Danielle Masursky

State University of New York Upstate Medical University, Syracuse, NY, United States

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Publications (14)38.01 Total impact

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    ABSTRACT: BACKGROUND:Theoretically, communication systems have the potential to increase the productivity of anesthesiologists supervising anesthesia providers. We evaluated the maximal potential of communication systems to increase the productivity of anesthesia care by enhancing anesthesiologists' coordination of care (activities) among operating rooms (ORs).METHODS:At hospital A, data for 13,368 pages were obtained from files recorded in the internal alphanumeric text paging system. Pages from the postanesthesia care unit were processed through a numeric paging system and thus not included. At hospital B, in a different US state, 3 of the authors categorized each of 898 calls received using the internal wireless audio system (Vocera(®)). Lower and upper 95% confidence limits for percentages are the values reported.RESULTS:At least 45% of pages originated from outside the ORs (e.g., 20% from holding area) at hospital A and at least 56% of calls (e.g., 30% administrative) at hospital B. In contrast, requests from ORs for urgent presence of the anesthesiologist were at most 0.2% of pages at hospital A and 1.8% of calls at hospital B.CONCLUSIONS:Approximately half of messages to supervising anesthesiologists are for activity originating outside the ORs being supervised. To use communication tools to increase anesthesia productivity on the day of surgery, their use should include a focus on care coordination outside ORs (e.g., holding area) and among ORs (e.g., at the control desk).
    Anesthesia and analgesia 02/2013; · 3.08 Impact Factor
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    ABSTRACT: The impact of delays in extubation on operating room (OR) workflow are challenging to assess because such delays may or may not be a bottleneck to the patient leaving the OR. We developed an observational measure that quantifies the influence of extubation times on OR workflow. The time from dressing on the patient (or its functional equivalent) to tracheal extubation was observed in ORs, among a cohort of adult patients undergoing elective (scheduled) general anesthesia. During the first 36 extubations, the measure was developed using qualitative methods. During the subsequent 64 extubations, qualitative observation was supplemented with quantitative measurement. Interrater reliability was assessed during the final 30 of the 64 extubations. Video 1 (see Supplemental Digital Content 1, http://links.lww.com/AA/A396) shows animation of a typical observation period. The developed measure was a single value for each case: whether at least 1 person was doing no visible physical activity potentially related to patient care for at least 1 minute between dressing on the patient and tracheal extubation. Assessing reliability, 2 raters' listings of cases with no versus 1 or more people idle were identical for 30 of 30 cases (95% lower confidence limit >90%). Spearman r = 0.99 (95% lower confidence limit 0.99) for time from dressing on patient to extubation. Predictive validity was shown by positive correlation between the percentage of cases with at least 1 person idle and extubation time (P < 0.0001): 21% for <5 minutes, 42% for 5 to 10 minutes, 87% for 10 to 15 minutes, and 100% for >15 minutes. Longer times to extubation are associated with an increased chance of at least 1 person waiting in the OR. This measure can be used in observational studies and for lean engineering projects to assess conditions when time to extubation affects workflow. Observers can combine use of this measure for extubation times with the previously developed measure for studying the influence of induction times on OR workflow.
    Anesthesia and analgesia 05/2012; 115(2):402-6. · 3.08 Impact Factor
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    ABSTRACT: We investigated whether changes in the number of cases performed by surgeons can be used as an appropriate surrogate for anesthesia departments' billed units. We used both number of cases performed and the American Society of Anesthesiologists' Relative Value Guide™ (ASA RVG) units to assess all operating room anesthetics of an anesthesia group for two sets of 13 four-week periods. The units correspond to Canadian basic units and time units. Although the number of ASA RVG units is an economically important variable that quantifies perioperative workload, the number of cases is a suitable surrogate for ASA RVG units when used to monitor individual surgeons. The pooled mean Pearson correlation coefficient between the two variables was r = 0.95, with 95% confidence interval 0.94 to 0.96. In addition, there were essentially none to very weak pairwise correlations among surgeons. Informal hospital analyses of relative changes in a surgeon's caseload over one year using anesthesia workload data or anesthesia billing data will generally give equivalent results. The principal importance of our findings is that they can be used by anesthesiologists, specifically department heads, in their role as part of operating room committees. Such committees institute plans to revise the caseload of one or a few surgeons, and they then evaluate the results of those plans. The findings of this study are applicable to all anesthesia groups and may be especially valuable to the heads of anesthesiology departments who do not have the data to repeat our analyses.
    Canadian Anaesthetists? Society Journal 03/2012; 59(6):571-7. · 2.31 Impact Factor
  • Franklin Dexter, Danielle Masursky
    International Journal for Quality in Health Care 06/2011; 23(3):219; author reply 220-1. · 1.79 Impact Factor
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    ABSTRACT: Perception of turnovers may be influenced less by actual turnover times per se than by a mental model of factors influencing turnover times. A survey was performed at a U.S. academic hospital in 2010. Each of the 78 subjects estimated characteristics of his/her turnover times in 2009. Responses were compared with the actual times. Numbers of comments were not proportional to actual total waiting times experienced. Surgeons with 2 or more comments (n = 10) averaged the same numbers of turnovers as did surgeons who made 1 or no comments (n = 13) (P = 0.62). Four of the 10 surgeons with 2 or more comments averaged <2 turnovers per month ("very few turnovers"). Perceptions of turnover times were influenced by opinion about team activity during shift change. Most (>79%) subjects thought that the time of the day with the subject's largest number of prolonged (>45 minutes) turnovers was at least 2 hours later than actual (P < 0.0001). Although most prolonged turnovers occurred around noon, 8 surgeons mentioned shift change qualitatively, and most (68%, P = 0.002) subjects estimated a time overlapping with shift change. Surgeons overall overestimated their observed percentage of prolonged turnovers (P = 0.020), and anesthesiologists' estimates were overall unbiased. Surgeons' bias cannot be explained by knowing times of a longer interval such as "skin to skin," because the other surgeons, with very few turnovers, had responses that were essentially identical (P ≥ 0.87). When we corrected for each subject's actual mean turnover time, surgeons' estimates for their averages were longer than were anesthesiologists' estimates (P = 0.002). Responses were again essentially indistinguishable from those of subjects with very few turnovers (P ≥ 0.23). Managers should not rely on surgeons or anesthesiologists for their expert judgment on turnover times. Managers should also not interpret comments about turnover times as literally referring to the time, but instead as factors perceived as contributing to the time (e.g., attitude about the facility and the activity of its personnel).
    Anesthesia and analgesia 02/2011; 112(2):440-4. · 3.08 Impact Factor
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    ABSTRACT: We recently determined how to use anesthesia information management system data to model the time from end of surgery to extubation. We applied that knowledge for meta-analyses of trials comparing extubation times after maintenance with desflurane and sevoflurane. In this study, we repeated the meta-analyses to compare isoflurane with desflurane and sevoflurane. A Medline search through December 2009 was used to identify studies with (1) humans randomly assigned to isoflurane or desflurane groups without other differences (e.g., induction drugs) between groups, and (2) mean and SD reported for extubation time and/or time to follow commands. The search was repeated for random assignment to isoflurane or sevoflurane groups. We considered extubation times >15 minutes (representing 15% of cases in the anesthesia information management system data) to be prolonged. Desflurane reduced the mean extubation time by 34% and reduced the variability in extubation time by 36% relative to isoflurane. These reductions would reduce the incidence of prolonged extubation times by 95% and 97%, respectively. Sevoflurane reduced the mean extubation time by 13% and reduced the SD by 8.7% relative to isoflurane. These reductions would reduce the incidence of prolonged extubation times by 51% and 35%, respectively. The pharmacoeconomics of volatile anesthetics are highly sensitive to measurement of relatively small time differences. Therefore, surgical facilities should use these values combined with their local data (e.g., mean baseline extubation times) when making evidence-based management decisions regarding pharmaceutical purchases and usage guidelines.
    Anesthesia and analgesia 05/2010; 110(5):1433-9. · 3.08 Impact Factor
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    ABSTRACT: Surgeon estimates of case durations are important for operating room (OR) management decision making because many cases are rare combinations of procedures with few or no historical data. Thoracic and spine surgeons updated their scheduled OR times on the day of surgery just before the "time out" in the OR. All elective (scheduled) general thoracic (n = 39) and spine surgery (n = 48) cases at 1 hospital were studied over 3-month and 1.5-month periods, respectively. Among cases with a change in predicted duration, most changes were made based on updates to the surgical or anesthetic procedures (thoracic 85%, spine 86%). For thoracic surgery, there was overall no significant median reduction in absolute prediction error (median 0 minutes, 95% confidence interval [CI] 0-0 minutes). Among the 37% of cases with changed predicted durations, there was a significant reduction in absolute error (median 38 minutes, 95% CI >7.5 minutes). For spine surgery, there was overall no reduction in the absolute error (median 0 minutes, 95% CI 0-0 minutes). Among the 29% of cases with changed predicted durations, absolute error was no worse, but not significantly better (point estimate of median reduction 34 minutes, 95% CI >0 minutes). Secondary observations made were no effect of updates on bias, frequent rounding of scheduled durations to the nearest half hour, and increased predictive error caused by decisions that reduced expected overutilized OR time. A systematic program of routinely and/or always asking for updated case duration predictions will not substantively improve OR management decision making. However, when a change in surgical approach, surgical procedure, or anesthetic procedure is identified (e.g., at the intraoperative briefing before case start), the updated estimate of case duration should be used, because such updates are not worse and often better than original estimates.
    Anesthesia and analgesia 02/2010; 110(4):1164-8. · 3.08 Impact Factor
  • Journal of Statistics Education 01/2010; 18:1-21.
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    ABSTRACT: Anesthesiologists are often paid extra for hours worked in the late afternoon and evening. Although anesthesiologists have little influence on their operating room (OR) assignments and workloads late in the afternoon, they can influence turnover times. OR turnover times on workdays were reviewed for n = 30 mo before there was incremental pay, for n = 15 mo with incremental pay for work past 3:30 pm, and for n = 8 mo with pay for work past 4:00 pm. The end point was the percentage of turnovers that were prolonged, defined as longer than 1 h. Turnovers straddling 3:30 pm (n = 3945), 4:00 pm (n = 3602), and 5:00 pm (n = 2834) were studied, as were those straddling 2:00 pm (n = 4407) as a control. In addition, qualitative (survey) assessment of n = 30 anesthesiologists was performed the last month to learn about their opinions on working late on weekdays. Most respondents considered an OR to run late if it finished after a specific time of day (87%, P < 0.001), unrelated to the room's type of procedures (90%, P < 0.001) or to the payment for working after 4:00 pm (100%, P < 0.001). There was no significant effect of implementation or changes to the incentive program on the incidences of prolonged turnover times at each of the studied times in the afternoon (all P > 0.14). Our results suggest that hospital administrators, deans, and other executives need not be especially concerned about disincentives produced by methods of internal compensation of anesthesiologists on highly visible OR turnover times late in afternoons.
    Anesthesia and analgesia 05/2009; 108(5):1622-6. · 3.08 Impact Factor
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    ABSTRACT: The economic costs of reducing first case delays are often high, because efforts need to be applied to multiple operating rooms (ORs) simultaneously. Nevertheless, delays in starting first cases of the day are a common topic in OR committee meetings. We added three scientific questions to a 24 question online, anonymous survey performed before the implementation of a new OR information system. The 57 respondents cared sufficiently about OR management at the United States teaching hospital to complete all questions. The survey revealed reasons why personnel may focus on the small reductions in nonoperative time achievable by reducing tardiness in first cases of the day. (A) Respondents lacked knowledge about principles in reducing over-utilized OR time to increase OR efficiency, based on their answering the relevant question correctly at a rate no different from guessing at random. Those results differed from prior findings of responses at a rate worse than random, resulting from a bias on the day of surgery of making decisions that increase clinical work per unit time. (B) Most respondents falsely believed that a 10 min delay at the start of the day causes subsequent cases to start at least 10 min late (P < 0.0001 versus random chance). (C) Most respondents did not know that cases often take less time than scheduled (P = 0.008 versus chance). No one who demonstrated knowledge (C) about cases sometimes taking less time than scheduled applied that information to their response to (B) regarding cases starting late (P = 0.0002). Knowledge of OR efficiency was low among the respondents working in ORs. Nevertheless, the apparent absence of bias shows that education may influence behavior. In contrast, presence of bias on matters of tardiness of start times shows that education may be of no benefit. As the latter results match findings of previous studies of scheduling decisions, interventions to reduce patient and surgeon waiting from start times may depend principally on the application of automation to guide decision-making.
    Anesthesia and analgesia 04/2009; 108(4):1257-61. · 3.08 Impact Factor
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    Danielle Masursky, Franklin Dexter, Nancy A Nussmeier
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    ABSTRACT: Implementation of initiatives to increase anesthesia group productivity depends not just on anesthesia groups, but on operating room (OR) nursing administration. OR nursing directors may encourage organizational change based on the needs of their hospitals and nurses. These changes may differ from those that would increase the anesthesia group's productivity. We assessed reward structures using (A) letters of nomination for the "OR Manager of the Year" award offered annually by the publication OR Manager, and (B) data from a salary/career survey of OR directors by the same publication. (A) There were 164 nomination letters submitted from 2004 through 2007 for 45 nominees. The letters contained n = 2659 full sentences and n = 50,821 words. We systematically created a list of 36 terms related to finance, profit, and productivity. We also analyzed the frequency of use of these terms relative to the use of the 15 most common relationship-oriented terms (e.g., compassion, encourage, mentor, and respect). (B) The salary/career survey's questions relevant to anesthesia group productivity had responses from 303 US OR directors, 97% of whom were nurses. We tested the strength of the relationship between the budget responsibility of the OR nursing director and his or her annual salary. (A) 2.6% of sentences in the nomination letters included at least one term related to profit and productivity (95% confidence interval 2.0%-3.2%). Relationship-oriented terms were 9.0 times more prevalent (95% confidence interval 7.1-11.4). (B) There was statistically significant positive proportionality between the OR nursing director's operational budget (including personnel) and his or her salary (Pearson r = 0.64, P < 0.001). The 10th percentile of the operational budget was $1 million and the 90th percentile was $36 million. The budget of $1 million was associated with a salary 22% less than the median and the budget of $36 million was associated with a salary 22% larger than the median. Through (A) organizational constituencies, and (B) compensation, many US OR nursing directors likely are encouraged to enhance relations with nursing staff, not to champion organizational initiatives that would reduce under-utilized OR time and OR nursing labor costs. Resulting decisions can differ from those that would increase the productivity (profit) of the anesthesia group. Anesthesia groups need to champion initiatives to increase anesthesia productivity, while being sensitive to institutional expectations of nursing directors.
    Anesthesia and analgesia 12/2008; 107(6):1989-96. · 3.08 Impact Factor
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    ABSTRACT: Previous studies of operating room (OR) information systems data over the past two decades have shown how to predict case durations using the combination of scheduled procedure(s), individual surgeon and assistant(s), and type of anesthetic(s). We hypothesized that the accuracy of case duration prediction could be improved by the use of other electronic medical record data (e.g., patient weight or surgeon notes using standardized vocabularies). General thoracic surgery was used as a model specialty because much of its workload is elective (scheduled) and many of its cases are long. PubMed was searched for thoracic surgery papers reporting operative time, surgical time, etc. The systematic literature review identified 48 papers reporting statistically significant differences in perioperative times. There were multiple reports of differences in OR times based on the procedure(s), perioperative team including primary surgeon, and type of anesthetic, in that sequence of importance. All such detail may not be known when the case is originally scheduled and thus may require an updated duration the day before surgery. Although the use of these categorical data from OR systems can result in few historical data for estimating each case's duration, bias and imprecision of case duration estimates are unlikely to be affected. There was a report of a difference in case duration based on additional information. However, the incidence of the procedure for the diagnosis was so uncommon as to be unlikely to affect OR management. Matching findings of prior studies using OR information system data, multiple case series show that it is important to rely on the precise procedure(s), surgical team, and type of anesthetic when estimating case durations. OR information systems need to incorporate the statistical methods designed for small numbers of prior surgical cases. Future research should focus on the most effective methods to update the prediction of each case's duration as these data become available. The case series did not reveal additional data which could be cost-effectively integrated with OR information systems data to improve the accuracy of predicted durations for general thoracic surgery cases.
    Anesthesia and analgesia 05/2008; 106(4):1232-41, table of contents. · 3.08 Impact Factor
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    ABSTRACT: Anesthesia department planning depends on forecasting future demand for perioperative services. Little is known about long-range forecasting of anesthesia workload. We studied operating room (OR) times at Hospital A over 16 yr (1991-2006), anesthesia times at Hospital B over 26 yr (1981-2006), and cases at Hospital C over 13 yr (1994-2006). Each hospital is >100 yr old and is located in a US city with other hospitals that are >50 yr old. Hospitals A and B are the sole University hospitals in their metropolitan statistical areas (and many counties beyond). Hospital C is the sole tertiary hospital for >375 km. Each hospital's choice of a measure of anesthesia work to be analyzed was likely unimportant, as the annual hours of anesthesia correlated highly both with annual numbers of cases (r = 0.98) and with American Society of Anesthesiologist's Relative Value Guide units of work (r = 0.99). Despite a 2% decline in the local population, the hours of OR time at Hospital A increased overall (Pearson r = -0.87, P < 0.001) and for children (r = -0.84). At Hospital B, there was a strong positive correlation between population and hours of anesthesia (r = 0.97, P < 0.001), but not between annual increases in population and workload (r = -0.18). At Hospital C, despite a linear increase in population, the annual numbers of cases increased, declined with opening of two outpatient surgery facilities, and then stabilized. The predictive value of local personal income was low. In contrast, the annual increases in the hours of OR time and anesthesia could be modeled using simple time series methods. Although growth of the elderly population is a simple justification for building more ORs, managers should be cautious in arguing for strategic changes in capacity at individual hospitals based on future changes in the national age-adjusted population. Local population can provide little value in forecasting future anesthesia workloads at individual hospitals. In addition, anesthesia groups and hospital administrators should not focus on quarterly changes in workload, because workload can vary widely, despite consistent patterns over decades. To facilitate long-range planning, anesthesia groups and hospitals should save their billing and OR time data, display it graphically over years, and supplement with corresponding forecasting methods (e.g., staff an additional OR when an upper prediction bound of workload per OR exceeds a threshold).
    Anesthesia and analgesia 04/2008; 106(4):1223-31, table of contents. · 3.08 Impact Factor
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    ABSTRACT: A 2002 survey of 468 Canadian orthopedic surgeons found that the "two principal reasons regional anesthesia is not favored" are "delays in operating rooms" and "unpredictable success." We reanalyzed the data from the study to evaluate whether these concerns were the best predictors of an individual surgeon's willingness to use peripheral nerve blocks for their patients. Of the five procedures included in the survey, three had relevant questions for our reanalysis of the results: arthroscopic shoulder surgery, arthroscopic anterior cruciate ligament reconstruction, and total knee replacement. A surgeon's preference for peripheral nerve block for him or herself strongly predicted his or her anesthetic preference for patients (all P < 0.001). Concordance rates were 89% for arthroscopic shoulder surgery, 87% for anterior cruciate ligament reconstruction, and 93% for total knee replacement. There was almost no incremental predictive value for the surgeon's preference for patients from the surgeon's perception of the times to perform a block (P > or = 0.27) or perception of block success rate (P > or = 0.30). There was also almost no direct predictive value for the surgeon's preference for patients from the surgeon's perception of the times to perform a block (Kendall's tau < or = 0.04, P > or = 0.28) or perception of block success rate (Kendall's tau < or = 0.02, P > or = 0.24). An economically important percentage of surgeons (37%, 95% confidence interval: 32%-41%) would choose a peripheral nerve block for their own surgery for some, but not all, of the procedures (i.e., for 1 or 2 versus 0 or 3). A surgeon's preference for peripheral nerve blocks for his or her own surgery predicted a surgeon's preference for his or her patients. Perceptions of delays and success rate did not add sufficient incremental information to the surgeon's preferences to be of economic importance. These results are important to better forecast the net economic impact on an anesthesia group of a regional block team.
    Anesthesia and analgesia 03/2008; 106(2):561-7, table of contents. · 3.08 Impact Factor