Introduction

The healthcare system in the United States continues to evolve with an increasing emphasis on high-quality, cost-effective, and efficient care. Enhanced recovery and clinical pathways for patients having surgery are now commonplace. These have been shown to decrease length of stay, potentially decrease costs, and improve outcomes [1,2,3,4,5,6]. Specific to the operating room, several reports have shown the positive impact of dedicated surgical teams on operating room efficiency [6,7,8,9,10].

The importance of efficient care and strategic staffing has been further highlighted by the COVID-19 pandemic. This has stressed hospitals and the medical system due to the volume of patients needing care, but now more recently, there is increasingly staffing shortages.

Our institution has invested significant resources to improve the quality and the efficiency of care for patients having spinal deformity surgery for adolescent idiopathic scoliosis [3]. While we have developed a robust pathway, it does not specifically call for a dedicated surgical team in the operating room. To identify ways to increase our OR efficiency in the current atmosphere of short staffing, as well as improve our clinical pathway, we sought to investigate the impact of a dedicated spine team. We hypothesized that all members of the surgical team—anesthesiologists, nurses, and surgical technologists—influence time in the operating room and that consistency with a dedicated team improves efficiency. In addition, we hypothesized that dedicated team members could improve clinical outcomes.

Methods

Prospective data were collected on consecutive patients undergoing PSF for adolescent idiopathic scoliosis within a standardized perioperative care pathway. All patients on this pathway during the study period were included. Three surgeons performed these procedures and were considered dedicated team members. The group of radiology technologists in our operating room is small and has all considered dedicated team members. Only those anesthesiologists who were part of the original care pathway implementation in 2015 were considered dedicated spine team members. Circulating nurses and surgical technicians were identified as dedicated spine team members by the orthopedic OR nurse coordinator who was not involved with this study. These individuals typically had extra training by working alongside our orthopedic nurse coordinator or experienced members of the team after showing interest in these cases. For all personnel, we only recorded the primary person assigned to the case and did not analyze those covering breaks, lunches, or shift change. Staffing of cases was performed by the OR nurse manager and anesthesiologist in charge each day and was not dictated by the care pathway.

Cases with 1 to 3 dedicated spine team members present (any combination of nurse, surgical technologist, and anesthesiologist) were compared to teams with no dedicated members. The cases with no dedicated team members served as our control. The impact of individual members was also analyzed. Demographics including height, weight, BMI, age, race, ethnicity, gender, and ASA classification were compared between groups as was the number of levels fused. Outcomes included surgical time, non-operative time, total operating room (OR) time, estimated blood loss (EBL), length of stay (LOS), and blood transfusions. Total operating room time was measured from the time the patient entered the operating room until the patient left. Surgical time was from incision until the dressing was applied. Non-operative time was the difference between total OR time and surgical time.

Certain outcomes (EBL, time outcomes, levels fused, LOS, and transfusions) were compared by the number of team members present (0, 1, 2, or 3). To evaluate whether any particular team member showed a significant effect on outcomes, each outcome was compared based on each type of member. For example, total OR time was compared between patients having a nurse who was a team member versus not a team member, regardless of the other providers. The same was done for the surgical technologist and the anesthesiologist.

Parametric or non-parametric tests were used for each outcome based on the distribution of the data points. These included one-way ANOVA models, Kruskal–Wallis tests, and Fisher’s exact tests. For those outcomes showing a significant effect, a linear regression model was performed across the number of team members. A trend test was performed to test whether there was a trend in mean outcome with an increasing number of team members. In addition, a regression model was run using zero team members as the reference and testing each increase in the number of team members against zero. These models yielded a coefficient for each team member group with estimates the mean change in outcome from having no team members.

Results

During the study period, March 2015 to July 2020, 367 patients had a PSF performed by the 3 orthopedic surgeons. Of the 29 anesthesiologists involved during the study period, 13 were members of the spine team and covered 77.6% of the cases. Six nurses, out of a total of 39 nurses, were spine team members but covered only 22% of the cases. There were 8 surgical technologists considered spine team members, out of 21 total, who covered 77.7% of the cases. In total, 16.3% of cases were covered by a complete dedicated team (3 out of 3 members), 51.8% with 2 out of 3, 26.2% with 1 out of 3, and 5.7% with no dedicated team members.

There was no difference in demographic characteristics, or the number of levels fused among the different groups, except gender (Appendix 1). Those cases with 2 or 3 team members present had significantly less females than those cases with no spine team member (p = 0.016).

Surgical time and total OR time were significantly decreased with the participation of each additional dedicated team member resulting in 43.86 min less surgical time and 50.8 min less total OR time when three spine team members were present compared to no team members (Table 1).

Table 1 Efficiency outcomes based on surgical team composition
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Independently, if the circulating nurse was a member of the spine team, the surgical time was lower by an average of 16.1 min (p = 0.037), but there was no difference in total OR time or non-operative time (Table 2). If the surgical technologist was a spine team member, the surgical time was lower by 24.0 min (p = 0.002) and total OR time was lower by 27.2 min (p = 0.001) (Table 3). Lastly, if the anesthesiologist was a member of the spine team, the non-operative time was lower by an average of 6.6 min (p = 0.003) (Table 4).

Table 2 Comparisons of outcomes if the circulating nurse was a dedicated spine team member
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Table 3 Comparisons of outcomes if the surgical technician was a dedicated spine team member
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Table 4 Comparisons of outcomes if the anesthesiologist was a dedicated spine team member
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No significant differences were observed in clinical outcomes including estimated blood loss, length of stay, blood transfusions, and pain scores based on dedicated team status (Table 5).

Table 5 Comparisons of clinic outcomes depending on team composition
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Discussion

The COVID-19 pandemic has stressed our medical system. During the various peaks, hospitals and ICUs were overwhelmed pushing physicians, nurses, and hospital staff to work long hours. However, as the acute inpatient needs of treating patients with COVID-19-related illnesses have decreased, a nationwide shortage of nursing and hospital staff has emerged [11]. Without a clear short-term solution to this problem, identifying more efficient ways to care for patients with limited resources is important, especially while trying to maintain quality care.

We sought to determine the effects of a dedicated spine surgical team on OR efficiency for patients having a PSF. The results were rather profound, showing a 43 min decrease in surgical time and a 50 min decrease in total OR time when the circulating nurse, surgical technologist and the anesthesiologist were members of the spinal fusion team for compared to a team without any dedicated members. Individually, these team members had a significant impact as well.

Our results support, and expand on, previously published work. Murgai et al. reviewed 146 patients treated for AIS [7]. This study reviewed the impact of circulating nurses and surgical technologists only, as all anesthesiologists were considered part of the spine team. The authors looked at all participants including breaks and relief for each case to calculate the percentage of nurses and technologists who were on the spine team. For cases covered by teams composed of > 60% dedicated nurses and surgical technologists, the surgical time and the total OR time were 27 min and 34 min shorter, respectively. In contrast to our research, this group found that dedicated teams resulted in lower EBL and less allogenic blood transfusions.

Flynn et al. published a reduction in total OR time of 77 to 111 min with the use of a dedicated spine team [6]. However, this report compared data before and after the implementation of a standardized protocol. In our research, we only reviewed patients after the implementation of our standardized pathway.

There are limitations of our study. First, it is a retrospective review of data. Second, we only did the analysis based on the primary circulating nurse, surgical technologist, and anesthesiologist. We did not account for breaks, relief, or trainees. Third, we did not evaluate outcomes based on experience or number of cases, but rather on our definition of being on the dedicated spine team. Finally, we did not evaluate the impact of our radiology technologists as there is a small group at our facility. Siddiqui et al. did find a decrease in fluoroscopy time and radiation dose with a dedicated spine technologist [12].

Implementing dedicated teams does have obstacles. With the current staffing shortages, ensuring that the spine surgical technologists and nurses are available is a challenge if there are multiple orthopedic surgery rooms running concurrently. Nursing leadership may prefer to have circulating nurses and surgical technologists rotate to maintain skills in multiple specialties rather than focus on a specific procedure. The fact that only 22% of our PSF cases were covered by a spine team nurse highlights this at our institution. Regardless, our data affirm the growing body of evidence that a dedicated spine team can improve efficiency in the operating room. While even one spine team member has an impact, having a more robust spine team maximizes efficiency. This time-saving is significant and could potentially allow for more cases to be performed in a day with the same surgical team.