February 22, 2018

Total joint cases on firm footing after OR team huddles

By: Elizabeth Wood

Effective use of a daily huddle and customized software for scheduling have had a dramatic impact on efficiency at NYU Langone Orthopedic Hospital in New York City. Cancellations on the day of surgery have dropped from a rate of about 10% prior to implementation of huddles to less than 1%, according to Linede (Kandy) Kraemer, MA, BSN, RN, CNOR, NE-BC, CSSM, director of operating rooms.

“We’ve also seen increased compliance with providing accurate and complete information at the time of booking. It’s not perfect, but it’s much better,” she notes.

Kraemer manages 16 ORs at NYU Langone Orthopedic Hospital, where more than 12,000 orthopedic procedures were performed in 2017, of which more than 4,000 were total joints.

The daily huddle and the software—the MEDTEL Platform, which connects the vendors, surgeons, scheduling office, central sterile processing, OR leadership, and implant coordinators—have been in place for the facility’s total hips, knees, and shoulder procedures for the past few years.

More recently, the process and technology have been explored by the spine and sports medicine service lines, according to Kraemer.

“We were looking at how to be more efficient in every aspect of our patient care,” Kraemer told OR Manager. Information flows from the surgeon’s office to the scheduling office, supply chain staff, central supply staff, clinical leadership in the OR, and the vendors. “We were looking for a way to be inclusive so everyone was getting the same information at the same time, so we could reduce any errors that would impact the patient on the day of surgery,” she says.

In 2012, NYU Langone Orthopedics adopted an electronic medical record (EMR) that improved the scheduling process, but there was still opportunity for missing information, Kraemer explains. “Our surgeons were able to book cases with little to no information—for example, they might book a total hip replacement without documenting which vendor and system they were using. As a result, we were unable to follow our implant loaned process, leading to potential delays on the day of surgery.”


Better communication

A new chief of adult reconstructive surgery, Richard Iorio, MD, was hired with a mandate to standardize the total joint service.

Under Dr Iorio’s leadership, and with the help of a consulting firm, a daily huddle was started to better plan for cases in relation to instrumentation, equipment, implant needs, and medical clearance. All stakeholders—including nurses, anesthesia providers, central supply staff, staff from preadmission testing (PAT) and the postanesthesia care unit, and implant coordinators—participate in the huddle.

Huddles are held at 11 am and last anywhere from 20 to 45 minutes, Kraemer says. Cases are reviewed 72 hours in advance, with updates at 48 hours if necessary.

The huddles are led by the chief of anesthesia or his designee, Kraemer says, and the EMR is checked to ensure all cases are reviewed with the PAT nurse practitioners. “Representatives from support services also attend to identify needs related to their areas of coverage—for example, implant coordinators contact vendors about implant and instrument needs and the expected start time of upcoming cases,” she adds.

The huddle has facilitated communication and improved the planning process. “Many, but not all, implants are consigned because of space constraints and minimal use,” Kraemer says. “We have to arrange for loaned instruments to be delivered with enough time for sterilization processing. Implant components can be specific for right or left, so it’s crucial to document laterality. If we have a last-minute change, that’s communicated to supply chain and implant coordinators.”

The huddle has also helped staff identify ways to improve clinical management of cases, Kraemer notes. A traditional total hip replacement, for example, is booked as an “arthroplasty hip total,” but unique procedure names were created for robotic cases, with titles specific to the equipment needed for the case. “That way, we identify any potential equipment conflicts and the appropriate implants that are compatible with the case,” she explains. “Robotic cases also require larger rooms because more equipment is needed.”


Slick new technology

The integrated software, which allows for communication across departments, is completely customized, and it’s customized for each individual surgeon’s office, according to Kraemer.

“They build a template specific to each office and which vendors they work with,” she explains. “The only information that has to be typed in is patient demographics, and everything else is a checkbox.”

Minimal training was needed to learn the software, she says.

Vendors have access to the software. They are notified and required to confirm equipment availability when a surgeon books a case so they can prepare to deliver the necessary equipment.

This is especially important when loaned trays are requested, which avoids the need for reprocessing during the day, Kraemer notes. “The software allows you to track delivery and pickup of instruments, so you can tell when vendors are compliant with your guidelines.”

Surgeon compliance is also monitored. Each week, Dr Iorio is notified of noncompliant surgeons and the number of cases affected. He then addresses the problem with them. Noncompliant surgeons’ cases are taken off the schedule and put on hold until the appropriate implants are obtained.

“When the process was first implemented, about 15 cases per week were noncompliant, and therefore put on hold,” she says. “We don’t like to do that because it has a huge impact on the patient.” That number has since been reduced to about 5 cases per week, so the discussion about which implants are needed has helped surgeons alter their booking behaviors.


Greater ownership

Since the daily huddles started, the number of implant coordinators has increased from two to seven, and they have become more engaged and responsive, Kraemer says. “We have full coverage now until 10 pm and on Saturdays during our elective schedule, in an effort to standardize our practice during hours of operation.”

Schedulers are more efficient and productive now.“They don’t just book cases here, they also do charge capture, so they have to review cases for accuracy and post the charges,” Kraemer says. “They manage the away schedule [times when surgeons are unavailable] so that block time becomes open time available to other surgeons. They don’t have to spend time and energy gathering data that should have been input from the beginning. And when the schedule comes to me, it’s more accurate and complete.”

For those interested in adopting these strategies, she says, it would be beneficial to conduct a site visit.

“Talk to others about whether their process is working, and see if what they’re doing is similar to what you envision for your organization,” she says. “And it’s important that everyone understand what the PAT process is and how that impacts your patients’ progress up to the day of surgery so you’re not cancelling cases.”

As Kraemer sees it, the way to make this process work is to involve leaders from all the key areas of the department in implementing changes. “Everyone has to have patient-centered care as the goal. How can we best improve the quality of our patient’s experience? That impacts the efficiency of the process. Everybody’s time is valuable,” she says. ✥

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