Bariatric efficiency at an academic tertiary care center

Background Operating room (OR) efficiency requires coordinated teamwork between the staff surgeon, anesthesia team, circulating nurse, surgical technician, and surgical trainee or assistant. Bariatric cases present unique challenges including difficult airways, challenging intravenous access, use of specialized surgical equipment, and synchronized exchange of orogastric tubes. The high contribution margin of these complex bariatric procedures rests on OR efficiency. Objective To compare the efficiency of bariatric surgeries performed by a single surgeon at a tertiary academic medical center with its inherent variability of OR staff to that of a private hospital with a standardized surgical team. Methods All laparoscopic Roux-en-Y gastric bypasses (LRYGB) performed by a single surgeon at University Hospitals Cleveland Medical Center (UHCMC) and a Community Affiliate (CA) from 2013 to 2015 were retrospectively reviewed. Patient demographics and preoperative comorbidities were compared. The variability of OR staff at each site was described. Four primary endpoints of the different OR phases were measured at the 2 locations and analyzed using standard statistical methods. Results The OR data of 74 cases of LRYGB at UHCMC and 106 cases at the CA were analyzed. Patient cohorts were comparable by age (45 +/- 12 vs. 45 +/- 10; p = 0.88), sex (82% vs. 79% female; p = 0.62), BMI (47.16 +/- 7.33 vs. 45.91 +/- 6.85; p = 0.25), and comorbidities. At CA, the teams who participated in LRYGB cases were fairly constant (8 circulating and scrub nurses, 4 anesthetists, 3 anesthesiologists), whereas at UHCMC there was great variability in the number of staff with 108 staff (39 circulating nurses, 57 scrub nurses/technicians, 59 anesthetists or anesthesia residents, 24 anesthesiologists) participated in LRYGB cases. There was no statistical difference between the total mean OR time and surgical time of the cases performed at the 2 sites (203 +/- 59 min vs. 188 +/- 39 min; p = 0.06; 152 +/- 56 min; 145 +/- 37 min; p = 0.36). However, the pre- and post-case times were longer at UHCMC compared to the CA (38 +/- 9 min vs. 33 +/- 6 min; p < 0.0001; 13 +/- 6 min vs. 10 +/- 3 min; p = 0.01). Conclusion The academic center has much greater variability in staff for these complex bariatric procedures. There was a trend toward longer OR times at the tertiary center as demonstrated by the difference in pre- and post-case times, but the consistent surgeon and assistant allowed for consistent surgical case time regardless of the setting. The implication of variability in OR staff can be overcome by the surgeon directing the procedure itself. The opportunity for improving the efficiency of bariatric surgery should focus on the perioperative care of the patient in OR that requires everyone to be familiar with the procedure.