title: Improving operative flow during pediatric airway evaluation: a quality-improvement initiative.
abstract: OBJECTIVE
  Microlaryngoscopy and bronchoscopy procedures (MLBs) are short-duration, high-acuity procedures that carry risk. Poor case flow and communication exacerbate such potential risk. Efficient operative flow is critical for patient safety and resource expenditure.
  
  
  OBJECTIVE
  To identify areas for improvement and evaluate the effectiveness of a multidisciplinary quality-improvement (QI) initiative.
  
  
  METHODS
  A QI project using the "Plan-Do-Study-Act" (PDSA) cycle was implemented to assess MLBs performed on pediatric patients in a tertiary academic children's hospital. Forty MLBs were audited using a QI evaluation tool containing 144 fields. Each MLB was evaluated for flow, communication, and timing. Opportunities for improvement were identified. Subsequently, QI interventions were implemented in an iterative cycle, and 66 MLBs were audited after the intervention.
  
  
  METHODS
  Specific QI interventions addressed issues of personnel frequently exiting the operating room (OR) and poor preoperative preparation, identified during QI audit as areas for improvement. Interventions included (1) conducting "huddles" between surgeon and OR staff to discuss needed equipment; (2) implementing improvements to surgeon case ordering and preference cards review; (3) posting an OR door sign to limit traffic during airway procedures; and (4) discouraging personnel breaks during airway procedures.
  
  
  METHODS
  Operating room exiting behavior of OR personnel, preoperative preparation, and case timing were assessed and compared before and after the QI intervention.
  
  
  RESULTS
  Personnel exiting the OR during the MLB was identified as a preintervention issue, with the surgical technologist, circulator, or surgeon exiting the room in 55% of cases (n = 22). The surgical technologist and circulator left the room to retrieve equipment in 40% of cases (n = 16), which indicated the need for increased preoperative preparation to improve case timing and operative flow. The QI interventions implemented to address these concerns included education regarding break timing, improvements in communication, and improvements in ordering and preparation of equipment. After the QI intervention, the surgical technologist exiting rate decreased from 20% (n = 8) to 8% (n = 5), and the circulator exiting rate decreased from 38% (n = 15) to 27% (n = 17). In addition, the rate of surgeon exiting decreased significantly (from 25% [n = 10 of 40] to 9% [n = 6 of 66]) (P = .03). The surgical technologist and circulating nurse remaining in the room were significantly associated with decreased operating time (1.84-minute decrease for surgical technologist [P = .04] and 1.95-minute decrease for circulating nurse [P = .001]).
  
  
  CONCLUSIONS
  Gains were made in personnel exiting behavior and case timing after implementation of the QI interventions, potentially leading to decreased risk. This process is easily reproduced and is widely accepted by stakeholders.
authors.affiliation: Department of Otolaryngology, University of Colorado School of Medicine, Aurora2Department of Pediatric Otolaryngology, Children's Hospital Colorado, Aurora.
authors.forename: Jeremy D
authors.initials: JD
authors.lastname: Prager
authors.affiliation: Department of Otolaryngology, University of Colorado School of Medicine, Aurora2Department of Pediatric Otolaryngology, Children's Hospital Colorado, Aurora.
authors.forename: Amanda G
authors.initials: AG
authors.lastname: Ruiz
authors.affiliation: Department of Pediatric Otolaryngology, Children's Hospital Colorado, Aurora.
authors.forename: Kristin
authors.initials: K
authors.lastname: Mooney
authors.affiliation: Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora.
authors.forename: Dexiang
authors.initials: D
authors.lastname: Gao
authors.affiliation: Department of Anesthesiology, University of Colorado School of Medicine, Aurora5Department of Anesthesiology, Children's Hospital Colorado, Aurora.
authors.forename: Judit
authors.initials: J
authors.lastname: Szolnoki
authors.affiliation: Division of Otolaryngology, Children's National Medical Center, Washington, DC.
authors.forename: Rahul K
authors.initials: RK
authors.lastname: Shah
mesh_terms: D000046:Academic Medical Centers; D001999:Bronchoscopy; D054869:Clinical Audit; D003120:Colorado; D003142:Communication; D017598:Efficiency, Organizational; D006776:Hospitals, Pediatric; D006801:Humans; D007828:Laryngoscopy; D009873:Operating Rooms / Q000458:organization & administration*; D010348:Patient Care Team; D061214:Patient Safety; D058996:Quality Improvement; D013996:Time and Motion Studies