Regional anesthesia, block room and efficiency: putting things in perspective

Abstract

N this issue of the Journal, Armstrong and Cherry report on the impact of using upper limb regional anesthesia on the different time intervals measured during the operative process. 1 Of particular interest is their conclusion that a block room (BR) devoted to the preoperative realization of regional techniques reduces the presurgical time in the actual operating room (OR). Although it seems self-explanatory that time spent performing the blockade in the BR will somehow allow for a shorter interval in the OR before the start of the surgery, the magnitude of the time saved and its cost need to be considered before these study results are used to advocate the creation of bona fide BRs in most hospitals. Because of the numerous variables and individuals 2 implicated in the operative process, only accurate data collection followed by interdisciplinary teamwork can be expected to enhance its efficiency significantly. 3 Still, it is interesting to examine the details of the process in order to pinpoint which elements can be modified and result in a positive impact. Is the presur-gical time spent on anesthesia a legitimate target for OR managers striving to increase the performance of their suite? How likely are we to improve the efficiency of the operative process by asking anesthesiologists to try to shorten that period? Dexter et al., using a computer simulation, studied the decrease in case duration required to complete an additional case during regular hours in an OR suite. 4 The decreases in each case's duration required to create enough new open OR time to reliably schedule another case were 30-39, 79-110 and 105-110 min for cases of a mean duration of one, two and three hours respectively. The model applied to an OR suite with one to 15 ORs. Since the magnitude of the time savings that can be expected following different modifications of the anesthesia technique, whether regional or general, are in the 13 to 23 min range 1,5,6 it may be unrealistic to expect that demands involving the anesthesiology staff alone will bring significant improvement in OR performance. In fact, a report using an actual case series of 709 consecutive patients undergoing a mix of 11 different elective operations at a tertiary care centre showed that anesthesia-controlled time would have to be decreased by more than 100% to permit one additional 30-min surgery to be performed after an eight-hour workday if the previous operations all lasted at least 45 min. 7 Naturally, OR suites where longer and more complex procedures are performed on a regular basis are the least likely to benefit from reductions in turnover times between cases. 8 Nonetheless, some authors have succeeded at increasing the number of cases performed following the implementation of measures targeting the anesthesia turnover time. 5 Sokolovic et al. found that increasing anesthesia staffing by one attending physician and one nurse allowed for the addition of about 0.6 case·day-1 in an OR suite in which a mean of 162 operations·month-1 were performed, and where the most frequent surgery was termination of pregnancy, a fairly short procedure. Is it really surprising to find that increasing human and therefore financial resources may lead to some increase in the number of patients treated? In a report on the effects of regional and general techniques on anesthesia controlled time in outpatient knee surgery, Williams et al. studied an institutional database including 369 patients undergoing anterior cruciate ligament reconstruction. 9 They concluded that, compared to general or combined general-regional anesthesia, proceeding with a regional technique in a BR decreased the anesthesia time in the OR by less than nine minutes·case-1 on average. As stated earlier, 1