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.