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Operating room costs control or cutting
Operating room costs control or cutting
Louis Block,
DPH
Control of costs, cost-containment, cost reduction are all fashionable words today. The time allotted for this presentation permits ample time to present certain generalities rather than some specifics. Within this time frame, generalities permit a greater degree of continuity than do specifics. This is so because the generalities are usually introductory and historical and thus lend themselves to such continuity. The problem of costs can best be related to when one is certain that there is an understanding of the big changes in surgical practice and technology, and in the operating room Louis Block i s president of the hospital consulting firm of Block, McGibony & Associates, Inc. Silver Springs, Maryland. H e received his BS degree at Columbia University, and earned a DPH degree at the University of Michigan. H e has authored several publications on hospital statistics and cost analysis. The article printed here was first presented by Dr. Block during the A O R N Houston Congress panel "Keeping patient costs down budget".
-
June 1972
nurses role today and tomorrow. Once this is determined, more objective comparisons are possible with respect to relationships that exist between and among the planners' role, the management role and the direct nursing role and costs. I will focus this approach on the planners' role. In the brief span of the last 30 years, the entire field of medicine has b e e n revolutionized by gigantic strides in biomedical knowledge and vast expenditures for facilities and equipment. The impressive advancements in the diagnosis and treatment of man's ills since the post World War I1 period have placed heavy demands upon all workers in the health care system, but especially upon those in surgical departments of hospitals. Operating rooms and their support services have experienced a greater increase in numbers and complexity of surgical and diagnostic techniques and equipment than most any other department in the hospital.
59
As we move into the ~ O ’ S ,ever more dramatic and complex technology is in the offering as hospitals attempt to make available the results of recent biomedical research. An interesting fact was related by Francis Ginsberg, RN, in an article entitled, “Surgeries for the 1970’s.”She wrote: “Even if all the research sponsored by the national institutes of health and private sources would stop tomorrow, it would be a t least a decade or two before advances made in the last 30 years could be made part of every physician’s practice and the services of every hospital in the country.” In electronic equipment alone, dozens of items now in use were not even available or known as recently as the middle 1950’s. This has exerted great pressures upon hospitals built prior to their discovery, to remodel or build on to, to accommodate such equipment, and to provide greater numbers and new kinds of personnel to function effectively with them. The change process is being speeded up by many forces, especially increased federa1 and local planning efforts toward making the availability of quality health services a right for all citizens. For example, the 55 regional medical programs which now cover the country deeply involve the entire health resources of communities in planning and implementing a greater availability of high quality diagnosis and care. Beginning with activities related only to heart disease, cancer and stroke, these agencies provided a focus for programs which are expanding the knowledge and activities throughout the full spectrum of health.
60
By expanding the capabilities of physicians and allied health personnel, these efforts are also expanding the numbers of patients who become recognized as needing care. From this backlog will come greater demands on hospital surgical services. To fully understand the problems created for operating room personnel during the past 30 years, let us review some major changes in the surgical treatment and diagnosis of disease which have already occurred. In the 1940’s, heart diseases were considered to be medical management problems, with drugs being the chief source of therapy. Today, corrective surgeries are possible for dozens of conditions ranging from congenital defects in the newborn to total transplant of a donor heart to replace a worn out one. This wide range of surgeries has required the use of an equal number of new and different pieces of equipment, the upgrading of knowledge and skills of all traditional members of the surgery team, and a whole new range of technicians to man the machines. Biomedical equipment is now used to monitor, analyze and record not only heart function, but lung and brain function, body temperature, blood pressure, blood chemistry and blood volume. In the past several years, 10,000 pacemakers have been implanted each year to assist hearts which would have failed and caused death in previous years. Formerly, it took only one doctor and one set of parents to establish the fact that a blue baby would eventually die. Today, more than 100 people-doctors, nurses and technicians-are involved in the diagnosis, surgical and post-operative care of such a baby.
AORN Journal
The future holds even more rapid developments and advancement. Christian Barnard, MD, now working with the National Aeronautics & Space Administration and General Electric Company, predicts audio and video linking of surgeons continents apart by satellite, as well as the transmission of vital patient information. Robert Shaw, MD, of the Western Research Center, a cardiovascular surgeon, who has studied with Enrico Fermi, the famous physicist, predicts that it is no longer a question of whether, but simply when the five physiological phenomena of oxygen level, PH and CO, of the blood, cardiac output, and volume of blood in the circulatory system will be measured continuously and simultaneously as a routine in all surgeries. Technological research is now being conducted for various high-energy techniques for cutting tissues and coagulating the blood simultaneously to provide for bloodless surgery. Engineer-physicians are d e v e 1o p i n g methods of inducing anesthesia by delivering a current of electricity to certain parts of the brain. Post-operative monitoring and surgical monitoring will be enhanced by instruments being developed for measuring reflexes, muscle tone, eye movement, eyesight, bowel motility, brain impedance, tongue position and the electrical properties of muscle. What was considered exotic and unusual in the past, or what wasn’t attempted a t all, will become routine in future operating rooms, bringing still increasing demands for facilities and workers in sufficient numbers who are adequately trained.
June 1972
When changes happen Sophisticated equipment and welldesigned new facilities are only as valuable as the persons who participate in their use make them. Their ability to provide large amounts of data, and m a k e measurements rapidly, depends heavily upon the humans who operate them to make them fully effective in providing higher levels of care. The use of electronic equipment, better measuring devices, computerized data provides the operating room team with more eyes and ears than they had formerly with which to guard patient care. Machines provide that data with which the professional combines training and experience in decision-making. Nor are machines infallible, but must be attended by those capable and competent enough to check their accuracy. The operating room nurse of today and tomorrow will require knowledge and skill unheard of 30 years ago, while technicians and lessertrained non-professionals adopt her previous activities and perform new ones. Janet Fitzwater, chief of the surgical nursing service of the clinical center, National Institute of Health in her article “Expanding Horizons in Operating Room Nursing” states that operating room nurses of today and tomxrow wilI require the following kinds of increased abilities beyond those traditionally associated with them:
1. Understand the fundamentals and uses of pacemakers, stimulators, myocardial and endocardial electrodes, heart-lung machines, fiber optic equipment, defibrillators, electrosurgical coagulation and cutting
61
elements, ultrasonic cleaners, and gas and steam sterilizers. 2. Make an effective selection of instruments and equipment for complicated surgical and diagnostic procedures. 3. Provide expert assistance to the surgeon. 4. Understand and utilize transducers. 5. Understand and use monitoring equipment. 6. Be capable of interpreting changes in ECGs and EEGs and take necessary action. 7. Keep constantly apprised of the arterial and venous pressure, heart rate, temperature, and other patient modalities, and take effective action in response to changing phenomena. 8. Be capable to advise on operating room construction and facilities. 9. Recognize the dangers involved, and necessary safety measures to be taken, when monitoring equipment and electronic devices are used. 10. Have a clear understanding of what constitutes malpractice and negligence, and know the proper action to be taken. 11. Provide and maintain a safe bacteriological environment. 12. Keep abreast of new surgical and diagnostic techniques as they develop and concurrently develop new nursing techniques to meet projected needs.
One of the major problems today is the question of whose responsibility it is to educate this “super nurse” for functioning in today’s operating room. In the past, the kind of nurse that chose operating room as her specialty came to make the choice after being exposed to it in the course of her training. Today, operating room experience has been deleted from the curriculum of virtually all nursing education programs, whether for the diploma, associate degree, or baccalaureate. New graduates, therefore, have a fear of seeking -jobs as operating room nurses. In the 1970’s, unless schools or hospitals accept the responsibility for providing organized programs to teach this body of knowledge and to provide the clinical facilities for practice, we could experience the disappearance of the professional nurse from the operating room. Master degree programs for nurses are providing for specializing in operating room supervision, but there remains a gap in knowledge and experience because basic educational programs are not integrating this important piece of the patient’s total spectrum of care into their curriculum. Unless nursing education recognizes and fills this gap, the results could be a more mechanical and impersonal style of care.
What’s fhe planner’s role?
13. Understand the medical research goals and assist in their attainment. 14. Participate in nursing research.
Let’s look at cost control, or whatever term you use, from the planning point of review in the operating room. The following are real areas of concern: 1. Relative c a p i t a 1 expenditures
15. Provide supportive care to surgical patients preoperatively, during surgery and postoperatively.
through an approach to standardixation of operating rooms to permit greater multi-purpose assignments by
62
AORN Journal
service. In other words, the multipurpose use of such rooms usually permits greater percentages of utilization and less needs for numbers. This may reduce square foot requirements which in turn reduce capital program outlays, equipment costs, and borrowing costs as well. These are quite high especially in the operating room areas since they are probably some of the most expensive square footages to provide.
2. The control of provision of special r o o m in rehtion to volumes of services to be performed. This attacks the equity of duplications from both a capital, operating, and quality of service point of view. For example, should we provide for highly specialized surgical areas, including the concept of hyperbaric chamber controls, everywhere in an area based on the desire of the individual physician groups and/or the individual hospital desires. Such approaches are costly in their initial investment, the standby special training of personnel required and what is even more important in highly sophisticated procedural requirements is the continued activity of highly specialized teams requiring continuing frequency of use of skills that might well be impaired without such frequency of use. Take open heart surgery, organ transplants as cases in point. 3. Failure to plan for an equity relationship in numbers of surgical beds available to numbers of operating rooms being made available can be costly in both directions. The failure
of promptness in handling desirable elective scheduling may be due to the lack of operating room time (actual or usable time-hours of serving on a routine basis), or to the lack of a bed
June 2972
to which to assign a patient even when surgical time is available. Obviously, the surgical suite capacity must be related in some way to the number of hospital beds; in a general hospital, however, this relationship is dynamic, not static. Within the surgical service, the various specialties have very different requirements for bed space and for operating room time. If one assumes that a hospital’s surgical facility is the proper size in relation to its number of beds, one set of problems is minimized. However, utilization problems tend to crop up even in well-planned hospitals when occupancy rates reach and remain a t 90 percent. If there is no regulatory policy, highly elective surgeries will occup available beds to the detriment of less elective cases. A hospital’s emergency capability also may suffer.
Not infrequently, occupancy rates are high and the utilization of the surgical suite is below capacity. This apparent paradox is caused by a combination of factors such as above normal length of stay in certain surgical categories: the scheduling of elective surgery as eye, ear, nose and throat procedures far in advance of less elective surgery and thereby using up available beds: and under utilization of rooms specifically designed for orthopedics, general, thoracic, and neurologic surgery. One technique often used to combat this problem is to limit the number of days before actual admission that a patient may be scheduled. This usually is not successful because the admitting physician may keep a number of elective surgery patients in re-
63
serve and admit them all a t once when beds become available. In a typical general hospital, there is great variation among specialties in length of stay and other data. For this reason a general rule, such as one operating room for 20 surgical patient beds, may fail in a given institution. It is important, therefore, to determine the length of stay for each specialty in order to estimate the number of surgical procedures that a given census would generate per day. It is tempting to combine all the specialties and to use one set of figures for all surgery; however, this decreases the accuracy of the predictions. For example, in one hospital the difference in average census is required to produce an expected five surgical cases per day in each of eleven surgical specialties (Fig. 1).
specialty, which in turn can limit the number of elective surgery admissions by specialty and vice versa.
4.The reluctant dragon approach of third party reimbursement groups to payment categories other than inpatient has, until recently, limited the development of the in-out surgical approaches which may well be less costly if properly used. The preceding are just some glaringly obvious planning factors that could help us control costs in the operating room area from a broad planning point of view. We did mention program planning as an area of cost concern. This involves not only the specific desires of the surgeon (individual and departmental), but requires a great deal of coordination with other disciplines such as anesthesiologists, and also to board policy and objectives with relation to the kind of a hospital this
Administration can establish admission policies that tend to regulate the size of the average census in each
Fig. 1 Average Daily Surgical Patient Census Required to Generate Five Surgical Cases Per Day Per Specialty Surgical specialty General
Colon and Rectal Gynecologic Urologic Thoracic Neurologic Plasric Oral Ophrhalmoloqic Otolaryngologic Orthopedic
64
Typical length of stay (days) 6.66 5.88 4.41 4.82 7.00 11.17
1.91 1.55 4.69 1.90 9.50
Required average surgical patient census
33.3 29.4 22.0 24.1 35.0 55.9 9.6 7.8 23.5 9.5 47.5
AORN Journal
institution is going to be. The hospital administration and board must be concerned with keeping a balance between services and their development to assure equity that will permit excellence in its total provision of services. Overemphasis in any one particular segment of service may be detrimental to other areas of development. The publicity and allure of highly specialized and sophisticated areas of concern may channel unsupportable sums into it and away from other equally important developments. (Examples we know of are organ transplants, greater emphasis on ultrasophisticated r a d i c a 1 surgeries and radiation therapies in the fields of cancer with a lesser emphasis on hematology and chemotherapy. Fortunately these are now being looked at.)
The operating room area has even a particularly obvious relationship balance within its own institution. It is a highly delegated referral service dependent upon other branches of medicine. A built-in equity proportion between both medicine and its subspecialties, and surgery and its subspecialties, provides for greater inhouse capabilities of utilization than an overemphasis that requires referrals from outside sources. I would like to close with a reminder. Inflation or increase in costs is that which most people talk about, and write about, because they are the most easily obtainable statistics which lend themselves to measurement and quite often to misleading interpretations. In fact, costs may be an expression of the problem crisis and not be truly the problem or crisis itself.
Nurses win rnisrepresenfufion case Please d i r e c t your attention to o claim o f "misrepresentation" which was investigated by t h e C a l i f o r n i a Department o f Insurance f o r ten Los Angeles registered nurses. The situation was resolved " i n favor" of each of t h e ten nurses and monies recovered. Statement: I n September o f 1969, a salesman came t o my home through a referral f r o m a f e l l o w operating room nurse. H e carried with him at that t i m e a p o r t f o l i o of xeroxed application and check payments of his other nurse clients. W e were to discuss a "savings-investment" program, one which w o u l d provide a "tax shelter" f o r me. H e stated that if I w o u l d p a r t i c i p a t e program f o r a p e r i o d of not less than t w o years, leaving my i n his "savings-investment" money at t h e disposal of his company, not only would my investment experience "growth," b u t that I w o u l d receive: 1 ) A bonus coupon f o r $81.09: 2 ) A share i n dividends: and 3) A l i f e insurance p o l i c y (which I did not need). I n June o f 1971. I had an opportunity t o reinvest my money in another investment. At this time, I took inventory of my assets and discovered that t h e "investment" program that I had been led t o believe as a "saving-investment" program was nothing more or less than a l i f e insurance p o l i c y of t h e so-called "participating" coupon variety. At t h e end of t w o years, after paying $1,050. 011 I could receive back would b e t h e "cash-out" value of approximately $300, plus t h e value o f t h e coupon. Inasmuch as t h e program had been grossly misrepresented, I sought legal counsel. Then, together w i t h nine other nurses who had also been duped i n t o the same program, an investigat i o n was i n i t i o t e d and a c l a i m o f "misrepresentation" was settled i n our favor b y t h e C a l i f o r n i o Department of Insurance. Question: H a v e you been mistokenly involved in t h e same or similar so-called "investment" program that is i n r e a l i t y only a " g i m m i c k e d ' l i f e insurnace policy? My understanding is that this so-colled "investment program" was sold t o a great number of nurses i n California. I f you are i n t h e same situation I was, you can g e t your hard-earned money back. For further information c a l l or w r i t e Beverly M a r c h , RN. H e a d Nurse, UCLA M e d i c a l Center, LOS Angeles, C a l i f .
June 1972
65
Louis Block,
DPH
Control of costs, cost-containment, cost reduction are all fashionable words today. The time allotted for this presentation permits ample time to present certain generalities rather than some specifics. Within this time frame, generalities permit a greater degree of continuity than do specifics. This is so because the generalities are usually introductory and historical and thus lend themselves to such continuity. The problem of costs can best be related to when one is certain that there is an understanding of the big changes in surgical practice and technology, and in the operating room Louis Block i s president of the hospital consulting firm of Block, McGibony & Associates, Inc. Silver Springs, Maryland. H e received his BS degree at Columbia University, and earned a DPH degree at the University of Michigan. H e has authored several publications on hospital statistics and cost analysis. The article printed here was first presented by Dr. Block during the A O R N Houston Congress panel "Keeping patient costs down budget".
-
June 1972
nurses role today and tomorrow. Once this is determined, more objective comparisons are possible with respect to relationships that exist between and among the planners' role, the management role and the direct nursing role and costs. I will focus this approach on the planners' role. In the brief span of the last 30 years, the entire field of medicine has b e e n revolutionized by gigantic strides in biomedical knowledge and vast expenditures for facilities and equipment. The impressive advancements in the diagnosis and treatment of man's ills since the post World War I1 period have placed heavy demands upon all workers in the health care system, but especially upon those in surgical departments of hospitals. Operating rooms and their support services have experienced a greater increase in numbers and complexity of surgical and diagnostic techniques and equipment than most any other department in the hospital.
59
As we move into the ~ O ’ S ,ever more dramatic and complex technology is in the offering as hospitals attempt to make available the results of recent biomedical research. An interesting fact was related by Francis Ginsberg, RN, in an article entitled, “Surgeries for the 1970’s.”She wrote: “Even if all the research sponsored by the national institutes of health and private sources would stop tomorrow, it would be a t least a decade or two before advances made in the last 30 years could be made part of every physician’s practice and the services of every hospital in the country.” In electronic equipment alone, dozens of items now in use were not even available or known as recently as the middle 1950’s. This has exerted great pressures upon hospitals built prior to their discovery, to remodel or build on to, to accommodate such equipment, and to provide greater numbers and new kinds of personnel to function effectively with them. The change process is being speeded up by many forces, especially increased federa1 and local planning efforts toward making the availability of quality health services a right for all citizens. For example, the 55 regional medical programs which now cover the country deeply involve the entire health resources of communities in planning and implementing a greater availability of high quality diagnosis and care. Beginning with activities related only to heart disease, cancer and stroke, these agencies provided a focus for programs which are expanding the knowledge and activities throughout the full spectrum of health.
60
By expanding the capabilities of physicians and allied health personnel, these efforts are also expanding the numbers of patients who become recognized as needing care. From this backlog will come greater demands on hospital surgical services. To fully understand the problems created for operating room personnel during the past 30 years, let us review some major changes in the surgical treatment and diagnosis of disease which have already occurred. In the 1940’s, heart diseases were considered to be medical management problems, with drugs being the chief source of therapy. Today, corrective surgeries are possible for dozens of conditions ranging from congenital defects in the newborn to total transplant of a donor heart to replace a worn out one. This wide range of surgeries has required the use of an equal number of new and different pieces of equipment, the upgrading of knowledge and skills of all traditional members of the surgery team, and a whole new range of technicians to man the machines. Biomedical equipment is now used to monitor, analyze and record not only heart function, but lung and brain function, body temperature, blood pressure, blood chemistry and blood volume. In the past several years, 10,000 pacemakers have been implanted each year to assist hearts which would have failed and caused death in previous years. Formerly, it took only one doctor and one set of parents to establish the fact that a blue baby would eventually die. Today, more than 100 people-doctors, nurses and technicians-are involved in the diagnosis, surgical and post-operative care of such a baby.
AORN Journal
The future holds even more rapid developments and advancement. Christian Barnard, MD, now working with the National Aeronautics & Space Administration and General Electric Company, predicts audio and video linking of surgeons continents apart by satellite, as well as the transmission of vital patient information. Robert Shaw, MD, of the Western Research Center, a cardiovascular surgeon, who has studied with Enrico Fermi, the famous physicist, predicts that it is no longer a question of whether, but simply when the five physiological phenomena of oxygen level, PH and CO, of the blood, cardiac output, and volume of blood in the circulatory system will be measured continuously and simultaneously as a routine in all surgeries. Technological research is now being conducted for various high-energy techniques for cutting tissues and coagulating the blood simultaneously to provide for bloodless surgery. Engineer-physicians are d e v e 1o p i n g methods of inducing anesthesia by delivering a current of electricity to certain parts of the brain. Post-operative monitoring and surgical monitoring will be enhanced by instruments being developed for measuring reflexes, muscle tone, eye movement, eyesight, bowel motility, brain impedance, tongue position and the electrical properties of muscle. What was considered exotic and unusual in the past, or what wasn’t attempted a t all, will become routine in future operating rooms, bringing still increasing demands for facilities and workers in sufficient numbers who are adequately trained.
June 1972
When changes happen Sophisticated equipment and welldesigned new facilities are only as valuable as the persons who participate in their use make them. Their ability to provide large amounts of data, and m a k e measurements rapidly, depends heavily upon the humans who operate them to make them fully effective in providing higher levels of care. The use of electronic equipment, better measuring devices, computerized data provides the operating room team with more eyes and ears than they had formerly with which to guard patient care. Machines provide that data with which the professional combines training and experience in decision-making. Nor are machines infallible, but must be attended by those capable and competent enough to check their accuracy. The operating room nurse of today and tomorrow will require knowledge and skill unheard of 30 years ago, while technicians and lessertrained non-professionals adopt her previous activities and perform new ones. Janet Fitzwater, chief of the surgical nursing service of the clinical center, National Institute of Health in her article “Expanding Horizons in Operating Room Nursing” states that operating room nurses of today and tomxrow wilI require the following kinds of increased abilities beyond those traditionally associated with them:
1. Understand the fundamentals and uses of pacemakers, stimulators, myocardial and endocardial electrodes, heart-lung machines, fiber optic equipment, defibrillators, electrosurgical coagulation and cutting
61
elements, ultrasonic cleaners, and gas and steam sterilizers. 2. Make an effective selection of instruments and equipment for complicated surgical and diagnostic procedures. 3. Provide expert assistance to the surgeon. 4. Understand and utilize transducers. 5. Understand and use monitoring equipment. 6. Be capable of interpreting changes in ECGs and EEGs and take necessary action. 7. Keep constantly apprised of the arterial and venous pressure, heart rate, temperature, and other patient modalities, and take effective action in response to changing phenomena. 8. Be capable to advise on operating room construction and facilities. 9. Recognize the dangers involved, and necessary safety measures to be taken, when monitoring equipment and electronic devices are used. 10. Have a clear understanding of what constitutes malpractice and negligence, and know the proper action to be taken. 11. Provide and maintain a safe bacteriological environment. 12. Keep abreast of new surgical and diagnostic techniques as they develop and concurrently develop new nursing techniques to meet projected needs.
One of the major problems today is the question of whose responsibility it is to educate this “super nurse” for functioning in today’s operating room. In the past, the kind of nurse that chose operating room as her specialty came to make the choice after being exposed to it in the course of her training. Today, operating room experience has been deleted from the curriculum of virtually all nursing education programs, whether for the diploma, associate degree, or baccalaureate. New graduates, therefore, have a fear of seeking -jobs as operating room nurses. In the 1970’s, unless schools or hospitals accept the responsibility for providing organized programs to teach this body of knowledge and to provide the clinical facilities for practice, we could experience the disappearance of the professional nurse from the operating room. Master degree programs for nurses are providing for specializing in operating room supervision, but there remains a gap in knowledge and experience because basic educational programs are not integrating this important piece of the patient’s total spectrum of care into their curriculum. Unless nursing education recognizes and fills this gap, the results could be a more mechanical and impersonal style of care.
What’s fhe planner’s role?
13. Understand the medical research goals and assist in their attainment. 14. Participate in nursing research.
Let’s look at cost control, or whatever term you use, from the planning point of review in the operating room. The following are real areas of concern: 1. Relative c a p i t a 1 expenditures
15. Provide supportive care to surgical patients preoperatively, during surgery and postoperatively.
through an approach to standardixation of operating rooms to permit greater multi-purpose assignments by
62
AORN Journal
service. In other words, the multipurpose use of such rooms usually permits greater percentages of utilization and less needs for numbers. This may reduce square foot requirements which in turn reduce capital program outlays, equipment costs, and borrowing costs as well. These are quite high especially in the operating room areas since they are probably some of the most expensive square footages to provide.
2. The control of provision of special r o o m in rehtion to volumes of services to be performed. This attacks the equity of duplications from both a capital, operating, and quality of service point of view. For example, should we provide for highly specialized surgical areas, including the concept of hyperbaric chamber controls, everywhere in an area based on the desire of the individual physician groups and/or the individual hospital desires. Such approaches are costly in their initial investment, the standby special training of personnel required and what is even more important in highly sophisticated procedural requirements is the continued activity of highly specialized teams requiring continuing frequency of use of skills that might well be impaired without such frequency of use. Take open heart surgery, organ transplants as cases in point. 3. Failure to plan for an equity relationship in numbers of surgical beds available to numbers of operating rooms being made available can be costly in both directions. The failure
of promptness in handling desirable elective scheduling may be due to the lack of operating room time (actual or usable time-hours of serving on a routine basis), or to the lack of a bed
June 2972
to which to assign a patient even when surgical time is available. Obviously, the surgical suite capacity must be related in some way to the number of hospital beds; in a general hospital, however, this relationship is dynamic, not static. Within the surgical service, the various specialties have very different requirements for bed space and for operating room time. If one assumes that a hospital’s surgical facility is the proper size in relation to its number of beds, one set of problems is minimized. However, utilization problems tend to crop up even in well-planned hospitals when occupancy rates reach and remain a t 90 percent. If there is no regulatory policy, highly elective surgeries will occup available beds to the detriment of less elective cases. A hospital’s emergency capability also may suffer.
Not infrequently, occupancy rates are high and the utilization of the surgical suite is below capacity. This apparent paradox is caused by a combination of factors such as above normal length of stay in certain surgical categories: the scheduling of elective surgery as eye, ear, nose and throat procedures far in advance of less elective surgery and thereby using up available beds: and under utilization of rooms specifically designed for orthopedics, general, thoracic, and neurologic surgery. One technique often used to combat this problem is to limit the number of days before actual admission that a patient may be scheduled. This usually is not successful because the admitting physician may keep a number of elective surgery patients in re-
63
serve and admit them all a t once when beds become available. In a typical general hospital, there is great variation among specialties in length of stay and other data. For this reason a general rule, such as one operating room for 20 surgical patient beds, may fail in a given institution. It is important, therefore, to determine the length of stay for each specialty in order to estimate the number of surgical procedures that a given census would generate per day. It is tempting to combine all the specialties and to use one set of figures for all surgery; however, this decreases the accuracy of the predictions. For example, in one hospital the difference in average census is required to produce an expected five surgical cases per day in each of eleven surgical specialties (Fig. 1).
specialty, which in turn can limit the number of elective surgery admissions by specialty and vice versa.
4.The reluctant dragon approach of third party reimbursement groups to payment categories other than inpatient has, until recently, limited the development of the in-out surgical approaches which may well be less costly if properly used. The preceding are just some glaringly obvious planning factors that could help us control costs in the operating room area from a broad planning point of view. We did mention program planning as an area of cost concern. This involves not only the specific desires of the surgeon (individual and departmental), but requires a great deal of coordination with other disciplines such as anesthesiologists, and also to board policy and objectives with relation to the kind of a hospital this
Administration can establish admission policies that tend to regulate the size of the average census in each
Fig. 1 Average Daily Surgical Patient Census Required to Generate Five Surgical Cases Per Day Per Specialty Surgical specialty General
Colon and Rectal Gynecologic Urologic Thoracic Neurologic Plasric Oral Ophrhalmoloqic Otolaryngologic Orthopedic
64
Typical length of stay (days) 6.66 5.88 4.41 4.82 7.00 11.17
1.91 1.55 4.69 1.90 9.50
Required average surgical patient census
33.3 29.4 22.0 24.1 35.0 55.9 9.6 7.8 23.5 9.5 47.5
AORN Journal
institution is going to be. The hospital administration and board must be concerned with keeping a balance between services and their development to assure equity that will permit excellence in its total provision of services. Overemphasis in any one particular segment of service may be detrimental to other areas of development. The publicity and allure of highly specialized and sophisticated areas of concern may channel unsupportable sums into it and away from other equally important developments. (Examples we know of are organ transplants, greater emphasis on ultrasophisticated r a d i c a 1 surgeries and radiation therapies in the fields of cancer with a lesser emphasis on hematology and chemotherapy. Fortunately these are now being looked at.)
The operating room area has even a particularly obvious relationship balance within its own institution. It is a highly delegated referral service dependent upon other branches of medicine. A built-in equity proportion between both medicine and its subspecialties, and surgery and its subspecialties, provides for greater inhouse capabilities of utilization than an overemphasis that requires referrals from outside sources. I would like to close with a reminder. Inflation or increase in costs is that which most people talk about, and write about, because they are the most easily obtainable statistics which lend themselves to measurement and quite often to misleading interpretations. In fact, costs may be an expression of the problem crisis and not be truly the problem or crisis itself.
Nurses win rnisrepresenfufion case Please d i r e c t your attention to o claim o f "misrepresentation" which was investigated by t h e C a l i f o r n i a Department o f Insurance f o r ten Los Angeles registered nurses. The situation was resolved " i n favor" of each of t h e ten nurses and monies recovered. Statement: I n September o f 1969, a salesman came t o my home through a referral f r o m a f e l l o w operating room nurse. H e carried with him at that t i m e a p o r t f o l i o of xeroxed application and check payments of his other nurse clients. W e were to discuss a "savings-investment" program, one which w o u l d provide a "tax shelter" f o r me. H e stated that if I w o u l d p a r t i c i p a t e program f o r a p e r i o d of not less than t w o years, leaving my i n his "savings-investment" money at t h e disposal of his company, not only would my investment experience "growth," b u t that I w o u l d receive: 1 ) A bonus coupon f o r $81.09: 2 ) A share i n dividends: and 3) A l i f e insurance p o l i c y (which I did not need). I n June o f 1971. I had an opportunity t o reinvest my money in another investment. At this time, I took inventory of my assets and discovered that t h e "investment" program that I had been led t o believe as a "saving-investment" program was nothing more or less than a l i f e insurance p o l i c y of t h e so-called "participating" coupon variety. At t h e end of t w o years, after paying $1,050. 011 I could receive back would b e t h e "cash-out" value of approximately $300, plus t h e value o f t h e coupon. Inasmuch as t h e program had been grossly misrepresented, I sought legal counsel. Then, together w i t h nine other nurses who had also been duped i n t o the same program, an investigat i o n was i n i t i o t e d and a c l a i m o f "misrepresentation" was settled i n our favor b y t h e C a l i f o r n i o Department of Insurance. Question: H a v e you been mistokenly involved in t h e same or similar so-called "investment" program that is i n r e a l i t y only a " g i m m i c k e d ' l i f e insurnace policy? My understanding is that this so-colled "investment program" was sold t o a great number of nurses i n California. I f you are i n t h e same situation I was, you can g e t your hard-earned money back. For further information c a l l or w r i t e Beverly M a r c h , RN. H e a d Nurse, UCLA M e d i c a l Center, LOS Angeles, C a l i f .
June 1972
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