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\begin{document}

\title{How to shorten anesthesia time through multidisciplinary team
collaboration in operating room}



\author[1]{Yiming Li}%
\author[1]{Chang Liu}%
\author[1]{Zhijun Zeng}%
\author[1]{Hao Yang}%
\author[1]{Chang Cao}%
\author[1]{Zhaohui Tang}%
\author[1]{Chengyu Wang}%
\author[1]{Chenghui Zhou}%
\author[1]{Yu Zhang}%
\author[1]{Jiqun He}%
\author[1]{Wei Wu}%
\affil[1]{Xiangya Hospital Central South University}%


\vspace{-1em}



  
  \date{May 25, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Background: How to shorten the anesthesia time is an important problem
to ERAS. The authors formulated a series of optimization measures and
verified that these measures could shorten the anesthesia time and
improve the operating room utilization efficiency by multidisciplinary
diagnosis and treatment pattern. Methods: 90 patients were random
selected to analyses the time of every preparing procedure and between 2
adjacent procedures, the multidisciplinary team established the
optimization measures accordingly. Then 95 patients for gastrointestinal
surgery received collaborative optimization measures that were
established after discussion among anesthesiologists, surgeons and
operating room nurses (optimization group), while 226 cases received the
conventional approaches (control group). The data obtained from
operating room monitoring recording of the two groups of patients were
analyzed. Results: The preparation times from the initial of induction
of anesthesia to start of surgery in optimization group were all
significantly shorter than those in control group (all
P\textless{}0.0001). In supine position surgery, the times from initial
of induction of anesthesia to start of urinary catheterization, from
urinary catheterization finish to start of disinfection, and from
completion of draping to start of surgery in patients receiving
optimization measures were all significantly superior to those receiving
conventional approaches (all P\textless{}0.0001); in lithotomy position
surgery, the times from the initial of induction of anesthesia to
positioning, from positioning finish to start of disinfection, and from
completion of draping to start of surgery in patients receiving
optimization measures were all significantly superior to those receiving
conventional approaches (all P\textless{}0.0001). Conclusions: The
established optimization measures based on multidisciplinary team
collaboration could significantly shorten the anesthesia time. The
optimized measures in this study are feasible and effective to shorten
the anesthesia time.%
\end{abstract}%



\sloppy


\subsection*{How to shorten anesthesia time through multidisciplinary
team collaboration in operating
room}

{\label{how-to-shorten-anesthesia-time-through-multidisciplinary-team-collaboration-in-operating-room}}

Yiming Li (M.D.) 1, Chang Liu (M.D.)1, Zhijun Zeng (Ph.D.)1, Hao Yang
(Ph.D.)1, Chang Cao (M.D.)2, Zhaohui Tang (Ph.D.)3, Chenghui Zhou
(M.D.)1, Yu Zhang (M.D.)1, Chengyu Wang (M.D.)1, Jiqun He (M.D.)2, Wei
Wu (Ph.D.)1

\begin{enumerate}
\tightlist
\item
  Department of Geratic Surgery, Xiangya hospital, Central South
  University, Changsha, China. (Y.L., C.L., Z.Z., H.Y., S.X., C.Z.,
  Z.Y., C.W., W.W.)
\item
  Operating Room, Xiangya hospital, Central South University, Changsha,
  China. (C.C., J.H.)
\item
  Department of Anesthesiology, Xiangya Hospital, Central South
  University, Changsha, China. (Z.T.)
\end{enumerate}

\textbf{Running Title:}

Shorten anesthesia time

\textbf{Correspondence:} Address correspondence to Dr. Wu: Department of
Geratic Surgery, Xiangya Hospital, Central South University, 78 Xiangya
road, Changsha, China, 410008. wwtw1972@126.com.

or

Dr. He: Operating Room, Xiangya Hospital, Central South University, 78
Xiangya road, Changsha, China, 410008. cshejiqun@126.com

\textbf{Research Support:}

Supported by the Chinese National Natural Science Foundation (Beijing,
China) grant No.81873581 and Hunan Science and Technology major project
(Changsha, China) grant No.2017SK1030.

\textbf{Competing Interests:}

The authors declare no competing interests.

Abstract:

\textbf{Background:} How to shorten the anesthesia time is an important
problem to ERAS. The authors formulated a series of optimization
measures and verified that these measures could shorten the anesthesia
time and improve the operating room utilization efficiency by
multidisciplinary diagnosis and treatment pattern.

\textbf{Methods:} 90 patients were random selected to analyses the time
of every preparing procedure and between 2 adjacent procedures, the
multidisciplinary team established the optimization measures
accordingly. Then 95 patients for gastrointestinal surgery received
collaborative optimization measures that were established after
discussion among anesthesiologists, surgeons and operating room nurses
(optimization group), while 226 cases received the conventional
approaches (control group). The data obtained from operating room
monitoring recording of the two groups of patients were analyzed.

\textbf{Results:} The preparation times from the initial of induction of
anesthesia to start of surgery in optimization group were all
significantly shorter than those in control group (all
P\textless{}0.0001). In supine position surgery, the times from initial
of induction of anesthesia to start of urinary catheterization, from
urinary catheterization finish to start of disinfection, and from
completion of draping to start of surgery in patients receiving
optimization measures were all significantly superior to those receiving
conventional approaches (all P\textless{}0.0001); in lithotomy position
surgery, the times from the initial of induction of anesthesia to
positioning, from positioning finish to start of disinfection, and from
completion of draping to start of surgery in patients receiving
optimization measures were all significantly superior to those receiving
conventional approaches (all P\textless{}0.0001).

\textbf{Conclusions:} The established optimization measures based on
multidisciplinary team collaboration could significantly shorten the
anesthesia time. The optimized measures in this study are feasible and
effective to shorten the anesthesia time.

\textbf{Key words:} Operating room, Enhanced recovery after surgery,
Optimization, Management, Anesthesia time.



\textbf{Introduction:}

Enhanced recovery after surgery (ERAS), also known as fast track surgery
(FTS), refers to the integration of multidisciplinary perioperative
treatment protocol aimed at acceleration of patient recovery. Various
research about surgery, anesthesia, and nursing have proved that a
series of evidence-based medicine optimization measures could bring
significant benefit to the patients, such as reduce trauma stress,
promote early recovery of body function, reduce the incidence of
postoperative complications and shorten the length of hospital stay
after surgery {[}1,2{]}. In recent years, the concept of ERAS has
rapidly expanded to different surgical disciplines, such as orthopedics,
thoracic surgery, general surgery, gynecology, and urology. At present,
ERAS is widely carried out mainly in the areas of preoperative
preparation, anesthesia management, analgesia, and nutrition support.
Among them, anesthesia runs through the entire surgical process and
provides appropriate surgical conditions to ensure the safety of
patients during the operation.

However, there are some serious risks during general anesthesia include
blood pressure change, heart attack or stroke. Therefore, how to shorten
the anesthesia time and then decrease those risk is an important problem
to ERAS {[}3{]}. Nevertheless, the current anesthesia management focuses
on the preoperative evaluation, induction models, anesthesia methods and
drugs, depth of anesthesia and intraoperative heat preservation, etc.
{[}4-9{]}, but often ignored the operating room Multi-disciplinary
collaboration between anesthesiologist, surgeon, and nurses and
optimizing workflows to reduce anesthesia time. At present, how to
reduce the anesthesia time through the management and optimization of
the operating room workflow has rarely been reported. This study
introduced how we formulated the optimization measures, and then
examined that the team of anesthesiologists, surgeons, and nurses in the
operating room collaborate to take a series of optimization measures
could shorten the anesthesia time and improve the operating room
utilization efficiency.

\textbf{Methods:}

\textbf{Formulation of optimization measures}

A random selection of 90 patients who underwent gastrointestinal surgery
in supine position in November 2017 was selected for the study. The
start time of anesthesia induction, the start time and end time of
catheterization, the start time and end time of prepare and drape the
operative site, and the start time of operation were obtained by the
monitoring recording in operating room. We calculate and record the time
of every procedure and between 2 adjacent procedures. After discussion
by 3 anesthesiologists, 3 surgeons, and 3 operating room nurses,
teamwork optimization measures will be established. (The researching
flow as show in the Fig 1)

\textbf{General information and data sources}

After establishment of the optimization measures, 321 patients for
gastrointestinal surgery were selected from 2017.12 to 2019 .02 to
examine whether the measures were effective. The surgery preparation
process for patients in the optimization group is led by the surgeon in
our department and is performed in close cooperation with the surgeon,
nurse, and anesthesiologist to implement the optimization measures
established in the discussion. Patients in other departments composed
the control group (the surgeons, anesthesiologists, and operating room
nurses in control group were not informed about the content of this
study. The data were obtained from operating room monitoring recording).
The control group of anesthesiologists, surgeons, and operating room
nurses performed the routine procedures.

\textbf{Inclusion criteria:} 1, 18 to 75 years old; 2, Gastrointestinal
surgery; 3, General anesthesia for tracheal intubation; 4. Urinary
catheterization in the operating room. \textbf{Exclusion criteria:} An
unexpected situation that caused the operation procedure to be
delayed(one 74-year-old man's false teeth fall into epiglottis during
orotracheal intubation, another 65-year-old man has difficult to insert
catheter and then had cystostomy, the data of the above two patients
were excluded from analysis because they are outlier). Firstly, we
recorded the start time of anesthesia induction, start time and end time
of urinary catheterization, start time and end time of disinfection,
start time of operation of the patients in the supine position
(catheterizing on the operating table before disinfection). Then
calculated the time from start of anesthesia to beginning of urinary
catheter, catheterization time, time from catheterization to start of
disinfection, disinfection time, draping time, time from end of draping
to start of surgery. we also recorded the start of anesthesia induction,
position start time and end time, disinfection start time and end time
of disinfection and draping, urinary catheterization start time and end
time, draping end time, operation start time of the surgical patients in
lithotomy position (catheterizing on the operating table after
disinfection), and calculated the time from the start of anesthesia to
adjusting posture, the time of adjusting posture, the time from the end
of the posture to the start of the disinfection, the time of the
disinfection, catheterization, and draping, the time from the end of
draping to the start of surgery.

\textbf{Statistics:}

SPSS 19.0 software was used for statistical analysis, the t-test was
used for the data between groups, and the \selectlanguage{greek}χ\selectlanguage{english}2 test was used for the count
data.

\textbf{Results:}

90 patients who underwent gastrointestinal surgery in November 2017 were
randomly selected. The total operation preparation time in the operating
room was 24.46 \selectlanguage{ngerman}± 1.16 minutes, and the time spent in each procedure is
shown in Table 1.

\textbf{Discuss to establish the optimization measures}

According to the time spent in each procedure shown in Table 1, the
establishment of optimization measures was determined after discussing
by a team including 3 anesthesiologists, 3 surgeons, and 3 operating
room nurses.

\textbf{The optimization measures:}

1) The scrub nurse should wash the hand before anesthesia, prepare the
items on the table and check the equipment, and prepare the
disinfectant. Circulating nurse place various equipment (including
laparoscope, trash can, electric knife, ultrasonic knife, etc.)
according to the type of operation. The circulating nurse prepares the
leg hanging device well first.

2) The surgeon start the procedure (the scrub nurse prepared well in
advance).

3) Anesthesiologist induces anesthesia; tow surgeon stand by, after the
patient loses consciousness, the circulating nurse undresses and poses
the patient; one surgeon catheterizes the urine, and the other one
surgeon prepare to disinfection. The disinfection of the surgical site
as soon as possible begins after catheterization and the circulating
nurse exposed the surgical site; the surgeon cooperate with the scrub
nurse or other doctors to drape the patient.

4) The surgeon and the scrub nurse cooperate to connect equipments
(electric knife, aspirator, ultrasonic knife, laparoscopic equipments,
etc.).

5) Check the patient and start the operation (start with the incision of
skin).

From December 2017 to February 2019, 96 patients in the optimized
surgical procedure group, 23 to 78 years old, 61 males and 35 females
(one 74-year-old male patient who lost dentures during tracheal
intubation and fell into the epiglottis, and the operation began after
the denture was took out, so this patient was withdrawed from the
study); 227 patients in the conventional control group, aged 202 to 76
years, 144 males and 83 females (one 65-year-old patient was difficult
to intubate the catheter. The suprapubic bladder puncture fistula
resulted in a delayed start of operation and was not included in this
study). There were no statistically significant differences between the
two groups in terms of factors such as gender, age, operative position,
and rate of intraday first operation. The two groups were comparable.
(Table 2).

The average preparation time in the optimized group from the start of
anesthesia induction to the start of operation was 11.72±0.30 minutes,
compared with 31.96±0.51 minutes in the control group, which has a
significant difference (Fig 2A). Clinically, there are some differences
in the pre-operative preparation between supine and lithotomy position.
The time of each procedure in the preparation process is also different.
Therefore, we further analyzed the time of preparation process of supine
and lithotomy group separately. The preparation time in the supine
position in the control group was 22.71± 0.49 minutes, while the time in
the optimized group was significantly lower than that in the control
group, which was 9.91 ± 0.13 minutes (p \textless{}0.0001, Fig 2B).
Then, we compared the time spent in each procedure between the optimized
supine surgery group and the corresponding control group. We found that
there was no significant difference in the time required for
catheterization, disinfection, and draping. The time 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, totaling 3 period of time were
significantly less than the control group (Fig 3).

The preparation time of surgery in the optimized lithotomy group was
15.83 ± 0.31 minutes, which was significantly less than the 32.49 ± 0.57
minutes of the control group (p \textless{}0.0001, Fig 2C). In the
optimized and control group of lithotomy position surgery, there was no
significant difference in time of adjusting posture, disinfection,
urethral catheterization and draping. Whereas the time from end of
anesthesia to adjusting posture, the end of adjusting posture to start
of disinfection, end of disinfection to start of urethral
catheterization, and the end of draping to the start of operation were
significant different between 2 groups, and the optimized group was
significantly shorter than the control group (Fig 4).

\textbf{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.

\textbf{Conclusion:}

Multi-disciplinary team collaboration and cooperation can significantly
shorten the anesthesia time by optimizing the surgical preparation
process. The optimization measures established in this study are
feasible and effective to shorten the anesthesia time.

\textbf{Table Legends:}

Table 1 Time of each procedure and between procedures before
Optimization

Table 2 Comparison of Optimized group and Control group

\textbf{Figure Legends:}

Fig 1 The researching flow chart.

Fig2. Comparison of Optimized group and Control group(A), Optimized
supine group and the corresponding control group(B), Optimized lithotomy
group and the corresponding control group (C).(***
\emph{P}\textless{}0.0001)

Fig3. Comparison of each procedure in optimized supine group and the
corresponding control group. (*** \emph{P} \textless{}0.0001)

Fig4. Comparison of each procedure in optimized lithotomy group and the
corresponding control group. (*** \emph{P} \textless{}0.0001)

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Table 1 Time of each procedure and between procedures before
Optimization\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
Preparation procedures & Time(minutes)\tabularnewline
\midrule
\endhead
Start of anesthesia to the beginning of urinary catheterization &
7.73\selectlanguage{ngerman}±4.52\tabularnewline
Urinary catheterization & 3.21\selectlanguage{ngerman}±3.36\tabularnewline
End of catheterization to start of disinfection &
8.43\selectlanguage{ngerman}±4.13\tabularnewline
disinfection & 2.05\selectlanguage{ngerman}±2.91\tabularnewline
Draping & 3.47\selectlanguage{ngerman}±3.87\tabularnewline
End of draping to start of operation & 7.85\selectlanguage{ngerman}±4.94\tabularnewline
Total preparing time & 31.75\selectlanguage{ngerman}±4.29\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{ngerman}

Table 2 Comparison of Optimized group and Control group\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
& Optimized group & Optimized group & Control group & P\tabularnewline
Sum & Sum & 95 & 226 &\tabularnewline
Gender & Gender & & & 0.9842\tabularnewline
Female & Female & 35 & 83 &\tabularnewline
Male & Male & 60 & 143 &\tabularnewline
Age & Age & & & 0.8957\tabularnewline
[?]50 & [?]50 & 39 & 91 &\tabularnewline
\textgreater{}50 & \textgreater{}50 & 56 & 135 &\tabularnewline
Position & Position & & & 0.7063\tabularnewline
Supine position & Supine position & 68 & 157 &\tabularnewline
Lithotomy position & Lithotomy position & 27 & 69 &\tabularnewline
Order of the operation & Order of the operation & & &
0.7112\tabularnewline
The first operation of the day & The first operation of the day & 16 &
42 &\tabularnewline
Not the first operation of the day & Not the first operation of the day
& 79 & 184 &\tabularnewline
Time(min) & Time(min) & 11.72 \selectlanguage{ngerman}± 0.30 & 31.96\selectlanguage{ngerman}±0.51 & \textless{}
0.0001\tabularnewline
\bottomrule
\end{longtable}

Figure 1\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

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Figure 2\selectlanguage{english}
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Figure 3\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

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Figure 4\selectlanguage{english}
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\textbf{Hosted file}

\verb`Tables.docx`  available at \url{https://authorea.com/users/353363/articles/477298-how-to-shorten-anesthesia-time-through-multidisciplinary-team-collaboration-in-operating-room}\selectlanguage{english}
\begin{figure}[H]
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\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Fig2-Comparison-of-Optimized-and-Control-group2/Fig2-Comparison-of-Optimized-and-Control-group2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Fig3-Comparison-of-each-procedure-in-supine-group2/Fig3-Comparison-of-each-procedure-in-supine-group2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
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\includegraphics[width=0.70\columnwidth]{figures/Fig4-Comparison-of-each-group-in-lithotomy-position2/Fig4-Comparison-of-each-group-in-lithotomy-position2}

\end{center}
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