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Tony Mira, Chairman and Chief Executive Officer of MiraMed

Inside information for anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs) on the most current best practices during changing times.

Practice Management Pearls: A Rundown of Recent Anesthesia Research

​We review a handful of e-posters presented at PRACTICE MANAGEMENT™ 2019 in Las Vegas on topics including the practice of "room flipping" by some surgeons, the addition of a full-time anesthesiologist to reduce same-day surgery cancellations in a preoperative care clinic, and strategies to address an increase in venous thromboembolism events.

The ASA's PRACTICE MANAGEMENT™ 2019 featured e-poster presentations on a wide range of topics of interest to anesthesia practitioners. We summarize some of them here and will review others in future eAlerts.

Note that each of these posters represents the experience of a single institution that may (or may not) relate to other anesthesia practices. However, the broader topics are all significant in anesthesia. Keep in mind that if you were to do the same study in your own institution, you might find a different result. The studies are intended to provide food for thought for anesthesia groups.

Room flipping. The practice among some surgeons of "room flipping"—simultaneously scheduling two cases in an effort to boost OR efficiency and capture more revenue—can lead to increases in staffing costs if the model is executed ineffectively, according to a study led by Neal Shah, MD, of the University of Pittsburgh Medical Center.

Dr. Shah and his colleagues analyzed six months of data on a surgeon at their medical center, who schedules two cases simultaneously, one day a week. They looked at scheduled start times, patient in/out times and hourly staff costs. Using that data they determined case length, turnover time, gap time and overtime. Gap time (downtime) was determined by subtracting 25 minutes from the turnover time between cases in each OR (25 minutes is the minimum average turnover time at their institution). Overtime was the difference between patient out of OR time and scheduled OR block end time.

The cost of staffing two ORs, with downtime, was more than $12,800 per week, compared to $8,500 per week if all cases had been scheduled in one OR. The projected cost savings of staffing one OR was $4,200 per week or an annual savings of more than $223,000.

The cost burden of the OR downtime associated with the flipping model when the model is not executed as intended indicates it's not the efficiency-boosting strategy some believe it to be. The use of anesthesiologist and CRNA time "must be considered based on the ability to generate income only when surgery is taking place," Dr. Shah said.

Surgery cancellations. Preoperative care clinics (PCCs) can reduce same-day surgery cancellations and improve patient satisfaction, according to reports, but little is known about the ideal setup for these services. A study by Megan Meyer, MD, Sanjana Vig, MD, MBA, and colleagues at the University of California San Diego (UCSD) found that staffing the PCC with a full-time anesthesiologist could be a key ingredient for success.

The PCC at UCSD was altered to include a full-time attending anesthesiologist to supervise, educate, and manage workflows and operations. The researchers compared data in windows before (October 2015-2016) and after (October 2016-2017) adding the full-time anesthesiologist, controlling for ASA class, sex, surgical service and age.

Cancellation rates of 3.1 percent and 2.6 percent occurred in the before and after periods, respectively (p=0.0004) even though the total number of cases seen in the PCC went up from 21,815 to 28,517. The significant drop in same-day cancellations saved the hospital system approximately $230,000 to $300,000. The savings associated with the anesthesiologist's presence in the PCC largely offset the added cost of the physician.

"An attending presence improves not only PCC workflows and efficiency, but also is associated with an improvement in the quality of preoperative evaluations and patient optimization," they concluded.

VTE prophylaxis. To address an increase in venous thromboembolism events (VTE) at their institution, researchers from Emory University led by Grant Lynde, MD, MBA, did a retrospective case-control review of general surgery patients from 2013 to 2018, with a focus on preoperative risk assessments and use of prophylaxis, to identify gaps in care for this leading preventable cause of patient morbidity and mortality. A control set was generated matched for age, gender, ASA-PS, and ASA Base Units.

Among the total of 171 charts reviewed, 98 patients experienced a VTE. None of the charts contained documentation of a preoperative assessment of VTE risk. Twenty-nine percent of patients experiencing a VTE had a Caprini score of 0-4. Sequential compression devices (SCDs) were placed on all patients preoperatively. Only 22 percent of patients with a Caprini score of 5 or more received heparin preoperatively (although 98 percent of patients with a score of 5 or greater received heparin postoperatively), and only 16 percent in that group experienced a VTE.

The odds ratio of developing deep vein thrombosis (DVT) among patients who did not receive heparin was 2.03 in the immediate perioperative period.

If all patients had been treated using the current guidelines from the American College of Surgeons, which emphasize individualized risk stratification, 17 fewer patients (16 percent of all patients and 23 percent of "at risk" patients) would have experienced DVT, the researchers reported. The finding that 29 percent of patients who experienced DVT had a Caprini score of less than 5 highlights the tool's limitations in assessing VTE risk, the authors also noted.

The findings identified several opportunities for improvement, notably, a heightened focus on the appropriate use of preoperative chemical prophylaxis and standardized preoperative assessment of individualized VTE risk.

All of the e-posters from PRACTICE MANAGEMENT™ 2019 can be seen here.

We want to hear from you. Do you have a topic you would like to see covered in an ABC eAlert? Please send your suggestions to

With best wishes,

Tony Mira
President and CEO