The idea of using a digital program to predict the position and sizes of the implants once seemed like a panacea.
Why wouldn’t a surgical team want a digital template of the surgery they were entering? But early on in the digital templating timeline, problems arose because of miscommunication and confusion between the digital imaging companies and the implant manufactures.
One element among many
Even now, with many of these miscommunications solved, the idea of a templating formula that would answer all the needs of planning a surgery remains implausible. The truth is that templating, although extremely valuable, is only one of the elements in the Pre-Op Plan. Without understanding the algorithms of Pre-Op Planning (POP), all of the templating in the world can’t ensure a successful surgical outcome.
Ironically, the realization that templating cannot stand alone without a comprehensive surgical plan or Pre-Op Planning could actually increase its use. Hospitals and group practices that include digital templating as one element within a coordinated Pre-Op Plan can reduce unnecessary equipment processing, improve staffing for complicated surgeries, minimize uncertainty, and enhance the confidence of the entire surgical team.
10,000 cases and counting
When digital templating became available, I had the advantage of POP for 30 plus years, using old acetate templates on hard-copy x-rays. After my first few hundred cases I realized that just drawing the implants on films was not enough; it would require multiple elements to develop Pre-OpPlanning algorithms.
Over the years, I have planned over 10,000 cases and catalogued nearly 3,000 of them. My analogy for POP is similar to predicting the weather. You use known historical data and blend it with existing data and variables to form a forecast.
A new communication template
An important element of POP is communication; it has become as important to the outcome of a total joint surgery as predicting the sizes of the implants. With the assistance of the OR staff, instrument room, and sales representatives, I designed a communication template for sharing relevant information. It soon became obvious that early communication could improve surgery schedules and even allow time for additional cases.
In the past, total joints were scheduled using the primary instruments and implants that were normally used. Because changes were made during the surgery, the OR staff would open the “backup instruments” in order to support the surgeon. If the case was considered complicated, anesthesia was notified and appropriate measures were taken. If the OR staff was not familiar with the extended challenges then the staff was adjusted. All of this obviously led to a longer turnover time, which in turn influenced the block time and the number of cases a surgeon could do. Today, hospitals are businesses with limited inventories of implants and instruments, which can also influence surgery schedules.
At my practice, we POP each case. For me it often means multiple two-room surgery days. An average surgery schedule in our orthopedic core may mean as many as 20 total joints per day. The responsibility of maintaining an efficient day is shared between the OR staff and the surgeons who had to prepare them for the day with early communication of the POP. Maintaining efficiency often comes down to three things:
Selecting the right instrument pans
One of the largest challenges is the flow of instrument pans. Our detailed planning helps direct the OR staff to open only the primary pans and keep optional ones in the room but not open. By only opening the primary pans, turnover time is decreased. Second, having the optional pans quickly available minimizes the time waiting for them to come from the instrument room. Finally, not opening the pans means they can be used for later cases in your room or other rooms.
With this planning, the OR coordinator is able to schedule flashing instrument pans or have loaner pans available to maintain the flow of the day. The implant coordinator is given adequate time to adjust the inventory and confirm that optional implants or instruments have been delivered. Because of limited inventory, sales representatives are given time to adjust their stock. They also have time to bring in loaner pans and confirm that the pans are complete.
This conservation of pans assists with turnovers and can be a cost savings element for the hospital. Historically these pans were opened and not used but because they were on the surgery field they were often soiled and required cleaning and reprocessed. There could be as many as four or five pans per case per room in need of reprocessing, translating into extra work and of course extra costs. Further, because of the reprocessing time, they might not have been available the next day, which could lead to the delay or even cancellation of cases.
Identifying optional equipment
One of the often unseen values of templating is the knowledge that optional implants, instruments and equipment maybe needed. For example, knowing ahead of time that a different OR table or additional x-rays maybe needed for the procedure can save valuable time. Having all these items available and ready for your case can greatly decrease turnover time. We sometimes think that we are the only room working and all the supporting items are always available. This misconception becomes more apparent with revision work and the need for multiple companies to support your case.
Optimal staffing
In our hospital I have the advantage of working with some of the finest skilled operating nurses in the world. Our Orthopedic supervisor and core coordinator are masterful in coordinating the room staff with the needs of the cases. Walking in to a room with this quality of staff drops my stress level considerably. No longer concerned with the instruments or inventory, the surgeon can focus on the case. Pre-Op Planning and communicating the cases to the OR team makes all the difference.