Category: Epidemiology, Health Policy, Socioeconomics & Outcomes
Introduction & Objective : Operating room (OR) expenses are a significant driver of healthcare costs. Baseline charges are $64-$115 per minute of OR time at our tertiary referral stone center. We sought to characterize OR delays during procedures for treatment of nephrolithiasis in our high volume stone center.
We identified ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) procedures performed at our institution. All operating room staff, excluding the surgeons, were blinded to the study. An online smartphone-accessible data collection instrument was created through the RedCap system. All time-related metrics, including time of anesthesia induction, procedure start and end times, were recorded. Additionally, any delays that prevented case progression were recorded. These were categorized as: 1. Missing/contaminated equipment, 2. missing personnel, 3. equipment malfunction, or 4. interruptions due to case complexity/challenge. The first two categories were regarded as preventable and the latter two non-preventable.
Forty URS and 18 PCNL cases were included. There was a total of 56 delays in 35 (65%) cases. Twelve (67%) PCNLs and 23 (58%) URSs had delays (p=0.57). The mean length of delay was 3.5 ± 3.15 minutes. Pre-start delays (n=17) were 4.46 ± 3.51 minutes on average while intraoperative delays (n=39) were 3.08 ± 2.93 minutes (p=0.167). Delays were evenly spread amongst the categories: 16, 15, 12, and 13 minutes, respectively. Thirty-one (55%) delays were preventable (mean 3.7 ± 3.15 minutes) while 25 (45%) were non-preventable (mean 3.23 ± 3.18 minutes) (p=0.58). This may translate to approximately $236-425 in preventable charges per case.
Conclusions : In the surgical management of stone disease, preventable delays are encountered frequently. This translated to significant additional charges. We demonstrate a rationale for the development of improved communication and workflow protocols to increase efficiency and prevent delays in an endourological surgical setting.
Rajat Jain– Assistant Professor, University of Rochester, Rochester, New York
Sara Maskal– Medical Student, Case Western Reserve School of Medicine, Cleveland, Ohio
Donald Fedrigon– Cleveland, Ohio
Emily Rose– Cleveland, Ohio
Manoj Monga– Head of the Endourology Unit, Cleveland Clinic Foundation, Cleveland, Ohio
Sri Sivalingam– Staff Urologist, Cleveland Clinic Foundation, Cleveland, Ohio
University of Rochester
Rochester, New York
Dr. Rajat Jain is an assistant professor of urology at University of Rochester in Rochester, New York, specializing in the treatment of urinary stones as well as BPH.
His undergraduate and medical education was completed at Washington University in St. Louis and New York University School of Medicine, respectively.
He completed residency in urology at Indiana University and went on to complete a fellowship in Advanced Endourology at Cleveland Clinic.
Case Western Reserve School of Medicine
Sara Maskal is a third year medical student at Case Western Reserve University School of Medicine.
Cleveland Clinic Foundation
Sri Sivalingam MD, MSc, FRCSC, is assistant professor of surgery at Cleveland Clinic Lerner College of Medicine at Case Western Reserve University. He is Director of the Center for Endourology and Stone Disease at Cleveland Clinic’s Hillcrest Hospital. Originally from Canada, he earned his Bachelors, Masters, and Medical degrees at the University of Toronto, and subsequently completed his urology residency at the University of Manitoba. He then completed a two-year fellowship in advanced Endourology and Minimally Invasive Surgery with a strong focus on urinary stone disease at the University of Wisconsin. He is board certified by both the American Board of Urology and the Royal College of Physicians and Surgeons of Canada.
Dr. Sivalingam's primary surgical, clinical, research and teaching interests include the treatment and prevention of urinary stone disease with several peer reviewed publications in this area. He is the co-director of the endourology research group and the fellowship program in stone disease at the Cleveland Clinic.