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Michael E. DeBakey VA Medical Center - Houston, Texas

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Wait Time for Knee Replacement Surgery Cut by 92%

October 6, 2008

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"We needed to implement an innovative approach to optimize orthopedic throughput, decrease the backlog, and meet the needs of our patient population in a more timely fashion," said David Green, M.D., Orthopedics chief. Above, Green examines Army veteran Grant Graves during a recent appointment.  PHOTO: Bobbi Gruner


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HOUSTON – Decreasing the amount of time veterans wait for health care appointments continues to be a high priority for administrators at the Michael E. DeBakey VA Medical Center (MEDVAMC). By focusing on ways to improve operating room efficiency and providing additional support services, the wait time for Total Knee Arthoplasty (TKA) surgery has decreased by 92 percent.

In the last few years, orthopedic surgeries at the MEDVAMC have steadily increased to the point where the number of patients exceeded surgical capacity.

“In the past, patients either waited eighteen months to two years or were referred to an outside facility for total knee replacement surgery,” said David Green, M.D., Orthopedics chief. “The old process only allowed a maximum of four TKA surgeries per week. We needed to implement an innovative approach to optimize orthopedic throughput, decrease the backlog, and meet the needs of our patient population in a more timely fashion.”

The number of orthopedic procedures at the MEDVAMC almost doubled from 515 in fiscal year 2006 to 1001 cases in fiscal year 2007. The number of joint replacements increased substantially from 70 in fiscal year 2006 to 350 in fiscal year 2008.  In order to meet the growing demand, a multidisciplinary team, consisting of surgeons, anesthesiologists, nurses, health technicians, supply specialists, and housekeepers, was formed to examine efficiency and streamline processes. The team believed if cases were better coordinated, orthopedic throughput in the operating room could be dramatically enhanced.

The team identified several barriers to decreasing surgery time. These included delays in patient identification, informed consent, site marking, intravenous antibiotics, preparation of patient by anesthesia, delay in room cleaning, and lack of needed instruments in the operating room.

“As we progressed, we recognized that improvement in these areas would also have a positive impact and huge potential for decreasing wait time for other surgeries performed at the DeBakey VA,” said Rogers Duplessis, Supply, Processing, and Distribution Section chief. “This initiative recently won the VA Systems Redesign Mid-Western Inpatient Flow Champions Award.”

During the transformation process, the team made sure the same high level of quality care was maintained before, during, and after the TKA surgery. To avoid confusion, each of the two operating rooms was designated as either a left or a right knee room. The morbidity and mortality rate of total knee replacements was also monitored to ensure increased efficiency was not obtained by compromising quality. To date, the measures have either improved or remained steady since implementation of the systems process redesign.

At the beginning of the project, a TKA required more than four hours of operating room time. Now, with the improvements, this has decreased to one to 1 1/2 hours. The first changes were preparing the operating room schedule at least one week prior and batch processing similar cases on a particular day. This allows for more time to assemble instrument trays and for nursing to verify trays are complete, ready, and labeled prior to surgery start time. Second, the Environmental Management Section provides additional staff to clean operating rooms. Another process change was the Anesthesiology Section starts spinal anesthesia in the Holding Area instead of the operating room.

“The team now completes ten TKA surgeries by 3:30 p.m. and the wait time for surgery is down from 18 months to four to six weeks,” said Grace Mathur, R.N., Operating Room nurse manager. “We take seriously the job of serving those who have served our country and strive to provide the best health care anywhere.”

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