A comparison of inhalational inductions for children in the operating room vs the induction room

Department of Anesthesiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH 45229-3039, USA.
Pediatric Anesthesia (Impact Factor: 1.85). 12/2011; 22(4):327-34. DOI: 10.1111/j.1460-9592.2011.03755.x
Source: PubMed


There has been debate about the use of an induction room (IR) compared with an operating room (OR) for inhalational induction in children. The quality of the anesthesia induction between these two physical environments has not been studied previously. We sought to compare child distress, OR utilization and efficiency, and parental satisfaction and safety, between an IR and an OR.
In a prospective observational study, we studied 501 developmentally appropriate children ages 1-14 years, American Society of Anesthesiologists (ASA) physical status I-III, presenting for the inhalational induction of anesthesia, undergoing outpatient or outpatient-admit ENT surgery. Inductions were performed in an IR (IR group) or OR (OR group) with parent(s) present. Child behavioral compliance was assessed using the Induction Compliance Checklist (ICC), a validated observational scale from 0 to 10 consisting of 10 behaviors; an ICC score ≥4 was considered poor behavioral compliance. Times for transport, anesthesia start, ready for surgery, surgery finish, out of OR, and total case process times were recorded. OR utilization and OR efficiency was derived using these times. Data on number and experience of clinical providers were also collected. Parent satisfaction with the induction was measured using a satisfaction survey. Safety was measured by recording respiratory complications during induction. The chi-squared test was conducted to determine whether induction location was associated with level of behavioral compliance. A multivariable proportional odds model was used to control for risk factors. OR utilization and efficiency were analyzed using the Wilcoxon-Mann-Whitney test.
There were no significant differences in ICC scores between the groups (P-value = 0.12). Anesthesia, nonoperative, and transport time were statistically less in the OR group when compared with the IR group, although total case process times were similar in both groups. While OR efficiency was significantly higher for the OR group (P-value = 0.0096), OR utilization did not differ between groups (P-value = 0.288). The OR group had a significantly higher number of anesthesia providers and a more experienced surgical team. Parents in the two groups were equally satisfied with their experience during induction, and none of the subjects had respiratory complications during the anesthesia induction.
We found no differences in child distress, parent satisfaction, and respiratory complications between inductions conducted in the IR vs the OR. Differences in utilization, efficiency, and turnover were minimal and not operationally significant. Capital equipment, space, and staffing strategies should be key drivers in considerations for the use of IRs, and in the design of ORs with IRs.

17 Reads
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective A quality improvement project to evaluate operating room efficiency and utilization and to identify areas for improvement. Methods A retrospective assessment of a single surgeon's surgical cases over a 6-month period at a tertiary children's hospital. Primary outcomes included case timing defined as T1, T2, T3 and T4. (T1) - Patient Enters OR–to–Procedure Start. (T2) - Procedure Start–to–Procedure End. (T3) - Procedure End–to–Patient Exits OR. (T4) - Patient Exits OR–to–Next Patient Enters OR (Turnover). Comparison to existing literature was performed and results were presented to stakeholders. Results A total of 180 surgical cases were reviewed, 92 Adenotonsillectomies (T&A), 33 Bilateral Pressure Equalization Tube Placement (PET) and 55 Microlaryngoscopies and Bronchoscopies (MLB). All outcomes were calculated by case type, except T4, and compared to available published data. T2 was compared to published benchmarks for otolaryngology demonstrating favorable operative times for T&A and PET. However, T4 was considerably longer at our institution (average 31.09). Overall OR efficiency was 20.58%. Conclusions The operating room represents one of a hospital's most costly resources. Ensuring that this resource is designed, staffed and utilized efficiently is of major importance to both the quality of patient care and financial productivity. Surgeons are key components of operating room efficiency, utilization and other measurements of institutional performance. How surgeons schedule and perform cases directly impacts, and is impacted by, these measurements of performance. For fields dominated by high volume, short duration procedures such as pediatric otolaryngology, T4 may be the most important variable in determining OR efficiency. By utilizing modern electronic medical records, surgeons can easily track OR time points thereby determining the potential causes of and solutions for OR inefficiency.
    International journal of pediatric otorhinolaryngology 05/2014; 78(5). DOI:10.1016/j.ijporl.2014.02.010 · 1.19 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Microlaryngoscopy and bronchoscopy procedures (MLBs) are short-duration, high-acuity procedures that carry risk. Poor case flow and communication exacerbate such potential risk. Efficient operative flow is critical for patient safety and resource expenditure. To identify areas for improvement and evaluate the effectiveness of a multidisciplinary quality-improvement (QI) initiative. A QI project using the "Plan-Do-Study-Act" (PDSA) cycle was implemented to assess MLBs performed on pediatric patients in a tertiary academic children's hospital. Forty MLBs were audited using a QI evaluation tool containing 144 fields. Each MLB was evaluated for flow, communication, and timing. Opportunities for improvement were identified. Subsequently, QI interventions were implemented in an iterative cycle, and 66 MLBs were audited after the intervention. Specific QI interventions addressed issues of personnel frequently exiting the operating room (OR) and poor preoperative preparation, identified during QI audit as areas for improvement. Interventions included (1) conducting "huddles" between surgeon and OR staff to discuss needed equipment; (2) implementing improvements to surgeon case ordering and preference cards review; (3) posting an OR door sign to limit traffic during airway procedures; and (4) discouraging personnel breaks during airway procedures. Operating room exiting behavior of OR personnel, preoperative preparation, and case timing were assessed and compared before and after the QI intervention. Personnel exiting the OR during the MLB was identified as a preintervention issue, with the surgical technologist, circulator, or surgeon exiting the room in 55% of cases (n = 22). The surgical technologist and circulator left the room to retrieve equipment in 40% of cases (n = 16), which indicated the need for increased preoperative preparation to improve case timing and operative flow. The QI interventions implemented to address these concerns included education regarding break timing, improvements in communication, and improvements in ordering and preparation of equipment. After the QI intervention, the surgical technologist exiting rate decreased from 20% (n = 8) to 8% (n = 5), and the circulator exiting rate decreased from 38% (n = 15) to 27% (n = 17). In addition, the rate of surgeon exiting decreased significantly (from 25% [n = 10 of 40] to 9% [n = 6 of 66]) (P = .03). The surgical technologist and circulating nurse remaining in the room were significantly associated with decreased operating time (1.84-minute decrease for surgical technologist [P = .04] and 1.95-minute decrease for circulating nurse [P = .001]). Gains were made in personnel exiting behavior and case timing after implementation of the QI interventions, potentially leading to decreased risk. This process is easily reproduced and is widely accepted by stakeholders.
    JAMA Otolaryngology - Head and Neck Surgery 12/2014; 141(3). DOI:10.1001/jamaoto.2014.3279 · 1.79 Impact Factor