Logistics and efficiency on a surgery day (Proceedings)

Running a high volume spay neuter operation requires much more than having efficient surgeons. Everything about the operation from scheduling appointments and intake of patients to discharge of patients after surgery must be organized and run efficiently. A chain is only as strong as its weakest link and a spay/neuter operation is only as efficient as its slowest component. While this presentation describes the operations of a high volume spay neuter clinic the concepts presented here can easily be transferred to any spay neuter function.

What are the tasks?

The obvious

     • Scheduling appointments

     • Intake of cases

     • Patient assessment

     • Patient induction

     • Presurgical prep

     • Anesthetic management

     • Surgery

     • Anesthetic recovery

     • Post-operative evaluation

     • Patient discharge

     • Maintaining medical records

Behind the scenes

     • Cleaning surgery suite(s), prep room(s), recovery area, cages/runs etc

     • Preparing surgery packs

     • Restocking

     • Ordering supplies

Appointments

To run efficiently any spay neuter program needs to run on an appointment only basis. The program must have a system to determine how many of each type of surgery can be performed in any given day. This decision must be based on the financial targets of the organization as well as the capacity of the system based on veterinary surgeon's skills, technical assistance available, hours of operation, and available facilities. In our spay neuter program we use a point system with adult dog spays counting 5 points, puppy spays counting 4 points, cat spays counting 3 points, adult dog castrations 2 points, and puppy and cat castrations 0 points. We can easily handle 70 points a day and this is with veterinary students performing a majority of the surgeries. Each program will have to determine its own ideal system and then strive to operate at maximum capacity. It is wise to anticipate up to a 5% no show rate and up to a 5% decline for surgery rate. To operate at maximum capacity, therefore, appointments are scheduled up to 110% of maximum. Occasionally you will get "burned" by this overbooking, but not often.

Intake of cases

To function effectively the program must have specific drop off and pick up time for patients. Staggering patient arrivals and discharges through the day is extremely disruptive and interferes greatly with efficient operations. Humane Alliance schedules all arrivals to occur between 8 am and 9 am and all discharges at 7:30 am the next morning except for surgeries on Fridays. For Friday surgeries discharges are at 5 pm the same day. Universal appointment and discharge times allow you to efficiently schedule personnel for the day and gives the veterinarians the opportunity to evaluate all patients before starting surgery.

Ideally, an office representative greets the clients, initiates the paperwork, and collect fees. The client and patient are then directed to a veterinary technician who confirms that the patient has been held off food for the appropriate time period, obtains a medical history and determines any obvious medical concerns.

Patient assessment

All patients must receive a physical examination by a licensed veterinarian. Ideally, the veterinarian who will be performing the surgery conducts this exam. The results of the examination, coupled with the medical history, are used to make the final determination as to whether or not to perform the surgery. All females should be examined for the presence of a spay scar; all males examined for the presence of testicles. It is up to the clinic/veterinarian to determine what medical conditions would disqualify a patient from surgery at that time, but every effort should be made not to anesthetize an animal that has already been spayed or neutered.

Patient induction

Each clinic/veterinarian will determine the acceptable anesthetic protocol and what situations might require a variation in anesthetic protocol. Many protocols involve preanesthetic sedation of the patient. When this is used it should be administered approximately 20 minutes prior to induction of anesthesia. The protocol we used is a combination of Ketamine®, butorphanol and dexmedetomidine. This is given IM to cats and puppies and the patients generally reach a surgical plan of anesthesia in 5 minutes. The same drug combination is given IV to adult dogs. A dose by weight chart is posted at the induction table to avoid the possibility of calculation errors and to expedite the induction process (See appendix). We administer an NSAID at the time of induction.

Presurgical prep

Hair is clipped from the surgical site and vacuumed off the patient. A lint roller is used to remove any small hair fragments that may stick to the skin at the surgical site and the patient is prepped with an appropriate presurgical scrub agent. We use chlorhexidine scrub. The surgical site is left covered with a chlorhexidine soaked gauze sponge until and during transport to the surgical suite. This sponge is removed once the patient is positioned and secured on the surgical table.

Anesthetic management

Each clinic/veterinarian will make the determination of whether or not patients need to be intubated. After induction we routinely place patients on a facemask with oxygen and only turn on gas anesthetic agent (Isoflurane®) if a patient starts to get light during surgery. With students performing most of our surgeries we still only have about 1 in 10 that requires Isoflurane®. The only animals that we routinely intubate are brachycephalics and extremely obese patients. Appropriate monitoring equipment is connected, for example pulse oximeter, but the staff is trained to carefully observe physiological parameters such as heart rate, respiratory rate, pulse rate and character, mucus membrane color and capillary refill time.

Surgery

The ideal surgery suite is set up with two surgical tables for one surgeon. To achieve maximum efficiency while the surgeon is performing surgery on one patient the next patient is induced, prepped, transported to the surgery suite and positioned on the surgery table. Sterile surgical packs, scalpel blades and the appropriate suture material are all opened and ready when the surgeon finishes the first surgery. In this way no time is wasted between surgeries. The surgeon finishes one patient, changes gloves and moves directly to the second patient. The most expensive component of any surgery program is the surgeon and you don't want the surgeon standing around waiting on the next patient. If your goal is 30 surgeries per surgeon per day and there is even just a 3 minute delay between finishing one surgery and starting the next surgery the wasted time for that surgeon is 90 minutes a day.

Anesthetic recovery

Patients should recover in the presence of medical staff. There are lots of options here. Humane Alliance uses what they call the beach and animals actually begin to recover on the floor of the operating room in full view of the surgeon and the support team. In this manner patients can be carefully observed and any delays in recovery or abnormal physiological parameters can be quickly noted and addressed. Once a patient is able to lift its head and begins to attempt to ambulate it should be moved to a quiet darkened room with minimal external stimuli. This allows the patients to finish recovery in calm area with minimal stress.

Post-operative evaluation All patients should be examined prior to discharge from the clinic. Patients should be conscious, mentally alert, and able to ambulate at the time of discharge. Incision sites should be clean and dry with no signs of swelling, active hemorrhage or self-trauma.

Patient discharge

All clinics must decide if patients will be discharged the afternoon of surgery or the morning after surgery. Humane Alliance routinely discharges patients at 8 am the day following surgery. The exception to this protocol is Fridays. On Fridays patients are discharged late in the afternoon the day of surgery.

When the owner/caretaker arrives to pick up their pet(s) a technician or veterinary assistant goes to retrieve the animal(s) while office personnel collect payment for services. The technician or veterinary assistant must check the animal(s) ID to ensure that they are retrieving the correct animal(s). He/she performs a final check of the patient examining the skin incision, the color of the gums, and the level of consciousness. Any concerns are brought to the attention of the veterinary surgeon prior to delivering the animals to the owner/caretaker.

If no complications are noted the patient is delivered to the owner/caretaker. All post-operative instructions are relayed to the owner/caretaker orally and given to him/her in writing as well. It is most efficient to have prepared standard discharge instructions for each of the procedures with a space for any recommendations specific to each patient.

Maintaining medical records

Generating the medical record is a responsibility of the office personnel and entry of specific patient data is the responsibility of the medical staff. The examining veterinarian enters results of the initial physical examination. The veterinary technician enters all information related to induction of and maintenance of anesthesia and the specifics of the surgical procedure. The veterinarian who conducts the post-operative patient evaluation enters results of that exam.

Cleaning surgery suite(s), prep room(s), recovery area, cages/runs etc.

     • Cleaning is an ongoing process throughout the day.

     • Kennel areas/cages and runs: As soon as a patient is discharged the cage or run is cleaned and sanitized in preparation for the next patient. When a patient is taken out of the kennel area for induction the cage/run should be immediately cleaned and disinfected.

     • Surgery suite: When a patient comes off a surgery table, the table is immediately cleaned in preparation for the next patient. The suite is cleaned thoroughly after the last surgery.

     • Prep room: The prep room table is cleaned between patients. The entire prep room is cleaned while the last surgery is being performed.

Preparing surgery packs

Ideally, packs are processed between surgeries, but never at the expense of getting the next surgery patient induced and prepped for surgery. If time permits surgery instruments are washed and run through the sonic cleaner immediately after use. Linens are collected and washed and dried as soon as a full load is obtained. Surgery and drape packs are assembled and autoclaved. Depending on staffing it may not be possible to keep pace with the surgeon(s) and get all packs processed between surgeries. If this is the situation completion of the pack preparation must wait until after surgeries are finished.

Restocking

Inventory lists should be maintained for each area of the clinic. Each list should indicate all items that should be present in the room and designate minimum and maximum quantities. Whenever an item is depleted to the minimum level of stocking it should be restocked to the maximum. Ideally this restocking would occur between surgeries in order to prevent the medical staff from ever running out of a needed item.

Ordering supplies

All inventoried items should be stored in a central location, also with designated minimum and maximum quantities. Office personnel should be responsible for reordering items when they reach the minimum in the central location.

Putting it all together

Basic objectives

Even though the mission of a spay neuter program is to spay and neuter as many patients as possible efficient systems and surgeries do not take precedent over patient health and safety.

The primary objectives, therefore, of any high volume spay neuter system include:

     • ensuring that all patients sent to surgery are safe anesthetic and surgery candidates,

     • performing all anesthetic and surgical procedures safely and efficiently with minimal risk to the patients, and

     • efficiently processing all patients in a manner that surgeons are never waiting for the next surgery patient.

Systems

All systems are designed for maximum efficiency.

All patients are seen on an appointment only basis and all appointments are set within a short (for example, 1 hour) timeframe. During this hour office personnel and all medical personnel are directed towards efficient intake of animals, taking medical histories and patient evaluations. Office personnel admit the patients, initiate the medical records, collect payment for services (perhaps) and transfer the patients to a veterinary technician or veterinary assistant. The veterinary technician collects the history, confirms that food has been withheld from the patient for the appropriate amount of time, and quickly examines the animal for any serious medical problem or injury that could disqualify the patient from surgery. While patients are being admitted the veterinarian(s) with the help of the veterinary assistant(s) are performing preoperative physical examinations. In this manner all patients are admitted, all medical records initiated, and all physical examinations are performed in a systematic way in little over 1 hour.

Once all patients are processed the surgeries should begin. The veterinary technician(s) with the help of the veterinary assistant(s) induce the first patient(s) and prep it for surgery while the surgeon(s) are checking the anesthesia machines and ensuring that the surgery rooms are ready. Once the first patient is prepped and placed on the surgery table and the surgeon is scrubbed and gowned and gloved for surgery the first surgery is started. Immediately the technician and assistant induce and prep the next patient. Their goal is to have the next patient placed on the second table and sterile instruments, scalpel blade, and suture opened and available while the surgeon is finishing up the first patient. When the surgeon places the last suture he/she should be able to immediately re-glove, move to the second table (the second patient), and begin the next surgery. In this manner the surgeon simply moves from one patient to the next with no delays between surgeries. Once the second patient is placed on the second surgery table the prep table is cleaned and made ready for the next patient.

When the surgeon has moved to the second table, the veterinary technician and assistant remove the first patient and place it in the recovery area. The recovery area can be in the surgery room in clear view of the surgeon or in the prep area in clear view of the medical staff. They then clear the used instruments and linens from the first table, clean the first table, and begin the induction and prep of the next patient. If there is time, while the surgeon is performing this second surgery, the instruments care cleaned, linens placed in a washing machine, and packs reassembled for autoclaving. Under no circumstances should preparation of packs interfere with getting the next patient prepped and on the table. Any instrument, linen and pack preparation that cannot be done between surgeries is delayed until all surgeries are completed.

Whenever a patient is removed from a cage or run kennel personnel clean and disinfect the areat hat cage/run should be cleaned and disinfected.

When all surgeries are finished the veterinarian(s) conduct post-operative examinations of all patients while the veterinary technicians do a final cleaning of the surgery room and prep room and restock supplies for the next day. Surgery pack preparation is finished. When medical personnel leave at the end of the day all rooms and packs should be ready for the next day.

Depending on the schedule for discharging the patients all patients should be fed. Pediatric patients should be fed immediately upon recovery. All patients should be provided water as soon as they are ambulatory in a controlled manner.

Conclusions

The systems employed by high-volume spay neuter clinics can be employed in any clinic situation. With trained personnel, appropriate systems, and efficient surgeons it is not unreasonable to safely perform 30 surgeries per day per surgeon.

Note:

Much of this paper is based upon materials produced by Humane Alliance and available on the Humane Alliance website: http://humanealliance.org/

All procedures / protocols described are consistent with the ASV guidelines for spay neuter programs: Looney, A.L., Bohling, M.W., Bushby, P.A., et al. (2008) The Association of Shelter Veterinarians veterinary medical care guidelines for spay-neuter programs. Journal of the American Veterinary Medical Association. 233, 74-86.