........................................................................

CHAPTER 11

V O L U M E T H I R T Y - S E V E N

STAFFING
AND CASE
SCHEDULING FOR ELECTIVE
OUT-OF-OPERATING
ROOM CASES

ALEX MACARIO, M.D., M.B.A.

PROFESSOR
DEPARTMENTS OF ANESTHESIA AND HEALTH RESEARCH & POLICY
STANFORD UNIVERSITY SCHOOL OF MEDICINE
STANFORD, CALIFORNIA

EDITOR: MEG A. ROSENBLATT, M.D.

ASSOCIATE EDITORS: JOHN F. BUTTERWORTH IV, M.D.
JEFFREY B. GROSS, M.D.

The American Society of Anesthesiologists, Inc.

........................................................................
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c 2009

The American Society of Anesthesiologists, Inc.
ISSN 0363-471X
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 Staffing and Case Scheduling for Elective
Out-of-Operating Room Cases

Alex Macario, M.D., M.B.A.

Professor
Departments of Anesthesia and Health Research & Policy
Stanford University School of Medicine
Stanford, California

We would like anesthesia coverage for our cases in out-of-OR location

ABC. Can you help us out?

What does one do with such a phone call? A good first step in this increasingly
frequent scenario is to look at your contract with the hospital, and see what language
exists for covering elective out-of-operating room (OR) cases. If this is the first time
that the anesthesia group has been asked to cover off-site cases, then discussion with
the hospital is in order. In contrast, the anesthesia group could have previously
negotiated that off-site cases will be covered by an anesthetist at the convenience of
the radiologist, gastroenterologist, plastic surgeon, or other out-of-OR proceduralist.
This approach requires obtaining financial support, sometimes referred to as a
service agreement, from the hospital to provide the anesthesia group with sufficient
compensation for professional services so that it can deliver the anesthesia care
requested in these often haphazardly scheduled out-of-OR locations. A good first step
is to define the anesthetizing locations and hospital services to be covered.
According to a 2005 survey of hospital contracts by the Medical Group
Management Association, 57% of hospitals provided some kind of contractual
compensation to anesthesiologists in 2004, up from approximately 50% in 2000. The
marginal cost of each additional anesthesiologist or nurse anesthetist demands that
anesthesia groups work with their hospitals and out-of-OR services to schedule cases
in the most economically viable way.
An anesthesia group has several important groups of people for whom it provides
service, including patients, surgeons, nurses, and hospital administrators. Properly
managing the relationship with the hospital administrator customer such as on issues
related to out-of-OR cases is an important goal. Otherwise, the anesthesia group runs
the risk of losing the right to be the exclusive provider of anesthesia services at that
facility. Conflicts have been reported in which the relationship has deteriorated to
the point that the anesthesia group leaves en masse. One factor in such a separation
can be opposing views on anesthesia service requirements. For example, a view
commonly held by anesthesiologists is that there is a limitless demand for anesthesia
services with or without compensation. In contrast, the administrator’s view may be
that the hospital is an extremely valuable location in which an anesthesia group can
serve as an exclusive provider, possibly expressed as ‘‘They ought to be paying us for
the constant flow of business they get.’’1
In fact, administrators know little about anesthesia. They are usually unaware of
the supply or demand for anesthetists (until there is a shortage), have little
experience with roles/culture of anesthesia groups (until there is a dispute), and

Copyright Ó2009 American Society of Anesthesiologists, Inc. 129

130 MACARIO

usually have many other pressing concerns such as, for example, a pending labor
dispute with the nurse union, or whether to partner or directly compete with
another hospital in town.
Hence, a proactive approach to staffing and case scheduling for out-of-OR cases
is helpful. A functional anesthesia service outside the OR will generate operational
and financial advantages for the hospital that are many multiples of the anesthesia
revenues. The goal for the anesthesia group is to work with the hospital and the
multiple out-of-OR services to schedule cases in a way that is economically viable for
all parties. This reflects the hospital’s desire to retain and grow physicians’ practices,
to enhance market share and reputation, and to fulfill community-service missions.
Optimizing out-of-OR scheduling has financial implications for all stakeholders.
Some anesthesia groups manage the uneven demand by assigning an anesthesiologist
daily to do ‘‘utility infielder’’ work for out-of-OR cases Monday through Friday, with
hours of 7:30 AM until 4:00 PM, for example. The list of their responsibilities includes
sites throughout the hospital, but often consists of electroconvulsive therapy, bone
marrow biopsy, and cardiology catheterization laboratory, or endoscopy. Sometimes
out-of-OR cases are simply added to the waiting list, but this is unsatisfactory to
everyone involved.
Some out-of-OR work can be urgent (e.g., coiling of cerebral aneurysm) or
emergent (e.g., wound closure for a child). These patients present different issues.
This chapter addresses only elective out-of-OR cases. Out-of-OR anesthetics can be
challenging not only because the anesthetizing environment differs from the OR, but
also in the scheduling issues that these cases will demonstrate.
With proper management, an efficient (well-functioning) out-of-OR elective
schedule can be in place. The goals of this chapter are to address scheduling of
elective out-of-OR cases with particular focus on

(1) the importance of case scheduling to minimize overutilized time

(2) the challenges of scheduling anesthesia services outside the operating room
(3) reviewing how Current Procedural Terminology (CPT) codes for out-of-OR cases
are not predictive of anesthesia times
(4) the recommendation that out-of-OR anesthesia block time be restricted to
services that average at least 10 hours of cases every 2 weeks. An ‘‘overflow
block’’ (i.e., first come-first scheduled time) is made available for any spillover
cases or services that have less than 10 hours cases/week
(5) The importance of computer-based enterprise-wide scheduling so that control of
scheduling of cases outside the OR is distributed to each out-of-OR service.

Out-of-OR Caseload Will Grow

There is much pent-up demand for out-of-OR anesthesia services. The shift to non-
OR settings will continue to expand, driven by cost savings (e.g., the office has lower
overhead than the OR), convenience for patients and physicians, desire by hospitals
to avoid sedation mishaps by nonanesthesiologists, and availability of new treatments
not dependent on a full-fledged OR. Although these increasing requests can be
burdensome to manage over the short term, the increasing needs indicate that
anesthesia services are valued in a growing number of venues. This is a positive trend
for the specialty over the longer term.
 OUT-OF-OR SCHEDULING 131

For anesthesia groups that primarily engage in medical direction of nurse

anesthetists, out-of-OR activities are out of the surgical suite by Medicare definition.
This means that medical direction is not possible as a result of geographic
restrictions, because all medical direction should occur within the OR suite. For
example, in one OR suite, if two cases are running late, one medical doctor could
cover two residents/certified registered nurse anesthetists. However, if there is one
case running late in the main OR suite, and one in a gastrointestinal laboratory that is
removed from the OR suite, then you need two anesthesiologists! In such practice
environments, endoscopic retrograde cholangiopancreatography may be commonly
scheduled in the OR with a certified registered nurse anesthetist to permit medical
direction.

Out-of-OR Scheduling Should Aim to Reduce Overutilized Time

Out-of-OR caseload may be inconsistent and the needed hours of anesthesia time
may vary widely from day to day (Fig. 1).
Nothing is more important in case scheduling than to allocate the appropriate
amount of time to each out-of-OR service on each day of the week.2 To illustrate
this, we will schedule two cerebral angiogram cases each lasting 2.5 hours into the
Radiology Suite Room 1 (Fig. 2, scenario 1). The radiology suite nurses and one
anesthesiologist are scheduled to work a 9-hour day. The matching of workload to
staffing has not been optimized. Little can be done on the actual day that the out-of-
OR procedures are performed to increase the efficient use of the nurses and the
anesthesiologist. Neither awakening patients more quickly nor reducing the turnover

8
Out-of-OR location #1 - October
average anesthesia hrs/weekday = 1.27
6

Anesthesia
4
Hrs/Day

0
10 /06
10 /06
10 /06
10 /06
10 /06
10 /06
10 /06
/1 6
/1 6
/1 6
/1 6
/ 6
/1 6
/1 6
/1 6
/1 6
/1 6
/2 6
/2 6
/2 6
/2 6
/2 6
/2 6
/2 6
/2 6
/2 6
/2 6
/3 6
/3 6
06
10 9/0
10 0/0
10 1/0
10 2/0
10 3/0
10 14/0
10 5 /0
10 6/0
10 7/0
10 8/0
10 9/0
10 0/0
10 1/0
10 2/0
10 3/0
10 4/0
10 5/0
10 6/0
10 7/0
10 8/0
10 9/0
10 0/0
1/
/2
/3
/4
/5
/6
/7
/8
/
10

Day of the month

FIG. 1. Anesthesia hours per day vary from day to day (0 hour to more than 8 hours for this
out-of-operating room [OR] location). The variability prompted the anesthesia group to form a
team that included the hospital administrator, scheduling personnel, the out-of-OR
proceduralist, and a representative from the anesthesia group to better coordinate case
scheduling.
132 MACARIO

Scenario #1: Under-utilization (each case is 2.5 hrs plus 1 hr turnover)

8AM 5PM

Case # 1 Case # 2

9 hrs block of anesthesia coverage

Under-utilized time (3 hrs)

Scenario #2: Over-utilization

8AM 5PM

Case # 1 Case # 2 Case # 3 (4 hrs)

9 hrs block of anesthesia coverage

Over-utilized Time (2 hrs)

FIG. 2. Underutilized hours reflect how early the room finishes. In scenario 1, if an
anesthesiologist and a radiology nurse were scheduled to work from 8 AM to 5 PM and instead
the room finished at 2 PM (including 1-hour turnover), then there would be 3 hours of
underutilized time. The excess staffing cost would be 33% (3 hours/9 hours). In contrast, for
scenario 2, 11 hours of out-of-operating room (OR) cases are performed in the out-of-OR
location with staff scheduled to work 9 hours. This means that the excess staffing cost is 36%
(2 hours/9 hours ¼ 18%, which is then multiplied by a ‘‘fudge’’ factor of 2 to include the
additional monetary and morale cost of staff staying late).

time, for example, will compensate for management’s poor initial choice of staffing
for Radiology Suite Room 1 or how the cases were scheduled in Room 1.
The optimal amount of block time to be allocated to a particular service should
minimize the amount of underutilized time and the more expensive overutilized
time.3
In contrast, if 11 hours of out-of-OR cases are performed in an out-of-OR location
with staff scheduled to work 9 hours, then the excess staffing cost is 36%4 (Fig. 2,
scenario 2). Overutilized hours are the hours that rooms run longer than the
regularly scheduled end time, or 2 hours in this example. Two hours/9 hours ¼ 18%,
which we then multiply by a ‘‘fudge’’ factor of 2 to include the additional cost of staff
staying late. One component of this is the monetary time and a half overtime cost
paid to staff, and the second is the recruitment and retention costs related to
disgruntled staff unexpectedly forced to work extra hours.
The key is to allocate appropriate time to each out-of-OR service based on
historical use. With that in mind, how does one deal with out-of-OR locations that
consistently run late? The answer: increase the size of the block time. For example, if
the interventional radiologist performs 12 hours worth of cases needing anesthesia
on 1 day every 2 weeks, do not assign 9 hours of interventional radiology block time
(8 AM to 5 PM) and have the anesthesiologist and interventional radiology nurses
frustrated by having to stay late. Rather, assign 12 hours of block time (8 AM to 8 PM)
so that anesthesia and nursing staff know they will be there 12 hours when they
arrive at work; overtime costs (particularly in terms of morale) will be reduced.
The common response to this approach is, ‘‘No one wants to be in the
interventional radiology room till 8 PM.’’ The answer to this is, ‘‘You are there now till
8 PM, so why not make scheduled interventional radiology time 12 hours and have a
more predictable workday duration?’’
Optimizing staffing costs requires that one find the best balance between
overtime and finishing early. Involvement by a high-level member of the facilities’
 OUT-OF-OR SCHEDULING 133

TABLE 1. Potential Out-of-OR Locations

Adult cardiac catherization laboratory
Pediatric cardiac catherization laboratory
Radiation oncology
Pediatric MRI
Adult MRI (occasionally patient needs anesthesia)
Pediatric CT
Adult CT
Gamma Knife noninvasive cerebral surgery
Interventional radiology laboratory
Electroconvulsive therapy suite
Office-based cosmetic surgery
Dental office
Gastrointestinal suite (e.g., colonoscopy)
Infertility clinic for oocyte retrievals
Pediatric specialty clinics (e.g., hematology--oncology)
Positron emission tomography scans

CT ¼ computed tomography; MRI ¼ magnetic resonance imaging; OR ¼ operating room.

administrative staff is often necessary to bring the budget and staff needed for
anesthesia time blocks for out-of-OR work.

Challenges of Scheduling Anesthesia Services

Outside of the Operating Room
Interestingly, despite only being a small fraction of the total caseload
(approximately 0.4% at a large academic medical center5), out-of-OR may represent
an important fraction of the sites needing anesthesia coverage first thing in the
morning (Table 1).
The median number of anesthetizing sites for anesthesia groups in the United
States rose from 20 in 2004 to 23 in 2006, whereas median encounters per site fell by
10%.* These data support the hypothesis that provider workload has not increased at
the same rate as the number of sites that groups must cover. This ‘‘horizontalization’’
of practice can stretch the anesthesia group’s ability to promptly provide staff.6
Furthermore, out-of-OR cases have different characteristics than OR surgical cases
that affect their management6 (Table 2).

CPT Codes for Out-of-OR Cases Are Not Predictive of

Anesthesia Times
Computed tomography/magnetic resonance imaging (CT/MRI) anesthesia time
estimates based on historical CPT codes are strikingly inaccurate. CPTs are not as
reliably predictive of out-of-OR anesthesia times as they are for surgery cases. One
study found that for CT and MRI imaging cases (with overall average duration of 2
hours), the mean percentage error in case duration estimate equaled 45%, which was
less accurate than for OR cases of comparable durations in which the average error
was 27%.8 CT and MR imaging cases have many different CPT codes, and most are
rare. The most common CPT (70553, MRI of brain without contrast) accounted for
31% of MR imaging anesthetics, and the most common three CPTs accounted for
44% of these anesthetics.

*
http://www.asahq.org/Newsletters/2007/12-07/Abouleish1207.html. Accessed July 12, 2008.
134 MACARIO

TABLE 2. Differences Between the Surgical Suite and Out-of-OR Anesthetizing Locations
K Out-of-OR locations are not as interchangeable as normal ORs. For example, a pediatric
electrophysiologist cannot perform his next case in the CT suite
K Out of-OR services are often small, composed of only one or a few physicians. Depending
on how time is allocated and cases scheduled, variation in workload at each location on
any day will be larger (e.g., as a result of physicians’ absences, vacations/meetings that will
be more noticeable with a small physician group than with a bigger group)
K Whereas OR turnover times are driven to be as brief as 15 to 20 minutes, out-of-OR
turnovers can be 1 hour or more. This is especially true when the change involves a move
from one geographic area to another. Factors increasing turnover times include the need
to transport patients to the PACU (sometimes through a maze of halls and elevators), and
the need to move the anesthesia machine and drug cart to a new location
K An anesthesiologist can cover only one site at a time outside the OR. For example, an
anesthesiologist supervising CRNAs/residents may do a preoperative evaluation on his
OR’s next patient during the current case. This becomes difficult when the next out-of-OR
case will be done at another site
K Diagnostic radiology cases (CT/MRI) that require anesthesia are often single cases (at least
in adult hospitals), in the middle of a list of other cases not needing anesthesia. As a result,
most facilities do not assign anesthesia blocks exclusively for CT/MRI cases requiring
anesthesia. It becomes challenging to predict a single case’s duration
K Unlike CT or MRI, interventional radiology cases requiring anesthesia are often scheduled
sequentially in one room so the management challenge is to estimate when the workday
will end, not just the duration of one case
K Relief for meals, bathroom breaks, and end of day for anesthesia providers working in the
interventional radiology suite present scheduling issues7

CRNA ¼ certified registered nurse anesthetist; CT ¼ computed tomography; MRI, magnetic resonance
imaging; OR ¼ operating room; PACU ¼ postanesthesia care unit.

Using the International Classification of Diseases, Ninth Revision, Clinical

Modification (ICD-9-CM) procedure codes instead of CPTs yields even less accuracy.
One cause of this inaccuracy is that the procedure codes reflect organs imaged, not
scanning times. For example, ICD-9-CM 88.38 could either be CT of the sinuses or
CT of the pelvis, which can differ by 10 minutes in scanning time. As a second
example, ICD-9-CM 88.97 could be either MRI of the abdomen or of the orbit, which
differ in scan duration. Differences in anesthetic times also arise based on the speed
of the machine used for imaging.
Often one can use estimates provided by a knowledgeable radiology technologist
to reduce the error 8 (Table 3).
Similarly, a diversity of procedures is performed during pediatric cardiac
catheterizations. Here, the most common CPT code accounted for 18% of anesthetics,
and the three most common CPTs accounted for 39% of anesthetics. Compared with
pediatric cardiac catheterization and CT/MRI, it is even more difficult to schedule
anesthetic times for interventional radiology cases. Again, the CPT codes are not
predictive and the anesthetics administered are usually long (average duration 4
hours).8 The three most common interventional radiology CPT codes accounted for
77% of interventional radiology anesthetics. The interventional radiology CPT (61624)
accounted for 63% of anesthetics. This CPT code encompasses a multitude of
procedures and does not specify the size of the lesion---‘‘transcatheter permanent
occlusion or embolization (e.g., for tumor destruction, to achieve hemostasis, to
occlude a vascular malformation), percutaneous, or any method’’ that involves the
‘‘central nervous system (intracranial, spinal cord).’’
Because interventional radiology often schedules their elective cases into
allocated time, the necessary end point that would be nice to predict with some
 OUT-OF-OR SCHEDULING 135

TABLE 3. Example From One Facility of Expert Estimate of Median Anesthesia Duration of
Diagnostic Radiology Cases
CT Case MRI Case
Thirty minutes (for anesthesia preparation, Forty-five minutes (anesthesia preparation,
induction, emergence, transport) induction, emergence, transport)
Plus 5 minutes scan time each for head, Plus 45 minutes scan time
facial bones, sinuses, or cervical spine Plus 30 minutes scan time if total spine or
Plus 15 minutes scan time each for brain, abdomen/pelvis extending into the thighs
neck, thorax, abdomen, pelvis, or thoracic Plus 15 minutes scan time if not using the
spine Siemens Avanto
Plus 5 minutes if not using the Siemens
six-slice spiral CT

For anesthetics performed in CT or MRI suites, each facility should use its radiology technologists and
anesthesia billing data to replace the numbers in Table 3 with its own values.
CT ¼ computed tomography; MRI ¼ magnetic resonance imaging.

accuracy is the finish time for the day’s entire list of cases, including turnovers.
Methods have been published to determine the time (e.g., 4 PM) up to when
interventional radiology can post an elective schedule to result in an 80% likelihood
that the anesthesia team will finish no later than a specified time (e.g., 6 PM).8

Provide Enough Open Access Anesthesia Time So That Each

Specialty Can Accommodate Most of Its Out-of-OR Cases
Within 2 Weeks
One reasonable approach is to provide anesthesia coverage for elective out-of-OR
patients within a defined number of ‘‘wait’’ days. As previously noted, 50% of US
patients stated that 2 weeks was the longest acceptable wait time for a procedure.9
Patient expectations for acceptable wait times will likely vary by country and by
medical system.
If the anesthesia department normally plans 10-hour workdays (from 7 AM to 5 PM)
for their anesthetists, then an out-of-OR service requesting anesthesia coverage
should receive a 1-day block of time provided that service averages at least 10 hours
of cases, including turnovers, every 2 weeks.10 The threshold of 10 hours is set high
to ensure that the allocated time remains filled.11,12 The anesthesia time commitment
needs to be a fixed time to reduce the likelihood that the proceduralist will wander
off (e.g., to do consults) leaving the anesthetist with dead time during the workday.
If the out-of-OR service has a new elective case needing to be scheduled and all
the allocated time (block) is filled for the next 2 weeks, then additional ‘‘overflow’’
time (i.e., first come first scheduled ‘‘unblocked’’ time) is made available on another
day of the week for the extra case.11 This way, the new case can be performed
within 2 weeks, but not by extending the duration of the original 10 hours staffed
workday. A service guarantee of a maximum patient waiting time removes the
argument that the anesthesia department is causing patients to wait unnecessarily
long. The service guarantee is no longer a commitment to a particular block (e.g., 10
hours) of anesthesia coverage but that the case will be performed within 2 weeks or
whatever time period that is mutually agreed on. One goal for the anesthesia group
136 MACARIO

TABLE 4. Example: Allocations of Two 10-hour Blocks/Day for Elective Out-of-OR Cases
During Each 2-Week Cycle for One Hospital
Monday Adult cardiology, pediatric cardiac catheterization
Tuesday Neuroradiology, MRI/CT
Wednesday Adult cardiology, open overflow time
Thursday Interventional radiology, MRI/CT
Friday Adult cardiology, pediatric cardiac catheterization

CT ¼ computed tomography; MRI ¼ magnetic resonance imaging; OR ¼ operating room.

could be to generate 8 hours of anesthesia billing time/day, while completing work

each day by 5 PM (Table 4).
By allowing professional practices to grow, open access scheduling increases
revenues for the hospital and the anesthesia group (but not necessarily at the same
rate per hour as in the OR). Planning for future staffing has the potential for
greater accuracy when the total hours of anesthesia time used in the past can be used
to forecast future needs.13 Without open access, previous workload can under-
estimate future needs if estimates of the previous workload excludes patients who
did not receive care because the wait was too long or no appointment could be
made.14

Example: Electrophysiology Laboratory

Let us assume that the anesthesia department has been requested to provide 10
hours of staffing each week for each of two adjacent electrophysiology rooms. The
total procedure times averaged 36 hours, including turnovers, every 2 weeks with a
standard deviation of 9 hours. A 40-hour allocation is made because

1. The electrophysiologists’ data reflected in-room times, whereas anesthesia

times would be longer
2. If patients will be provided service within a reasonable number of weeks, more
time needs to be allocated to services with relatively large variations in
workload. Large variations in workload among weeks and rooms will result
from there being long cases that cannot be ‘‘packed’’ well.15 Electrophysiology
has many such cases
3. The relative cost of an hour of overutilized time was assumed to be twice the
cost of a scheduled hour. This implies that for every 1 day that goes late, 2 days
should finish early

Example XYZ
Data analysis for out-of-OR location XYZ is summarized in Table 5. On Mondays,
how much anesthesia time (e.g., 8, 10, 12, 13 hours) should be allocated to XYZ?

Efficiency of use of out-of -OR time ¼

½hours of underutilized time þ
½hours of overutilized time multiplied by a fudge factor ðusually assumed to be 2Þ to
account for overtime=staff morale:
 OUT-OF-OR SCHEDULING 137

TABLE 5. Dates and Number of Anesthesia Hours, Including Turnovers, for Out-of-OR
Location XYZ
Mondays 4/2/ 6 4/9/ 6 4/16/ 8 4/23/ 10
2007 2007 2007 2007
Tuesdays 4/3/ 4.5 4/10/ 8.67 4/17/ 18.94 4/24/ 7.25
2007 2007 2007 2007
Wednesdays 4/4/ 7.75 4/11/ 11.02 4/18/ 6.13 4/25/ 5.8
2007 2007 2007 2007
Thursdays 4/5/ 9.42 4/12/ 0 4/19/ 4.48 4/26/ 0
2007 2007 2007 2007
Fridays 4/6/ 6.32 4/13/ 8.37 4/20/ 0 4/27/ 0.67
2007 2007 2007 2007

Normally, the minimum amount of data to make this determination would be 2 to 3 months worth of
Monday with 9 months being preferred.
OR ¼ operating room.

When you run the numbers for this example using this efficiency formula, it
computes that 8 hours is the optimal allocation on Mondays because this amount
mathematically minimizes underutilized and the more expensive overutilized time.
In this particular situation, with an 8-hour allocation and 6, 6, 8, and 10 hours of
work on successive Monday, there would be 2, 2 and 0 hours of underutilized time,
respectively, for the first three Mondays and 2 hours of overutilized time, multiplied
by 2, for the fourth Monday for a total of 8 inefficiency hours. No other OR allocation
(e.g., 7, 10, 13 hours) gives a lower amount of inefficiency hours. This efficiency
hour analysis would be repeated to calculate optimal allocated time duration for each
day of the week. Any additional caseload can be covered by the overflow anesthesia
time.

Example: Electroconvulsive Therapy

Sometimes a hospital will experience improved efficiency in out-of-OR work,
more by luck than design. At this facility, the hospital negotiated to have all
electroconvulsive therapy (ECT) carried out by a single psychiatrist. This avoided
delays on account of waiting for the next psychiatrist to show up. Because ECT
patients are often hospitalized or require prompt care, the psychiatrist service is
provided open access to anesthesia time on 3 days each week. A psychiatry nurse
uses a web site to enter how many ECTs have been scheduled for each of the next
three ECT sessions (1 week). Specific patients continue to be scheduled into the OR
information system on the working day before ECTs. Once the data are entered,
software calculates a short-term forecast of the number of ECTs to plan on that day
and the predicted end time, after which the anesthesia providers can be scheduled
elsewhere. The result is e-mailed to the scheduler assigning anesthetists.

Example: Using Utilization as a Metric for Changing Out-of-OR Block

Time
Utilization of out-of-OR allocated anesthesia times can be computed in two ways,
raw and adjusted. Raw utilization is the total numbers of hours that the patient is
in room divided by the hours of allocated block time. Adjusted utilization adds in a
‘‘time credit’’ to the numerator for the turnover times so as to not penalize out-of-OR
services that have short cases and can do many cases within a block. Conventional
wisdom has always been that utilization is a commonly used criterion for changing
out-of-OR block time, but this has important limitations (Table 6).
138 MACARIO

TABLE 6. Top 10 Limitations to Using Utilization as a Metric for Changing Out-of-OR Block
Time16
1. Optimal utilization differs among subspecialties
Not all proceduralists can achieve utilization 4 90%. For example, the office-based
cosmetic surgeon is much more likely to know in advance what cases she is doing---and fill
up her out-of-OR time months ahead of time, than the electrophysiology cardiologist who
only knows a day or two in advance which patients will require evaluation
2. Utilization is poorly related to contribution margin. Contribution margin ¼ hospital revenue
generated by a surgical case, less all the variable costs resulting from the hospitalization.
If an out-of-OR procedure is paid by case rate, then a slow proceduralist will have high
utilization but low profitability for the hospital
3. Estimates of utilization are not accurate for individual out-of-OR physicians
Wide confidence intervals for utilization are likely for out-of-OR because of random
variations in the numbers of patients each week requesting treatment
4. Efforts to increase utilization can impair growth of some subspecialties
For example, recent newspaper articles have highlighted a hospital’s interventional
neuroradiology program. Grateful patient donations total $2 million. However, the two
neuroradiologists travel frequently and often cancel cases. The hospital benefits
strategically from the interventional procedures despite low utilization of the anesthesia
block time
5. Utilization percentages can be artificially inflated
The out-of-OR proceduralist purposely slows down at end of day (or wanders of between
cases) to fully utilize block, worried that block time will be reduced if utilization is low
6. Subspecialties with longer case durations will have lower utilizations
Cannot fit long cases (e.g., transjugular intrahepatic portosystemic shunts) as neatly into
block time as many short cases
7. Utilization correlates poorly with waiting times for quick access to free OR time
Although many facilities believe high utilization can be accomplished without sacrificing
access to out-of-OR time on short notice, these two aspects are not separable. The greater
the ‘‘out-of-OR utilization,’’ the less the convenience (able to book cases when desired) for
proceduralists and patients
8. Increasing utilization (without being mindful of differences in contribution margin/patient
from differing insurance plans) could reduce total revenues
Overall adjusted utilization at one hospital’s radiology suite is 90%. Some administrators see
the radiology suites as 10% empty. They think that revenues could be increased without any
change in staffing costs. The hospital signs a contract to become a preferred provider for an
additional insurance plan. The hospital will provide out-of-OR services on plan members at a
discounted rate in hopes of increasing utilization above 90%. However, the new patients
recruited at a discount displace more lucrative patients reducing revenues overall!
9. Utilization does not reflect the potential for future expansion
Some procedures are becoming extinct, whereas others are growing and therefore need to
anticipate growth areas and provide more out-of-OR time for those
10. Utilization may require ‘‘downstream’’ services
If proceduralist with high utilization performs cases that will be admitted to the ICU for
postoperative care and there are no available ICU beds, then giving more time to this out-
of-OR proceduralist ultimately would not work

ICU ¼ intensive care unit; OR ¼ operating room.

Enterprisewide Scheduling Enables Control of Out-of-OR

Scheduling to Be Distributed to Each Out-of-OR Service
Inherent problems in scheduling out-of-OR cases for anesthesia include the fact
that out-of-OR cases are often written on a paper calendar, whereas OR cases (at least
in the United States) are most often entered on an electronic schedule. In such a
system, rebookings/cancellations for out-of-OR anesthetics may not get passed on to
the anesthesia scheduler in a timely fashion.
 OUT-OF-OR SCHEDULING 139

Computer-based enterprisewide patient scheduling systems permit clerks, nurses,

physicians, or patients (e.g., through the Internet) to schedule appointments
throughout a multiple-specialty physician group or healthcare system. One
application of these systems is to coordinate patient scheduling in surgeons’ clinics
with patient scheduling in surgical suites or with out-of-OR areas. Better
synchronization of such schedules is an important objective. Just as some radiology
departments allow clerks at physicians’ offices to schedule radiologic procedures
through a web browser, and some clinics allow patients to schedule their own
appointments,17 the anesthesia department can allow clerks and nurses in other
departments to schedule directly into out-of-OR anesthesia time.18
Advantages to scheduling out-of-OR anesthetics using an enterprisewide schedul-
ing system include (1) clinic nurses and radiology schedulers do not have to phone
the anesthesia department and wait to see whether someone answers; and (2)
anesthetics can be coordinated with other appointments the patient may have on the
same date. For example, a patient’s schedule for the day might include preanesthesia
evaluation at 9 AM, anesthetic starting at 11 AM, CT machine at 11:30 AM, and oncology
clinic at 3 PM.
Deciding when patients should arrive for their out-of-OR case is also challenging.
When patients are told to arrive too early in the morning for a procedure scheduled
in the afternoon, they risk a long wait and the unpleasantness of remaining nil per os
(NPO) for most of the day. In contrast, when patients do not arrive early enough,
they may be unavailable in the event that a preceding case is cancelled or finishes
early.
Asking patients to arrive a fixed number of hours before their scheduled out-of-OR
procedure is less useful than an approach that calculates the earliest time that their
scheduled case could begin. A good rule of thumb is that if the preceding case is
cancelled or finishes early, the patient should be ready and waiting 19 times of 20.
Thus, OR staff should wait only 5% of the time. Mathematically, the earliest possible
start time is calculated from the scheduled and actual start times of historical cases
performed by the same suite, service, and day of the week.
Knowledge of ‘‘the earliest possible start time’’ for each case, in conjunction with
revised NPO guidelines, allows some patients to eat or drink on the morning of a
procedure with little chance their case would have to be postponed because of food
consumption. An example of a calculator that performs such analyses for one
hospital is available online at www.CaseDuration.com, a site of the Division of
Management Consulting of the Department of Anesthesia, University of Iowa.

Conclusions
Many anesthesia groups face increases in demand for anesthesia to facilitate
procedures performed outside the OR. In these settings, it may be difficult to keep an
anesthesiologist working all day without scheduling gaps. Providing a functional
anesthesia service outside the traditional OR is a common contributing factor to the
need for service agreements between anesthesia groups and hospitals, often
including a stipend for professional services. Involvement by a high-level
administrator of the facility is helpful to bring together the budget, data analysis,
staffing, and scheduling for out-of-OR cases. Anesthesiologists need good inter-
personal skills and greater flexibility to work successfully as part of a procedure team
outside the OR.
140 MACARIO

Staffing and case scheduling for out-of-OR anesthesia differs from that of ORs.
From the start, anesthesia departments should establish a goal to allow out-of-OR
patients to undergo their scheduled procedure within a reasonable number of days
(e.g., 2 weeks). A convenient way to accomplish this end is to provide the
proceduralists with open access to defined blocks of anesthesia-staffed out-of-OR
time. Generating a realistic schedule may require the direct input of the specialists
because it is difficult to predict the duration of out-of-OR cases. When an anesthesia
group is perceived by surgeons, hospital managers, and out-of-OR proceduralists as
being ‘‘service-oriented,’’ the anesthesia group will have an easier time negotiating
hospital support.
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