Discussion:
Since the Danish surgeon, Kehlet first proposed and explored the concept
of rapid rehabilitation surgery in 1997, the concept of rapid
rehabilitation has been expanded to a certain extent and successfully
applied in many surgical diseases, including rapid rehabilitation
surgical treatment for colorectal resection, one of the most successful
models [1,10-11]. At present, there is a lot of evidence-based
medical evidence affirming the effect of rapid rehabilitation surgery.
Through a series of perioperative or surgical treatments and the
advancement of ideas, it has shortened the recovery time of patients’
physiological functions, reduced the length of hospital stay and medical
costs, decrease complications and readmission rates and increased
utilization of medical resources without affecting safety [12-13].
not only that, the optimizing OR utilization is vital for delivering
efficient and cost-effective care [14-15]. However, most of the
current studies mainly focused on strategy of surgical treatment or
scheduling, but the feasibility and efficiency of the processes are
often overlooked. The patients remain in an unphysiological condition at
general anesthesia, and the risk of blood pressure change, heart attack
or stroke was hard to be eliminated. Therefore, the noneffective wait
time should be as few as possible to decrease those risk to a certain
extent. Silber et al. confirmed in their research that prolonged
operation time and anesthesia time can affect the quality of surgery and
the efficiency of treatment [16]. At present, the progress of
surgical methods and concepts has been recognized, and the operation
time itself is difficult to control. Therefore, the researchers have
reduced the non-effective time and enhanced the operating room
utilization by management methods, such as optimizing the surgery
schedules.[17-18] And further shortening the anesthesia time can
also help reduce the number of anesthetic drugs used by patients, reduce
systemic stress reactions and drug side effects, and speed up patients
Recovery, to achieve the goal of rapid recovery [19-20].
The anesthesia not only throughout the entire operation period, and also
exceeds the operation time. Anesthesia time could separate into 3 parts:
before the operation, during the operation, and post-operative
anabiosis. The length of the operation time is related to factors such
as the surgical method, the patient’s condition, the medication and
experience of the surgeon. There are so many uncontrollable factors
during the operation, so it is difficult to shorten the operation time
[21-22]. After operation, the surgeon has few works to do when
patient is resuscitating in the anesthesia resuscitation room. And
notably, it has been validated that the effective capacity of the PACU
could increase through an improved schedule strategy [23]. In this
research, we have only interfered the process before the operation. If
we could optimize more process in whole period at anesthesia and
cooperate better, there was much more noneffective wait time could be
utilized.
Clinically, the surgical preparation requires cooperation of surgeons,
anesthesiologists, and operating room nurses. There are many links
between the steps of surgical preparation, such as anesthesia, urinary
catheterization, disinfection, and draping. The smoothness of
cooperation directly determines the length of anesthesia time before the
operation. Actually, the cooperation is due in large apart to the
surgeon’s leadership of the team, and the optimization measure might be
another aspect to foster leadership which could improve both safety and
efficiency in the OR[24].
In this study, we firstly investigated the time of each step and the
connection time between steps. We found that the links between two
adjacent steps were not close enough, and the procedures could be
overlapped at the same time were performed separately, resulting in a
longer time for the operation preparation. After discussions by multiple
surgeons, anesthesiologists, and operating room nurses, they agreed that
there are many optimizable process and then established some
optimization measures. In the subsequent controlled study, the
optimization measures were taken in the optimization group of patients
by multi-disciplinary cooperation, compared with the same period of
routine preparation procedures of the same operation. After the patients
of optimization group entering the operating room, It took 11.72 ± 0.30
minutes from the start of anesthesia induction to the start of
operation, which is significantly shorter than 31.96±0.51 minutes of the
control group, which confirms that the optimization measures we have
established are feasible and effective. We further analyzed the time
spent in each procedure during the surgical preparation of the supine
and lithotomy positions and found that the time of proficient procedures
was similar (such as catheterization, disinfection, draping, etc.), but
the time between two adjacent procedures has significant differences
(such as from the end of anesthesia induction to the start of
catheterization, from the end of catheterization to the start of
disinfection, from the end of the draping to the start of operation in
the supine position operations; from anesthesia start to adjacent
posture, the end of adjacent posture to start disinfection, and the end
of draping to the start of operation of lithotomy position).
ERAS is not limited to surgery at present, and it is not entirely up to
the surgeon. With the outreach of the concept of ERAS, it is necessary
to pay more attention the perioperative period. Cooperation of the
entire medical team such as surgeons, nurses, anesthesiologists, could
help us exploring a more complete, safe, and feasible operating
procedure and operating system management mode. The preoperative
preparation process could be optimized through good communication and
close cooperation of members in the team. The optimized measures could
make the connection process between operations smoother, and could
further reduce the anesthesia time on the premise of ensuring the
safety, not only promote the rapid recovery of patients, and improve the
operating room turnover efficiency, saving more medical resources at the
same time.