Economic impact of prolonged tracheal extubation times on operating room time overall and for subgroups of surgeons: a historical cohort study

Abstract

Background: Prolonged tracheal extubation time is defined as an interval ≥ 15 min from the end of surgery to extubation. An earlier study showed that prolonged extubations had a mean 12.4 min longer time from the end of surgery to operating room (OR) exit. Prolonged extubations usually (57%) were observed during OR days with > 8 h of cases and turnovers, such that longer OR times from prolonged extubation can be treated as a variable cost (i.e., each added minute incurs an expense). The current study addressed limitations of the generalizability of these earlier investigations.

Methods: The retrospective cohort study included cases performed at a university hospital October 2011 through June 2023 with general anesthesia, tracheal intubation and extubation in the OR where the anesthetic was performed, and non-prone positioning. The primary endpoint was the interval from end of surgery to OR exit. Mean OR time differences with/without prolonged extubation were analyzed pairwise by surgeon. The variance among surgeons was estimated using the DerSimonian-Laird method with Knapp-Hartung adjustment for the sample sizes of surgeons. Proportions were analyzed after arcsine transformation, and the inverse taken to report results.

Results: There were prolonged extubations for 23% (41,768/182,374) of cases. Prolonged extubations had a mean 13.3 min longer time from the end of surgery to OR exit (95% confidence interval 12.8-13.7 min, P < 0.0001). That result was among the 71 surgeons each with ≥ 9 cases having prolonged extubation times and ≥ 9 cases with typical extubation times. Results were similar using a threshold of ≥ 3 cases, comprising 257 surgeons (13.2 min, P < 0.0001). Among the 71 surgeons with at least nine prolonged extubations, on most days with a prolonged extubation during at least one of their cases, there were > 8 h of cases and turnover times in the OR (77%, 73%-81%, P < 0.0001). Results were similar when analyzed for the 249 surgeons each with ≥ 3 cases with prolonged extubation (76%, P < 0.0001).

Conclusions: Matching earlier findings, prolonged tracheal extubation times are important economically, increasing OR time by 13 min and usually performed in ORs with lists of cases of sufficient duration to treat the extra time as a variable cost.

Keywords: Airway extubation; Anesthetics; Inhalational; Models; Operating rooms; Statistical.

Fig. 1

Graphical portrayal of the influence of prolonged times to tracheal extubation on the interval from the end of surgery to operating room exit. The green percentages show the frequency when the increase in time would represent a variable cost from a long-term perspective, including (when rational) small revisions to staff scheduling [4, 5]. The threshold used was 8 h because, for suites with workloads less than 8 h, small differences in operating room time are not independently associated with significant increases in overutilized time [4, 5]. The sample sizes of 71 and 257 surgeons, respectively, shown in the figure, had at least one eight-week period with least 9 (or 3) cases with a prolonged extubation and at least 9 (or 3) without a prolonged extubation. The sample sizes for the percentages shown in green font were 71 and 249 surgeons, respectively, with at least one eight-week period of at least 9 (or 3) cases with a prolonged extubation during a regular workday. There is the value of 12.4 min with red circle because our previous study estimated that, pairwise by surgeon, prolonged extubations were associated with mean 12.4 min longer from end of surgery to operating room exit (standard error of the mean 0.6 min) [2]. The objective of the current study was to address the multiple limitations, with the earlier study, listed in the Introduction