Lack of Impact of Nil-Per-Os (NPO) Time on Goal-Directed Fluid Delivery in First Case versus Afternoon Case Starts: A Retrospective Cohort Study

Abstract Background Goal Directed Fluid Therapy (GDFT) represents an objective fluid replacement algorithm. The effect of provider variability remains a confounder. Overhydration worsens perioperative morbidity and mortality; therefore, the impact of the calculated NPO deficit prior to the operating room may reach harm. Methods A retrospective single-institution study analyzed patients at UC Irvine Medical Center main operating rooms from September 1, 2013 through September 1, 2015 receiving GDFT. The primary study question asked if GDFT suggested different fluid delivery after different NPO periods, while reducing inter-provider variability. We created two patient groups distinguished by 0715 surgical start time or start time after 1200. We analyzed fluid administration totals with either a 1:1 crystalloid to colloid ratio or a 3:1 ratio. We performed direct group-wise testing on total administered volume expressed as total ml, total ml/hr., and total ml/kg/hr. between the first case start (AM) and afternoon case (PM) groups. A linear regression model included all baseline covariates that differed between groups as well as plausible confounding factors for differing fluid needs. Finally, we combined all patients from both groups, and created NPO time to total administered fluid scatterplots to assess the effect of patient-reported NPO time on fluid administration. Results Whether reported by total administered volume or net fluid volume, and whether we expressed the sum as ml, ml/hr., or ml/kg/hr., the AM group received more fluid on average than the PM group in all cases. In the general linear models, for all significant independent variables evaluated, AM vs PM case start did not reach significance in both cases at p = 0.64 and p = 0.19, respectively. In scatterplots of NPO time to fluid volumes, absolute adjusted and unadjusted R2 values are < 0.01 for each plot, indicating virtually non-existent correlations between uncorrected NPO time and fluid volumes measured. Conclusions This study showed NPO periods do not influence a patient’s volume status just prior to presentation to the operating room for surgical intervention. We hope this data will influence the practice of providers routinely replacing calculated NPO period volume deficit; particularly with those presenting with later surgical case start times.

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Lack of Impact of Nil-Per-Os (NPO) Time on Goal-Directed Fluid Delivery in First Case versus Afternoon Case Starts: A Retrospective Cohort Study

10.21203/rs.2.11714/v2 ◽

2019 ◽

Author(s):

R Ryan Field ◽

Tuan Mai ◽

Samouel Hanna ◽

Brian Harrington ◽

Michael-David Calderon ◽

...

Keyword(s):

Operating Room ◽

Medical Center ◽

Fluid Administration ◽

Fluid Replacement ◽

Primary Study ◽

Start Time ◽

Fluid Delivery ◽

First Case ◽

Patient Reported ◽

The Impact

Abstract Background: Goal Directed Fluid Therapy(GDFT) represents an objective fluid replacement algorithm. The effect of provider variability remains a confounder. Overhydration worsens perioperative morbidity and mortality; therefore, the impact of the calculated NPO deficit prior to the operating room may reach harm. Methods: A retrospective single-institution study analyzed patients at UC Irvine Medical Center main operating rooms from September 1, 2013 through September 1, 2015 receiving GDFT. The primary study question asked if GDFT suggested different fluid delivery after different NPO periods, while reducing inter-provider variability. We created two patient groups distinguished by 0715 surgical start time or start time after 1200. We analyzed fluid administration totals with either a 1:1 crystalloid to colloid ratio or a 3:1 ratio. We performed direct group-wise testing on total administered volume expressed as total ml, total ml/hr, and total ml/kg/hr between the first case start (AM) and afternoon case (PM) groups. A linear regression model included all baseline covariates that differed between groups as well as plausible confounding factors for differing fluid needs. Finally, we combined all patients from both groups, and created NPO time to total administered fluid scatterplots to assess the effect of patient-reported NPO time on fluid administration. Results: Whether reported by total administered volume or net fluid volume, and whether we expressed the sum as ml, ml/hr, or ml/kg/hr, the AM group received more fluid on average than the PM group in all cases. In the general linear models, for all significant independent variables evaluated, AM vs PM case start did not reach significance in both cases at p=0.64 and p=0.19, respectively. In scatterplots of NPO time to fluid volumes, absolute adjusted and unadjusted R2 values are < 0.01 for each plot, indicating virtually non-existent correlations between uncorrected NPO time and fluid volumes measured. Conclusions: This study showed NPO periods do not influence a patient’s volume status just prior to presentation to the operating room for surgical intervention. We hope this data will influence the practice of providers routinely replacing calculated NPO period volume deficit; particularly with those presenting with later surgical case start times.

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Lack of Impact of Nil-Per-Os (NPO) Time on Goal-Directed Fluid Delivery in First Case versus Afternoon Case Starts: A Retrospective Cohort Study

10.21203/rs.2.11714/v4 ◽

2019 ◽

Author(s):

R Ryan Field ◽

Tuan Mai ◽

Samouel Hanna ◽

Brian Harrington ◽

Michael-David Calderon ◽

...

Keyword(s):

Operating Room ◽

Medical Center ◽

Fluid Administration ◽

Fluid Replacement ◽

Primary Study ◽

Start Time ◽

Fluid Delivery ◽

First Case ◽

Patient Reported ◽

The Impact

Abstract Background: Goal Directed Fluid Therapy(GDFT) represents an objective fluid replacement algorithm. The effect of provider variability remains a confounder. Overhydration worsens perioperative morbidity and mortality; therefore, the impact of the calculated NPO deficit prior to the operating room may reach harm. Methods: A retrospective single-institution study analyzed patients at UC Irvine Medical Center main operating rooms from September 1, 2013 through September 1, 2015 receiving GDFT. The primary study question asked if GDFT suggested different fluid delivery after different NPO periods, while reducing inter-provider variability. We created two patient groups distinguished by 0715 surgical start time or start time after 1200. We analyzed fluid administration totals with either a 1:1 crystalloid to colloid ratio or a 3:1 ratio. We performed direct group-wise testing on total administered volume expressed as total ml, total ml/hr, and total ml/kg/hr between the first case start (AM) and afternoon case (PM) groups. A linear regression model included all baseline covariates that differed between groups as well as plausible confounding factors for differing fluid needs. Finally, we combined all patients from both groups, and created NPO time to total administered fluid scatterplots to assess the effect of patient-reported NPO time on fluid administration. Results: Whether reported by total administered volume or net fluid volume, and whether we expressed the sum as ml, ml/hr, or ml/kg/hr, the AM group received more fluid on average than the PM group in all cases. In the general linear models, for all significant independent variables evaluated, AM vs PM case start did not reach significance in both cases at p=0.64 and p=0.19, respectively. In scatterplots of NPO time to fluid volumes, absolute adjusted and unadjusted R2 values are < 0.01 for each plot, indicating virtually non-existent correlations between uncorrected NPO time and fluid volumes measured. Conclusions: This study showed NPO periods do not influence a patient’s volume status just prior to presentation to the operating room for surgical intervention. We hope this data will influence the practice of providers routinely replacing calculated NPO period volume deficit; particularly with those presenting with later surgical case start times.

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Lack of Impact of Nil-Per-Os (NPO) Time on Goal-Directed Fluid Delivery in First Case versus Afternoon Case Starts: A Retrospective Cohort Study

10.21203/rs.2.11714/v5 ◽

2019 ◽

Author(s):

R Ryan Field ◽

Tuan Mai ◽

Samouel Hanna ◽

Brian Harrington ◽

Michael-David Calderon ◽

...

Keyword(s):

Operating Room ◽

Medical Center ◽

Fluid Administration ◽

Fluid Replacement ◽

Primary Study ◽

Start Time ◽

Fluid Delivery ◽

First Case ◽

Patient Reported ◽

The Impact

Abstract Background: Goal Directed Fluid Therapy(GDFT) represents an objective fluid replacement algorithm. The effect of provider variability remains a confounder. Overhydration worsens perioperative morbidity and mortality; therefore, the impact of the calculated NPO deficit prior to the operating room may reach harm. Methods: A retrospective single-institution study analyzed patients at UC Irvine Medical Center main operating rooms from September 1, 2013 through September 1, 2015 receiving GDFT. The primary study question asked if GDFT suggested different fluid delivery after different NPO periods, while reducing inter-provider variability. We created two patient groups distinguished by 0715 surgical start time or start time after 1200. We analyzed fluid administration totals with either a 1:1 crystalloid to colloid ratio or a 3:1 ratio. We performed direct group-wise testing on total administered volume expressed as total ml, total ml/hr, and total ml/kg/hr between the first case start (AM) and afternoon case (PM) groups. A linear regression model included all baseline covariates that differed between groups as well as plausible confounding factors for differing fluid needs. Finally, we combined all patients from both groups, and created NPO time to total administered fluid scatterplots to assess the effect of patient-reported NPO time on fluid administration. Results: Whether reported by total administered volume or net fluid volume, and whether we expressed the sum as ml, ml/hr, or ml/kg/hr, the AM group received more fluid on average than the PM group in all cases. In the general linear models, for all significant independent variables evaluated, AM vs PM case start did not reach significance in both cases at p=0.64 and p=0.19, respectively. In scatterplots of NPO time to fluid volumes, absolute adjusted and unadjusted R2 values are < 0.01 for each plot, indicating virtually non-existent correlations between uncorrected NPO time and fluid volumes measured. Conclusions: This study showed NPO periods do not influence a patient’s volume status just prior to presentation to the operating room for surgical intervention. We hope this data will influence the practice of providers routinely replacing calculated NPO period volume deficit; particularly with those presenting with later surgical case start times.

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Lack of Impact of NPO Time on Goal-Directed Fluid Therapy Resuscitation in AM versus PM Case Starts: A Retrospective Cohort Study

10.21203/rs.2.11714/v1 ◽

2019 ◽

Author(s):

R Ryan Field ◽

Tuan Mai ◽

Samouel Hanna ◽

Brian Harrington ◽

Michael-David Calderon ◽

...

Keyword(s):

Operating Room ◽

Fluid Therapy ◽

Medical Center ◽

Fluid Administration ◽

Fluid Replacement ◽

Primary Study ◽

Start Time ◽

Patient Reported ◽

Goal Directed Fluid Therapy ◽

The Impact

Abstract Background: Goal directed fluid therapy (GDFT) represents an objective fluid replacement algorithm. The effect of provider variability remains a confounder. Overhydration worsens perioperative morbidity and mortality; therefore, the impact of the calculated NPO deficit prior to the operating room may reach harm. Methods: A retrospective single-institution study analyzed patients at UC Irvine Medical Center main operating rooms from September 1, 2013 through September 1, 2015 receiving GDFT. The primary study question asked if GDFT suggested different fluid resuscitation after different NPO periods, while reducing inter-provider variability. We created two patient groups distinguished by 0715 surgical start time or start time after 1200. We analyzed fluid administration totals with either a 1:1 crystalloid to colloid ratio or a 1:3 ratio. We performed direct group-wise testing on total administered volume expressed as total ml, total ml/hr, and total ml/kg/hr between the AM and PM groups. A linear regression model included all baseline covariates that differed between groups as well as plausible confounding factors for differing fluid needs. Finally, we combined all patients from both groups, and created NPO time to total administered fluid scatterplots to assess the effect of patient-reported NPO time on fluid administration. Results: Whether reported by total administered volume or net fluid volume, and whether we expressed the sum as ml, ml/hr, or ml/kg/hr, the AM group received more fluid on average than the PM group in all cases. In the general linear models, for all significant independent variables evaluated, AM vs PM case start did not reach significance in both cases at p=0.64 and p=0.19, respectively. In scatterplots of NPO time to fluid volumes, absolute adjusted and unadjusted R2 values are < 0.01 for each plot, indicating virtually non-existent correlations between uncorrected NPO time and fluid volumes measured. Conclusions: This study showed NPO periods do not influence a patient’s volume status just prior to presentation to the operating room for surgical intervention. We hope this data will influence the practice of providers routinely replacing calculated NPO period volume deficit; particularly with those presenting with later surgical case start times.

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Spinal anesthesia in a designated block bay for total joint arthroplasty: improving operating room efficiency

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2020-101773 ◽

2020 ◽

Vol 45 (12) ◽

pp. 975-978

Author(s):

Ryland Kagan ◽

Stephanie Zhao ◽

Andrew Stone ◽

Alicia J Johnson ◽

Thomas Huff ◽

...

Keyword(s):

Spinal Anesthesia ◽

Operating Room ◽

Total Joint Arthroplasty ◽

Group Versus ◽

Joint Arthroplasty ◽

Start Time ◽

Serious Adverse Events ◽

Mixed Effect ◽

Exact Test ◽

First Case

BackgroundCreating highly efficient operating room (OR) protocols for total joint arthroplasty (TJA) is a challenging and multifactorial process. We evaluated whether spinal anesthesia in a designated block bay (BBSA) would reduce time to incision, improve first case start time and decrease conversion to general anesthesia (GA).MethodsRetrospective cohort study on the first 86 TJA cases with BBSA from April to December 2018, compared with 344 TJA cases with spinal anesthesia performed in the OR (ORSA) during the same period. All TJA cases were included if the anesthetic plan was for spinal anesthesia. Patients were excluded if circumstances delayed start time or time to incision (advanced vascular access, pacemaker interrogation, surgeon availability). Data were extracted and analyzed via a linear mixed effects model to compare time to incision, via a Wilcoxon rank-sum test to compare first case start time, and via a Fisher’s exact test to compare conversion to GA between the groups.ResultsIn the mixed effect model, the BBSA group time to incision was 5.37 min less than the ORSA group (p=0.018). The BBSA group had improved median first case start time (30.0 min) versus the ORSA group (40.5 min, p<0.0001). There was lower conversion to GA 2/86 (2.33%) in the BBSA group versus 36/344 (10.47%) in the ORSA group (p=0.018). No serious adverse events were noted in either group.ConclusionsBBSA had limited impact on time to incision for TJA, with a small decrease for single OR days and no improvement on OR days with two rooms. BBSA was associated with improved first case start time and decreased rate of conversion to GA. Further research is needed to identify how BBSA affects the efficiency of TJA.

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First-case tardiness reduction in a tertiary academic medical center operating room: A lean six sigma perspective

Perioperative Care and Operating Room Management ◽

10.1016/j.pcorm.2016.12.001 ◽

2016 ◽

Vol 5 ◽

pp. 7-12 ◽

Cited By ~ 2

Author(s):

Pedro Ramos ◽

Eloisa Bonfá ◽

Patrícia Goulart ◽

Marion Medeiros ◽

Nélson Cruz ◽

...

Keyword(s):

Operating Room ◽

Six Sigma ◽

Medical Center ◽

Academic Medical Center ◽

Lean Six Sigma ◽

First Case ◽

Academic Medical

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The Impact of Service-Specific Staffing, Case Scheduling, Turnovers, and First-Case Starts on Anesthesia Group and Operating Room Productivity: A Tutorial Using Data from an Australian Hospital

Anesthesia & Analgesia ◽

10.1213/01.ane.0000244535.54710.28 ◽

2006 ◽

Vol 103 (6) ◽

pp. 1499-1516 ◽

Cited By ~ 223

Author(s):

Catherine McIntosh ◽

Franklin Dexter ◽

Richard H. Epstein

Keyword(s):

Operating Room ◽

First Case ◽

Anesthesia Group ◽

Using Data ◽

The Impact ◽

Australian Hospital

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Lean methods to improve operating room elective first case on-time starts in a large, urban, safety net medical center

The American Journal of Surgery ◽

10.1016/j.amjsurg.2018.05.002 ◽

2018 ◽

Vol 216 (2) ◽

pp. 194-201 ◽

Cited By ~ 8

Author(s):

Charles Coffey ◽

Edward S. Cho ◽

Eric Wei ◽

Allison Luu ◽

Maria Ho ◽

...

Keyword(s):

Operating Room ◽

Medical Center ◽

Safety Net ◽

First Case ◽

Urban Safety ◽

Improve Operating Room ◽

Lean Methods ◽

Improve Operating

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A Successful Organized Effort to Improve Operating Room First-Case Starts in a Tertiary Academic Medical Center

The American Surgeon ◽

10.1177/0003134820951430 ◽

2020 ◽

pp. 000313482095143

Author(s):

Melissa M. J. Chua ◽

Keith Lewis ◽

Yi-An Huang ◽

Mary Fingliss ◽

Alik Farber

Keyword(s):

Operating Room ◽

Medical Center ◽

Academic Medical Center ◽

Or Efficiency ◽

Patient Dissatisfaction ◽

Real Time Measurement ◽

First Case ◽

Academic Medical ◽

Improve Operating Room ◽

Operational Plan

Background Operating room (OR) inefficiency drives up cost, decreases revenue, and leads to surgeon, staff, and patient dissatisfaction. Given a low mean first-case start rate in our tertiary academic medical center, we developed a process to improve first-case start rates in an effort to increase OR efficiency. Methods A working group of the OR Executive Committee was constituted to develop and implement a multistep operational plan. This plan was predicated on a sensible staggered start framework, coordination of stakeholder responsibilities, a visual preoperative Stop/Go checklist tool, real-time measurement, and feedback. Results Within 11 days of implementation, 95% of first-start OR cases were tracked to start on time. Throughout the observation period (May 2015-July 2016), the goal of a daily mean 80% on-time start rate was either met or exceeded. Conclusions Implementation of an organized collaborative effort led to dramatic improvements in first OR case on-time rates. Such improvement in OR utilization may lead to an increase in staff and patient satisfaction and cost reduction.

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