2024 FSA Podium and Poster Abstracts
P032: INCREASING THE PERCENTAGE OF FIRST CASE ON-TIME STARTS IN THE LABOR & DELIVERY OPERATING ROOMS
Paloma Toledo, MD, MPH1; Michelande Ridore, MS2; Eva Hoffman1; Olga Abiri2; Colleen Virgins2; Michelle Fletcher1; 1University of Miami; 2Jackson Memorial Hospital
Background: Delays in first case on-time case starts (FCOTS) can result in operating room (OR) inefficiency, dissatisfaction, for patients, their providers, and OR staff, and greater facility costs. Though standards for increasing main OR efficiency have been described in the literature, little research has been conducted in labor and delivery (L&D) units. The L&D setting poses additional challenges to on-time starts given the unpredictable nature of add-on cesarean deliveries. The average percentage of FCOTS at our Women’s Hospital was 12% over the past year with some months having a zero percentage of on-time first case starts. The objectives of this project were to describe the barriers to on-time case starts in L&D operating rooms and develop interventions to reduce case delays. Our aim was to increase our percentage of on-time first cases in the L&D ORs from 12% to 75% within one year of the project initiation.
Methods: A multidisciplinary team was established with representation from quality, obstetrics, anesthesiology, nursing, scheduling, and operating room staff in November 2022. The operational definition of first case on-time start was any case in which the patient was in the OR at the time of scheduled surgery. All L&D procedures are included in the primary outcome measure. Failure modes effect analyses, process mapping, and interventions were developed using the IHI Model for Improvement to test via rapid Plan-Do Study cycles. Montgomery rules via statistical process control charts were used to measure statistically significant changes in the outcome and process measures.
Results: Patient-, provider-, and systems-level contributors to the delays were identified. Patient-level factors included patients not arriving on-time, not having the appropriate bloodwork performed prior to surgery, and not being appropriately fasted for surgery. Provider-level factors included lack of staff due to care of another patient, or changes in the order of scheduled cases on the day of surgery. Systems-level factors included the lack of a clean/available OR, or issues related to the admission order set. Structure, process, team member and patient engagement interventions were identified, and changes implemented included standardizing patient instructions, standardizing order sets, and accessing a back-up OR which can be used in the event of an unscheduled “crash” cesarean delivery. Since the inception of the project, there have been no months with 0% on-time starts and we surpassed our target of 75% at the end of the project period (Figure 1).
Conclusions: A multidisciplinary team identified several barriers to on-time case starts and using QI methodology we were able to surpass our goal of 75% at our safety net hospital. The team continues to track the percentage of FCOTS, as well as reasons for the delays on a daily basis. This quality improvement team is using the framework used to improve FCOTS for improving other maternal outcomes.