170 - Operational Efficiency: Winning the Battle Against OR-PACU Holds

Description: The operating room (OR) is a key revenue center in any healthcare organization. Thus, more effective throughput management in the perioperative areas prevents surgical delays and OR-to-PACU holds. According to Childers and Maggard-Gibbons (2018), the mean cost of operating room time in acute care hospitals was $36 to $ 37 per minute.
The purpose of this process improvement project is to mitigate throughput management issues, thereby preventing OR-to-PACU holds. The project aims to decrease the OR-to-PACU holds by 25% in PY 2024.

In performance year (PY) 2023, Kaiser Permanente Sacramento Medical Center's average baseline holds of 54 translates to a total of 9,260 minutes per month. The amount of time wasted due to throughput inefficiencies costs the organization a considerable amount of revenue.

During implementation, perioperative leaders collaborated to mitigate multiple factors that affected throughput issues. The assistant nurse managers (ANMs) initiated a daily review of the number of cases, collaborating with other leaders across the continuum, exemplifying the effectiveness of this approach. On a high census day, despite handling 35-45 total cases— including total joint (TJ) surgeries, hospital ambulatory surgeries (HAS), high hospital census at level red or black, fully operational twelve (12) surgical OR suites running— no OR holds occurred. All PACU bays were occupied, and staffing remained optimal across both shifts, with average recovery times met for regular HAS, joints, lumbar, or critical care patients’ procedures. This operational efficiency not only ensured timely patient recovery but also maximized surgical capacity, allowing surgeons to service a greater number of patients.

Moreover, multifaceted interventions have been conducted to maintain sustainable flow and mitigate surgical delays. The process improvements include early notification of the ANM from the Unit Assistant (UA) regarding the OR closing status, based on the case type. Additionally, standardizing the communication approach by OR circulating nurse alerting the PACU nurse to post-operative ICU patient or level-of-care changes. Also, strategically utilize overflow recovery spots to prevent OR delays. Furthermore, utilizing BRN and ANM inclusion in recovery staffing to bridge care gaps, and increasing AM and PM core staffing to meet the needs during busy hours.

In performance year (PY) 2024, OR holds decreased by 25–35%, ultimately reaching zero OR-to-PACU holds during key months. This directly translated into reclaimed surgical time and expanded patient access to timely procedures.

Additionally, Kaiser Permanente Sacramento's Pre-Op and Post-Anesthesia Care Unit (PACU) achieved a significant operational milestone: the elimination of all OR-to-PACU holds, a result of focused workflow redesign and effective staffing coordination. Patients were transitioned directly from the OR to PACU bays upon surgical completion, avoiding prolonged Operating Room (OR) time. This initiative significantly improved OR efficiency, increased surgical throughput, and enhanced both financial outcomes and patient satisfaction by reducing surgical backlog hours and enabling more cases to be completed.

In conclusion, the combination of real-time coordination, strategic staffing, and escalation protocols led to a measurable decrease in OR holds, significantly improved throughput, and elevated the standard of perioperative care.