C.S. Mott Children’s Hospital Operating Room Surgery ...ioe481/ioe481_past_reports/f0302.pdf ·...

C.S. Mott Children’s Hospital Operating Room Surgery Turnover Time Analysis

Final Report

December 19, 2003 Program & Operations Analysis Department

University of Michigan, Ann Arbor

Submitted To: Karen Lam, Clinical Nurse Manager, Mott OR

Mary Duck, Senior Management Systems Coordinator

Submitted By: Nicole Dub, Senior IOE Student

Thomas Laesch, Senior IOE Student Meera Meerkov, Senior IOE Student

Atul Porwal, Senior IOE Student

Table of Contents

Page Executive Summary

Introduction 1 Methodology 1 Summary of Findings and Recommendations 1 Conclusions 4

Introduction 5 Background 5 Goals and Objectives 5 Scope 6 Approach and Methodology

Data Collection 6 Analysis 7

Current System Description 7 Findings 9 Conclusions 10

Pre-Operation Background 10 Findings 11 Conclusions 11

Anesthesia Background 12 Findings 13 Best Practice Observed 13 Conclusions 13 Recommendations 14

Anesthesia Technician Background 14 Findings 14 Best Practice Observed 16 Conclusions 16 Recommendations 16

Scrub Background 16 Findings 16 Best Practice Observed 17 Conclusions 17 Recommendations 17

Circulator Background 18 Findings 18

Best Practice Observed 19 Conclusions 19 Recommendations 19

Perioperative Technician/OR Aide Background 19 Findings 20 Best Practice Observed 22 Conclusions 22 Recommendations 22

Surgical Resident Background 23 Findings 23 Best Practice Observed 23 Conclusions 23

Attending Surgeon Background 23 Findings 24 Best Practice Observed 24 Conclusions 24 Recommendations 25

Post Anesthesia Care Unit Background 25 Findings 25 Conclusions 25 Recommendations 25

Implementation Step 26

List of Appendices

A Departmental Schedule of Surgeries B Data Collection Sheet C Data Collection Sample Size D Interview Questions D1 Scrub, Circulator, PT Interview Questions D2 Surgeon Interview Questions D3 PACU/Pre-Op Interview Questions E Observational Data from September-November

List of Figures # Figure Page 1 Average Closure to Cut by Service 9 2 Average Patient Out to Patient In Time by Service 10 3 Anesthesia Technicians arrive within 2 minutes after page 64 % of cases 15 4 Anesthesia Technician to Clean and Stock Station in 5+ minutes in 76% of cases 15 5 Time from Dressing End to Patient Out 18 6 Elapsed Time Between PT Page and PT Arrival 20 7 Elapsed Time for PTs to Prepare for Next Patient 21 8 Time Elapsed for Scrub to Open Sterile Supplies 21 9 Implementation Chart of Current OR Delays 27

List of Tables

# Table Page 1 Summary of Findings and Recommendations 2 2 Timeline of Observed Cases 8 3 Timeline of Observed Cases with Gaps Identified 29

Executive Summary Introduction The C.S. Mott Children’s Hospital Operating Room (OR) staff has voiced concerns regarding the turnover efficiency. Room turnover is defined from the time when one patient leaves the operating room to when the next patient is brought in. However, to accurately investigate the room turnover, we had to observe the processes that occurred from when the surgeon closed the incision of the current patient to the time the surgeon performed the first incision of the next patient. Thus, this project studied the current Mott OR surgical turnover procedures and conducted a time study analysis designed to find opportunities for improvement. The purpose of this report is to briefly explain the findings, conclusions, and recommendations that resulted from the analysis of the surgical turnover time in the Mott OR. Methodology This study included three stages. First, a time study was completed by during which each team member spent approximately six to seven hours per week from September 22, 2003 to November 7, 2003 observing surgical cases in the OR. Data was recorded on a data collection sheet developed by the team. Data was also received from the Omni OR system regarding relevant case data during the time period of our study. Second, formal interviews were conducted by the team with circulators, scrubs, perioperative technicians (PTs), surgical staff and anesthesiology staff as well as the manager of the Post Anesthesia Care Unit (PACU) and Pre-op. Third, the data collected in the OR by the team was analyzed using statistical software and recommendations were generated for improvement. These suggestions should be implemented in the OR procedures, making the surgical turnover period more efficient. Summary of Findings and Recommendations We observed the seven main positions in the Mott OR. These positions include anesthesia, anesthesia technicians, scrubs, circulators, PTs/operating room assistants (OR Aides), surgical residents, and surgeons. Although the pre-op and PACU processes were beyond the scope of this project, delays that occur in these processes impact the surgical turnover rate in the OR. The following table provides information concerning the key findings and recommendations made in the Mott OR.

Table 1: Summary of Findings and Recommendations Background Findings Recommendations

Pre-op encompasses a number of events that must take place before the patient is allowed to enter the room.

• The consent form was incomplete in 9.0% of observed cases

• There was a problem with the H&P form in 5.2% of observed cases

• Time between room ready and patient arrival (all sterile supplies opened to patient in room)

- Average of 11 min. +/- 10 min.

N/A

Anesthesia is responsible for intubating/extubating the patient and monitoring his/her vital signs during the surgery. Anesthesia must also pre-operatively evaluate the patient and verify that the consent form is signed and completed. Anesthesia consists of attendings, residents, and CRNAs.

• Time to situate and intubate a patient (time between patient in and induction end)

- Average of 12 min. +/- 7 min. • Time to wake and extubate a patient, if

applicable (time between dressing end and extubation end)

- Average of 5 min. +/- 5 min. • In 78% of observed cases, the attending

anesthesiologist assisted in transporting the patient into the operating room, or he/she was in the room before the patient was brought in.

• In 81% of observed cases, the attending anesthesiologist was in the room prior to the patient needing extubation.

• Anesthesia needs to emphasize the importance of having complete consent forms prior to when the patient is brought into the holding room. This will alleviate the consent form delay occurring in pre-op.

Anesthesia technicians are in charge of cleaning and stocking the anesthesia station between surgical cases.

• Time it takes anesthesia technicians to complete their job (time from in to out)

- Average of 7.5 min. +/- 4.5 min.

• To decrease and standardize the time it takes the technicians to clean and stock the anesthesia station, he/she should utilize a cart or small bin stocked with the most commonly needed supplies. This will decrease the number of times necessary to leave the operating room to get additional supplies.

The scrub assists the surgical team during the surgery. They are responsible for opening sterile supplies, setting up the room for surgery and keeping track of the instrumentation used during the surgery to make sure nothing is left behind in the patient.

• When the scrub began break down of the room before patient had left:

- Average cleaning time for the PTs was 6.6 min. +/- 2.6 min.

• When the scrub did not begin break down of the room before the patient had left:

- Average cleaning time for the PTs was 7.3 min. +/- 3.4 min.

• Wasted materials were noticed when all sterile supplies are opened.

• The scrub should begin break down of the room before the patient has left. The break down should include closing waste and soiled linen bags, resulting in faster cleaning times for the PTs.

• Extra supplies should be separated from the required supplies on the cart. This can be done by putting a divider on the bottom shelf, designating one side for extra supplies. As a result, unneeded equipment will not be opened and subsequently thrown out unused.

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Background Findings Recommendations Circulators are responsible for the overall flow of the case. They complete the case paperwork, get supplies, and arrange for patient transfers in and out of the room. They also care for the patient during induction and extubation.

• The time to call PACU is not standardized PACU prefers a 10-15 minute

warning Time from dressing end to patient out

is 10.3 +/- 7.9 minutes • Delays are not being recorded in the Omni

OR system

• Call PACU when dressing ends • Stress the importance of recording

lengths and causes of delays in the Omni OR system to benefit continual improvement.

PTs must assist the scrub and circulator with any activities that are necessary. The PTs should also prepare the operating room for the next patient by cleaning the room and picking the appropriate instruments.

• In 6.5% of the cases observed, delays were caused by wrong instruments being prepared or the correct instruments not being ready.

• In 62.5% of the observed cases, PTs arrived within one minute after page.

• 2 PTs – average cleaning time of 6.8 min. • PTs spend 12.5% of their day cleaning rooms.

• Page PTs to notify them of changes to the schedule or when rooms are ready for cleaning.

• Only two supporting staff members should clean each operating room when it is ready for turnover (PTs or OR Aides).

• A beeper study should be implemented to determine the primary activities of PTs.

Surgical residents are responsible for assisting the surgeon during surgery. They are present to gain more knowledge and experience of the OR. Residents are medical school graduates.

• In 90.9% of cases, the resident was in the room prior to intubation.

• In 76.5% of cases, the resident performed the first incision.

• Resident should fully understand surgeon requirements for and nuances of the cases and communicate them during setup to the scrub, circulator, and anesthesia.

Surgeons are the leaders involved in the surgery. He/she sets the atmosphere of the operating room.

• In 16.9% of observed cases, a formal role call was performed.

• Strictly encourage and monitor role call completeness.

PACU is the final stop for patients during surgery. It is a closely monitored department where each patient is given the close attention they require. Each patient has one nurse who monitors them.

• In 11.7% of the cases, a PACU hold occurred lasting anywhere from two to over thirty minutes.

• Perform a follow up study of PACU to reduce the frequency and longevity of holds.

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Conclusion From our observations, many of the specific findings result from lack of communication between staff members. Relaying relevant information to all affected personnel will strengthen team dynamics creating a cohesive unit. All staff needs to remember that the team consists of surgical staff, anesthesia staff, and operating room staff. The staff needs to recognize they are all members of the same team, and individual actions affect the whole. Working together and helping one another will improve the efficiency of the operating room.

Introduction The C.S. Mott Children’s Hospital Operating Room (OR) staff has voiced concerns regarding the turnover efficiency. Room turnover is defined from the time when one patient leaves the operating room to when the next patient is brought in. However, to accurately investigate the room turnover, we had to observe the processes that occurred from when the surgeon closed the incision of the current patient to the time the surgeon performed the first incision of the next patient. Thus, this project studied the current Mott OR surgical turnover procedures and conducted a time study analysis designed to find opportunities for improvement. The purpose of this report is to briefly explain the findings, conclusions, and recommendations that resulted from the analysis of the surgical turnover time in the Mott OR. Background C.S. Mott Children’s Hospital in Ann Arbor, Michigan is a world-renowned institution for the health care of children. As part of the University of Michigan Health System, C.S. Mott Children’s Hospital has strived for a high degree of excellence, and is currently ranked the fifth best children’s hospital by Child’s Magazine. The OR department of Mott is an essential part of the hospital. The nine operating rooms handle, on average, 35 to 45 cases per day. Every type of pediatric surgery, including cardiovascular, orthopedic, and neurology is performed in the Mott OR. See Appendix A for the departmental schedule of surgeries. While every case needs to be handled in a slightly different manner, one process component of each case that can be standardized to maximize efficiency is the turning over of the room between cases. A similar study of the surgical turnover time was performed at the University Hospital in September 2002. The findings revealed gaps of time that could be eliminated. For example, the study found that some tasks would be more efficient performed in parallel rather than sequential. There is also a potential for improvement for every individual involved in the surgery; some tasks benefited when the staff worked as a team rather than individually. Members of the Mott staff were informed of this study and deemed a similar one to be valuable to their OR. Goals and Objectives The goals of the study were the following:

• Recommend ways to reduce the time between operations • Review the first case of the day and the start effectiveness • Clarify roles of staff to properly understand the division of labor • Improve overall OR functions related to case timeline to create a standard

flowchart during surgical turnover

Scope The project consisted of observing and documenting components and delays of the surgical turnovers during surgical blocks1 in the Mott OR. In addition, the project examined the cohesiveness of the OR staff as well as the first case start effectiveness. The project will not look at any clinical aspects from the first incision to the beginning of closure. The scope of the study applies only to the OR at Mott Children’s Hospital in Ann Arbor, Michigan. Approach and Methodology To examine the processes that occur during the surgical turnover in the operating rooms at C.S. Mott Children’s Hospital, we completed the following steps. Data Collection First, to understand the current protocols that guide the work done during the surgical turnover, we:

• Performed a time study to collect data concerning the process that occurs during the surgical turnover. To collect the data, each team member spent approximately six hours per week in the Mott OR, observing a total of 77 cases. Data was collected on a standardized data collection form developed by the team and approved by the project coordinator and client. See Appendix B for the data collection form.

• Received data from the Omni OR System2 regarding all surgical cases in the OR (sampled and non-sampled) during the time period of our study, September 1, 2003 to November 7, 2003. See Appendix C for the data collection sample size.

• Informally interviewed perioperative technicians (PTs), scrubs, and circulators involved in the surgeries in the Mott OR.

• Formally interviewed two Clinical III Nurses(circulators, scrubs), two PTs, one attending anesthesiologist, the manager of pre-op and post anesthesia care unit (PACU), and one attending physician. Refer to Appendix D for interview questions.

The data collected was used to calculate the average time and steps staff needs to finish one surgery and prepare for the following case. Note that due to the confidential nature of the data involving patient information, all project team members were required to sign a patient confidentiality form. Also, all project team members were coached by the nursing educator and the client coordinator, a former OR consultant, on how to observe cases and collect data, as well as how to maintain sterile technique in the case.

1 Surgical Block – When a surgeon follows him/herself in consecutive cases. 2 Omni OR System – Database system utilized by C.S. Mott Children’s Hospital Operating Room to record data relevant to surgical cases.

Analysis The team input the data collected from the time study into an Excel spreadsheet and a flowchart was developed to document the processes that take place during surgical turnover. In addition to our observed data, relevant information was extracted from the Omni OR System and anecdotal information was gathered from the interviews. We looked for ways to improve the productivity of the surgical turnover in the Mott OR by identifying steps that can occur in parallel. We also investigated team dynamics and determined ways to improve the team cohesiveness of the OR staff by properly defining division of labor. Current System Description: Current System The C.S. Mott Children’s Hospital Operating Room utilizes seven different positions to perform a surgery: surgeons, residents, scrubs/scrub technicians, circulators, anesthesia staff/residents/certified registered nurse anesthetists (CRNAs), anesthesia technic ians, and PTs/operating room assistants (OR Aides). The main responsibilities that must be performed for a successful operation are listed below. The following steps are also illustrated in the timeline in Table 2. The observed average times with one standard deviation are listed in the table with the activities.

• Surgeon Closes the incision of the patient Prepares for the next surgery

• Surgical Resident Closes the incision of the patient Completes paperwork for the case and escorts patient to PACU Prepares for the next surgery

• Scrub/Scrub Technician Assists in closing of incision of patient Breaks down room Sets up room for next case

• Circulator Care for patient Fills out paperwork Arranges for current patient transport to PACU Arranges for next patient Sees next patient Helps scrub with room setup Preps patient for surgery

• Anesthesia Attending/Anesthesia Resident/CRNA Monitors patient condition until closing complete Extubates and transfers patient to PACU Brings in next patient from holding room Intubates and monitors next patient

• Anesthesia Technician Cleans and sets up anesthesia station for next operation

• PT/OR Aide Cleans and sets up room for next operation

Table 2: Timeline of Observed Cases

Findings: Current System The average lengths of surgical turnovers (closure to cut) vary greatly among departments as shown in Figure 1. Cardiology (Cardiac) and neurology (Neurosur) cases require an extensive amount of closing and longer induction times, resulting in the longest surgical turnovers. Orthopedics (Ortho), pediatric surgery (PedSurg), and urology have the next longest surgical turnovers. The services with the shortest surgical turnovers are ophthalmology (Opth), otolaryngology (Oto), and plastics. The cases performed in these services are generally smaller in nature and require minimal closing.

The turnover time (patient out to patient in) mimics the fluctuations in surgical turnover times as shown in Figure 2. The types of cases being performed in a service determine the amount of cleaning and setup that occur during room turnover. Cardiology, neurology, orthopedics, and pediatric surgery require extensive cleaning and setup time. Ophthalmology, otolaryngology, plastics, and urology cases generally require smaller setup and less cleaning time.

Figure 1: Average Closure to Cut by Service

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CARDIAC NEUROSUR OPTH ORTHO OTO PEDSURG PLASTICS UROLOGY Source: Omni OR Data from September – November, 2003

IOE 481C.S. Mott Surgery Turnover Time Analysis

December 1, 2003

Service

70.90

54.35

79.11

43.93

78.48

115.60 114.62

55.25

Conclusions: Current System Currently, the time between patient out to patient in is longer than desired. The preferred turnover time by service is listed later in the report. Pre-Operation Background: Pre-Op Before a patient can be operated on, he/she must undergo a pre-operative evaluation. For out-patients this process is done in pre-op while in-patients are examined in his/her room and in the holding room. Out-patients are asked to arrive one hour prior to the scheduled operation start time to allow adequate time to complete the necessary pre-op steps. Once a patient arrives, a nurse will meet with the patient and his/her family to discuss the operation, answer questions, and check the patient’s current condition. Members of the anesthesia and surgical staff also come to see the patient in the pre-op area to perform their pre-operation duties, as well as checking the consent and health and physical (H&P) forms, respectively. Once the patient has completed the pre-op process, he/she will eventually be transported to the holding room. This does not take place until the circulator in the operating room calls pre-op to tell them to send the patient to the holding room.

Figure 2: Average Patient Out to Patient In by Service

31.85

24.76

39.36 41.53

40.68

25.99

36.60

27.38

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CARDIAC NEUROSUR OPTH ORTHO OTO PEDSURG PLASTICS UROLOGY

Service

IOE 481C.S. Mott Surgery Turnover Time Analysis

Source: Omni OR Data from September – November, 2003

December 1, 2003

In the holding room, patients are commonly given a pre-medication to relax. The pre-med takes between 10 and 20 minutes to take effect. At that time, the patient can be brought into the OR. Findings: Pre-Op The following findings were generated from the data collected:

• The consent form was incomplete in 9.0% of observed cases. • There was a problem with the H&P form in 5.2% of observed cases. • A pre-med delay only occurred in 1.3% of observed cases. • Time between room ready and patient arrival (all sterile supplies opened to patient

in room) Average of 11 minutes +/- 10 minutes3

• Arrival time to pre-op prior to scheduled surgery start 1 hour or more – 66.5%*4 45 minutes to 1 hour – 12.4%* 30 minutes or less – 3.6%*

• Total time patient spent in holding room (circulator call to pre-op to patient in) Average of 39 minutes +/- 19 minutes

Conclusions: Pre-Op A patient cannot be administered a pre-med or enter the operating room until an H&P and consent forms are on file. Therefore, it is essential that these forms be filled out and completed prior to the patient being brought to the holding room. This will alleviate the majority of delays found in pre-op. Members from the anesthesiology and surgical staff have to make sure the proper forms are complete. We expected the frequency of pre-med delays to be much higher. The 1.3% of occurrences only refers to the observations in which the anesthesia staff verbally announced the delay. Our assumption was based upon the gap of 11 minutes between when the room was ready and when the patient entered. We perceived this gap to be a result of waiting for a pre-med to take effect. The majority of the patients are arriving with enough time before the scheduled start of the surgery. The small percentage of patients that are arriving less than 30 minutes prior to the start may cause a delay in his/her arrival to the operating room, but it is difficult to reduce this delay. The patient may have extenuating circumstances beyond the control of the Mott OR. A way for pre-op to handle these situations is to expedite the late patients through the pre-op process to try to get him/her ready for the operation. Delays in pre-op are lengthening the average time a patient spends in the holding room. Ideally, a patient should only be in the holding room for between 15 to 30 minutes to ease the patient anxiety regarding the upcoming surgery. From our observations, the average time a patient is spending in the holding room is exceeding the maximum desired time.

3 One standard deviation is represented by (+/-) 4 An asterisk (*) implies the finding was generated from the Omni OR System data

By reducing the frequency of delays caused by consent, H&P, and pre-meds, in addition to accommodating late arrivals, the total time a patient spends in the holding room can be reduced to the desired 15 to 30 minutes. Anesthesia Background: Anesthesia Anesthesiology plays a critical role not only during the surgery, but also before and after the surgery. The role of anesthesia actually starts the day before the surgery when the anesthesia resident reviews the patient’s chart. If the patient is an in-patient, the resident visits the patient in the hospital room to review the chart. If the patient is an out-patient, the resident reviews the chart without consulting with the patient. The day of the surgery, the anesthesia resident or CRNA and/or the attending anesthesiologist arrive to the operating room to finalize the set up of the anesthesia station. After set up, a pre-operative evaluation of the patient is performed, taking five to ten minutes. It is anesthesia’s job to make sure that the consent form is signed before he/she transfers the patient to the operating room. The consent form can be completed up to six months prior to surgery during a pre-surgery evaluation. The option to use a pre-med is often determined by the age of the patient:

• Under two years old - lack of “stranger anxiety,” usually no pre-med needed. • Between the age of two and seven - “stranger anxiety” exists, usually receives

pre-med. • Over the age of seven - often understands events occurring, usually no pre-med

needed.

After bringing the patient into the room, the resident or CRNA and the attending anesthesiologist intubate the patient. This includes attaching the IV, inserting the central line, and hooking the patient up to the breathing machine. During the surgery, the resident or CRNA stays in the operating room and continuously monitors the patient’s vitals as well as administers drugs. The attending anesthesiologist does not have to be present during the entire surgery, but must be present during intubation, extubation, and any other critical moments. The attending anesthesiologist is usually assigned to run two rooms. There is a perception that this causes delays due to the fact the attending anesthesiologist is not present in the room. The scheduling staff tries to arrange the two rooms so cases are staggered, not to create a problem with the attending anesthesiologist needing to be in two rooms at once. However, there are times when the attending anesthesiologist is in one room, and is needed in the other.

Findings: Anesthesia The following findings were generated from the data collected:

• Time to situate and intubate a patient (time between patient in and induction end) Average of 12 minutes +/- 7 minutes

• Time to wake and extubate a patient, if applicable (time between dressing end and extubation end)

Average of 5 minutes +/- 5 minutes • In 78% of observed cases, the attending anesthesiologist assisted in transporting

the patient into the operating room, or he/she was in the room before the patient was brought in.

• In 81% of observed cases, the attending anesthesiologist was in the room prior to the patient needing extubation.

Best Practice Observed: Anesthesia The best practices we observed during observations are the following:

• Promptly going to pre-op after transferring the current patient to PACU. • Bringing the patient down to the operating room only after the H&P and consent

forms are signed and correct. • Having two residents in high turnover rooms (i.e. Otolaryngology) so one can

finish the current patient, while the other resident evaluates the next patient.

Conclusions: Anesthesia Overall, a major issue that delays anesthesia’s job is the fact C.S. Mott is a teaching facility. This is the main factor for the high variation in the time to intubate and extubate a patient. A majority of the work is performed by an anesthesia resident with the attending anesthesiologist guiding him/her. Moreover, it takes a resident more time to perform the procedures than it does for an attending anesthesiologist. This is an inherent flaw in the system, and therefore, cannot be corrected. An additional issue that justifies the high variation in the intubation process is that the patients are children. In an adult hospital, IVs are started in the holding room. However, it is difficult to administer an IV on a nervous child and sedatives are often needed. This explains the large variation in the time to situate and intubate the patient. The staff perception that a delay occurs as a result of the attending anesthesiologist absent during critical moments is not founded. He/she did not seem to have a problem being present prior to intubation and extubation. In 78% of the cases, he/she was either in the room before the patient was brought in, or he/she came in with the patient. In 81% of the cases, the attending anesthesiologist was in the room before extubation was required. The only way to totally alleviate this delay would be to have one anesthesia staff per room. However, the costs alone make this remedy infeasible.

Recommendations: Anesthesia We recommend the Mott OR implement the following:

• Anesthesia needs to emphasize the importance of having complete consent forms prior to when the patient is brought into the holding room. This will alleviate the consent form delay occurring in pre-op.

• The resident or CRNA needs to communicate with the circulator during the surgery regarding the status of the next patient. This will allow him/her to determine what needs to be done during the pre-operative evaluation; i.e. if the consent form needs to be completed and signed.

Anesthesia Technician Background: Anesthesia Technician The anesthesia technician’s job is to clean, stock, and setup the anesthesia station after each surgery. They come into the operating room when the room is ready for turnover. Findings: Anesthesia Technician The following findings were generated from the data collected:

• Time it takes anesthesia technicians to arrive to operating room (time from paged to arrival)

Average of 3 minutes +/- 3 minutes • In 64% of observed cases, anesthesia technicians arrive within two minutes of

being paged. Refer to Figure 3 for a break down of the arrival times. • Time it takes anesthesia technicians to complete their job (time from in to out)

Average of 7.5 minutes +/- 4.5 minutes • In 76% of the cases, anesthesia technicians required 5+ minutes to clean and stock

the anesthesia station. Refer to Figure 4 for a break down of cleaning times.

Figure 3: Anesthesia Technicians arrive within 2 minutes after page 64 % of cases

0 min 25%

1 min 20%

2 min 19%

3 min 5%

4 min 7%

5 min 12%

6 min 7%

7+ min 5%

Source:Observational Data fromSeptember - November, 2003

December 1, 2003

IOE 481 C.S. Mott Surgery Turnover Time Analysis

Figure 4: Anesthesia Technician to Clean and Stock Station in 5+ minutes in 76% of cases

2-4 min 24%

5-7 min 35%

8-10 min 25%

11-13 min 10%

14+ min 6%



December 1, 2003

Best Practice Observed: Anesthesia Technician The best practice we observed during observations is the following:

• Promptly arriving to the operating room after the patient is transferred to PACU Conclusions: Anesthesia Technician Anesthesia technicians arrive promptly to the OR after being paged. Delays caused by anesthesia technicians taking a while to arrive to the OR are not a problem. This is illustrated in 64% of the cases when the anesthesia technicians arrive within 2 minutes. The high standard deviation in the time it takes the technician to clean and stock the station is caused by him/her leaving the room several times to get additional supplies. This can also be observed in Figure 4 above. With about equal percentages, the technician cleaning time is 2-4 minutes and 8-10 minutes, occurring in 25% of cases. The most common time was 5-7 minutes; this was observed 35% of the time. Recommendations: Anesthesia Technician We recommend the Mott OR implement the following:

• To decrease and standardize the time it takes a technician to clean and stock the anesthesia station, he/she should utilize a cart or small bin stocked with the most commonly needed supplies. This will decrease the number of times necessary to leave the operating room to get additional supplies.

• The target time for anesthesia technicians to clean and stock the anesthesia station should be 5 minutes.

Scrub Background: Scrub The primary job of the scrub is to assist the surgical team. The interaction between the scrub and the surgeon determines the flow of the case. He/she is responsible for opening sterile supplies and setting up the back table for surgery. The scrub keeps track of the instrumentation used during the surgery to make sure nothing is left in the patient. Once closing is complete, the scrub breaks down the back table, gathers the used instruments, and removes the instruments from the room. Sometimes the scrub begins to break down the room by bagging trash, for example, before the patient leaves. Findings: Scrub The following findings were generated from the data collected:

• When the scrub began break down of the room before patient had left: Average cleaning time for the PTs was 6.6 minutes +/- 2.6 minutes

• When the scrub did not begin break down of the room before the patient had left: Average cleaning time for the PTs was 7.3 minutes +/- 3.4 minutes

• Surgical case flow is disrupted if the scrub takes a break during the surgical case. • Wasted materials were noticed when all sterile supplies are opened.

Best Practices Observed: Scrub The best practices we observed during observations are the following:

• If the scrub begins break down before the patient leaves the operating room, PTs turnover the room quicker.

• In rooms with many cases, having the scrub/circulator remain in the room and help reduced the cleaning time.

Conclusions: Scrub In many of the observed cases, the scrub began to break down the room before the patient had left, resulting in reduced PT cleaning times. Breaking down the room involved gathering all the waste into garbage bags and collecting the dirty linens. Although the current job description for the scrub nurse or scrub tech does not include helping with room break down before the patient exits the room, cleaning time is reduced by one minute when he/she does. As prescribed by the nurses union, the scrub is allotted a 15 minute break for every 4 hours he/she is working. Currently, scrubs take breaks whenever the break nurse arrives in the OR, ready to take over the duties of the present scrub. The switch of the scrub often occurs during the surgical case causing the present nurse to brief the break nurse on the current status of the surgery. Also, the scrub providing a break for the current scrub must become acclimated with how the back table is set up along with the manner in which this particular operating room functions. This can cause a discontinuity in the surgical case flow. Extra equipment is usually picked for the case and combined with necessary equipment on the cart, but not always used in the surgery. Some scrubs choose to open everything that is placed on the cart, however, others only open what they expect to utilize. Once any sterile supplies are opened, they must be thrown away, regardless of whether or not they were used for the surgery. Recommendations: Scrub We recommend the Mott OR implement the following:

• The scrub should begin break down of the room before the patient has left the operating room. The break down should include closing waste and soiled linen bags, resulting in faster cleaning times for the PTs.

• Breaks should be taken by the scrubs between surgical cases, when feasible. In this case, the break scrub will open the sterile supplies and begin the set up of the room for the next case. By having the scrub take a break between surgical cases, there will be no discontinuity in the surgical case flow caused by a switch of scrub nurses.

• Extra supplies should be separated from the required supplies on the cart. This can be done by putting a divider on the bottom shelf, designating one side for extra supplies. As a result, unneeded equipment will not be opened and subsequently thrown out unused.

Circulator Background: Circulator The circulator is responsible for overall patient care, including the efficient transfer of patients to and from the OR. In addition, circulators provide support to the other members of the surgical staff in the OR. Some tasks include obtaining additional supplies for the scrubs and assisting anesthesia with patient care during intubation and extubation. After the patient has been transferred to PACU, the circulator goes to the holding room to consult the next patient. The circulator speaks to the patient and family to confirm consent and verify H&P. During the surgery, the circulator is responsible for completing paperwork and recording the times key events and delays occur. Once the case is nearing the end, the circulator must call pre-op to have the next patient brought to the holding room and PACU to notify them that a patient is coming out of the OR. Findings: Circulator The following findings were generated from the data collected:

• The circulators top priority is patient care, which was evident from our observations.

• The time when circulators call PACU is not standardized. • Time between when dressing was complete to when the patient left the room was:

Average 10.3 minutes +/- 7.9 minutes The variation between departments is shown below in Figure 5.

• Delays are not being recorded in the Omni OR System.

Best Practices Observed: Circulator The best practices we observed during observations are the following:

• Circulators informing status of next patient to all personnel. • Completing paperwork prior to dressing end. • After patient is transferred to PACU, going directly to pre-op to consult next

patient. Conclusions: Circulator PACU prefers to be notified 10-15 minutes prior to the time the patient will be able to leave the room. However, there is much variability in the time it takes to the patient to wake up, making it difficult for the circulator to determine the appropriate time to call PACU. From our observations, we determined the optimal time to contact PACU is at dressing end. This allows PACU adequate time to prepare appropriate personnel and equipment. The Omni OR System has fields available to record when delays occur. In most cases, these fields are not used. Delays which we recorded were not subsequently recorded in the Omni OR data. Recording delays benefits the OR by providing data for continual improvements. Recommendations: Circulator We recommend the Mott OR implement the following:

• The circulator should call PACU after dressing ends to give PACU the desired 10-15 minute warning period.

• Stress to circulators the importance of recording lengths and causes of delays in the Omni OR System.

Figure 5: Time from Dressing End to Patient Out

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CARDIAC NEUROSUR OPTH ORTHO OTO PEDSURG PLASTICS UROLOGY

SERVICE IOE 481 C.S. Mott Surgery Turnover Time

Analysis

Source: Observational Data from September - November, 2003

December 1, 2003

Perioperative Technician/Operating Room Assistant Background: Perioperative Technician/Operating Room Assistant PTs/OR Aides provide support for the operating room by obtaining equipment and cleaning the operating room during turnover. PTs/OR Aides arrive at the operating room following surgeries to clean when they are paged by the circulator. PTs are also responsible for picking cases and transporting in-patients from their rooms to the holding room. OR Aides have fewer responsibilities than PTs. When asked, PTs help the scrub open sterile supplies and stock the rooms. At the beginning of their shift, PTs are assigned three to five rooms to provide assistance and are given a schedule of surgeries for each room. Commonly, the schedule changes frequently throughout the day. The perception of the staff of the OR is that the PTs/OR Aides only responsibility is to clean the operating rooms. Findings: Perioperative Technician/Operating Room Assistant The following findings were generated from the data collected:

• In 6.5% of the cases observed, delays were caused by wrong instruments being prepared or the correct instruments not being ready.

• Time between page and PTs/OR Aides arrival. Refer to Figure 6. In 62.5% of the observed cases, PTs/OR Aides arrived within one minute. In 4.2% of the observed cases, PTs/OR Aides never arrived.

• The cleaning time fluctuates when varied numbers of PTs/OR Aides clean the rooms. Refer to Figure 7.

1 PT/OR Aide – average of 7.5 minutes 2 PTs/OR Aides – average of 6.8 minutes 3+ PTs/OR Aides – average of 7.3 minutes

• The average time required to open sterile supplies varies among surgical departments (time from begin room setup to all sterile supplies opened). Refer to Figure 8.

Cardiac surgeries § Average of 20.0 minutes +/- 14.1 minutes

Neurological surgeries § Average of 29.5 minutes +/- 26.2 minutes

Remaining surgical departments § Average of 11.0 minutes +/- 8.4 minutes

• PTs spend 12.5% of their day cleaning rooms.5

5 Calculated – 7 PTs working 8 hour shifts with average case load of 30 cases/day with 7 minute cleaning time for 2 PTs. Cleaing time/Total Time = 7 hours/56 hours = 12.5%.

December 1, 2003



Figure 7: Elapsed Time for PTs/OR Aides to Prepare for Next Patient

Figure 6: Elapsed Time Between PT Page and PT Arrival

5+ min 13%

3 min

4 min4%

Best Practices Observed: Perioperative Technician/Operating Room Assistant The best practices we observed during observations are the following:

• PT offering assistance when supplies are being opening. • PTs asking the circulator the status of the next case to prepare instruments

properly. • PTs/OR Aides thoroughly cleaning the operating room, including the tables, bed,

floor as well as under all equipment and machinery.

Conclusions: Perioperative Technician/Operating Room Assistant Lack of communication with the charge nurse creates difficulty for the PTs regarding changes to the schedule. Due to the nature of the OR, cases are often canceled, switched, or added on. This causes great confusion for the PTs when they are not informed of changes, resulting in delays in 6.5% of observed cases. The perception that PTs/OR Aides do not arrive promptly to clean rooms once paged is untrue. In reality, PTs/OR Aides arrived within one minute in 62.5% of observed cases. However, a problem which might warrant investigation is PTs/OR Aides not showing at all. In 4.2% of the cases, no PT/OR Aide arrived after numerous pages, and the cleaning of the room was completed by scrubs and circulators. Please refer to Figure 6.

Figure 8: Time Elapsed for Scrub to Open Sterile Supplies

20.00

29.50

15.00 14.40

5.71

10.23 12.33 12.67

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20

25

30

35

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December 1, 2003


The ideal number of PTs/OR Aides necessary to clean a room is two. Certain services, such as cardiac surgery and neurosurgery require longer cleaning times, as noted in Figure 7. However, the optimal number of PTs/OR Aides required to clean a room remains constant at two. For cases which require longer times to open sterile supplies, it is essential that the PTs assist the scrub. This will expedite the primary setup of surgery. In the majority of the services, the small quantity of sterile supplies needing to be opened does not require further assistance from the PT. However, in other services, PT assistance is necessary to open the extensive amount of supplies. The opinion of many OR staff members is that a PTs only responsibility is cleaning rooms during turnover. However, PTs spend only 12.5% of the day cleaning the operating rooms. The staff is not aware of the PTs other responsibilities. Recommendations: Perioperative Technician/Operating Room Assistant We recommend the Mott OR implement the following:

• Communication between the charge nurse and the PTs/OR Aides can be improved if each PT/OR Aide carries a pager. Thus, PTs/OR Aides can be paged when there are changes to the schedule. If PTs/OR Aides have not arrived after a lengthy time, the PTs/OR Aides assigned to the room can be paged using their beeper. This will ensure the PTs/OR Aides responsible for the turnover of a certain room are clearly aware it is ready for turnover.

• Only two supporting staff members should clean each operating room when it is ready for turnover (PTs or OR Aides).

• For large cases, it is vital that PTs offer assistance in opening sterile supplies. For the smaller cases, PT assistance may not be required, however still offered.

• A beeper study should be implemented to determine the primary activities of PTs. This will allow the staff to understand the role that PTs play in the OR.

Surgical Resident Background: Surgical Resident Surgical residents are responsible for assisting the surgeon during surgery. They are responsible for consulting the patient before the surgery, assisting surgeon during the surgery, and completing paperwork following the surgery. The residents escort the patient to PACU following the completion of the procedure. They are present to gain more knowledge and experience in the OR. Residents are medical school graduates, learning to be specialists in a concentration. The level in residency program determines the extent to which they participate in the operation. Residents are assigned to work with surgeons and over time learn surgeons’ preferences when performing cases. Findings: Surgical Resident The following findings were generated from the data collected:

• In 90.9% of cases, the resident was in the room prior to intubation.

• In 76.5% of cases, the resident performed the first incision. Best Practice Observed: Surgical Resident The best practices we observed during observations are the following:

• Preparing the OR according to known surgeon preferences. • Arriving early to prepare and complete any tasks necessary prior to surgery.

Conclusions: Surgical Resident Surgical residents have consistently made themselves available prior to surgery to assist with preparation. In 90.9% of the cases, the resident was in the room prior to intubation. Having the resident available well before surgery allows for an efficient surgical preparation. The extent to which C.S. Mott Hospital is a teaching facility is demonstrated by the high percentage of cases where the resident makes the first incision. Once acclimated to the OR environment, the resident is bestowed more responsibility in the surgery, ranging from closing the incision to assisting with more critical moments. Attending Surgeon Background: Attending Surgeon Active participation by surgeons during an operation helps the OR run smoothly and efficiently. Surgeons sometimes operate in swing rooms; conducting two surgeries simultaneously in two rooms. This helps to maximize the surgeons time in the OR. Surgeons are responsible for setting the atmosphere in the OR. They are responsible for conducting a formal role call prior to incision, guiding staff members during the surgery, and being present for the critical moments of the surgery. The OR staff look to the surgeons for leadership. Surgeons reported that between cases they often go back to their office to complete work. It would assist them if they had an area near the OP to check e-mail, make calls, and complete dictation. Findings: Attending Surgeon The following findings were generated from the data collected:

• In 9.1% of observed cases, tardiness of surgeon caused a delay. • Lack of communication of add-on cases creates confusion for surgeons and all

surgical staff. • In 16.9% of observed cases, a formal role call is being performed.

Best Practice Observed: Attending Surgeon The best practices we observed during observations are the following:

• Being present well before induction to allow ample time to prepare for surgery.

• Setting a positive team environment in the OR by learning all staff members name, for example.

Conclusions: Attending Surgeon Allowing a surgeon to operate in swing rooms minimizes the surgeon’s time in the OR while maximizes the amount of surgeries he/she can conduct. The downfalls of swing rooms are that often surgeries must wait for a surgeon to arrive before a critical part can be executed. Practice of swing rooms optimizes surgeons OR time, but may not be optimal for OR staff time. In 9.1% of observed cases, a delay was caused waiting for a surgeon to arrive. Lack of communication causes delays for the OR when scheduling add-ons. Numerous individuals must be contacted to prepare for the unexpected case, including surgeons, residents, nurses, and perioperative technicians. It was reported that the extent of the problem is evident during summer months when there is an overabundance of add-on cases. A safety precaution being implemented in ORs across the country is a formal role call. Role call is a formal procedure conducted prior to any incisions where the patient, surgery, and correct site of surgery on the body are verified. Only in 16.9% of the cases observed was a formal role call conducted. This is a mandatory safety procedure which requires 100% compliance by February 2004. The first case of the day sometimes is delayed because of surgeon tardiness. If the surgeon is late for surgery, typically, the surgery must wait, delaying that and any subsequent cases. When tardiness delays the surgery, it creates a large inefficiency. Quantifying this was difficult because often, residents would begin surgeries without the surgeon present. Recommendations: Attending Surgeon We recommend the Mott OR implement the following:

• Investigate if the usage of swing rooms outweighs the delays and usage reduction of the OR.

• Create a surgeon work station area, allowing surgeons to conduct work near the OR in between cases.

• Schedule time for add-on cases into the existing schedule by forecasting expected number of add-ons for each day.

• Strictly monitor role call compliance. Post Anesthesia Care Unit (PACU) Background: PACU Once a surgery is over, patients are brought to PACU for recovery. There are two phases that comprise PACU: Phase 1 and Phase 2. Patients are brought to Phase 1 by the anesthesiologist and surgical resident where they are extubated if not already done so in

the operating room. The patient is then closely monitored by a nurse on a one to one ratio until they have woken up. Once the nurse believes the patient is awake and alert, out-patients are transported next door to Phase 2 and in-patients are transported to their room. Out-patients are then discharged from Phase 2 once they have fully recovered. When an operation is nearing the end, it is the circulators responsibility to inform PACU that a patient will be coming down soon. In some instances, a PACU hold will occur, wherein PACU can not accept additional patients at that moment. A PACU hold occurs when either there are no available beds or no available nurses to monitor the incoming patient. Findings: PACU The following finding was generated from the data collected:

• In 11.7% of the cases, a PACU hold occurred lasting anywhere from two to over thirty minutes.

Conclusions: PACU A PACU hold decreases OR utilization and efficiency. When a PACU hold occurs, the operating rooms are forced to wait for the hold to cease, resulting in unnecessary downtime. Investigating the root cause of a PACU delay exceeded the scope of this study, preventing further analysis. Recommendations: PACU We recommend the Mott OR implement the following:

• Perform a follow up study of PACU to reduce the frequency and longevity of holds.

Implementation Step After presenting our findings, the next step is to derive a method to implement our recommendations. The first step was to create a graph to identify the frequency of delays. We prioritized delays using frequency of occurrences in addition to feasibility to remedy as our criterion. Refer to Figure 9.

• The most frequent type of delay observed was a PACU hold. However, to alleviate this delay requires a study to determine the root causes of these delays.

• Incomplete or missing consent and/or H&P forms were the second most frequent problems. They can be reduced if the staff does what is required of them by ensuring the forms are complete prior to surgery.

• The third most commonly observed delay was caused by the correct instrumentation not being available. This was caused by a change in schedule when the proper people were not informed that different instruments and supplies must be picked. These delays can easily be reduced if the staff communicates better with the charge nurse so that all related personnel are aware of scheduling changes as soon as they occur.

• The next delay commonly observed was due to surgeons not being present in the OR. This delay was due to surgeons either operating in swing rooms or arriving

tardy to the OR. By eliminating swing rooms, surgeons would always be available for critical moments of surgery.

• The patient not arriving to the hospital on time causes the next delay. Pre-op would like the patient to be at the hospital at least an hour prior to the start of the scheduled surgery. This is an inherent weakness in the system, and therefore, cannot be remedied.

• The PTs not showing up to clean the operating room is the next delay. A study should be conducted to determine the primary activities of the PTs.

Frequency of Observed Delays

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From the timeline developed based on our observations in Table 2, we were able to identify gaps of time that could be eliminated. The average turnover time from patient out to next patient in can possibly be reduces by eliminating gaps of time between steps as seen in Table 3. Eleven minutes can be reduced by eliminating the following gaps:

• Four minutes from when closing is complete to when anesthesia begins to wake and extubate the patient.

• Two minutes from when the patient is extubated to when he/she is transferred to PACU.

• Five minutes from when the room is ready to when the patient is brought in. Three additional minutes can be eliminated by shortening the following processes:

• One minute can be reduced from PT cleaning time to emulate the University Hospital Operating Room PT cleaning time of 6 minutes.


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Figure 9: Implementation Chart of Current OR Delays December 1, 2003

• Two minutes can be reduced from the primary setup time by utilizing PTs to help open sterile supplies.

Each finding on its own is not significant time savings. However, the findings do not put the burden of change on any one team member. It is reasonable to think that each could obtain one minute savings in their tasks. While a reduction in turnover time of 14 minutes may be unlikely, a reasonable estimate of half, or 7 minutes, is achievable. If the turnover is reduced by 7 minutes for each surgical case performed, there are approximately 30 cases performed at the Mott OR per week, so this would result in 210 minutes of saved time. This is not enough time to perform additional surgical procedures because these time savings are divided among the nine operating rooms. Instead, this reduction in turnover time could reduce overtime as well be used for staff education and operating room upkeep, such as stocking the supplies. The goal of this project was to listen and observe staff to provide an unbiased view of the turnover efficiency. By each person contributing their part, C.S. Mott Children’s Hospital can uphold to its high degree of excellence.

Table 3: Timeline of Observed Cases With Gaps Identified

Room

Monday

TuesdayW

ednesdayThursday

Friday

Treatment R

oom 1

Urology

Urology O

tolaryngologyP

ed Surg

Orthopedics

Orthopedics

Treatment R

oom 2

AM

: Ped D

ental P

M: P

eds Surg

Optham

ologyN

ephrologyH

ospital Dental

AM

: Ped D

ental P

M: P

ed Derm

Room

1P

ed Surg

Ped S

urgP

ed Surg

Ped S

urgP

ed Surg

Room

2O

tolaryngologyA

M: O

ral Surg

PM

: Peds S

urgO

tolaryngologyO

tolaryngologyA

M: O

to P

M: P

lastic Surgery

Room

3O

pthamology

Plastic S

urgeryO

tolaryngologyP

ed Surg

Plastic S

urgery

Room

4TX

P, O

TO, P

lastics, P

ed Surg

Neurosurgery

Neurosurgery

Orthopedics

Neurosurgery

Room

5O

rthopedicsO

rthopedicsO

rthopedicsO

rthopedicsO

rthopedics

Room

6O

pthamology

Urology

Urology

Urology

Ped S

urg

Room

7C

ardiovascularC

ardiovascularU

rologyC

ardiovascularC

ardiovascular

Room

8C

ardiovascularC

ardiovascularC

ardiovascularC

ardiovascularC

ardiovascular

Mott OR Block Schedule

aporwal

Text Box

Appendix A

Room Event ObserverCase Surgeon Date

Time NotesInstruments brought into room Scrub - PTScrub begins room set up

Did PT help? Yes – NoWas picked case complete? Yes – NoWas extra equipment picked? Yes – NoWhat was missing, if any? Yes – NoFirst CountDid PT help open sterile supplies? Yes – No

All supplies openedScrub Scrubs inResident entersSurgeon pagedPatient brought in Who?

Was room ready? Yes - NoWas surgeon present? Yes - NoRole call #1 Yes - NoWas patient asleep? Yes - No

Back table readyAnesthesiologist enters

Was patient asleep? Yes - NoIntubation endsResident enters scrubbed inSurgeon enters scrubbed inCirculator begins prepping patientCirculator finishes prepping patientPositioning of patientDraping of patient beginsDraping of patient endsAnesthesiologist leavesFirst incision

Role call #2 Yes - NoWho performed incision? Surgeon - Resident

Surgeon leaves (# of times)

First Case of the Day

aporwal

Text Box

Appendix B

Previous Case Time NotesClosing beginsClosing ends and dressing appliedDressing finishAnesthesiologist entersPACU pagedNext patient pagedTransfer bed brought inPatient extubated/transferred to PACUScrub begins breakdown of roomSecond CountScrub takes instruments out of room

Started before patient removed? Yes - NoAnesthesiologist leavesResident leavesPatient out of roomAnesthesiologist tech entersAnesthesiologist tech leavesPTs PagedPT arrives How many? 1 – 2 – 3 - more

Who helped?PT leaves

Room Event ObserverCase Surgeon DateInstruments brought into room Scrub - PTScrub begins room set up

Did PT help? Yes – NoWas picked case complete? Yes – NoWas extra equipment picked? Yes – NoWhat was missing, if any? Yes – NoFirst CountDid PT help open sterile supplies? Yes – No

All supplies openedScrub Scrubs inResident entersSurgeon pagedPatient brought in Who?

Was room ready? Yes - NoWas surgeon present? Yes - NoRole call #1 Yes - NoWas patient asleep? Yes - No

Back table readyAnesthesiologist enters

Was patient asleep? Yes - NoIntubation endsResident enters scrubbed inSurgeon enters scrubbed inCirculator begins prepping patientCirculator finishes prepping patientPositioning of patientDraping of patient beginsDraping of patient endsAnesthesiologist leavesFirst incision Who? Surgeon - Resident

Role call #2 Yes - NoSurgeon leaves (# of times)

Roo

m T

urno

ver

Data Collection Sample Size

Service # Cases Observed* # Cases Omni OR System** Cardiac Surgery 4 128 Neurosurgery 2 87 Ophthalmology 9 174 Orthopedics 7 247

Otolaryngology 12 182 Pediatric Surgery 34 346

Plastics 5 111 Urology 4 166 Total 77 1441

* Observational Data from September 16, 2003 to November 7, 2003 ** Omni OR System Data from September 1, 2003 to November 7, 2003

Appendix C

Interview Questions Scrubs, Circulators, Perioperative Technicans Name: Position: Number of years in current job: 1. What is your role in the OR, specifically during the surgical turnover, from closure to

cut? 2. What do you think about the current efficiency in the OR? Where do inefficiencies

come from? 3. Where can improvements be made? 4. Do you think all members of the surgical team work well together? 5. What do you think are the benefits of good team work and problems associated with

poor team mentality? 6. Do you think everyone performs their job in a standardized manner? 7. Do you think the Mott OR is run in a manner similar to other pediatric OR’s? 8. What do you think would be the best manner to institute standardized procedures in

the OR (for jobs, role call, etc)? 9. Do you feel like you are over or under worked? Is there enough staffing for your job

and other positions in the OR? 10. Any other questions or comments? 11. Possibility of shadowing you during your work day for a few hours?

Appendix D1

Interview Questions Surgeon Positions Held: Number of years at Mott/elsewhere:

1. What do you think about the current efficiency of the OR? Where do the inefficiencies come from?

2. Where do you think improvements can be made?

3. What is your view of the OR team dynamics? Does some work better together than others? Can you request certain nurses to work with you?

4. How can the H&P forms be done better? 5. What is your view on swing rooms? Can they be done effectively or do they

create too many problems? 6. At what time should the surgeon be paged to come to the room? What do

surgeons do during the time between cases? 7. How do you decide how much of the operation will be performed by the resident? 8. How can one go about getting the surgeons to follow the rules, i.e. arrive on time? 9. Do you or your residents offer suggestions to improve the efficiency of the OR? 10. What is your opinion on the current communication system in the OR?

Appendix D2

Questions about Pre-Op and PACU Position: Number of years in current job: Previous related jobs: PRE-OP 1. Description of protocol for pre-op. Including differences for in and out patients. 2. How strictly is this protocol followed? 3. What are sources for delays in pre-op? How often do they occur? 4. How much time do most patients spend in pre-op? 5. When should the circulator in the OR call for the next patient? 6. How do current and past delays effect future cases? 7. How big is the staff of pre-op? 8. How many patients and families are allowed in pre-op at one time? 9. How do the presences of families complicate the pre-op process? 10. What are some inefficiencies seen in pre-op? 11. Where can improvements be made in pre-op? 12. What is the best way to implement standardized protocols and get staff to follow them? 13. How is the Mott pre-op different from other ones in the hospital or elsewhere? 14. Is there a way for staff to offer suggestions for improvement?

Appendix D3

PACU 1. What exactly is the PACU and what does it stand for?

a. Number of beds b. Staffing? c. Ever used for Pre-op (e.g. first cases of the day)?

2. How long on average is each patient in the PACU? 3. How often do patients exceed that average time? 4. Is this a cause of holds? How often do hold’s occur and how long do they normally last? 5. Do surgical scheduling changes effect the PACU operations? 6. Are surgical schedules made taking into account PACU capacity? 7. Is there a standard protocol for PACU operations? 8. Is this protocol followed strictly? 9. What is the best way to implement standardized protocols and get staff to follow them? 10. Where do you see inefficiencies in the PACU? 11. How can these inefficiencies be improved and eventually eliminated? 12. When should the circulator call the PACU to notify them a patient is ready to be taken

there? 13. If a PACU hold exists, in what order do you accept patients into the PACU? (type of

surgical case, etc?) 14. How does the Mott PACU differ from the UH PACU or another others that you know

of? 15. Are there ways for the staff to suggest improvements?

Appendix E

Room Event Surgery Surgeon Observer Date #Instruments brought in Scrub/PT

What was missing, if any?

First Count

All supplies opened

Scrub scrubs in

Resident enters

Surgeon paged

Patient brought in

Back table ready?

Anesthesiologist enters

2 Left heel cord lengthening ORTHO Farley Nicole 9/16 1 7:40 Scrub 8:20 8:00 8:03 8:27 8:07

2 Percutaneous pinning right salter ORTHO Farley Nicole 9/16 2 10:40 Both

modified case slightly, different surgery than booked 11:09 10:51 10:59 11:00 10:54 10:40

4Rt. Inguinal Hernia Repair W/ Perioneoscopy PEDSURG Hirschl Meera 9/17 1 7:20 Scrub

4 Left Inguinal Hernia repair Laparoscopic PEDSURG Hirschl Meera 9/17 2 9:45 Scrub Suture Kit4 Orchiopexy UROLOGY Wan Nicole 9/24 2

4 Cystoscopy/retrograde UROLOGY Wan Nicole 9/24 3 10:24 PT needed radiology 10:34 10:45 11:00 10:36 10:34 10:364 Varicocelectomy UROLOGY Wan Nicole 9/24 4 11:44 Circulator 12:13 11:58 11:58 12:19 12:03 12:15 12:032 Bilateral myringotomy & tubes OTO Alexander Atul 9/25 12 Stent removal UROLOGY Parks Atul 9/25 2 9:10 PT 9:24 9:25 9:03 10:19 10:24 9:27 10:246 Excision Mass (L) Neck PEDSURG Bruch Meera 9/26 1 7:29 7:58 7:35 7:47 7:45 7:41 8:01 7:406 Port Placement and Removal PEDSURG Bruch Meera 9/26 2 8:49 Scrub 9:13 9:03 9:04 8:59 8:57 9:17 8:576 Hernia Repair Umbilical PEDSURG Bruch Meera 9/26 3 11:16 Scrub 11:37 11:25 11:29 11:39 11:39 11:28 11:37 11:286 Recureent LIH Repair PEDSURG Bruch Meera 9/26 4 12:25 Scrub 12:46 12:30 12:31 12:24 12:29 12:40 12:302 Direct Laryngoscopy/Bronchoscopy OTO Koopmann Nicole 10/1 1 7:35 8:05 7:38 8:052 Tube Removal OTO Koopmann Nicole 10/1 2 8:34 Scrub 8:42 8:46 8:45 8:44 8:42 8:442 Direct Laryngoscopy/Bronchoscopy OTO Koopmann Nicole 10/1 3 9:25 9:41 9:19 9:412 Bil. Myringotomy OTO Koopmann Nicole 10/1 4 10:10 Scrub 10:12 10:06 10:15 10:15 10:205 Hardware Removal Ankle ORTHO Farley TJ 10/1 1 7:15 In already 7:44 7:53 7:25 7:57 7:43 8:10 7:505 Hardware Removal Tibia ORTHO Farley TJ 10/1 2 10:02 PT 10:03 10:10 10:29 10:22 11:05 10:20 10:52 10:283 Cleft Palate Repair PLASTICS Bruchman Meera 10/3 1 7:32 Scrub 7:51 7:41 7:43 7:35 7:56 7:38 7:56 7:38

3Excisional biopsy of right occiput scalp cyst PLASTICS Bruchman Meera 10/3 2 12:56 Scrub 13:21 13:15 13:06 13:00 13:18 13:25 13:14

1 Broviac removal PEDSURG Geiger Atul 10/6 11 Broviac removal PEDSURG Geiger Atul 10/6 2 9:30 PT 9:38 9:36 9:47 9:58 9:47 9:47 9:423 Recess LMR OPTH Delmonte TJ 10/6 1 7:20 Scrub 8:08 7:47 7:58 7:54 7:54 7:47 8:06 7:523 Recess MR OU OPTH Delmonte TJ 10/6 2 8:40 Scrub 9:17 8:45 9:10 8:49 9:20 9:06 9:19 9:063 Cataract OPTH Delmonte TJ 10/6 3 10:23 Scrub 11:31 10:30 10:32 10:40 11:22 10:45 10:41 10:45

3 Cataract - ECCE OS OPTH Delmonte TJ 10/6 4 12:49 ScrubYes - Ocutong instruments 1:20 1:00 1:03 1:05 1:31 1:10 1:40 1:10

3 Bil Myringotomy & tubes OTO Lesperance Nicole 10/8 1 7:27 Scrub 7:33 7:47 7:20 7:42 7:35 7:423 Direct Laryngoscopy/Bronchoscopy OTO Lesperance Nicole 10/8 2 8:23 8:31 8:36 8:27 8:363 Tonsillectomy & adenoidectomy OTO Lesperance Nicole 10/8 3 9:21 Scrub 9:25 9:26 9:30 9:30 9:303 EUA nose poss foreign body removal OTO Lesperance Nicole 10/8 4 10:13 Scrub 10:20 10:25 10:16 10:26 10:163 Tonsillectomy & adenoidectomy OTO Lesperance Nicole 10/8 5 11:09 Scrub 11:14 11:12 11:19 11:20 11:20 11:203 Tonsillectomy & adenoidectomy OTO Lesperance Nicole 10/8 6 12:29 12:17 12:23 12:20 12:233 Revision R Choanal atresia repair OTO Lesperance Nicole 10/8 7 13:10 Scrub 13:34 13:20 13:25 13:20 13:25 13:34 13:253 Closure of Submucous Cleft PLASTICS Kasten Meera 10/10 2

Observational DataSeptember - November, 2003

IOE 481 C.S. Mott Turnover Time Analysis

Appendix E

3 Maxillary Impressions, etc PLASTICS Kasten Meera 10/10 3 11:35 Scrub 12:16 11:44 11:51 12:07 12:09 11:51 12:03 11:518 Chest Closure CARDIAC Bove Meera 10/10 1 Scrub 8:36 8:15 8:24 8:50 9:05 8:35 8:41 8:218 Unifocalization of pulmonary artery CARDIAC Bove Nicole 10/15 1 6:30 Scrub 7:15 7:00 9:00 8:10 8:08 7:25 8:08

1Lf Inguinal Hernia Repair and Scope of Opposite Side PEDSURG Geiger Atul 10/16 1 8:49 8:30 8:34 8:45 8:56 8:43 8:53 8:50

1 Exploratory laparotomy PEDSURG Geiger Atul 10/16 2 10:09 Scrub 10:19 10:20 10:14 10:19 10:14 10:20 10:061 Broviac removal PEDSURG Geiger Atul 10/16 3 11:14 Scrub 11:19 11:34 11:24 11:26 11:21 11:201 Redo Circ PEDSURG Geiger TJ 10/17 1 7:20 In Already 7:47 7:34 7:36 7:47 7:40 7:46 7:501 Excision Dermoid Cyst PEDSURG Geiger TJ 10/17 2 9:08 Scrub Yes - Draping 9:28 9:14 9:18 9:15 9:33 9:19 9:29 9:191 Umphalocele PEDSURG Geiger TJ 10/17 3 10:29 Scrub 10:53 10:34 10:35 10:43 10:50 10:33 10:50 10:331 Open Nissen, G Tube, Ladd's PEDSURG Geiger TJ 10/17 4 11:52 Scrub 12:29 12:09 12:12 12:21 12:11 12:30 12:116 Double Lumen Sorenson Placement PEDSURG Geiger Meera 10/17 1 7:30 Scrub 7:51 7:37 7:41 7:43 8:08 7:47 7:50 7:476 Double Lumen Broviac Placement PEDSURG Geiger Meera 10/17 2 8:30 Circulator 9:23 8:38 9:06 9:13 9:26 9:24 9:26

6 Port out, PICC Plant PEDSURG Geiger Meera 10/17 3 10:50 ScrubYes-Bovie, Suture, Gloves 10:58 11:02 11:19 12:01 11:17 11:11 11:17

6 Lap Chole PEDSURG Geiger Meera 10/17 4 12:44 Scrub 13:04 12:53 12:49 12:44 12:50 13:00 12:513 Exam under Anesth OPTH Delmonte TJ 10/20 1 7:10 In Already 7:52 7:22 7:53 7:53 7:02 7:543 Exam under Anesth, extra surgery OPTH Delmonte TJ 10/20 2 7:10 In Already Yes 9:09 9:09 10:05 9:41 9:50 9:31 9:09 9:311 Broviac removal PEDSURG Geiger Atul 10/23 11 Laparoscopic liver biopsy PEDSURG Geiger Atul 10/23 2 9:35 Scrub - 9:42 9:43 9:49 9:59 9:53 10:00 9:53

4 Myelomeningocele repair NEURO Garton Nicole 10/24 1 7:00 PT

had to wait for needles in the autoclave 7:48 7:53 8:19 7:56 7:45 8:25 7:48

4 Medtronic pump placement NEURO Garton Nicole 10/24 2 11:22 Scrub 11:57 11:33 11:35 11:48 11:22 11:28 11:52 11:308 Tricuspid valvuloplasty CARDIAC Bove TJ 10/27 1 6:30 Scrub 8:49 7:55 7:51 7:37 7:518 Redo CARDIAC Bove TJ 10/27 2 14:11 Scrub 14:50 14:21 14:21 14:42 15:05 14:27 15:07 14:271 LIT w/peritoneoscopy PEDSURG Coran Nicole 10/29 1 7:00 PT 7:40 7:32 7:35 8:02 7:58 7:47 7:581 Excision choledochal cyst PEDSURG Coran Nicole 10/29 2 9:32 Scrub 9:39 9:41 10:06 10:07 9:47 9:50 9:471 LIHH PEDSURG Coran Atul 10/30 1 8:59 8:54 8:411 Circumcision PEDSURG Coran Atul 10/30 2 10:19 PT 10:31 10:23 10:26 10:27 10:34 10:26 10:31 10:265 Removal IM nails righ forearm ORTHO Blakemore Meera 10/31 2 7:45 Scrub 8:39 8:05 8:36 8:32 8:32 8:40 8:325 Removal left patella hardware ORTHO Blakemore Meera 10/31 3 9:06 PT 9:38 9:17 9:30 9:20 9:52 9:40 9:275 IM Nail Removal Left Radius ORTHO Blakemore Meera 10/31 4 10:54 Circulator 11:17 10:58 11:08 11:08 11:06 11:17 11:063 Posterior capsulotomy OPTH Delmonte Nicole 11/3 1 7:00 PT 8:15 7:48 7:50 7:48 7:49 8:08 7:193 RE-RECESS MR ou OPTH Delmonte Nicole 11/3 2 9:31 Scrub 9:55 9:37 9:41 9:40 9:52 9:38 9:50 9:383 RECESS MR OU OPTH Delmonte Nicole 11/3 3 10:56 Scrub 11:00 11:08 11:00 11:15 11:05 11:11 11:051 Excision skin lesion/cyst/tag/FB PEDSURG Coran Atul 11/6 1 8:341 Peritoneoscopy PEDSURG Coran Atul 11/6 2 9:18 Scrub 9:14 9:15 9:20 9:50 9:25 9:401 Laparoscopic splenectomy PEDSURG Coran Atul 11/6 3 11:24 Scrub 11:45 11:37 11:37 11:38 11:56 11:381 Excision Lesions Butt PEDSURG Coran TJ 11/7 1 7:15 In Already 7:40 7:45 7:49 7:45 7:56 7:581 Open Nissen PEDSURG Coran TJ 11/7 2 9:05 Scrub 9:40 9:15 9:15 9:26 9:18 9:37 9:231 Bronchoscopy + Lap Nissen PEDSURG Coran TJ 11/7 3 11:28 PT 11:55 11:37 11:40 11:45 12:09 12:14 11:55

6 Redo. Circumsion Peds. PEDSURG Coran Meera 11/7 1 7:23

Yes-thought they we were doing a different procedure 8:09 7:35 7:46 7:50 8:03 7:40 7:55 7:40

6 Left inguinal hernia repair PEDSURG Coran Meera 11/7 2 9:03 Scrub 9:47 9:12 9:15 9:32 9:38 9:24 9:386 LIH w/ Peritoneoscopy PEDSURG Coran Meera 11/7 3 11:02 Scrub 11:15 11:09 11:43 11:38 11:19 11:38



Appendix E

Intubation ends

Resident enters scrubbed in

Surgeon enters scrubbed in

Circulator begins prepping patient

Circulator finishes prepping pateint

Positioning of patient

Draping of patient begins

Draping of patient ends

Anesthesiologist leaves

First incision

Who performed incision

Surgeon leaves SURGERY

Closing Begins

Closing ends/dressing applied

Dressing finished

Aneth. Enters

PACU paged

next patient paged

8:14 8:33 8:33 8:22 8:25 8:20 8:43 Resident 9:35 10:13 10:27 10:22

11:14 11:13 11:25 11:13 11:24 11:24 11:26 11:22 11:30 Surgeon

9:42 10:07 10:09 10:15 10:09 10:09

10:47 10:56 10:54 10:58 10:54 10:58 10:59 10:55 11:06 Resident 11:18 11:28 11:2012:20 12:34 12:34 12:34 12:37 12:20 12:38 12:40 12:20 12:41 Surgeon 14:11 14:30 14:31 14:29 14:33

8:49 8:51 8:51 8:5210:35 10:45 10:45 10:42 10:45 10:35 10:45 10:46 10:40 10:52 Resident

7:56 8:00 8:02 8:03 7:57 8:04 8:05 8:01 8:06 Fellow 8:06 8:17 8:25 8:26 8:32 8:269:04 9:14 9:10 9:11 9:08 9:14 9:17 9:06 9:24 Fellow 9:45 10:42 10:54 10:55 10:59 10:59 10:56

11:36 11:38 11:37 11:38 11:37 11:38 11:39 11:41 Resident 11:45 12:00 12:06 12:07 12:1112:41 12:41 12:42 12:44 12:41 12:44 12:45 12:48 Fellow

8:15 8:03 8:10 8:14 8:14 8:15 8:16 Surgeon 8:26 8:19 8:198:53 8:46 8:52 8:48 8:50 Resident 9:05 9:05 9:05 9:06 9:069:44 9:39 9:45 9:45 9:47 9:48 9:49 Surgeon 9:52 9:55 9:50

10:20 10:18 10:33 10:20 10:20 10:20 10:21 Resident 11:03 11:05 11:087:52 8:02 8:14 7:59 8:05 7:53 8:06 8:08 7:53 8:15 Resident 9:08 9:27 9:36 9:38 9:45

10:38 10:54 11:11 10:47 10:53 10:53 11:03 10:40 11:15 Resident7:50 8:01 8:45 7:58 8:01 8:01 8:18 8:21 10:30 8:22 Resident 9:34 12:15 12:32 12:35 12:00 12:38 12:46

13:28 13:35 13:35 13:38 13:35 13:38 13:39 13:40 Resident9:08 9:10 9:12 9:14 9:14 9:14

10:00 10:07 10:04 10:05 10:06 10:08 10:09 10:15 10:09 Resident 10:22 10:23 10:25 10:27 10:29 10:297:57 7:59 8:03 8:02 8:04 8:05 8:07 8:00 8:08 Surgeon 8:24 8:25 8:25 8:30 8:24 8:249:15 9:10 9:26 9:20 9:23 9:18 9:24 9:27 9:17 9:30 Surgeon 10:03 10:04 10:04 10:09 10:07

11:05 11:20 11:30 11:22 11:25 11:10 11:26 11:28 11:08 11:35 Surgeon 12:17 12:20 12:12

1:18 1:51 1:51 1:52 1:54 1:34 1:55 1:56 2:03 Resident7:49 7:35 7:48 7:48 7:48 8:10 7:49 Resident 8:15 8:15 8:17 8:15 8:098:46 8:31 8:31 8:49 8:50 8:50 Resident 9:06 9:10 9:05 9:059:46 9:41 9:43 9:44 9:45 9:46 9:52 9:50 Surgeon 9:57 9:57 10:01 10:00 9:56

10:30 10:31 10:32 10:30 10:30 10:31 10:34 10:34 Resident 10:50 10:50 10:58 10:50 10:4411:29 11:29 11:35 11:30 11:30 11:31 11:34 11:32 Resident 11:22 11:55 11:55 11:56 12:00 11:5612:35 12:29 12:35 12:35 12:36 Resident 12:44 12:44 12:41 12:4613:38 13:46 13:48 13:45 13:46 13:40 13:49 13:49 13:42 13:48 Resident 14:00 14:00 14:00 14:12 14:02 14:04

11:08 11:10 11:11 11:14 11:29



Appendix E

12:17 12:23 12:24 12:22 12:25 12:19 12:25 12:26 12:22 12:36 Surgeon9:02 9:02 9:05 9:06 9:07 9:08 9:20 9:10 Resident 9:38 9:40 9:44 9:43

9:08 9:07 9:06 9:04 9:06 8:50 9:07 9:11 10:34 9:14 Surgeon 12:57 13:26 13:28 12:32 12:57 12:07

8:56 9:04 8:59 9:03 8:57 9:05 9:06 8:54 9:07 Resident 9:07 9:34 9:37 9:40 9:41 9:43 9:3010:19 10:21 10:21 10:21 10:20 10:23 Surgeon 11:04 10:59 11:02 11:05 11:04 11:0511:25 11:26 11:24 11:25 11:22 11:23 11:27 Resident 11:30 11:31 11:34 11:31 11:29

8:02 8:12 8:11 8:09 8:13 8:14 8:15 8:15 Surgeon 8:30 8:40 8:41 8:43 8:48 8:409:30 9:38 9:36 9:36 9:37 9:38 9:40 9:31 9:40 Fellow 9:57 10:03 10:04 10:09 9:40

10:40 11:03 11:04 11:06 11:06 11:07 11:08 Fellow 11:29 11:3112:14 12:49 12:49 12:51 12:40 12:52 12:54 12:55 Resident

7:55 8:03 7:58 8:02 8:03 8:04 8:06 8:07 Resident 8:11 8:14 8:17 8:20 8:15 8:139:37 9:36 9:39 9:40 9:38 9:40 9:41 9:43 9:43 Resident 9:58 10:04 10:05 10:05 10:30

11:43 11:44 11:45 11:45 11:46 11:55 Resident 12:05 12:07 12:10 12:28 12:3012:56 13:05 13:02 13:04 13:01 13:05 13:07 12:55 13:10 Fellow

8:09 8:10 8:02 Resident 8:33 8:33 8:33 8:359:45 10:31 10:32 10:32 10:34 10:26 10:34 10:35 9:45 9:44,10:37 Resident

9:11 9:12 9:17 9:0810:10 10:20 10:20 10:19 10:20 10:15 10:16 10:19 10:24 Resident 10:55 10:59 11:04 11:06 11:12 11:00

7:59 8:41 8:40 8:30 8:34 8:25 8:43 8:45 8:30 8:49 Resident 10:05 10:50 10:52 10:50 11:00 10:2811:40 12:19 12:16 12:05 12:15 11:50 12:20 12:24 11:56 12:25 Both 13:20 13:45 13:50 13:51 13:48 13:07

8:05 9:14 9:14 8:18 8:20 8:52 9:15 9:19 9:20 Surgeon 13:35 13:45 13:50 12:17 12:2914:42 15:11 15:17 15:03 15:10 14:49 15:16 15:20 15:22 Fellow

8:07 8:15 8:15 8:18 8:18 8:19 8:22 8:20 Fellow 8:58 9:02 9:02 8:45 8:52 8:5210:08 10:16 11:04 10:12 10:13 10:06 10:16 10:18 10:15 10:20 Fellow

8:43 9:00 9:20 8:56 9:00 8:51 9:01 9:02 8:55 9:03 Resident 9:23, 9:48 9:50 9:58 9:59 9:55 10:1110:33 10:33 10:37 10:38 10:42 10:42 10:42 10:43 10:44 Fellow 11:00 11:12 11:13 11:14

8:47 8:52 8:539:36 9:41 10:00 9:40 9:44 9:45 9:45 9:49 9:28 9:49 Resident 10:13 10:13 10:30 10:34 10:25 10:15

11:18 11:25 11:50 11:24 11:29 11:23 11:29 11:30 11:22 11:33 Resident 11:55 12:02 12:06 11:56 12:078:05 8:10 8:10 8:12 8:13 8:06 8:14 8:15 8:13 8:17 Resident 8:57 9:04 9:07 9:05 9:12 9:209:52 9:48 9:57 9:55 9:57 9:57 9:59 10:12 10:01 Surgeon 10:40 10:43 10:30 10:44 10:45

11:12 11:16 11:23 11:17 11:20 11:12 11:21 11:25 11:14 11:27 Both 12:10 12:14 12:15 12:15 12:16 12:198:40 8:42 8:42 8:42 8:44 8:45 8:50 Resident 9:01 9:05 9:06 9:10 9:10

9:36 9:25 9:45 9:45 9:46 9:41 9:46 9:47 9:50 Resident 10:47 10:50 10:51 10:53 10:5311:49 11:52 11:57 12:02

8:10 8:17 8:16 8:17 8:14 8:19 8:21 8:24 8:23 Fellow 8:30 8:39 8:43 8:46 8:359:40 9:47 10:34 9:45 9:46 9:50 9:51 9:52 Fellow 10:54 11:12 11:15 11:15 11:00

12:23 12:22 12:23 Resident

7:55 7:58 8:00 8:02 7:57 8:02 8:03 7:50 8:05 Fellow 8:19 8:21 8:41 8:43 8:24 8:43 8:509:49 9:51 10:22 9:50 9:53 9:50 9:53 9:54 9:59 9:56 Fellow 10:31 10:39 10:45 10:46 10:49 10:46

11:53 11:50 12:15 11:56 12:00 11:56 12:00 12:01 11:55 12:03 Rellow 12:23 12:24 12:30 12:32 12:24 12:36 12:20



Appendix E

Transfer bed brought in

Patient extubated /transferred

Scrub begins breakdown

2nd Count

Scrub takes instuemnts out

Started before patient removed?

Aneth. Leaves

Resident leaves

Patient out of room

Anesth. Tech enters

Aneth. Tech leaves PTs Paged PTS Arrive

How Many

Who helped

PTs leave

10:20 10:15 9:57 10:31 No 10:31 10:31 10:33 10:45 10:29 2 10:40

10:10 10:16 10:10 10:07 10:16 Yes 10:19 10:19 10:19 10:20 10:29 10:09 10:19 3 10:24

11:24 11:24 11:20 11:30 No 11:29 11:29 11:29 11:35 11:39 11:30 11:35 2 11:4214:32 14:38 14:15 14:26 14:40 Yes 14:41 14:41 14:41 14:41 14:42 3 14:53

8:52 8:57 9:01 9:03 No 8:59 9:02 9:02 9:04 9:06 9:03 9:03 3 Scrub 9:09

8:27 8:34 8:27 8:24 8:34 No 8:34 8:34 8:34 8:36 8:41 8:36 1 OR Aide 8:4410:58 11:04 10:56 10:46 11:04 Yes 11:04 11:15 11:04 11:11 11:15 11:05 11:06 3 11:1312:10 12:09 12:08 12:07 12:21 Yes 12:15 12:15 12:15 12:17 12:21 12:15 12:16 2 12:24

8:29 8:30 8:26 8:38 8:34 8:34 8:35 8:40 Scrub+Circ 8:389:07 9:08 9:08 9:08 Yes 9:12 9:12 9:12 9:12 9:15 1 Scrub 9:179:54 9:55 9:52 10:01 10:01 10:01 10:01 10:13 9:55 10:00 3 Scrub 10:07

11:06 11:08 11:07 11:09 Yes 11:10 11:10 11:10 Scrub+Circ 11:159:44 9:41 9:35 9:35 9:48 Yes 9:52 9:52 9:52 9:54 10:00 9:53 9:54 2 10:00

12:35 12:46 12:32 12:15 12:48 Yes 12:48 12:48 12:48 12:49 12:58 12:48 12:49 2 12:56

9:14 9:19 9:10 9:21 No 9:21 9:21 9:21 9:24 9:30 9:21 9:22 4 9:2810:30 10:29 10:25 10:35 No 10:34 10:32 10:34 10:40 10:45 10:34 10:35 2 10:42

8:27 8:29 8:25 8:25 8:27 Yes 8:33 8:33 8:33 8:35 8:39 8:33 Scrub Tech10:06 10:10 10:04 10:08 Yes 10:12 10:15 10:16 10:20 10:15 10:15 2 10:2212:19 12:20 12:15 12:18 Yes 12:35 12:35 12:35 12:36 12:40 12:35 12:35 2 12:42

8:16 8:18 8:16 8:18 No 8:18 8:18 8:18 8:10 8:22 8:15 8:18 2 Scrub 8:229:08 9:11 9:08 No 9:11 9:11 9:11 9:17 9:22 9:12 9:10 1 Scrub 9:209:58 10:00 9:57 10:03 No 10:03 10:03 10:00 10:08 10:03 10:05 3 10:11

10:53 10:55 10:51 10:51 11:00 No 10:59 11:00 11:00 10:55 11:02 11:00 11:02 1 11:1111:59 12:02 11:56 12:04 No 12:04 12:04 12:04 12:04 12:15 12:04 12:09 3 Scrub 12:1112:47 12:59 12:47 No 13:00 13:00 13:00 12:58 13:06 13:01 2 Scrub+Circ 13:0714:06 14:10 14:10 14:09 14:23 No 14:21 14:21 14:21 14:25 14:29 14:23 0 Scrub+Circ 14:3011:11 11:27 11:10 11:28 Yes 11:28 11:28 11:28 11:29 11:38 11:28 11:29 3 11:37



Appendix E

9:40 Transferred 9:41 9:48 Yes 9:54 9:54 9:54 9:41 9:55 9:58 10:10 213:33 13:49 13:25 13:05 13:45 Yes 13:49 13:49 13:49 13:45 14:00 13:51 1 14:16

9:44 9:55 9:33 9:33 9:57 Yes 9:47 9:58 9:56 10:00 10:06 9:56 9:57 2 Scrub 10:0411:05 11:08 11:03 11:08 Yes 11:08 11:08 11:08 11:10 11:19 11:10 11:11 4 11:1411:35 11:35 11:34 11:36 Yes 11:36 11:36 11:44 11:54 11:36 11:45 2 Circ 11:49

8:45 Transferred 8:43 8:40 9:02 Yes 9:04 9:04 9:04 9:04 9:07 8:55 1 9:0810:06 10:10 10:05 10:05 10:13 No 10:13 10:13 10:13 10:13 10:20 10:13 10:14 1 Circ 10:2011:32 Transferred to NICU 11:32 11:28 11:42 No 11:41 11:40 11:41 11:42 11:50 11:41 11:42 1 Scrub 11:50

8:21 Transferred 8:21 8:13 8:23 Yes 8:24 8:24 8:24 8:27 8:33 8:24 8:22 2 8:2910:30 10:39 10:06 9:59 10:11 Yes 10:07 9:16 10:41 10:42 10:49 10:41 10:42 2 10:49

12:26 12:11 12:13 Yes 12:29 12:15 12:31

8:34 8:33 8:33 8:38 Yes 8:40 8:40 8:40 8:42 8:48 8:40 8:42 1 Only linens 8:44

9:21 9:27 9:18 9:10 9:26 Yes 9:29 9:29 9:29 9:34 9:43 9:29 9:29 2 9:3511:08 11:10 11:00 11:00 11:21 No 11:20 11:20 11:20 11:10 11:29 11:21 3 11:29

10:49 11:02 10:49 10:25 11:05 No 11:05 11:05 11:05 11:07 11:15 11:05 11:05 3 11:2113:58 13:59 13:46 13:25 14:01 No 14:01 14:01 14:01 14:04 14:07 14:02 14:02 2 14:1313:46 Transferred 13:40 13:32 14:02 No 13:56 13:56 13:56 13:55 14:23 13:57 13:57 2 14:10

9:06 9:07 9:05 8:56 9:17 No 9:17 9:17 9:17 9:22 9:32 9:17 9:21 2 Circ 9:27

10:00 10:09 9:46 9:54 10:13 Yes 9:59 10:00 10:13 10:13 10:19 10:13 10:14 2 10:1911:17 11:23 11:15 11:13 11:25 Yes 11:24 11:24 11:24 11:24 11:26 2 11:32

8:56 8:53 8:59 Yes 8:59 8:59 8:59 9:01 9:01 2 9:0710:43 10:17 10:44 10:14 10:44 Yes 10:27 10:46 10:46 10:47 10:54 10:45 10:46 2 10:5112:13 12:16 12:07 12:12 Yes 12:20 12:20 12:20 12:33 12:36 12:20 12:21 1 12:33

9:14 9:18 9:05 9:13 9:16 Yes 9:20 9:20 9:20 9:20 9:25 9:20 9:21 1 9:2910:46 10:49 10:43 10:45 10:52 No 10:52 10:52 10:52 10:52 11:00 10:52 10:52 3 10:5612:17 12:21 12:14 12:12 12:25 No 12:23 12:23 12:23 12:20 12:32 12:23 12:35 2 Scrub 12:40

9:08 9:10 9:06 9:11 Yes 9:10 9:14 9:10 9:14 9:19 9:10 9:11 4 9:1710:54 10:55 10:51 10:45 11:10 Yes 11:10 11:10 11:10 11:12 11:20 11:10 11:12 2 11:20

8:44 8:50 8:40 8:29 8:45 Yes 8:54 8:55 8:55 9:00 9:06 8:56 8:59 2 Scrub 9:0511:18 Transferred 11:15 10:54 11:24 No 11:24 11:24 11:24 11:29 11:35 11:24 11:25 1 Scrub 11:28

8:46 8:55 8:43 8:56 Yes 8:35 8:56 8:56 8:58 8:56 8:57 1 9:0210:50 10:56 10:45 10:35 10:59 Yes 10:59 10:59 10:59 11:02 11:06 10:59 10:53 2 OR Aide 11:0312:35 12:44 12:29 12:28 12:57 Yes 12:55 12:55 12:55 12:56 13:02 12:45 12:49 1 13:01



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