CRITICAL APPRAISAL

Effect of anesthesia Staffing Ratio on First-Case Surgical Start Time

York Chen, Rodney A. Gabriel, Bhavani S. Kodali, Richard D. Urman

Journal of Medical Systems, 40 (5) : 115-20 (2016)

Pradini
1506815610

Pembimbing
dr. Aries Perdana, SpAn-KAKV

Departemen Anestesiologi dan Terapi Intensif

Fakultas Kedokteran Universitas Indonesia
2019
GENERAL

What type of article is this (e.g., research /data-based, clinical paper, review, editorial?)
Research/data-based

If this is a research article/data-base article, what makes it this type of article? Identify
2-3 characteristics of the article.

1. End Product: The article presents original findings based on the conception of a
study design and its implementation.
2. Methodology: The article/study seeks to obtain data in a systematic fashion (e.g., the
introduction’s literature search, the attempt to measure variables consistently and
accurately in the methods section, the summation of findings in the results sections,
etc.).
3. Style: The article’s findings and design are presented in an objective and frank
manner (also discussing the limitations) in order that the reader may judge,
implement, question, and/or disregard the evidence.

State the research question posed by the authors :

How do anesthesia staffing ratios effected first case surgical start times?

APPRAISAL GUIDE COMMENTS

I. Are the results of the trial valid?
1. Did the study address a
clearly focused issue?
2. Did the authors use an
appropriate method to answer
this question?
Yes. The research question was stated clearly both in the abstract
and the introduction section of the research report.
The purpose of this study was to to evaluate the effect anesthesia
staffing ratios have on first case start times.
The need for the study was adequately substantiated in several
instances in the abstract and introduction section.
The design of this study was not clearly stated in the paper, but
from the method explained and the result of the study you can see

3. Were the cases recruited
in an acceptable way?
4. Were the controls selected
in an acceptable way?
that this study is a case control study with solo staffing ratio as
the control.
Data was collected retrospectively and analyzed over a period of
4 years and on more than 8,700 cases. The researchers examined
whether staffing ratios of attending only (solo staffing ratio),
attending working with 1 resident/certified registered nurse
anesthetist (CRNA) (1 to 1), or attending covering 2
residents/CRNAs (1 to 2) had a significant effect on first patient
in room time (FPIR) and first case on time start (FCOTS). And
comparing between those groups, which one has the best odds on
first case on surgical time start.
Yes. The sampling was total sampling (they gather all the data
between 2010-2014), recruited from datas saved in a computer
for the circulating nurse to log perioperative times in each OR,
including patient arrival into the operating room, induction start
and induction complete. From here we can say that the cases was
representative of a define population.
There was also an established reliable system for selecting all the
cases. First case start times were excluded if the case was added
on that morning or if the order of cases was changed. Only cases
originally scheduled for 7:30 am (9:30 am on Wednesdays) were
included in the study. FPIR on time was defined as the patient
entering the OR by 7:30, except for Wednesdays when elective
cases start at 9:30. FCOTS was defined as the time from patient
in room to induction complete. The cutoff was 20 min for all
cases except for cardiac and neurosurgery, which had a cutoff of
35 min.
There are several potential source of bias in this study. First, the
times used for calculation of FPIR and FCOTS are manually
entered by the OR circulator nurse. As a result, there is likely a
small amount of variability in the accuracy of those times due to
human error. Also, there may be some subjectivity in regards to
the induction complete time used to calculate FCOTS as what

5. Was the exposure
accurately measured to
minimise bias?
6. Aside from the
experimental intervention,
were the groups treated
equally?
7. Have the authors taking
account of confounding
factors in the design and/or in
their analysis?
II. What are the results/findings?
1. How large was the
treatment effect?
one nurse considers induction complete may not be the case for
another nurse or the anesthesia provider.
No, as what I stated before the times used for calculation of FPIR
and FCOTS are manually entered by the OR circulator nurse. As
a result, there is likely a small amount of variability in the
accuracy of those times due to human error.
Yes. There is no differences in way of calculating FPIR and
FCOTS in all groups.
Using retrospective data, the authors using multivariate logistic
regression in their analysis to take account of the confounding
factors
The bottom line result stated that there was statistically
significant difference in FCOTS across all services when
controlling for ASA PS, age and ABUs. Although it is not the
case for FPIR, but the analysis was appropriate for the design by
using a univariate logistic regression to determine if ASA PS, age
group,base units,or staffing ratios were associated with FPIR and
FCOTS. The following reference groups were chosen for each
group : ASA PS I for ASA PS, age less than 50 in the age group
(compared to 50–64 years old, 65–79 years old, and>80 years
old), base units less than or equal to 5 in the base units group
(compared to 6–10,11–15,or>15), and solo staffing ratio
(compared to 1 to 1 and 1 to 2). All were associated with FCOTS
and FPIR outcomes and were therefore included in the
subsequent multivariate logistic regression analysis. For both
FPIR and FCOTS, a multivariate logistic regression model was
fitted to the data to determine if staffing ratios were associated

2. How precise was the
estimate of the treatment
effect?
3. Do you believe in the
results?
III. Will the results help locally?
1. Can the results be applied
to the local population?
2. Do the results of this study
fit with other available
evidence?
with FPIR and FCOTS. ASA PS, age group, and anesthesia base
units (ABU) were used as covariates for this model. This analysis
was done for all surgeries and then separately for each surgery
group. Results were reported as odds ratios (OR) with their
corresponding 95 % confidence interval (CI). ORs were
considered statistically significant if the 95% CI did not include
1.00 within its range and if p values <0.05. Billing data consisting
of the ABU value was used to control for case complexity.
They presented their statistical results on Table 1-3. from the
tables we can see that the p-value and odds ratio on each cases
group was statistically significant with a considerable large size.
Yes. The design and methods of this study sufficiently flawed to
make the results unreliable
Yes it is. Though the study is targerted in the authors own
institution but by using univariate and multivariate logistic
regression in the analysis they can show the clear correlation
between staffing ratios and OR time metrics. And help us to
understand how variations in an anesthesia team model can
change efficiency measures.
Hard to say. While there is quiet a lot study describing risk factors
affecting OR time metrics but there is limited published data
analyzing the effects of anesthesia staffing ratios on OR time
metrics.