April 2009




Cutting pediatric exam times

by Rich Daly EyeWorld Contributing Editor



Challenging patients can have their exam times cut by nearly two-thirds through recommended steps

The quest for increased efficiency in time-consuming examinations has led researchers to develop and test five measures that helped them cut pediatric exam times by two-thirds.

Researchers looking to cut pediatric examination times at the University of Miami, Miami, introduced five steps: the use of three anesthesia providers for two rooms, digital remote communication, a change in patient scheduling, standardization of case order, and streamlining administration of pre-op medications. The result was a reduction in mean turnover times from 12.1 minutes to 3.8 minutes. Also decreased was the 90th percentile of longest turnover times from 14.5 minutes in 2003 to 5.8 minutes in 2007, despite a progressive increase in the number of cases per day. “We recommend these interventions to all large eye or general inpatient hospitals attempting to accommodate a full day of examinations under anesthesia for children with retinoblastoma or other vision-threatening ocular diseases,” wrote Michael Vigoda, M.D., M.B.A., Department of Anesthesiology, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, and colleagues.

The study, titled “Targeting operating room inefficiencies in the complex management of vision-threatening diseases in children,” was published in the September 2008 issue of the Archives of Ophthalmology.

The successful use of the efficiencies over four and a half years in anesthesia examinations of infants and children who ranged in age from 1 month to 10 years old led Dr. Vigoda and his colleagues to conclude that it is possible to efficiently provide such anesthesia-based exams to difficult patients even in nonpediatric environments. The exam efficiency tools identified by the research are very welcome at increasingly busy ophthalmic facilities, said D.S. Gombos, M.D., clinical co-director, Retinoblastoma Center at Texas Children’s Cancer Center and Hemtaology Service, Houston, and professor of ophthalmology, M.D. Anderson Cancer Center, Houston.

“All of us who do frequent and multiple exams under anesthesia are always trying to deal with turnover time,” Dr. Gombos said. The size and scope of the research got the attention of M. Edward Wilson, M.D., director, Albert Florens Storm Eye Institute, Medical University of South Carolina, Charleston, S.C., because the authors retrospectively analyzed more than 1900 cases and typically did 15 to 18 cases per day.

Dr. Wilson said the appeal of their efficiency findings is that they are transferable to any large eye clinic or general operating room. The key to successfully implementing changes such as those suggested by the authors is to get all key staff behind the new approach, including anesthesia professionals, nurses, and physicians.

“These findings provide some published benchmark targets to discuss with my anesthesia team,” Dr. Wilson said. “While topical anesthesia adult cases are often benchmarked, general anesthesia targets for eye cases have been difficult to establish.”

The suggested efficiency steps that appeared most effective to Dr. Gombos were the use of two rooms and three anesthesiologists.

“All of the things they have done are potentially doable but you need the money and resources to be able to do that, and that doesn’t necessarily come easily to every institution,” Dr. Gombos said. Also effective is the wireless remote communication used by the authors. A similar system at Dr. Gombos’s facility has been very effective because it eliminates wasted time looking for staff.

The least effective of the five suggested interventions, according to Dr. Wilson, appears to be the change in patient scheduling. The authors used testing blocks that had pediatric patients all arrive by 7:30 a.m., while the last anesthesia exam was not typically completed until after noon. “In my experience, this increase in wait time for the children scheduled in the later morning is not justified,” Dr. Wilson said. “Rather, an arrival one hour prior to a predictable start time will assure that if a family has transportation problems, the next family is already in place to move ahead.”

He noted that these patient exams have highly predictable case lengths so the start times should be accurate if the turnover time is controlled.

The practical impact of reduced patient waits not only benefits the medical facility and the medical professionals involved, but it also reduces the discomfort of the children who have to abstain from food, as well as helping beleaguered parents.

“If they see an improvement in [testing] then parents pick up on that,” Dr. Gombos said.

Future research that might help further improve efficiency, Dr. Wilson said, would examine whether one surgeon doing general anesthesia exams or short surgeries was more efficient using one room compared with using two rooms. The analysis should include revenue and cost analysis.

Editors’ note: Drs. Gombos and Wilson have no financial interests related to their comments.

Contact information

Gombos: dgombos@mdanderson.org

Wilson: 843-792-7622, wilsonme@musc.edu

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