High Performing Operating Rooms Robert B. Zann MD FACS

EFFICIENCY HIGH PERFORMING OR TEAM APPROACH

Office Reimbursement Description Patients Medicare Total Surgery Total Hip Arthroplasty MD 1 $1486.73 Total Knee Arthroplasty MD 1 $1605.67 Office Visits 5Pt’s/hr Est. Patient Level 3 3 $53.16 $159.48 New Patient Level 4 2 $139.70 $279.40 X-Rays Pelvis, 2 views 2 $60.20 $120.40 Knee, 2 views 3 $60.20 $180.60 $739.88/hr

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

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 $ 408.00

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 $$$

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

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

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

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

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

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 R/L @ __________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 R/L @ __________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

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-100 1 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

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 1.51 - 2.0 sec = 2.5mg. 1.21 - 1.5 sec = 5mg. < 1.2 = 7.5mg. If NO, list directive: 20. • ARIXTRA 2.5mg. subcutaneous q 24 hours, -  • Start @ PM 21. • Lovenox 40mg subcutaneous q 24 hours, -  • Start @ 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

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

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

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 1 hr One Room/Pre-op 20 min 45 min Two Rooms/no Pre-op -20 min(pt already in 2nd room) 10-15 min Two Rooms/Pre-op -30 min(pt. already in 2nd room) 5-10 min

My Average Operating Time Patient enters room to Patient exiting room Total Hip 57 min Total Knee 70 min Bilateral Knees 120 min Time from Incision to Wound Closure Total Hip 34.5 min Total Knee 49.9 min Bilateral Knee 96.5 min

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

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

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

1st Case THA started @ 7:50am

1st Case instruments removed Prior to completion of procedure

Immediate operative dictation

Completion of operative note and post-op orders

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

Post-operative discussion with family

2nd case completed @ 9:15 am 2nd room cleaned by 9:25am

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

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

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-24-48 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

Thank You!