Surgical Case Sequencing and Patient Flow: A Simulation Study With Downstream Resources

Surgical sequencing impacts patient flow and hospital operations. Discrete event simulation has been used to study these effects, specifically examining heuristics such as shortest cases first (SCF) and longest cases first (LCF). We propose a commonly used but previously unquantified and under-characterized heuristic, outpatient cases first (OPF), and examine its impact on hospital operations.

A discrete event simulation was developed in SimPy to compare three heuristics - OPF, SCF, LCF - to a baseline simulation and quantify operating room (OR) and post-anesthesia care unit (PACU) holds along with last case completion times. Partial implementation by a few surgeons and shifting cases to an ambulatory center was also simulated for comparison.

Based on simulations, OPF decreased OR holds by 54% and PACU holds by 15%. SCF increased OR holds by 22% and PACU holds by 11%. LCF increased OR holds by 37% and decreased PACU holds by 11%. For OPF, decreases in holds did not require full system adoption. Large improvements could be achieved with a small group of specifically identified surgeons. Applying OPF reduced average hold times versus shifting cases to an ambulatory center.

Case sequencing, specifically prioritizing outpatient procedures first, could lead to reductions in patient flow delays. We provide considerations for implementation, including identifying specific groups with outsized impact.