperative assessment and workup before proceeding with surgery. Cancelled cases were defined as cases on the final copy of the published OR schedule that did not occur.