We appreciate the interest of Dr. Macfarlane and colleagues in our work on throughput for major orthopedic surgery.1They describe a block room model, fully staffed by an anesthesia block team, for increasing throughput at their institution. This block room can easily function as a prep area for the next surgical case. We are in agreement with the team at Toronto Western Hospital, Toronto, Ontario, Canada, that an appropriately managed block room could provide an important component of the resources needed for high-throughput operation serving complex orthopedic surgical patients. To be effective in a high-throughput operating room process, such a facility likely would need to have substantial unused capacity so as to be able to feed such an operating room in a reliable and timely fashion. The other difficulty that might arise is the orientation of the block team around priorities that do not align directly with the high-throughput operation, such as teaching, placement of competing blocks, and coordination of patients from multiple surgical services.

Macfarlane and colleagues report an average increase of 0.3 additional arthroplasties per day despite the capacity of their system to have done an additional one each day. We observed a similar tendency and agree that appropriate scheduling is the lynchpin for making a high-throughput operation show the results that one should expect from such a system. As did Macfarlane et al. , we likewise observed an inability by our surgical schedulers to “fill” the high-throughput operating room to capacity.

*Cleveland Clinic, Cleveland, Ohio. schubea@ccf.org

Smith MP, Sandberg WS, Foss J, Massoli K, Kanda M, Barsoum W, Schubert A: High-throughput operating room system for joint arthroplasties durably outperforms routine processes. Anesthesiology 2008; 109:25–35