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Medication Adherence and Operating Room Efficiency for a Surgical Subspecialty

The implementation of a 5-step reminder process and pharmacist consultation/visit improved medication adherence and reduced operative delays.
Federal Practitioner. 2017 March;34(3):16-19
March 6, 2017|Federal Practitioner
Kiersten Norby, MD;Koijan Kainth, MD;Rosanne Ganzel, RN;Julie A. Wagner, RN;Cornelius H. Lam, MD, PhD
Author and Disclosure Information

Dr. Norby is a surgery resident; at the time this article was written, Dr. Kainth was a neurosurgery resident; and Dr. Lam is a professor of neurosurgery; all at the University of Minnesota in Minneapolis. Ms. Ganzel and Ms. Wagner are nurses, and Dr. Lam is the chief of neurosurgery at Minneapolis VAMC. Dr. Kainth is currently a neurosurgeon in private practice.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.

Medication Adherence Program

In order to ensure medication adherence prior to surgery there were 5 points of contact with a patient from the time the patient was scheduled for surgery and the date of the surgery (Figure 1):

  1.  The coordinator reviewed medications with patient at time of scheduling
  2. A letter was sent with specific instructions about medications
  3. Preoperative medicine clearance
  4. Preoperative neurosurgery appointment
  5. Call from pharmacist 1 week before surgery

Results

The authors reviewed 10 months of the neurosurgical service prior to initiation of the protocol. Of 317 analyzed cases, 30 were delayed/cancelled. Among these, 5 cases with the possibility of a 6th were cancelled due to medication issues. Following the initialization of the study, 50 patients underwent preoperative counseling with the pharmacist and the neurosurgery coordinator and had an OR Medication Compliance Worksheet created.

Review of the OR Medication Compliance Worksheet demonstrated that 2 patients were nonadherent with their medications.

The first patient did not use a prescribed inhaler, and the second patient did not take preoperative pain medication. Review of the anesthesiology records did not document a delay or cancellation in any of the 50 cases. The first patient received a nebulizer treatment prior to surgery, but this did not delay the case. All patients with anticoagulation or antiplatelet prescriptions had discontinued these medications prior to surgery (Figure 2).

 

Discussion

The OR is one of the most expensive areas in an acute care hospital.2 Cancellations or delays can have significant negative financial implications (about $1,500 per hour of lost revenue).19 In order to improve OR efficiency and reduce preoperative delays, the causes of preoperative delays must be determined.

Some delays and cancellations result from either preoperative or perioperative issues. Prolonged wait time and postponement may cause preoperative delays. Perioperative delays include delays in getting into the OR once the patient has arrived in the hospital as well as delays during the operation. These delays can be due to both human error and system deficiencies.20

One Toronto, Canada study looked at the different etiologies for delays in cranial and spinal procedures and found that equipment failure followed by physical transit into the OR were the top reasons for delays.21 These researchers also found that first cases each day sometimes had a higher incidence of delays than did subsequent cases because several ORs prepare to start simultaneously, which causes an increased demand on hospital support services (eg, registration desk, imaging department, nurses in the patient holding area, or transportation). The number of these support staff remains constant throughout the day, whereas the first-case patients all arrive at about the same time, causing a bottleneck in the early morning. The authors looked at 1 facet of the delay problem as an ongoing analysis for hospital efficiency improvement.

With the implementation of a simple 5-step process, medication adherence was > 90% and the impact of nonadherence on surgical procedure delays was eliminated during the trial period. In this sample, nonadherence did not impact surgery, which resulted in fewer delays and cancellations. The process emphasized repetition and communication, involving 5 reminders between the date of OR scheduling and the date of the actual surgery. The authors found that in this quality improvement study, redundancy in the workflow actually improved the efficiency of the patient’s hospital course.

Within the OR, there are many perspectives to consider for improving OR efficiency. For instance, Archer and colleagues present several distinct perspectives: that of the health care institution, the individual practitioner, the patient, and evidenced-based medicine.2 According to Strum and colleagues, OR inefficiency is the sum of under- and overutilized time and efficiency is highest when OR inefficiency is minimized.22 An OR is considered underutilized when it is staffed at regular wages but not used for surgery, setup, or cleanup. An OR is considered overutilized when the OR staff receives overtime wages, multiplied by the relative cost of overtime compared with straight time. Delayed or cancelled surgeries can result in idle operating room staff, while repeat or correlative studies (ie, electrocardiogram, drug levels) may overutilize support services.

Limitations

This study has obvious limitations due to its small scale. Because the protocol implementation resulted in few delays, a very large cohort would have been necessary to attain statistical power.

Conclusion

By improving OR efficiency and reducing preoperative delays, surgical capacity can be increased.

In this study, the authors demonstrate that with little addition of cost, medication nonadherence can be reduced or eliminated as an issue for surgical delays. With the implementation of the 5-step reminder process as well as the addition of a pharmacist consultation/visit, medication adherence was > 90% among preoperative patients in this small study. With the number of patients with complex medication regimens, increasing medication adherence in the preoperative period is not only important in reducing operative delays, but also an opportunity to ensure the patient is safe and optimally treated. ˜

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