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The OR Schedule vs. Teaching
Elizabeth Davis, RCDS, Alejandro Escobar, M.D., Jan Ehrenwerth, M.D., Gail Watrous, R.N., Paul Barash, M.D.
Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, United States.
Introduction: In a University setting does peri-induction teaching increase intra-operative costs by lengthening the time to surgical incision? We undertook this independent observer based study to detail actual time spent teaching in the period from patient on table to skin incision and to compare teaching vs non-teaching elective cases.

Methods: Following IRB review, trained observers were randomly assigned to one of the OR's to collect data. Teaching was defined as "Any conversation or guided demonstration between members of the operating room team that transfers or imparts knowledge". Measurements were obtained using 5 minute units (stopwatch). Each unit was scored 1 if 50% or more of the total unit was spent teaching and 0 if < 50% or no teaching occurred. Percent teaching time (% teach = teaching units/total units∗100) was calculated for each patient. Time in minutes was noted for anesthesia release time (ART=induction start to anesthesia release for surgical prep and positioning), time of incision and case length. Data are expressed as mean +/- SD. Statistical analysis included the following tests: ANOVA, unpaired t-test, and linear regression, p<0.05 was considered significant.

Results: A total of 1558 cases were observed which included 15,551 total time units. Seventy-five percent (1167/1558) of cases had an element of teaching (% teach = mean 46.4% range 5-96%). In this group % teach was significantly associated with higher ASA Physical Status (ASA PS)(p = 0.004). Time of case start was also significantly associated with % teach (p=0.004). Non-predictors of % teach are: year of residency training and presence of invasive monitoring. In twenty five percent of cases (n=391/1558) no teaching occurred. Non-teaching cases (nteach) were compared to teaching (teach) cases to examine those factors that might identify differences. General anesthesia cases had a longer time to incision in teach than in nteach cases 10.7 units (+/- 3.6) vs 7.7 units (+/- 4.8), respectively (p=0.001). The period induction to tracheal intubation differed significantly (teach 2.6 units [+/- 1.4] vs nteach 2.1 units [+/- 0.8] p=<0.001). MAC, regional anesthesia and invasive monitoring showed no significant difference teach vs nteach (p=NS). In actual minutes ART was 41% greater for teach 23.5 min (+/- 15.9) vs. nteach 13.7 min (+/- 12.2) p = 0.001. Time to incision was 32% greater teach 45.4 min (+/- 22.7) vs. nteach 32.1 min (+/- 18.7). p=<0.001. Linear regression comparing % teach to incision time demonstrated a significant positive linear relationship (p=<0.001). Each percent increase in teaching contributes 0.18% increase in time to incision. Thus teaching accounted for a mean increase to incision of 6.6 minutes (Range 0.98-21.3). However, this represents only 3% of mean total case length time (6.6/223.5 min).

Conclusions: This study found increased percent teaching by ASA PS, time of case start and general anesthesia as primary technique. Depending on the complexity of an individual case, increased 'teaching opportunity' may significantly increase time to incision in a direct relationship to percent of teaching.

Supported by a research grant from Yale New Haven Hospital.

Anesthesiology 2003; 99: A1318