Outcomes of Orthopedic Hand Surgeries in Minor Procedure Rooms at
a Veterans Affairs Medical Center
Nicole Look, MD,
Andy Lalka, MPH,
Hannah Korrell, BS,
Kyle Kabrick, RN,
Angela Wheeler, RN,
Rajshri Bolson, MD
Department of Orthopedic Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
Department of Orthopedic Surgery, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO
Received for publication May 12, 2020
Accepted in revised form October 14, 2020
Available online xxx
Purpose: There is a high demand for minor hand surgeries within the veteran population. The objective
of this study was to compare clinical outcomes and resource use at a Veterans Affairs Medical Center
(VAMC) of hand surgeries performed in minor procedure rooms (MPR) and operating rooms using local
anesthesia with or without monitored anesthesia care.
Methods: We retrospectively evaluated all patients undergoing carpal tunnel release, de Quervain's
release, foreign body removal, soft tissue mass excision, or A1 pulley release at a VAMC over a 5-year
period. Data collected included demographic information, mental health comorbidities, presence of
preoperative and postoperative pain, complications after surgery, time to surgery, number of personnel
in surgery, turnover time between cases, and time spent in the postanesthesia care unit. Statistical
analysis included Fisher exact or chi-square analysis to compare MPR versus operating room groups and
Student ttest or Mann-Whitney test to compare continuous variables.
Results: In this cohort of 331 cases, 123 and 208 patients underwent surgery in MPRs and operating
rooms, respectively. Preoperative and postoperative pain were similar between the MPR and operating
room groups. Complications were slightly lower in the MPR group versus the operating room group (0%
MPR vs 2.9% operating room). Median time from surgical consult to surgery was 6 days less for MPR
patients (15 vs 21). The MPR cases also used fewer personnel during surgery, averaging 4.76 versus 4.99
people. The MPR patients spent 9 minutes less in the postanesthesia care unit (median, 36 vs 45 minutes)
and turnover time between cases was nearly 8 minutes faster in MPRs than in operating rooms (median,
20 vs 28 minutes).
Conclusions: Minor procedure rooms at a VAMC allow more veteran patients to be scheduled for minor
hand surgeries within a shorter time frame, utilize less staff and postoperative monitoring, and maintain
excellent outcomes with limited complications.
Clinical relevance: Minor hand surgeries in MPRs have outcomes equivalent to those of operating rooms
with improved time savings and resource use.
Copyright ©2020, THE AUTHORS. Published by Elsevier Inc. on behalf of The American Society for Surgery of the Hand.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Minor procedure rooms (MPRs) are gaining popularity among
hand surgeons globally. Designed as smaller spaces for shorter
surgeries, MPRs provide less rigid environmental controls of
ventilation and surfaces compared with operating rooms.
toward wide-awake, local anesthesia hand surgeries conducted in
MPRs offers multiple advantages for the hospital system, providers,
Previous studies illustrated signiﬁcant cost savings
with ofﬂoaded demand for main operating rooms.
more, MPRs have the potential to shorten wait times, reduce pa-
tient costs, and maintain satisfaction with comparable outcomes to
the performance of minor hand surgeries in operating rooms using
general anesthesia or regional blocks.
The US Veterans Affairs health care system depends on a ﬁxed-
cost business model to provide care to over 9 million veterans.
Continued demand for elective upper-extremity procedures has
Declaration of interests: No beneﬁts in any form have been received or will be
received by the authors related directly or indirectly to the subject of this article.
Corresponding author: Nicole Look, MD, Department of Orthopedic Surgery,
University of Colorado Anschutz Medical Campus, 13001 East 17th Place, Aurora, CO
E-mail address: firstname.lastname@example.org (N. Look).
Contents lists available at ScienceDirect
Journal of Hand Surgery Global Online
journal homepage: www.JHSGO.org
2589-5141/Copyright ©2020, THE AUTHORS. Published by Elsevier Inc. on behalf of The American Society for Surgery of the Hand. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Journal of Hand Surgery Global Online xxx (2020) 1e5
guided the exploration of alternative options for improving access
to care of elective surgeries in government-run insurance
There are sparsely distributed Veterans Affairs Medical
Centers (VAMC) throughout the United States, a limited number of
hand surgeons at these facilities, and a shortage at times of oper-
ating room availability.
As such, it is of utmost importance to
consider cost-effectiveness and resource use for this population.
The objective of this study was to compare time from consult to
surgery, personnel use, time spent in the postanesthesia care unit
(PACU), turnover time between cases, and overall complications of
minor hand surgeries performed in operating rooms and MPRs at
a VAMC. We speciﬁcally evaluated carpal tunnel release (CTR), de
Quervain's release, foreign body removal, soft tissue mass exci-
sion, and A1 pulley release, cases that were established as
appropriate for MPRs based on VAMC policies. We hypothesized
that these procedures, performed under local anesthesia with or
without monitored anesthesia care (MAC) in MPRs, would
demonstrate outcomes similar to those of operating rooms but
would result in shorter time to surgery and quicker turnover
times. We also hypothesized that MPR cases would require fewer
personnel during surgery and less monitoring by nursing staff
Materials and Methods
We conducted a retrospective chart review of consecutive hand
surgeries performed in MPRs or operating rooms by one
fellowship-trained orthopedic hand surgeon from 2015 to 2020 at a
single-site VAMC. Inclusion criteria were patients aged greater than
18 years who underwent CTR, de Quervain's release, foreign body
removal, soft tissue mass excision, or A1 pulley release. Patients
were excluded if they underwent a procedure not previously listed
in either an operating room or MPR. Exempt status determination
and waiver of consent was granted from our state’s institutional
review board before we started research.
Referral to the hand clinic was made by the primary care pro-
vider. Any advanced imaging, diagnostic tests, and/or corticosteroid
injections were performed by the orthopedic hand surgeon before
surgery. Patients with noteworthy medical comorbidities were
evaluated before surgery by an anesthesiology provider. Scheduling
cases depended on the patient’s chosen day of the week and cor-
responding room availability. No patient was excluded from MPRs
based on comorbidities. Shared decision-making guided whether
the patient underwent wide-awake, local anesthesia versus local
with MAC. If the patient’s medical history was concerning or the
patient requested a sedative, an anesthesiology provider was
available for MAC on the day of surgery to ensure the safety of the
patient throughout the procedure. The MPRs offered enough space
and equipment for anesthesiology staff.
Local anesthesia was injected at the planned surgical ﬁeld in the
preoperative area. The volume of injection depended on the site,
consisting of 1% lidocaine with 1:100,000 epinephrine buffered
with 8.4% sodium bicarbonate in a 10:1 ratio.
This was done at
least 25 minutes before the incision to achieve the full vasocon-
strictive effects of epinephrine.
The patient was transferred to the
MPR or operating room on a gurney and positioned supine with a
hand table. Sterile technique was used for all procedures. Personnel
could include the staff surgeon, an orthopedic surgery resident, an
anesthesiologist, an anesthesiology assistant, a circulating nurse
and/or a surgical technician. Surgical cases booked as local-only
anesthesia did not include stafﬁng from the anesthesiology team.
If bleeding inhibited the view of the surgical site, either a single-use
sterile forearm tourniquet or a sterile ﬁnger tourniquet was used at
the discretion of the operative surgeon. After surgery, patients were
brought to either phase I or phase II of PACU based on a clinical
determination by the anesthesiologist. Typically, if no sedation was
given, they were taken straight to phase II. All were monitored by
nursing staff until they were deemed safe to discharge home and
provided with discharge instructions.
We collected demographic data including age at the time of
surgery, sex, race, and medical comorbidities, speciﬁcally dia-
betes, obesity, and hypothyroidism.
We deﬁned prior diagnoses
of anxiety, depression, bipolar disorder, and/or posttraumatic
stress disorder as mental health comorbidities. The presence of
pain during preoperative and ﬁnal postoperative clinic appoint-
ment was noted. The period from the date of the clinic visit, when
the patient decided on surgery, to the date of surgery was calcu-
lated. Variables on the day of surgery included the American So-
ciety of Anesthesiologists (ASA) physical status classiﬁcation
system score given by the surgeon or the anesthesiologist, time in
the PACU before discharge home, and turnover time. Additional
data included square footage of each MPR and operating room, as
well as number of personnel present in each case. Postoperative
complications were characterized by the presence of superﬁcial or
deep infection and/or the need to return to the operating room
within 6 weeks.
Descriptive statistics were produced for MPR and operating
room groups. We analyzed categorical data with chi-square or
Fisher exact tests when appropriate. Normality of continuous data
was assessed using the Shapiro-Wilk test and histograms. Normal
data were analyzed using Student or Welch’sttest between groups.
Mann-Whitney U test was used for nonnormal data presented with
median and interquartile ranges (IQRs). Simple logistic regression
was used to model the effects of categorical variables on the like-
lihood of MPR. Multiple logistic regression was used to determine
whether mental health and surgery location predicted the likeli-
hood of local or MAC anesthesia. We performed statistical analysis
with Stata software (version 14.2, College Station, TX).
A total of 331 eligible cases were included with 123 cases in the
MPR and 208 in the operating room group (Table 1). We found a
statistically signiﬁcant difference (P¼.002) in the median age, at 66
years for the MPR group and 61 years for the operating room group.
Race and sex were not signiﬁcantly associated with MPR or oper-
ating room groups. Procedure types were similar between the MPR
and operating room groups, with the exception of soft tissue mass
excisions. These occurred at a signiﬁcantly higher frequency in the
operating room group (n ¼62 [29.8%] vs n ¼12 [9.8%]; P¼.001).
Anesthesia method was strongly associated with MPR and oper-
ating room status; 29 patients used MAC in addition to local
anesthesia in the MPR group (23.5%) compared with 150 in the
operating room group (72.1%; P¼.001).
We used the ASA score as a surrogate for medical comorbidities;
it was similar between the MPR and operating room groups (2.46
MPR vs 2.31 operating room; P¼.055) (Table 2). Among patients in
the MPR group, 25 had diabetes (20.3%), 26 were obese (21.1%), and
11 had hypothyroidism (8.9%). In the operating room group, 39 had
diabetes (18.8%), 25 were obese (12%), and 14 had hypothyroidism
(6.7%). Mental health comorbidities were similar between MPR and
operating room groups (MPR: n ¼64 [52.4%] vs operating room:
n¼102 [49.1%]; P¼.154).
The presence of preoperative painwas similar between MPR and
operating room groups. Postoperative pain was slightly higher in the
MPR group but not statistically signiﬁcant (n ¼20 [16.3%] vs n ¼23
[11.1%]; P¼.191) (Table 2). Postoperative infection was extremely
low and similar between groups, with no infections in the MPR
group and only 5 cases in the operating room group. Compli-
cations were slightly lower in the MPR group than the operating
N. Look et al. / Journal of Hand Surgery Global Online xxx (2020) 1e52
room group (MPR: n ¼0 vs operating room: n ¼6 [2.9%]; P¼
.045). Examples of complications included superﬁcial surgical
site infection necessitating oral antibiotics (n ¼3), deep surgical
site infection leading to return to the operating room for irri-
gation and debridement (n ¼2), and prolonged pain with
concern for retained foreign body leading to surgical wound
exploration and scar excision (n ¼1).
Median time between surgical consult and surgery was 6 days
less for patients in the MPR group (15 days [IQR, 14 days] vs 21 days
[IQR, 18 days]; P¼.004) (Table 2). The MPR patients also required
fewer personnel during surgery, averaging 4.76 people (SD, 0.77
people) compared with 4.99 people (SD, 0.81 people; P¼.015).
Patients undergoing surgery in MPRs spent 9 minutes less in the
PACU (median, 36 vs 45 minutes; P¼.001). Turnover time was
nearly 8 minutes faster in MPRs than in operating rooms (20.5 vs
28.2 minutes; P<.001).
We implemented simple logistic regression to model the like-
lihood of MPR use based on procedure. Soft tissue mass excision
was 74% less likely to occur in the MPR (odds ratio of 0.26, 95%
conﬁdence interval [CI], 0.13e0.52; P¼.001) (Table 3). Carpal
tunnel release, A1 pulley release, foreign body removal, and de
Quervain's release were not predictive of MPR use. When anes-
thesia was included as a predictive variable, local anesthesia alone
was 8.4 times more likely to occur in the MPR (odds ratio of 8.4, 95%
CI, 5.0e14.0; P¼.001) (Table 2).
Multivariable logistic regression was used to model the likeli-
hood of local with MAC use in the presence of mental health co-
morbidity and MPR or operating room use. Patients with a mental
health comorbidity were 80% more likely to undergo local anes-
thesia with MAC (odds ratio of 1.8, 95% CI, 1.09e2.96; P¼.022)
(Table 4). Operating room patients were 8.8 times more likely to
undergo local anesthesia with MAC (odds ratio of 8.84, 95% CI,
5.23e14.9; P¼.001). Procedure type including CTR, trigger ﬁnger
release, soft tissue excision, and de Quervain release were not
signiﬁcantly predictive of local anesthesia with MAC use. Foreign
body removal was signiﬁcantly associated with wide-awake, local
anesthesia use, and the impact on the model was minimal (3 cases
in local anesthesia with MAC and 11 cases in wide-awake, local
There is a high demand for hand surgeries within the veteran
population, but because of limited resources, veterans may expe-
rience a delay in surgical care.
We questioned whether MPRs offer
similar outcomes but improved resource use (for CTR, de Quervain's
release, foreign body removal, soft tissue mass excision, and A1
pulley release) compared with operating rooms at a VAMC. We
observed similar rates of infection and postoperative pain between
groups. Our hypothesis that MPRs would provide a shorter time to
surgery and quicker turnover time was supported by the results.
Furthermore, MPRs used fewer personnel during surgery and less
monitoring by nursing staff in the PACU.
Previous studies focused on outcomes related to infection to
demonstrate the safety of MPRs.
Operating rooms have
strict infection control guidelines for environmental cleaning and
disinfection, sterilization of instruments, air handling, and
personnel management. A systematic review reported low surgical
site infection rates in ofﬁce-based MPRs.
However, the authors
argued that the results may not be generalizable due to differences
in sterilization standards. For example, in the United Kingdom,
there must be 25 air changes per hour (ACPH) in an inpatient
operating room, compared with 15 ACPHs in an outpatient surgical
suite and 10 ACPHs in a clinic treatment room.
In the United
States, the Facility Guidelines Institute (FGI) recommends 20 ACPHs
in an inpatient operating room and 15 ACPHs in an MPR, although
not all states have adopted these recommendations.
LeBlanc et al
evaluated the infection rate of CTR performed in MPRs with only
ﬁeld sterility. Of the 1,504 CTRs, they found a superﬁcial infection
rate of 0.4% and a deep infection rate of 0%, which is comparable to
previous studies of CTR performed in the operating room. Rhee
reported a surgical site infection of 1% among wide-awake,
local anesthesia surgeries using ﬁeld sterility in a clinic setting.
Our ﬁndings of infection rate support previously published results
with a surgical site infection rate of 0% in the MPR group and 2.4% in
the operating room group. Although ﬁeld sterility, as demonstrated
Minor Procedure Rooms Versus Operating Rooms: Patient Demographics,
Procedures, and Anesthesia Methods
Age, y (median [IQR]) 66 (16) 61 (19) .002
Male sex (%) 82 86 .277
White 96 152 .276
Black 9 18
Hispanic 9 28
Other 9 10
Carpal tunnel release 68 91 .001
de Quervain's release 2 2
Foreign body removal 6 8
Soft tissue mass excision 12 62
Trigger ﬁnger release 35 45
Local/MAC 29 150 .001
Wide-awake, local anesthesia 94 58
Bold font indicates statistical signiﬁcance with a P<.05.
Clinical Characteristics and Outcomes
Clinical Characteristics MPR
Preoperative pain (% yes) 67.5 67.8 .954
(% yes) 16.3 11.1 .191
Infection (% yes) 0 2.4 .142
American Society of
2.46 (0.62) 2.31 (0.67) .055
Mental health Comorbidity (% yes) 52.4 49.1 .154
Minutes in PACU, median (IQR) 36 (22) 45 (40) .001
Turnover time, min 20.5 (8.1) 28.2 (23.1) .001
Consult to surgery in days,
15 (14) 21 (18) .004
Complications (% yes) 0 2.9 .045
Personnel, mean (SD) 4.76 (0.77) 4.99 (0.81) .015
Unknown in 4 MPR and 3 operating room patients.
Simple Logistic Regression Evaluating MPR Use by Procedure Type and Anesthesia
Procedure Odds Ratio 95% CI P Value
Carpal tunnel release 1.00 Reference e
de Quervain's release 1.34 0.18e9.74 .774
Foreign body removal 1.00 0.33e3.02 .995
Soft tissue mass excision 0.26 0.13e0.52 .001
Trigger ﬁnger release 1.04 0.61e1.79 .885
Local/MAC 1.00 Reference e
Wide-awake, local anesthesia 8.4 5.0e14.0 .001
N. Look et al. / Journal of Hand Surgery Global Online xxx (2020) 1e53
in this report, yielded low infection rates, we continue to practice
main operating room sterility in both MPRs and operating rooms.
Expedited access to hand surgery can be achieved for the vet-
eran population with MPRs.
We found a statistically signiﬁcant
difference in time to surgery between MPRs and operating rooms.
On average, patients were able to undergo surgery about 6 days
earlier. During the data collection period, the VAMC moved to a
new building with the addition of MPRs. An increased number of
available rooms may have allowed more patients to undergo sur-
gery sooner. The use of MPRs for CTR, de Quervain's release, foreign
body removal, and A1 pulley release was equivalent, all of which
are typically done after trialing nonsurgical management. On the
other hand, soft tissue mass excisions were about 74% less likely to
occur in MPRs based on our study’s results (Table 3). This is directly
related to the VAMC’s policy of performing soft tissue mass excision
of a size greater than 5 cm in the operating room. Although patient
preference can inﬂuence the time frame for surgical scheduling, our
ﬁnding that patients waited on average 6 days less for procedures
in MPRs suggests that MPRs have the potential to expedite veteran
access to care.
VAMCs could beneﬁt from substantial cost savings. Rhee et al
demonstrated a 70% to 85% cost savings for a military health care
system in the United States by performing CTR, de Quervain's
release, and A1 pulley release in a clinic setting without anesthe-
siology or PACU staff present.
In this study, we found MPR cases
required signiﬁcantly fewer staff than operating rooms, although
the clinical signiﬁcance of this ﬁnding is unclear when the average
difference was 0.25 people. Furthermore, selection bias related to
data collected from an older VAMC without dedicated MPRs com-
bined with data collected from the current VAMC may have inﬂated
the number of personnel for operating room cases. Otherwise, the
difference may be related to a reduction in the number of anes-
thesiology staff needed, because patients were 8.4 times more
likely to undergo wide-awake, local anesthesia in MPRs. Our VAMC
is a teaching facility with the presence of trainees. Findings would
likely have been altered if learners were not included in the
documentation of personnel during surgery.
Additional space savings may be gained by transitioning more
surgical cases to MPRs, based on their reduced size requirements.
The size of MPRs is recommended to be 160 ft
anesthesiology staff. The recommended size of an outpatient
operating room with is 270 ft
, whereas an inpatient operating
room should be about 400 ft
We found that MPRs were on
average 231.1 ft
and operating rooms averaged 523.6 ft
facility. Therefore, about 2 MPRs can be built for every single
operating room. Furthermore, we found turnover time between
cases to be about 8 minutes shorter for MPRs than operating rooms.
The difference may be based on the size of the space and regula-
tions for how each space is sanitized before the next case. Thus,
there can be a greater variability in time between cases when
operating in the operating room. Because the 5 procedures in this
study are typically less than 30 minutes long, a difference of 8
minutes can greatly affect the ability to schedule more cases.
Time spent in the PACU also contributes to overall patient cost.
On average, patients in the MPR group were discharged from the
PACU 9 minutes sooner than the operating room group. Based on
the 2018 Facility Guidelines Institute guidelines, each operating
room requires one phase I and one phase II recovery room. By
comparison, each procedure room requires only one phase II re-
At our VAMC facility, patients who did not receive
sedative intravenous medications were transferred directly to
phase II, where they were evaluated by only one nurse before
discharge. Patients receiving sedative intravenous medications,
regardless of MPR or operating room, were monitored by a nurse in
phase I and another nurse in phase II of the PACU. A staged pro-
spective study of bilateral CTR, in which one hand was given only
local anesthesia and the other hand received local anesthesia plus
sedation, found the total time in the surgical facility to be
approximately 26 minutes less with local-only anesthesia.
compared local-only CTR with sedated CTR in the operating
room. The PACU times were signiﬁcantly longer in the sedation
group (84 minutes) compared with the wide-awake, local anes-
thesia group (7 minutes). They noted that each minute in the PACU
costs $12.16, leading to signiﬁcant cost savings with decreased
Limitations of the current study warrant discussion. The study
was performed at a single academic orthopedic practice within the
Veterans Affairs Health Care System; a multicenter study of prac-
tices throughout the country may provide greater external validity.
Furthermore, construction of a new VAMC hospital was completed
in 2018 and orthopedic surgical care was transferred to that facility
shortly afterward. Because the previous hospital did not include
MPRs, all cases in the MPR group were conducted at the new VAMC
hospital. Only 11.7% of cases in the operating room group were
performed at the new hospital. Therefore, there is potential for
selection bias owing to the lack of proper randomization. Our re-
sults indicate decreased use of operating rooms for CTR, de Quer-
vain's release, foreign body removal, soft tissue mass excision, and
A1 pulley release with the advent of MPRs. Although we would
need more data from the current VAMC to assess this relationship,
MPRs likely allow for increased operating room availability for
invasive hand surgeries requiring anesthesia.
Second, this was a retrospective chart review lacking patient-
speciﬁc outcome measures. Multiple studies have established
high levels of patient satisfaction in clinic-based procedure rooms
with wide-awake, local anesthesia.
Our study uniquely focused
on veteran patients, a population with a high prevalence of
depression, anxiety, bipolar disorder, and posttraumatic stress
Although there is concern that patients with psychiatric
diagnoses might poorly tolerate wide-awake, local anesthesia, a
study at a VAMC found no difference in requests for sedation,
operative time, time in an operating room, or complications in
patients with psychiatric diagnoses who underwent either awake
or sedated CTR.
In our study, 52% of all patients were diagnosed
with mental health comorbidities. A similar ratio of these patients
underwent procedures in MPRs (52.4%) versus operating rooms
(49.1%). However, they were more likely to undergo local or MAC
rather than wide-awake, local anesthesia. It is unclear whether this
was based on patient preference or availability of space. The
perspective of veteran patients with psychiatric diagnoses on un-
dergoing wide-awake procedures warrants further investigation.
Performing hand surgeries in MPRs at a VAMC maintains
excellent outcomes with limited complications and decreased
resource use. Patients can be scheduled for surgery within a shorter
time whereas surgeons can schedule more surgeries owing to
shorter turnover times. This allows more patients within the vet-
eran population to be treated in a safe and effective manner.
Multivariate Logistic Regression Evaluating Local/MAC Use After Adjusting for MPR
and Mental Health Disorder
Characteristic Odds Ratio 95% CI PValue
MPR 1.00 Reference
Operating room 8.84 5.23, 14.90 .001
Mental health disorder
No 1.00 Reference
Yes 1.80 1.09, 2.96 .022
N. Look et al. / Journal of Hand Surgery Global Online xxx (2020) 1e54
This material is the result of work supported with resources and
the use of facilities at the Rocky Mountain Regional Veterans Affairs
Medical Center. The content is solely the responsibility of the au-
thors and does not necessarily represent the ofﬁcial views of the
Veterans Administration or the United States Government.
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