The production pressure and the

anaesthesiologist how do we perform?

Issue 66 ESA Newsletter
Gabriel M. Gurman
Chief Editor
gurman@bgu.ac.il
It has been a long time since hospital administrations, all over the world, found out that
the operating room (OR) represents a genuine financial source, rather than an
embarrassing place of work, full of demands and high wages.
This discovery led almost instantaneously to a sustained campaign of increasing the
OR performance by increasing not only the number of active hours but also the
efficiency of the staff per unit of time. This phenomenon was named production
pressure and it was clearly documented in the classical paper of Gaba et al.
(Anesthesiology 1994;8:488-500). The authors defined production pressure as overt or
covert pressures and incentives on personnel to place production, not safety, as their
primary priority.
In other words, in our field of activity, the practitioner is supposed to take care, first, of
the amount of money generated and only afterwards of the patients safety. Needless to
say, this is an issue that must be discussed and recommendations issued.
But first of all one has to analyse the role of the anaesthesiologist in the process of
improving the production efficiency. Since our main activity is performed in a team,
the question is how important our specific contribution to this process would be.
The main obstacles in the way of increasing the OR efficiency start with prevention of
cancelled cases, go on with shortening the time between one intervention and another,
then a correct and realistic scheduling of cases, and last, but not least, efficient use of
the recovery rooms (a function also called post-anaesthetic care unit).
It is clear that the anaesthesiologist has only a peripheral role regarding prevention of
case cancellation. Due to the introduction of the outpatient anaesthesia clinics in almost
every hospital, today we have the possibility to correctly assess the surgical patients
medical status, to take measures for improving it, and prepare him/her for the surgical
procedure. Only then can the surgeon schedule the patient for an operation, and thus the
system, from our point of view, would prevent undesired cancellation of elective cases.
Correct scheduling of cases is based on the assumption that the surgical team has the
ability to predict the duration of each intervention and thus to efficiently use the number
of OR hours allocated to each department. But this assumption is far from being correct.
A recent study of Travis and collab. in Brit Med J (2014;349:g7182) showed that both
general surgeons and anaesthesiologists underestimated the duration of cases, on
average, by more than 30 minutes.

For sure, medicine in general and surgery specifically, are not industrial domains. Since
we deal with human sufferance and also encounter unexpected events, it is difficult, if
not impossible, to correctly predict the duration of each surgical procedure, which can at
any time complicate and need more time to restore the patients condition to normal.
And from this point of view we, the anaesthesiologists, as Travis proved, are in good
company!
It is common knowledge that every single OR schedule can be disturbed by unplanned
cases, a situation that produces a delay in taking care of those patients already waiting
for an elective surgical procedure. RA Gabriel (J Clin Anesth 2016;31:238-46)
published a comprehensive study about the mechanism of OR inefficiency and found,
among many other interesting things, that unplanned surgery was encountered far more
among elderly patients, a result that would surprise nobody.
The recovery rooms could represent a real bottle neck in the OR activity. It is clear
that while some 40% of the anaesthesia incidents take place in the immediate
postoperative period, it would be too difficult, if not impossible, to plan recovery room
activity with a very high chance of exactitude. Paucity of recovery room beds, either
because of incorrect initial planning or because of patients complicating immediately
after surgery and anaesthesia, creates a real, almost daily problem, which could be
solved only by allocating more beds to intensive care units (used as a pop-off valve),
desirable yet difficult to accomplish.
So, the feeling is that blaming anaesthesia for OR inefficiency has no real chance of
success. This estimation is emphasized by a recent presentation by Victor and his
colleagues, at the last ASA meeting (Anesthesiology 2015; Abstract A1161), in which
he analysed more than 15,000 elective surgical cases and reasons for delaying the
performance of a surgical intervention.
The study revealed ten causes of delay, all except one having no connection whatsoever
with anaesthesia activity. Nurses inefficiency, incomplete patient data, and surgeons
running two rooms simultaneously occupied the first three places on this interesting list.
Among the ten reasons, the only one related to anaesthesia was line placement of and
performance of a regional block. Justifying the performance of these manual procedures
seems to be completely futile and above the scope of this paper. I would just conclude
that all the data from the literature indicate that the anaesthesia provider cannot be
blamed for the OR inefficiency and that many other factors, objective as well as
subjective, could fully explain the difficulties in the permanent fight for better OR
activity.
But I would like to come back to the so called anaesthesiologist dilemma, that one
asking him/her to choose between a better efficiency and the care for patient safety.
Gabas results, published some 20 years ago, are not too encouraging. Analysing the
results of the production pressure in the OR, he got some very worrisome responses
from American peer anaesthesiologists. More than 50% reported mistakes that could be
attributable to fatigue, and more than 60% suggested that this could be explained by the
high workload. And not less impressive was the fact that a good part of those who
answered the questionnaires have recognized the fact that by reducing the workload,
they might jeopardize their own place of work.

I am not aware of any similar study performed in European hospitals, and maybe the
time has come for such a comprehensive research. I also acknowledge the fact that there
is a full list of differences between the two continents regarding the organization of OR
activity. But one cannot deny that the permanent demand for a higher utilization of the
OR facilities and the need for a quick return of equipment investment could lead, in any
hospital, in any country, to a situation similar to what our American colleagues defined
as production pressure.
We all know that the aim of a fruitful combination between the need for efficient results
in the OR and the care for patient safety is sometimes difficult to achieve. But I am sure
that my conclusion would be accepted by all our readers: first, each of us is supposed to
actively contribute to a better OR efficiency. This is our interest, not less than that of
other members of the surgical team. But at the same time patient safety is our primary
goal.
As Posner and Freund (Anesth Analg 2003;96(4):1104-8) have pointed out: It is
believed that a safe process will maximize the chances of a good outcome, and safety in
provision of anaesthesia care is supported by professional standards, guidelines, and
customary practice.