title: Lack of utility of a decision support system to mitigate delays in admission from the operating room to the postanesthesia care unit.
abstract: BACKGROUND
  When the phase I postanesthesia care unit (PACU) is at capacity, completed cases need to be held in the operating room (OR), causing a "PACU delay." Statistical methods based on historical data can optimize PACU staffing to achieve the least possible labor cost at a given service level. A decision support process to alert PACU charge nurses that the PACU is at or near maximum census might be effective in lessening the incidence of delays and reducing over-utilized OR time, but only if alerts are timely (i.e., neither too late nor too early to act upon) and the PACU slot can be cleared quickly. We evaluated the maximum potential benefit of such a system, using assumptions deliberately biased toward showing utility.
  
  
  METHODS
  We extracted 3 years of electronic PACU data from a tertiary care medical center. At this hospital, PACU admissions were limited by neither inadequate PACU staffing nor insufficient PACU beds. We developed a model decision support system that simulated alerts to the PACU charge nurse. PACU census levels were reconstructed from the data at a 1-minute level of resolution and used to evaluate if subsequent delays would have been prevented by such alerts. The model assumed there was always a patient ready for discharge and an available hospital bed. The time from each alert until the maximum census was exceeded ("alert lead time") was determined. Alerts were judged to have utility if the alert lead time fell between various intervals from 15 or 30 minutes to 60, 75, or 90 minutes after triggering. In addition, utility for reducing over-utilized OR time was assessed using the model by determining if 2 patients arrived from 5 to 15 minutes of each other when the PACU census was at 1 patient less than the maximum census.
  
  
  RESULTS
  At most, 23% of alerts arrived 30 to 60 minutes prior to the admission that resulted in the PACU exceeding the specified maximum capacity. When the notification window was extended to 15 to 90 minutes, the maximum utility was <50%. At most, 45% of alerts potentially would have resulted in reassigning the last available PACU slot to 1 OR versus another within 15 minutes of the original assignment.
  
  
  CONCLUSIONS
  Despite multiple biases that favored effectiveness, the maximum potential benefit of a decision support system to mitigate PACU delays on the day on the surgery was below the 70% minimum threshold for utility of automated decision support messages, previously established via meta-analysis. Neither reduction in PACU delays nor reassigning promised PACU slots based on reducing over-utilized OR time were realized sufficiently to warrant further development of the system. Based on these results, the only evidence-based method of reducing PACU delays is to adjust PACU staffing and staff scheduling using computational algorithms to match the historical workload (e.g., as developed in 2001).
authors.affiliation: From the Departments of *Anesthesiology and †Bioinformatics and Surgery, Vanderbilt University, Nashville, Tennessee; ‡Division of Management Consulting, Department of Anesthesia, University of Iowa, Iowa City, Iowa; §Department of Nursing, Vanderbilt University Medical Center; ¶Departments of Anesthesiology, Bioinformatics, and Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; and ‖Department of Anesthesiology, Jefferson Medical College, Philadelphia, Pennsylvania.
authors.forename: Jesse M
authors.initials: JM
authors.lastname: Ehrenfeld
authors.forename: Franklin
authors.initials: F
authors.lastname: Dexter
authors.forename: Brian S
authors.initials: BS
authors.lastname: Rothman
authors.forename: Betty Sue
authors.initials: BS
authors.lastname: Minton
authors.forename: Diane
authors.initials: D
authors.lastname: Johnson
authors.forename: Warren S
authors.initials: WS
authors.lastname: Sandberg
authors.forename: Richard H
authors.initials: RH
authors.lastname: Epstein
mesh_terms: D000761:Anesthesia Department, Hospital / Q000458:organization & administration*; D000762:Anesthesia Recovery Period; D001071:Appointments and Schedules; D001509:Bed Occupancy; D003441:Crowding; D003661:Decision Support Techniques; D017598:Efficiency, Organizational; D006801:Humans; D009870:Operating Room Information Systems; D009873:Operating Rooms / Q000458:organization & administration*; D010343:Patient Admission; D010360:Patient Transfer / Q000458:organization & administration*; D010561:Personnel Staffing and Scheduling / Q000458:organization & administration; D016528:Postanesthesia Nursing / Q000458:organization & administration*; D011997:Recovery Room / Q000458:organization & administration*; D012189:Retrospective Studies; D013714:Tennessee; D062606:Tertiary Care Centers; D013997:Time Factors; D016526:Workload