Case schedule

[SJH]

I'm a circulator and I'm curious how other hospital handle their case scheduling and add ones. I'm getting very frustrated because the cases that are scheduled in my assigned room change constantly. I am on our ortho team but I often circulate other specialties.

When I arrived at work this morning my room was scheduled for two lap choles (general), a skin grafting (plastics), followed by and ORIF distal radius (ortho). We started the first chole and they move the plastics case to a different room. About an hour later they moved the ortho case to a different room. Then moved a colorectal case in to follow the choles. . Soon after they moved the colorectal case back out and put the ortho case that was originally in my room back in. Lastly, they put a lap appy add on in. All of these changes were made in an 8 hour period. And keep in mind that we usually run 16 rooms and only had 8 running today because the case load was low due to the holidays. Add on's were minimal and we had plenty of staff standing around. Is it normal for cases to be moved around like this at other hospitals? There are times when the cases in my room change 4 - 6 times in 8 hours. And all the rooms are like this so it's not just mine.  And it's also not uncommon for a room to go from a lithotomy OB/Gyn case, to prone neuro case on a Jackson table, to a supine vascular case on a stille. It's almost impossible to prepare in advance with all the changes they make through the day and it feels so inefficient to constantly move beds and equipment in and out of the same room. We have two robot rooms but none of the other rooms are assigned to a specialty. Any feedback is appreciated.

[Rose_Queen, BSN, MSN, RN]

How it is where I work:

Block time has a schedule for when it releases, sometimes 48 hours before start of day and sometimes 24 or even 6 hours before start of day. Once block time is released, it's fair game for anyone to book cases in that room. Even if it's generally an ortho room, it may end having any service there. Same for team members- if the case volume isn't there for their service line, the expectation is that they scrub/circulate whatever is scheduled. Then there's the fact that anesthesia has more say than the charge nurse over where and when cases go.

There are just so many moving parts that go into what is essentially playing Tetris with cases, especially with add ons:

• who booked their case when (unless emergent or urgent, add ons are typically completed in the order they are booked)
• availability of the surgeon (are they in the office seeing patients? are they operating somewhere else?)
• availability of the anesthesia provider (this may be why you had staff standing around- you had people, but anesthesia didn't so can't open another room)
• availability of instrumentation, especially cases involving *shudder* loaner sets that have to be brought in and sterilized
• availability of the patient (are they coming in from the office? in the ED? on the floor? when did they last eat? are there any concerning labs that would require additional treatment before surgery is safe like an elevated INR?)

You don't mention how long you've been a circulator or whether you've ever taken the charge role. I would encourage you if you haven't had the opportunity to try to spend a day with the charge nurse to see the "behind the scenes" process of surgery Tetris. It's surprising how much you can learn about the why and how. I'll be honest and say that charge is a thankless role, because you have surgeons chomping at the bit to get their cases done, anesthesia wanting to get cases done, and staff who push back when what's in their room changes. I only lasted two years in the role, and it wasn't even on day shift where the bulk of the cases happen. Then again, I also had more surgeons pestering me about their add on cases sooooo.......

[SJH]

Thanks for the response. The cases that are being moved around aren't add on cases or being moved because of add on cases. We often have about staff to open an add on room so those cases can go pretty quickly.  I understand all the moving parts but at this hospital it doesn't  matter if we have 20 cases or 65 cases. They move scheduled cases around constantly. As soon as you hit procedure stop they start playing tetris. So when you get back from PACU you have a different surgery. No call, no page, no warning that you are getting a different case. Our CRNA's are even starting to complain about it.