1. High Performing
Operating Rooms
Robert B. Zann MD
FACS

2. EFFICIENCY HIGH PERFORMING OR TEAM APPROACH

3. Office Reimbursement Description Patients Medicare Total Surgery
Total Hip Arthroplasty MD $
Total Knee Arthroplasty MD $
Office Visits 5Pt’s/hr
Est. Patient Level $ $159.48
New Patient Level $ $279.40
X-Rays
Pelvis, 2 views $ $120.40
Knee, 2 views $ $180.60
$739.88/hr

4. DRG 544 Major Joint Replacement or Reattachment
DRG Reimbursement- $11,000.00
OR Charges
1 Hour $4,125.00
every minute thereafter $40.00
Supplies that are built in to the First hour cost are:
Room Equipment
FTE’s
Custom Packs
Dressing, Suction, Bovie, extra gowns

5. Incremental Charges #315.00 Items such as: Extra Charges
Cement
Cement Mixing Supplies
Irrigation supplies
Kamvac suction
Stapler
Extra Charges
Stryker Pain Pumps $200.00
Intra Articular Injection $450.00
Implant Cost $ ??
Platelet Rich Plasma Spray $

6. ACU Charges PACU Room Rates Per hour $ 478.50 First Half Hour $ 959.00
Every minute thereafter $ 12.50
Room Rates
Private vs Semi-Private $$$

7. TEAM APPROACH Surgical Team ANESTHESIA OR PERSONNEL
M.D., P.A., R.N., Surgical Coordinator
ANESTHESIA
MD, CRNA
OR PERSONNEL
Orthopedic OR Coordinator
Stryker Representative

8. PRE-OP Surgical Team Pre-op rounds (one week pre-op)
H&P, Pre-op Orders - MD, & PA
X-ray rounds – entire team
Pre-op Labs- Medical Clearance
Post-op Orders- Preliminary Completion
Post-op note- Preliminary Completion
Pre-Op Holding
Consent and H&P signed
Initial correct site on patient

9. Pre-operative x-ray rounds (1 week prior to surgery)

10. Anesthesia OR Personnel Pre-op consultation Optimal 24-48 hours pre-op
Regional Anesthesia Administration in Pre-Op holding area
OR Personnel
Confirmation of Patient, Procedure & Site
Confirmation of Consent
Confirmation of Labs

11. Stryker Representative
Pre-operative templating
Proper Instrumentation
Multiple instrument sets
Turn over instrumentation as needed
Correct Prosthesis
Assist in room turnover

12. Pre-op Orders PRE-OP ORDERS: KNEE (Dr. Robert Zann #339) DIAGNOSIS
REGULAR DIET
LAB WORK DONE AS OUTPATIENT BY Dr Results to O.R.
CHEST X-RAY
EKG
CBC, SMA 12, LYTES, PLATELET COUNT
ADDITIONAL LABS: PT, PTT
MEDICAL / CARDIAC CLEARANCE BY DR.
CLEAN CATCH U/A
TYPE AND SCREEN UNITS BLOOD
BILATERAL BK AE HOSE
RESERVE CPM MACHINE
RESERVE ELECTRIC COOL
NPO AFTER MIDNIGHT FOR SURGERY IN AM
CONSENT FOR TOTAL KNEE ARTHROPLASTY
START IV IN OPPOSITE UPPER EXTREMITY AS OPERATIVE KNEE
WITH 18 GA INTERCATH __________cc/hr
PRE-OP ANTIBIOTIC: TO BE GIVEN PER O.R. PROTOCOL
ADDITIONAL AGENT:_______________________________________
CELEBREX 200mg 1 PO 1 HOUR PRIOR TO SURGERY UNLESS ALLERGIC
TO SULFA OR SULFONAMIDES
M.D. Signature _____________________ M.D. # 339
PRE-OP ORDERS: HIP (Dr. Robert Zann #339)
DIAGNOSIS
REGULAR DIET
LAB WORK DONE AS OUTPATIENT BY Dr Results to O.R.
CHEST X-RAY
EKG
CBC, SMA 12, LYTES, PLATELET COUNT
ADDITIONAL LABS: PT, PTT
MEDICAL / CARDIAC CLEARANCE BY DR.
CLEAN CATCH U/A
TYPE AND SCREEN UNITS BLOOD
BILATERAL BK AE HOSE
NPO AFTER MIDNIGHT FOR SURGERY IN AM
CONSENT FOR TOTAL HIP ARTHROPLASTY
START IV IN OPPOSITE UPPER EXTREMITY AS OPERATIVE HIP
WITH 18 GA INTERCATH __________cc/hr
PRE-OP ANTIBIOTIC: TO BE GIVEN PER O.R. PROTOCOL
ADDITIONAL AGENT:_______________________________________
CELEBREX 200mg 1 PO 1 HOUR PRIOR TO SURGERY UNLESS ALLERGIC
TO SULFA OR SULFONAMIDES
M.D. Signature ____________________ M.D. # 339

13. Post-op Orders Dr. Robert Zann #339) Pg. 1 of 4
1. Vital Signs: Q 4 hours
2. Diet as tolerated • Reg •
3. IV: D5 LR at 75 cc/hr until tolerating po fluids, then MAP
4. X-Rays in PACU
•Knee portable A/P and Lateral (long Cassette) • R • L
•Hips portable A/P and Pelvis - see tip of prosthesis • R • L
5. LABORATORY
•H & H, BMP in PACU, H & H QAM x 3
If Hb is less than or equal to 8 grams, transfuse 1 unit Blood(Autologous if available), repeat H/H post transfusion
•If Potassium is below 3.5 in PACU, add 40 meq. to first IV liter
•Creatinine with calculated clearance in PACU and Daily
notify M.D. if less than 30ml/min
6. If Temperature > 102o, get urine culture & blood cultures
x 2, then notify physician
7. If Temperature > 101o, give Tylenol as ordered & ecourage incentive spirometer
8. Incentive Spirometry Q1H while awake
9. Bilat. BK A-E hose for hips; contralateral for knees
10. Physical Therapy: OOB TODAY; • Crutches • Walker
11. Weight bearing: • Full • Partial • Toe Touch
12. Foley catheter PRN - If used, • discontinue Post-op Day #1, or
• Discontinue after the epidural catheter is discontinued
M.D. Signature __________________________ M.D. # 339
( Dr. Robert Zann #339) Pg. 2 of 4
13. Remove Hemovac in A.M. Post-op Day # 1
14. Start daily dressing changes Post-op Day # 1 - Adaptic and 4x4’s
15. Neurovascular checks to lower extremities every 2 hours for 24 hours, then every 4 hours for 24 hours
16. Dress in regular clothes starting PO day #1
17. MEDICATIONS:
•Pre-op Meds per Medical Dr. Consultant
•TYLENOL 650mg. P.O. Q4H PRN Temp. > 101 F
•FEOSOL 325 ONE P.O. daily
•AMBIEN 5mg. P.O. nightly prn sleep, may repeat x 1
•DARVOCET N TAB P.O. Q4H prn mild pain
•PERCOCET 5/325 1 TAB P.O. Q4H prn mild to moderate pain
•PERCOCET 5/325 2 TABS P.O. Q4H prn moderate pain
•MORPHINE SULFATE _____________ Q4H prn severe pain
•CELECOXIB (Celebrex) 200mg 1 orally daily
•COLACE One P.O. Daily until B.M., then discontinue
•LAX of choice
•ZOFRAN 4mg I.V. or P.O. Q6H prn for nausea
•ANTACID of choice 30cc orally every 4 hours as needed
•REGLAN 10mg IV IVP every 8 hours x 48 hours
•OXYCONTIN 20mg orally every 12 hours
M.D. Signature _________________________ M.D. # 339

14. Post-Operative Orders
(Dr. Robert Zann #339) Pg. 3 of 4
18. POST OP-ANTIBIOTICS:
•Cefazolin 1gm intravenously every 8 hours for 3 doses (24 hours)
•Clindamycin 600mg intravenously every 8 hours for 3 doses (24 hours)
•Vancomycin 1 gm intravenously every 12 hours for 2 doses (24 hours)
•Other
19. Coumadin Per Protocol After Daily Pro Time ( ) Yes ( ) No
PT & PTT DAILY, ( ) YES ( ) NO
START: ______________ 10mg P.O. first dose Date:_______________ Time:_______________
then daily thereafter according to Scale / INR as follows:
> 2.0 = No Coumadin
sec = 2.5mg.
sec = 5mg.
< 1.2 = 7.5mg.
If NO, list directive:
20. • ARIXTRA 2.5mg. subcutaneous q 24 hours, -
 • PM
21. • Lovenox 40mg subcutaneous q 24 hours, -
 • AM
22. • PCA Pump - discontinue POD #1 – for break through pain,
Toradol 15mg I.V. Q6H prn x 24 hours
23. • Epidural Catheter - when discontinued – for break through pain,
Toradol 15mg I.V. Q6H prn x 4 doses within 24 hours, then discontinue
M.D. Signature _________________________ M.D. # 339
POST-OP ORDERS: HIP/KNEE (Dr. Robert Zann #339) Pg. 4 of 4
24.• TOTAL HIP OR KNEE CARE PLAN
•TOTAL KNEE CARE
A. Apply Cool Ice Machine at 50o
B. CPM Machine for Total Knees; Range: 0-45 3 hours BID
Increase 5-20 daily
START: Post–op Day #2
C. Knee patients OOB after surgery and Flex Knees 900 as tolerated
D. Knee Immobilizer for comfort and quadricep weakness
• TOTAL HIP CARE
A. Hip dislocation precautions and exercise
B. Special instructions for deviation from protocol:
25. CONSULTS:
A. Medical Dr. __________________________
B. Rehabilation Facility
C. Social Service
D. Occupational Therapy - if patient is being discharged home
E. Radiation Oncology Prophylatic Radiation Therapy ( )Yes ( )No
26. HOME HEALTH CARE:
• COMMUNITY HOME HEALTH • MED-TECH
M.D. Signature _____________________ M.D. # 339

15. POST-OPERATIVE NOTE: (Dr. Robert Zann #xxx) #
Name of Operating Surgeon: Dr. Zann
Name of Assistants:Tolson/ Veech / Fenton / Huffman
Findings- Osteoarthritis Left Hip
Pre-op Diagnosis- Osteoarthritis Left Hip
Post-op Diagnosis- same
Technical Procedures Used- Left Total Hip Arthroplasty
Implants:
Femur-
Head-
Acet-
Insert-
Anesthesia
Blood Loss cc
Drains one medium hemovac
Specimens removed Left femoral head
Complications
Comments Intra- Articular Injection
“ Incision
M.D. Signature ____________________ M.D.# xxx
POST-OPERATIVE NOTE: (Dr. Robert Zann #xxx) #
Name of Operating Surgeon: Dr. Zann
Name of Assistants:Tolson/ Veech / Fenton / Huffman
Findings- Osteoarthritis Left Knee
Pre-op Diagnosis-Osteoarthritis Left Knee
Post-op Diagnosis- same
Technical Procedures Used- Left Total Knee Arthroplasty
Implants:
Femur- #
Tibia- #
Tibial insert- # / mm
Patella mm cemented
Anesthesia
Blood Loss cc
Drains one medium hemovac
Specimens removed- distal femur, and proximal tibial and patella
Complications
Comments Intra- Articular Injection
M.D. Signature ____________________ M.D.# xxx

16. COMPUTER DATA
Average Time for Pre-Op Nursing Assessment and preparation
Average Time for Administration of Anesthesia
Average Time for Operating Room Preparation
Average Surgical Time
Surgical Turnover Time
Last Staple insertion to next case skin incision
Operating Room Turnover Time
Patient out of room to next patient in room

17. Turnover Time Issues Turnover Time : Hospital Surgical
Surgical Turnover Time
Defining Turnover Time- Last Staple to Incision
Hospital Turnover Time
Patient exiting room and next patient entering room
Ways to alleviate or decrease the turnover time
Anesthesia- Pre-op holding Area vs In room
Anesthesia Administered in Prep-op Holding
Patient in room and positioned immediately- no delays
Anesthesia Administered in the OR
20 min for Hip
30 min for Knees
Additional Time to the turnover $$$$
Turnover Time : Hospital Surgical
One Room/no Pre-op 20 min hr
One Room/Pre-op 20 min min
Two Rooms/no Pre-op min(pt already in 2nd room) min
Two Rooms/Pre-op min(pt. already in 2nd room) min

18. My Average Operating Time
Patient enters room to Patient exiting room
Total Hip min
Total Knee min
Bilateral Knees min
Time from Incision to Wound Closure
Total Hip min
Total Knee min
Bilateral Knee min

23. Greeting patients in Pre-Op Admission @ 7:00am
Confirming laboratory results and signing operative consent

24. 1st Case Total Hip Arthroplasty in room @ 7:30am

25. 2nd Case- Total Knee Arthroplasty room setup @ 7:30am
2nd Case- TKA patient receiving Femoral Nerve Block 7:30am

26. 1st Case THA started @ 7:50am

27. 1st Case instruments removed Prior to completion of procedure

28. Immediate operative dictation

29. Completion of operative note and post-op orders

30. 2nd Case-TKA in room @ 8:00am

31. Post-operative discussion with family

32. 2nd case 9:15 am
2nd room cleaned by 9:25am

33. 2nd Case closing-completed @ 9:15 am
3rd Case in 9:00am

34. Case 3 following patient confirmation, correct side confirmation
And preliminary completion of post-operative orders

35. Conclusions The most efficient is two rooms with a pre-op holding area
The least efficient is one room without pre-op holding
Reduction in Turnover Time (surgical turnover time!)
Early Admission for Same-Day Lab Work,
i.e. PT/PTT, Bleeding time, Platelet count, EKG, etc..
Pre-op Anesthesia Evaluation hrs prior to admission
First Case with shortest time for Anestetic Administration
i.e. THA rather that TKA
Use of Pre printed templates (orders, post-op notes)
Immediate Post operative dictation
Clearance of all instruments and trial component during wound closure
Availability of Multiple instrument sets
Cooperation of OR personnel to initiate room cleaning as patient is transported from room

36. Thank You!