Efficiency of Foot and Ankle Surgeries Completed on the Preoperative Stretcher vs Operating Room Table: A Randomized Controlled Trial

Abstract

Background:

Extremity surgeons frequently operate on the preoperative stretcher rather than the operating room (OR) table. This study sought to identify differences between stretcher-based (SB) and OR table–based (TB) procedures with regard to time efficiency and OR team member preferences.

Methods:

We conducted a prospective randomized controlled trial comparing the efficiency of SB vs OR TB foot and ankle procedures. Fifty-two patients undergoing a hardware removal, isolated gastrocnemius recession, soft tissue procedure, or foreign body removal at our day surgery unit were included. Start time and exit time were recorded. “Start time” was the number of minutes between the patient entering the OR and first incision. “Exit time” was the number of minutes between the procedure ending and the patient exiting the OR. Surveys were disseminated to OR staff who participated in the included cases.

Results:

The total measured time in the OR was an average 6 minutes shorter in the Stretcher group compared to the OR Table group (10 minutes vs 16 minutes, P < .001). SB procedures were associated with a significantly shorter start time (median difference = 4 minutes, P = .001), but not exit time (median difference = 1 minute, P = .058). No difference was found in actual surgical time. Thirty (96.8%) OR team members perceived SB procedures as enhancing OR efficiency, and 30 (96.8%) respondents considered SB procedures to be equal or superior to OR TB procedures in terms of patient safety. All would recommend or strongly recommend SB procedures.

Conclusion:

We found SB foot and ankle procedures to require less room time than OR TB procedures. Particularly for high-volume specialties, an average 6 minutes saved per case may meaningfully improve overall OR efficiency. Most OR team members believed that SB surgery improves OR efficiency and is the safer option for OR team members.

Level of Evidence:

Level II, randomized controlled trial, survey.

Introduction

Operating rooms are simultaneously a primary revenue stream and significant cost for hospital operations. ³ With rising demands for surgical services, increasing procedure expenses, and diminishing reimbursements, health systems are seeking opportunities to streamline surgical processes and maximize operating room efficiency. Such efforts are particularly relevant within elective orthopaedic surgery, which is reported to have the highest median revenue per case at ambulatory surgery centers ¹² and has been shown to generate 39% of hospital reimbursement and 35% of hospital net revenue in the United States. ¹

Within elective orthopaedic surgery, as little as 54% of OR time may be spent actually operating. ¹⁷ Consequently, efforts to enhance OR efficiency often focus on optimizing aspects outside of the time dedicated to performing the surgical procedures themselves. These efforts have the greatest potential in specialties performing many small cases leading to numerous OR cycles in each surgical day. For example, reducing carpal tunnel and trigger finger release procedure times by 4 minutes was found to result in an annual cost savings of approximately US$46 335. ¹⁰ Additionally, a study by Gonzalez et al ⁹ found that a 3-minute decrease in short-leg splint application time could lead to 30 minutes saved per day.

As such, foot and ankle surgeons frequently choose to perform simple procedures on the preoperative stretcher to avoid the need to transfer the patient onto and off of the OR table. Beyond the speculated time-savings, operating on the stretcher is also believed to be advantageous for surgical staff, as lateral patient transfers require 3 to 5 people for safe execution and have been shown to pose an injury hazard to staff and anesthetized patients.^2,16,18 Moreover, lateral patient transfers necessarily impede parallel processing in the OR and, consequently, efficiency.

We conducted a randomized controlled trial comparing the efficiency, as measured by OR time excluding procedure time, of performing minor foot and ankle surgeries on the stretcher vs the OR table. Additionally, we surveyed OR staff who participated in both case types about their perceptions and preferences pertaining to OR table–based (TB) and stretcher-based (SB) procedures. We hypothesized that SB and OR TB procedures would not differ with respect to OR efficiency, and that OR team members would prefer SB procedures and perceive them to be the safest for patients and their colleagues.

Materials and Methods

Study Design

We conducted a prospective randomized controlled trial comparing the efficiency of foot and ankle surgeries completed on the preoperative stretcher and OR table. In addition, staff participating in both SB and OR TB procedures throughout the study were surveyed about their preferences and perceptions of each case type. IRB approval was granted previous to initiating this randomized controlled trial and staff survey (2022P000197).

Study Population

All adult patients undergoing a hardware removal, isolated gastrocnemius recession, soft tissue procedure, or foreign body removal at our day surgery unit by 1 fellowship-trained foot and ankle surgeon (EMB) were included. These procedure types were selected for inclusion as they are all commonly performed on both operating surfaces at our ambulatory surgery center.

Fifty-two patients undergoing the included procedures were included, with 26 patients randomized to the OR Table group and 26 patients randomized to the Stretcher group.

The staff survey was distributed to 31 OR team members including the primary surgeon, surgeons in training, circulating nurses, anesthesiologists, certified registered nurse anesthetists (CRNAs), and scrub technicians who participated in the included cases. Verbal consent was obtained from each patient for study participation, and completion of the staff survey served as implied consent.

Randomization

Patients were randomized into 2 equal-sized groups using the simple randomization opaque sealed envelope technique.^4,13 Patients were randomized prior to case setup on the day of surgery. A research assistant who was not involved in the procedure opened the envelope containing allocation information and informed the surgical staff of the group assignment.

Interventions

Patients randomized to the Stretcher group remained on the preoperative stretcher for their procedure, whereas patients randomized to the OR Table group were transferred to the OR table for surgery. Identical standard-of-care draping protocols were used for both groups. The surgical safety pause process remained constant throughout the data collection period.

The survey for OR team members was created using REDCap (Research Electronic Data Capture). ¹¹ Survey responses were anonymized and comprised 8 questions (Figure 1). OR staff participating in the included cases received an invitation to complete the survey via email.

Figure 1.

OR staff survey. Respondents were presented with a dropdown menu for question 1 with the following mutually exclusive options: anesthesiologist, certified registered nurse anesthetist, circulating nurse, surgeon, scrub tech.

Outcome Measures

To capture time spent transferring and positioning the patient onto or off of the operating surface, we collected “start time” and “exit time” as our primary outcomes. Start time was the number of minutes between the patient entering the OR and first incision. Exit time was the number of minutes between the completion of dressing/splint placement and the patient exiting the OR. Time points were recorded in EMR by the circulating nurse and confirmed by the research assistant who was present for each case to ensure consistent definitions of the time points were utilized across all cases.

Sample Size

We based our power analysis on results from our retrospective pilot study, ¹⁴ which found that the mean between-group difference in “start time” was 3.2 minutes, with an SD of 3.9 minutes, resulting in an effect size of ~0.8. Therefore, we performed a 2-sided power analysis with an alpha of .05 and 80% power and determined that a minimum of 26 participants would need to be enrolled in each group to power to detect the same effect size in our primary outcome (OR start and exit time).

Statistical Analyses

Means and frequencies were computed for all continuous and categorical variables, respectively. To compare continuous variables between groups, we used 2-sided independent sample t tests or Mann-Whitney U tests, where appropriate. To compare categorical variable groups, 2-sided Pearson χ² or Fisher exact tests were used. SPSS, version 27 (IBM Corp, Armonk, NY) was used for all statistical analyses.

Results

Cohort Characteristics

Baseline characteristics of patients in each group are shown in Table 1. Fifty-two patients were recruited from January 2022 to August 2023. The Stretcher and OR Table groups were comparable with regard to age (P = .834), body mass index (P = .427), ASA status (P = .894), anesthesia used (general anesthesia vs not P = .291), and procedure type (P = .326). Patient sex was significantly different between groups (P = .002) with more males in the stretcher group. At a minimum of 4 weeks, patient charts were reviewed for complications. There were exactly 2 surgical site infections in each group, with 1 patient from the stretcher group ultimately requiring an irrigation and debridement to resolve the infection. No emergencies or critical incidents were reported in either group.

Table 1.

Description of Cohort. ^a

	Stretcher (n = 26)	OR Table (n = 26)	P Value
Age b	50.7 (16.1)	49.7 (16.1)	.834
Sex
Female	14 (54)	24 (92)	.002
Male	12 (46)	2 (8)
Race
Asian	2 (8)	2 (8)	.252
Black or African American	1 (4)	0 (0)
Declined or Other	0 (0)	3 (12)
White	23 (88)	21 (81)
Ethnicity
Hispanic	1 (4)	3 (12)	.494
Declined	2 (8)	3 (12)
Not Hispanic	23 (88)	20 (77)
Body mass index b	28.3 (5.3)	29.6 (6.8)	.427
ASA status
1	2 (8)	2 (8)	.894
2	21 (81)	22 (85)
3	3 (12)	2 (8)
Anesthesia
General/TIVA	3 (12)	7 (27)	.291
No general (eg, MAC, nerve block, combination thereof)	23 (88)	19 (73)
Procedure
Hardware removal	15 (58)	12 (46)	.326
Mass/ganglion excision or biopsy	5 (19)	8 (31)
Gastrocnemius recession	2 (8)	5 (19)
Irrigation and debridement	2 (8)	1 (4)
Foreign body removal	2 (8)	0 (0)

Abbreviations: ASA, American Society of Anesthesiologists; MAC, monitored anesthesia care; OR, operating room; TIVA, total intravenous anesthesia.

a

Unless otherwise noted, values are n (%).

b

Data are reported as mean (SD).

Primary Outcomes

Each of the measured phases—start time and exit time—was analyzed in addition to the total measured time for each case. Start time and exit time were found to be nonnormally distributed and, therefore, a Mann-Whitney U test was used to compare groups.

The total measured time was on median 6 minutes shorter in the Stretcher group than the OR Table group (10 minutes vs 16 minutes, P < .001) (Figure 2). For SB procedures, “start time” was significantly shorter (median difference = 4 minutes, P = .001), but “exit time” was not (median difference = 1 minute, P = .058). The median “start time” for OR TB procedures was 11 minutes 30 seconds (range, 7-25 minutes) vs 7 minutes 30 seconds (range, 2-23 minutes) for SB procedures. The median “exit time” for OR TB procedures was 4 minutes (range, 1-8 minutes) vs 3 minutes (range, 1-8 minutes) for SB procedures (Table 2). Overall actual surgical times did not differ between groups (Supplemental Table 1). Adverse positioning events did not occur in either group.

Figure 2.

Boxplots comparing the summed start time and exit time of OR table–based and stretcher-based procedures.

Table 2.

Comparison of Operating Efficiency on the Preoperative Stretcher vs OR Table.

	Stretcher,Median (min-max)	OR Table,Median (min-max)	Median Difference	P Value
Start time	07:30 (2:00-23:00)	11:30 (7:00-25:00)	4:00	.001
Exit time	03:00 (1:00-8:00)	04:00 (1:00-8:00)	1:00	.058
Summed start time and exit time	10:00 (3:00-27:00)	16:00 (10:00-32:00)	6:00	<.001

Staff Survey Results

Thirty-one OR team members completed surveys (100% response rate). Respondents had an average of 7.7 years of experience at the day surgery center. Circulating nurses comprised the majority of surveyed OR staff (n = 10; 32.3%), followed by surgeons (n = 7; 22.6%), anesthesiologists (n = 5; 16.1%), CRNAs (n = 5; 16.1%), and scrub technicians (n = 4; 12.9%).

Thirty staff members (96.8%) reported thinking that SB surgeries increase OR efficiency relative to OR TB procedures, whereas 1 (3.2%) felt they had no effect on OR efficiency. No respondents believed that SB procedures worsen OR efficiency. When asked about staff safety, 21 respondents (67.7%) thought SB procedures increased staff safety, and the remaining 10 (32.3%) thought they have no effect. With respect to patient safety, 15 respondents (48.4%) felt that SB procedures are equivalent to OR TB procedures, 1 (3.2%) believed they worsen patient safety, and 15 (48.4%) thought they improve patient safety. Overall, 64.5% of staff would recommend, and the remaining 35.5% would strongly recommend, SB procedures to other surgery centers (Figure 3).

Figure 3.

Staff perceptions of stretcher-based compared to OR table-based procedures.

Discussion

The operating room is one of the hospital’s most resource-intensive areas, where even minor time-savings can yield substantial gains in efficiency and revenue. With the aging of our population and associated escalating demand for surgical interventions, enhancing OR efficiency has become critical to effectively address the needs of more patients while controlling expenses.^6,7 This is the first randomized controlled study to compare SB and OR TB surgeries. Our findings reveal modest, potentially valuable time savings associated with SB compared to OR TB foot and ankle procedures. On average, SB procedures resulted in a median time savings of 6 minutes and are perceived to enhance OR efficiency by most of the OR team members at our day surgery center.

Our finding that SB foot and ankle surgeries resulted in a median time savings of 6 minutes aligns closely with findings from previous research examining SB hand surgery. For example, Gonzalez et al ¹⁰ investigated the impact of SB hand tables on OR efficiency and, using a similar system of measurement, observed a reduction of 2 minutes in both start time and exit time, equating to a 4-minute decrease per case. Similarly, Garras et al ⁸ found that 7.5 minutes could be saved per case when patients remained on the stretcher and a hand table was used instead of the OR table. Another study by Eguia et al ⁵ reported slightly smaller time savings of 2.5 minutes when studying whether SB surgery could reduce induction time (analogous to start time in the current study) for pediatric adenotonsillectomies. Collectively, these findings suggest that performing procedures on the preoperative stretcher can yield modest yet significant time savings across various types of surgeries.

Although saving 6 minutes per case might seem inconsequential, if 10 SB cases are completed in 1 day, surgical team members could recoup up to 1 hour if this workflow modification was instituted alone. Although an hour may not necessarily provide sufficient time for an additional case during the operative day, the time savings nonetheless have financial ramifications. Published OR costs per minute range from $37 to $62^3,15; as such, an hour of saved time could translate to $2220 to $3720 per day. The financial savings are striking on further extrapolation—OR records indicate that the senior author and his 3 partners each performed roughly 6 cases meeting the inclusion criteria in a typical month. Thus, our group is estimated to save 28.8 hours and $63 936 to $107 136 annually. Beyond the financial benefits, having an extra 60 minutes for approximately 5 staff members could enhance overall efficiency and potentially contribute to staff wellness, as this reclaimed time could be allocated to other work or personal purposes.

Most OR staff members reported thinking that SB surgeries enhance OR efficiency and improve staff safety while increasing—or at least maintaining—patient safety levels comparable to OR TB procedures. Only 6% of OR staff preferred OR TB procedures in the ambulatory setting whereas 42% preferred SB procedures. Despite these perceptions, OR staff most commonly (52%) did not have a preference between SB and OR TB procedures. In their feedback, some staff members highlighted that operating on the stretcher maximizes time savings when cases are scheduled consecutively, as the need to switch table types between cases can elongate turnover times. This insight leads us to conclude that SB procedures are most effective at improving OR efficiency when performed sequentially. Conversely, when cases suitable for SB procedures are interspersed between larger cases requiring the OR table, switching between operating surfaces is unlikely to be more efficient or preferable for the staff.

This study has several limitations. This research involved a single surgeon practicing at one ambulatory surgery center which could limit the generalizability of our results. Nonetheless, this approach also represents a notable strength of the study as it minimized variability resulting from different locations and surgeons. Second, the senior surgeon and OR staff were not blinded which may have biased our results. Third, we acknowledge “start time” and “exit time” are incomplete proxies for OR efficiency, as fluctuations in procedure time itself, for example, have the potential to overwhelm the time-savings identified herein. That said, we did not find this to be the case in our cohort. Additionally, we did not collect differences in turnover time between cases, which may be impacted by the operating surface if there is a need to reorganize the room. As such, we conservatively assume that the time-savings associated with SB procedures found herein can be expected only if there is no additional time needed to dismantle and move the OR bed from the prior case. Finally, we did not survey patients regarding their experience of the operating surface. That said, we hypothesize that patients would prefer the stretcher experience given that it does not require them to be moved (or move themselves) onto and off of an oftentimes less comfortable operating table. Future studies should examine patient preferences to better inform operating surface decision-making for the included case types.

Conclusion

We found modest, yet reliable, time savings associated with SB compared to OR TB foot and ankle surgery. An average 6 minutes saved per case may have a meaningful impact on overall OR efficiency, particularly for high-volume specialties. Most OR staff thought operating on the stretcher improves OR efficiency and is safer for OR team members. Our findings support the selective use of SB procedures

Supplemental Material

sj-pdf-1-fao-10.1177_24730114241270272 – Supplemental material for Efficiency of Foot and Ankle Surgeries Completed on the Preoperative Stretcher vs Operating Room Table: A Randomized Controlled Trial

Supplemental material, sj-pdf-1-fao-10.1177_24730114241270272 for Efficiency of Foot and Ankle Surgeries Completed on the Preoperative Stretcher vs Operating Room Table: A Randomized Controlled Trial by Emily B. Parker, Jeremy T. Smith, Gregory Lausé and Eric M. Bluman in Foot & Ankle Orthopaedics