The Effect of Anesthesia Type on Nonsurgical Operating Room Time

The Effect of Anesthesia Type on Nonsurgical Operating Room Time

SCIENTIFIC ARTICLE The Effect of Anesthesia Type on Nonsurgical Operating Room Time Nicholas M. Caggiano, MD, Daniel M. Avery III, MD, Kristofer S. M...

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SCIENTIFIC ARTICLE

The Effect of Anesthesia Type on Nonsurgical Operating Room Time Nicholas M. Caggiano, MD, Daniel M. Avery III, MD, Kristofer S. Matullo, MD

Purpose To determine the effect of local-only anesthesia on nonsurgical time compared with monitored anesthesia care (MAC)/local and general anesthesia. Our hypothesis was that localonly anesthesia cases would have lower nonsurgical times compared with MAC/local and general anesthesia. Methods We retrospectively reviewed the surgical records of 1,179 patients undergoing elective hand surgery. For each case, we recorded the type of anesthesia used (general, MAC/ local, or local-only anesthesia) and in-room presurgical time, in-room postsurgical time, and, if relevant, room turnover time. We did not record room turnover times for the first case of the day or for cases after procedures that did not meet inclusion criteria. We also recorded the presence of any anesthesia providers (anesthesiologist vs anesthesia-assistant [certified registered nurse anesthetist]). Results A total of 566 cases performed on 501 patients met inclusion criteria. Room turnover times were not calculated for 304 cases. The choice of anesthesia had a significant effect on nonsurgical operating room time. Local anesthesia cases had significantly less nonsurgical time compared with general anesthesia and MAC/local. Cases performed under MAC/local anesthesia also had significantly reduced nonsurgical time compared with general anesthesia. The presence of a certified anesthesia assistant had no effect on any time metrics recorded. Conclusions Choice of local anesthesia, when appropriate, may facilitate rapid operating room turnover and improve overall facility efficiency with lower costs. (J Hand Surg Am. 2015;(-):-e-. Copyright Ó 2015 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Operating room efficiency, local anesthesia, nonsurgical time.

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are increasingly limited. Decreasing reimbursements and larger patient populations have placed pressure on administrators to increase efficiency. As OSPITAL FINANCIAL RESOURCES

From the Department of Orthopaedic Surgery, St. Luke’s University Hospital, Bethlehem, PA. Received for publication September 12, 2014; accepted in revised form January 29, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Kristofer S. Matullo, MD, Department of Orthopaedic Surgery, St. Luke’s University Hospital, 801 Ostrum Street, PPHP 2, Bethlehem, PA 18015; e-mail: [email protected] 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.01.037

both a major cost center and source of revenue, the operating suite is an important focus for eliminating inefficiencies.1 Previous studies have examined the role of reducing room turnover time to increase throughput in the operating suite.2e5 However, nonsurgical time, defined as the time elapsed from surgery end time for one patient until the surgery start time for the next patient, has been shown to be a better target for increasing operating room efficiency.1,6e9 Nonsurgical time includes room turnover time and anesthesia induction, positioning, prepping, draping, and emergence time. Analysis of these times and their components presents opportunities to eliminate inefficiencies and improve productivity.

Ó 2015 ASSH

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EFFECT OF ANESTHESIA ON NONSURGICAL TIME

With the increasing popularity of wide-awake local anesthesia, the hand surgeon has a variety of available choices with regard to anesthesia. Local-only anesthesia does not require supervision by the anesthesiology staff and does not incur induction or recovery times if the patient receives the block in a preoperative area; however, not all patients can tolerate local-only anesthesia. General anesthesia provides maximum patient anesthesia but it also carries risks that are nontrivial, requires monitoring by the anesthesiology staff, incurs induction and emergence times, and requires sign-out and transfer of care in the recovery room, all of which increase nonsurgical time. Monitored anesthesia care combined with local anesthesia (MAC/local) offers a compromise between the 2, providing sedation that may satisfy patients who cannot tolerate local-only anesthesia while avoiding many of the risks inherent in intubation and paralysis. However, MAC/local requires the presence of an anesthesiologist or anesthetist and incurs induction, emergence, and recovery times that increase nonsurgical time. In this study, we sought to determine the effect of local-only anesthesia on nonsurgical time compared with MAC/local and general anesthesia. Our hypothesis was that local-only anesthesia cases would have shorter nonsurgical times compared with MAC/ local and general anesthesia.

At our institution, an anesthesiologist administers regional blockade in the preoperative holding area while the previous surgical case is ongoing. However, we had no way to determine whether a delay existed in transferring the patient from the preoperative holding area to the operating room owing to administration of the regional blockade. For this reason, we excluded all cases involving regional blockade. Selection of anesthesia During the outpatient appointment before surgery, the surgeon gave each patient the option of local-only anesthesia, MAC/local, or general anesthesia. The surgeon explained the risks and benefits of each to the patient, and the patient then chose the form of anesthesia preferred for surgery. The surgeon ordered preadmission testing for patients electing MAC/local or general anesthesia if their history warranted, whereas local-only patients did not require preadmission testing. Local-only anesthesia Patients choosing local-only anesthesia had local blockade performed using 1% lidocaine with 1:100,000 epinephrine, with a 10:1 addition of 8.4% sodium bicarbonate, which was delivered approximately 20 to 30 minutes before incision. The senior author or his physician assistant performed this blockade in the outpatient surgical holding area between cases. Patients undergoing local-only anesthesia did not have intravenous catheters placed. To promote efficient use of time in the operating suite, each patient had blockade administered as the preceding patient was being transported into the operating room (except for the first case of the day, in which case the blockade was performed 20 minutes before the first-case start time). At the conclusion of the case, the surgeon’s physician assistant escorted local-only patients back to the outpatient surgical holding area, where they gathered their belongings and exited the hospital at their convenience without the need for further monitoring.

MATERIALS AND METHODS Inclusion and exclusion criteria After obtaining approval from our institutional review board, we performed a retrospective review of the surgical records of 1,179 patients undergoing elective hand surgery. All procedures were performed by a single surgeon at our Level I academic center between July 2012 and April 2014. To control for equipment setup time between cases, we included only procedures that required no more equipment than a hand pack (an all-inclusive pack with drapes, sponges, dressings, basin, bulb syringe, needle board, and prep solution) and up to 2 trays (a standard soft tissue set and possibly an endoscopic carpal tunnel set). We excluded cases that required more trays, fluoroscopy, drills, implants, microscopes, microinstrumentation, special positioning, or special equipment needed for cases such as fracture fixation or arthroplasty. Arthroscopy monitors and light source and camera equipment are permanently stored in the operating room, and thus cases requiring this equipment did not incur additional room setup time and were not excluded. J Hand Surg Am.

Monitored anesthesia care/local and general anesthesia Patients who chose MAC/local or general anesthesia had an intravenous catheter placed by the nursing staff in the preoperative anesthesia holding area. The operating room staff performed any presurgical anesthesia workup and placement of intravenous catheters while the previously scheduled surgical case was under way or before the scheduled start time for the first case of the day. After the anesthesiologist interviewed them, patients who opted for MAC/local r

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TABLE 1. Type of Anesthesia

Average Surgical Times, by Anesthesia Type Cases, n (%)

Room Turnover Time, min

In-Room Presurgical Time, min

In-Room Postsurgical Time, min

Total Nonsurgical Time, min

General

150 (27)

16.4 (9e56)

16.6 (2e33)

7.9 (2e31)

40.6 (22e86)

MAC/local

284 (50)

15.0 (5e53)

12.5 (3e30)

5.7 (1e21)

32.3 (22e83)

Local

132 (23)

11.7 (5e23)

10.6 (1e26)

2.3 (1e11)

24.5 (16e60)

Data are shown as mean (range) unless otherwise specified.

TABLE 2.

KruskaleWallis Analysis of Variance Effect of Anesthesia on Nonsurgical Operating Room Time (KruskaleWallis Analysis of Variance)

c2

Cases, n

Degrees of Freedom

P Value

Room turnover time

262

22

2

< .001

In-room presurgical time

566

167

2

< .001

In-room postsurgical time

566

273

2

< .001

Total nonsurgical time

262

107

2

< .001

anesthesia had sedating medication administered to them in the operating room. After completion of the timeout and the official start time of the procedure, the operating surgeon provided local blockade. For patients who had elected general anesthesia, the surgeon provided local medication at the completion of the surgical case before dressing application. At the conclusion of the case, patients emerged from sedation or intubation in the operating room. The anesthesia staff subsequently transported those patients to the postanesthesia care unit for monitoring until the nursing and anesthesia staff deemed them stable for discharge.

equipment are permanently stored in the operating room, and thus cases requiring this equipment did not incur additional room setup time. Data gathered For each case, we recorded the time the patient entered the room, the start and end times of the procedure, the time the patient left the operating room, and, if relevant, the time the next patient entered the operating room. We subsequently calculated 3 time quantities for each case: the time elapsed between the patient entering the room and the start of the case (in-room presurgical time); the time elapsed from the end of the case to the patient leaving the room (in-room postsurgical time); and, if relevant, the time elapsed between the previous patient leaving the room and the next patient entering the room (room turnover time). We then calculated total nonsurgical time as the sum of room turnover time, inroom presurgical time, and in-room postsurgical time. We did not calculate total nonsurgical time for the first case of the day or for cases immediately after excluded cases, because turnover time varied depending on the complexity of the case. Increased times for in-room postsurgical time caused by postanesthesia care unit delays, such as a full recovery room requiring the patient to wait before leaving the operating room, were not specifically noted. These delays are inherent in any form of anesthesia that requires postsurgical monitoring and thus should be included in any comparison against a form of anesthesia that does not require such monitoring (ie, local-only anesthesia). We also recorded the

Operative data All surgical cases were performed in the main operating suite of the hospital. Although there is a separate preoperative holding area for ambulatory patients, there are no dedicated ambulatory operating rooms. All staff members in the room were dedicated orthopedic surgical technicians and circulating nurses. Staff members assigned to each room varied from day to day. At our institution, staff members are assigned to cases on a daily basis. Staff members routinely cover both inpatient and ambulatory procedures. For each case, the patient arrived in the room on a stretcher, which doubled as an operating room table, preventing the time delay of moving a patient onto or off a separate table. All endoscopic procedures were performed in the same room. As mentioned above, the arthroscopy monitors, light source, and camera J Hand Surg Am.

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TABLE 3.

Multiple ManneWhitney U Post Hoc Analysis Type of Anesthesia

Room turnover time

Cases, n

Mean Minutes

Local-only

60

11.7

General

66

16.4

Local-only

60

11.7

MAC/local

136

15.0

MAC/local

136

15.0

66

16.4

Local-only

132

10.6

General

150

16.6

Local-only

132

10.6

MAC/local

284

12.5

General In-room presurgical time

In-room postsurgical time

Total nonsurgical time

MAC/local

284

12.5

General

150

16.6

Local-only

132

2.3

General

150

7.9

Local-only

132

2.3

MAC/local

284

5.7

MAC/local

284

5.7

General

150

7.9

Local-only

60

24.5

General

66

40.6

Local-only

60

24.5

MAC/local

136

32.3

MAC/local

136

32.3

66

40.6

General

type of anesthesia used (local-only, MAC/local, or general) and the presence of any anesthesia providers (anesthesiologist with or without a certified registered nurse anesthetist [CRNA]). We calculated in-room presurgical and in-room postsurgical times for all included cases. We calculated room turnover time only if both the previous and following cases were included in the study. We did not calculate room turnover times for the first case of the day. At our institution, the patient may not enter the operating room if the attending physician is not available to start the case. Therefore, for cases performed on a day in which the surgeon used more than J Hand Surg Am.

% Change

ManneWhitney U

P Value

29

998

< .001

22

3,010

.003

9

3,583

.020

36

2

< .001

15

12,527

< .001

25

8,325

< .001

71

749

< .001

60

2,263

< .001

28

13,591

< .001

40

273

< .001

24

1,296

< .001

20

1,940

< .001

one operating room, we calculated in-room presurgical time and in-room postsurgical time, because these were not affected by multiple rooms. However, for these cases we did not calculate room turnover time because we could not determine whether any delay in turnover resulted from the surgeon’s presence in another operative suite. For all surgical cases, regardless of the use of a second room, the staff surgeon either would be in the room when the patient arrived or would enter the room with the patient. At the conclusion of the case, the staff surgeon would dictate the operative report while the physician assistant or senior resident would close the skin and apply dressings. Once the patient r

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TABLE 4. Type of Anesthesia

Endoscopic Carpal Tunnel Release: Average Surgical Times, by Anesthesia Type

Cases, n (%)

Room Turnover Time, min (mean [range])

In-Room Presurgical Time, min (mean [range])

In-Room Postsurgical Time, min (mean [range])

Total Nonsurgical Time, min (mean [range])

50 (22)

18.3 (12 e56)

16.3 (5e24)

7.3 (2e18)

43.0 (32e86)

General MAC/local

120 (53)

15.0 (5e53)

12.5 (3e30)

6.0 (1e21)

32.4 (22e83)

55 (24)

11.6 (8e16)

11.0 (3e26)

2.3 (2e10)

24.7 (18e46)

Local

TABLE 5.

Endoscopic Carpal Tunnel Release: KruskaleWallis Analysis of Variance Effect of Anesthesia on Nonsurgical Operating Room Time

c2

Cases, n

Degrees of Freedom

P Value

Room turnover time

105

17

2

< .001

In-room presurgical time

225

53

2

< .001

In-room postsurgical time

225

106

2

< .001

Total nonsurgical time

105

46

2

< .001

left the room, either the staff surgeon or the physician assistant would escort the patient to the holding area.

anesthesia, 284 were performed with MAC/local, and 132 were performed with only local anesthesia (Table 1). Of the 202 cases performed with general anesthesia or MAC and for which we could calculate turnover time, 146 included a CRNA and 56 had only an anesthesiologist. Appendix A and Table E1 (available on the Journal’s Web site at www.jhandsurg.org) list the procedures included in this study. The choice of anesthesia had a significant effect on room turnover time, in-room presurgical time, inroom postsurgical room time, and total nonsurgical time (Table 2). Compared with general anesthesia, local-only anesthesia reduced total nonsurgical time by 40% (Table 3). Local-only anesthesia reduced total nonsurgical times by 24% compared with MAC/ local. In addition, MAC/local significantly reduced total nonsurgical time by 20% compared with general anesthesia. The presence of a CRNA had no significant effect on any of the time metrics recorded, with minimal reductions in room turnover (16.0 to 15.2 min; P ¼ .438), in-room postsurgical time (6.8 to 6.6 min; P ¼ .767), and total nonsurgical time (35.1 to 34.9 min; P ¼ .896). The presence of a CRNA had a minimal increase in in-room presurgical time (12.3 to 13.1 min; P ¼ .160). For the subgroup analysis of endoscopic carpal tunnel release, the choice of anesthesia had a significant effect on room turnover time, in-room presurgical time, in-room postsurgical room time, and total nonsurgical time (Table 4). After Bonferroni correction, the difference in room turnover time and in-room presurgical time between local-only and MAC/local

Statistical analysis Our primary outcome variables (room turnover time, in-room presurgical time, in-room postsurgical time, and total nonsurgical time) were not normally distributed, and thus we performed KruskaleWallis analysis of variance to determine the effect of the type of anesthesia had on these variables; significance was accepted at P < .050. We performed multiple ManneWhitney U tests with Bonferroni correction for comparison among the 3 forms of anesthesia; P < .017 denoted significance. Because the data for each type of anesthesia did not have identical distribution, ManneWhitney U tests examined mean values as opposed to median values. Finally, independent t tests determined whether the presence of a CRNA had a significant effect on outcome variables. Because nearly 40% of our included cases were endoscopic carpal tunnel release, we included a separate subgroup analysis for that procedure. RESULTS A total of 566 procedures performed on 501 patients met inclusion criteria. Room turnover times were not calculated for 304 cases: 152 cases were the first case of the day, 125 cases occurred on days in which the surgeon had more than one operating room, and 27 cases were preceded by cases that required considerable room cleanup and breakdown time. One hundred fifty of the included cases were performed under general J Hand Surg Am.

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TABLE 6.

Endoscopic Carpal Tunnel Release: Multiple ManneWhitney U Post Hoc Analysis Type of Anesthesia

Room turnover time

In-room presurgical time

In-room postsurgical time

Total nonsurgical time

Cases, n

Mean Minutes

Local-only

24

11.6

General

20

18.3

Local-only

24

11.6

MAC/local

61

15.0

MAC/local

61

15.0

General

20

18.3

Local-only

55

11.0

General

50

16.3

Local-only

55

11.0

MAC/local

120

12.5

MAC/local

120

12.5

General

50

16.3

Local-only

55

2.3

General

50

7.3

Local-only

55

2.3

MAC/local

120

6.0

MAC/local

120

6.0

General

50

7.3

Local-only

24

24.7

General

20

43.0

Local-only

24

24.7

MAC/local

61

32.4

MAC/local

61

32.4

General

20

43.0

did not achieve significance. Although MAC/local cases showed a reduction in in-room postsurgical time compared with general anesthesia, this turned out to be nonsignificant (Tables 5, 6).

ManneWhitney U

P Value

37

53

< .001

23

498

.022

18

382

.012

33

336

< .001

12

2,649

.035

23

1,218

< .001

68

107

< .001

62

341

< .001

18

2,417

.044

43

16

< .001

24

244

< .001

25

187

< .001

Previous studies explored strategies for reducing nonsurgical time in the operating suite. Head et al5 demonstrated that a dedicated “swing-room” for regional blockade produced shorter turnover times and faster discharge times. However, nearly 30% of patients in that study received regional blockade and required sedation intraoperatively. Friedman et al2 and Mariano et al8 demonstrated that the use of an induction room reduced both anesthesia induction time and room turnover time. The models used in those studies also necessitated constant patient monitoring by an anesthesiologist or qualified anesthesia assistants, which incurred additional costs.

DISCUSSION The current economic climate of decreasing reimbursements and the accountable care organization model require that hospitals and providers find new ways to decrease costs while maximizing revenue. Surgical turnover time has proven a popular target for such studies, at least in part because the operating suite comprises a large portion of the hospital’s balance sheet in terms of both costs and revenues.1 J Hand Surg Am.

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Avery and Matullo3 showed that the use of a dedicated operating room staff yielded faster turnover time between cases that could lead to an increase in the number of cases performed per day or earlier completion of the day’s cases and thus early redeployment of staffing resources and a possible reduction in on-call pay. Harders et al7 demonstrated that a coordinated multidisciplinary process redesign could lead to a significant decrease in nonsurgical time. Their effort included the use of early notification of environmental services for room turnover, a single patient monitoring system, and mobile interchangeable operating tabletops. That study demonstrated that increased communication and coordinated activities could significantly reduce nonsurgical time. We examined the effect of anesthetic choice on nonsurgical time. Wide-awake local anesthesia cases have garnered much attention recently in hand surgery. Patients undergoing local-only anesthesia require less in-hospital time and preoperative testing and report less preoperative anxiety.13 Wide-awake local anesthesia allows for intraoperative active motion, which is useful when performing trigger finger release and flexor tendon repair.14 Local-anesthesiaeonly cases consume fewer resources because they do not require the supervision of an anesthesiologist or monitoring in a postanesthesia care unit and necessitate no use of anesthesia drugs or gas with the exception of local medication. Our average turnover times (16, 15, and 11 min for general, MAC/local, and local-only cases, respectively) may seem low compared with recently published times of 24 to 42 minutes in hand surgery.7,15 However, at our institution we have the benefit of a dedicated orthopedic staff, which has been shown to reduce average turnover time3 from 31 to 20 minutes. In addition, to remove confounding variables, we only calculated room turnover times if both the case preceding and the case after the turnover required no more equipment than a soft tissue set and possibly an endoscopic carpal tunnel set. This eliminates common causes of turnover delay, such as moving tables, implants, fluoroscopic equipment, and microscopes in and out of the room. Certain characteristics of our institution may have an effect on the efficiencies we were able to realize with local-only anesthesia. In our hospital, patients undergoing local-only anesthesia do not require an intravenous catheter. It is our understanding that some institutions require all patients to have an intravenous catheter placed regardless of the anticipated method of anesthesia. Policies such as these will certainly lead to differing turnover times among institutions. J Hand Surg Am.

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Strengths of our study include limiting cases analyzed to smaller soft tissue cases using one pack and one tray with or without an endoscopic carpal tunnel release set. With this selection criterion, the staff only needs to open a standardized amount of instrumentation for all cases evaluated. We think this eliminates the need to search for other sets and the time to open multiple sets. We did not include cases that required equipment the staff had to move into the room or set up, such as fluoroscopy, implants, and microscopes, which could lengthen the turnover time between rooms and the setup time. We used dedicated operating room staff to eliminate the variable of non-orthopedic staff increasing turnover time, as demonstrated previously.3 The weaknesses of our study include the fact that it was retrospective in nature. To help eliminate recall bias for cases, we used a database of all operative cases to identify all surgeries by the senior author within the study time frame. Because the nurses were responsible for recording start time, stop time, in-room time, and out-of-room time in the nursing reports, mistakes might have been made as to the exact time of day. However, we think these are negligible and are likely consistently spread across all cases throughout the study period and therefore do not affect the overall times markedly. Our study may contribute to the growing number of ways to improve process flow and maximize efficiency in surgery of the hand. With significantly less time between cases and less nonsurgical time, possible effects could include ending the operative day earlier or performing more cases in a given time frame. This increased efficiency could increase revenue by allowing for the completion of more cases in a day, allowing for reallocation of staff, or preventing additional spending by limiting overtime pay. Future studies evaluating the financial effects of this increased efficiency would be required. REFERENCES 1. Marjamaa R, Vakkuri A, Kirvela O. Operating room management: why, how and by whom? Acta Anaesthesiol Scand. 2008;52(5): 596e600. 2. Friedman DM, Sokal SM, Chang Y, Berger DL. Increasing operating room efficiency through parallel processing. Ann Surg. 2006;243(1): 10e14. 3. Avery DM III, Matullo KS. The efficiency of a dedicated staff on operating room turnover time in hand surgery. J Hand Surg Am. 2014;39(1):108e110. 4. Macario A. Are your hospital operating rooms “efficient”? A scoring system with eight performance indicators. Anesthesiology. 2006;105(2): 237e240. 5. Head SJ, Seib R, Osborn JA, Schwarz SK. A “swing room” model based on regional anesthesia reduces turnover time and increases case throughput. Can J Anaesth. 2011;58(8):725e732.

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11. Lalonde D. Minimally invasive anesthesia in wide awake hand surgery. Hand Clin. 2014;30(1):1e6. 12. Lalonde D, Bell M, Benoit P, Sparkes G, Denkler K, Chang P. A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase. J Hand Surg Am. 2005;30(5):1061e1067. 13. Davison PG, Cobb T, Lalonde DH. The patient’s perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study. Hand (N Y). 2013;8(1):47e53. 14. Lalonde D, Martin A. Epinephrine in local anesthesia in finger and hand surgery: the case for wide-awake anesthesia. J Am Acad Orthop Surg. 2013;21(8):443e447. 15. Hanss R, Buttgereit B, Tonner PH, et al. Overlapping induction of anesthesia: an analysis of benefits and costs. Anesthesiology. 2005;103(2):391e400.

6. Sandberg WS, Daily B, Egan M, et al. Deliberate perioperative systems design improves operating room throughput. Anesthesiology. 2005;103(2):406e418. 7. Harders M, Malangoni MA, Weight S, Sidhu T. Improving operating room efficiency through process redesign. Surgery. 2006;140(4): 509e514; discussion 514e506. 8. Mariano ER, Chu LF, Peinado CR, Mazzei WJ. Anesthesiacontrolled time and turnover time for ambulatory upper extremity surgery performed with regional versus general anesthesia. J Clin Anesth. 2009;21(4):253e257. 9. Williams BA, Kentor ML, Williams JP, et al. Process analysis in outpatient knee surgery: effects of regional and general anesthesia on anesthesia-controlled time. Anesthesiology. 2000;93(2):529e538. 10. Katz RD, LaPorte DM. Use of short-acting local anesthetics in hand surgery patients. J Hand Surg Am. 2009;34(10):1902e1905.

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APPENDIX A: INDICATIONS AND CONTRAINDICATIONS TO LOCAL-ONLY ANESTHESIA As previously described,10e12 nearly all patients are candidates for local anesthesia. Amino amide anesthetics such as lidocaine and bupivacaine are metabolized by the liver and thus are not safe in patients with hepatic failure. Patients with a history of allergy to amino esters or para-aminobenzoic acid are not suitable for use of an amino ester anesthetic such as procaine, tetracaine, and benzocaine. The use of epinephrine should be avoided in patients with preexisting circulatory issues in the finger, such as Buerger disease or other vasculitides. The presence of significant medical comorbidities warrants a discussion between the patient and surgeon. Some patients and surgeons prefer the use of

TABLE E1.

sedation (MAC/local) in these cases because this allows for close monitoring of the patient by an anesthesia professional during and after the procedure. Others have noted that commonly used agents for sedation, including propofol and ketamine, cause notable physiologic alterations such as cardiac and pulmonary depression, whereas local-only anesthesia avoids these potential complications. The senior author performs all local-only cases in the main operating suite of a Level I trauma center. Although there is no anesthesiologist or nurse-anesthetist in the room during local-only cases, the staff includes at least 2 professionals certified in advanced cardiac life support and numerous anesthesia professionals are available for immediate consultation in the same operating area.

Count of Included Procedures Procedure

Endoscopic carpal tunnel release

Count

Local-Only

MAC/Local

General

225

55 (24%)

120 (53%)

50 (22%)

Trigger finger release

93

36 (39%)

41 (44%)

16 (17%)

Mass excision/biopsy

74

15 (20%)

28 (38%)

31 (42%)

de Quervain release

26

9 (35%)

11 (42%)

6 (23%)

Epicondylar release

14

0

7 (50%)

7 (50%)

2 (22%)

3 (33%)

4 (44%)

8

0

8 (100%)

0

5

1 (20%)

1 (20%)

3 (60%)

Irrigation and debridement

4

0

3 (75%)

1 (25%)

Neurolysis

3

0

2 (67%)

1 (33%)

Tendon reconstruction

2

0

2 (100%)

0

Flap/division

1

0

0

1 (100%)

Open carpal tunnel release

9

Fasciectomy Tenolysis

Guyon canal release

1

0

1 (100%)

0

Ulnar nerve transposition

1

0

0

1 (100%)

Bursectomy

1

0

1 (100%)

0

Marsupialization/ablation

1

0

0

1 (100%)

2 of the above procedures

93

13 (14%)

55 (59%)

25 (27%)

3 of the above procedures

5

1 (20%)

1 (20%)

3 (60%)

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