User login
Predictors of Unplanned Postoperative Visits in a Veterans Affairs Hand Surgery Practice
Predictors of Unplanned Postoperative Visits in a Veterans Affairs Hand Surgery Practice
Patients make unplanned appointments after elective soft tissue hand surgery for real or perceived complications when they experience pain, anxiety, or fear. Unplanned appointments can create travel and financial burdens for patients and families. These appointments take time away from scheduled appointments and can contribute to late arrivals and delays in other clinics. Unscheduled appointments contribute to poor access when staff are diverted from scheduled appointments. If predictive factors can be identified, unplanned appointments may either be ameliorated or avoided with better perioperative risk management or education.
Methods
The US Department of Veterans Affairs (VA) North Florida/South Georgia Veterans Health System (NFSGVAHS) and University of Florida Institutional Review Board approved a retrospective chart review of all plastic surgery cases performed at the Malcom Randall VA Medical Center (MRVAMC) and Lake City VAMC operating rooms from July 1, 2018, through December 31, 2019, and January 1, 2021, through June 30, 2022 (nonurgent surgeries were discouraged during the COVID-19 pandemic). Elective soft tissue hand surgery cases were identified based on the operative description found in the Surgical Service Surgeon Staffing Report reviewed monthly by the Service Chief. Potential indicators of unplanned visits were recorded, including age; sex; diagnosis of diabetes, depression, anxiety, or posttraumatic stress disorder (PTSD); current smoking status; and residential zip code. We used the first 3 digits of the patients’ zip codes, which indicate region, as an estimate of proximity to the MRVAMC, which has a 50-county catchment area across North Florida and South Georgia. Diagnoses were found on the “problem list” from the electronic health record documented in the history and physical examinations before surgery. Clinic notes were examined for 3 months postsurgery to identify unplanned postoperative visits and the reason for the appointment. A χ2 analysis was conducted using Excel Version 2402. P < .05 was used to determine whether age (> 60 years), sex, proximity to MRVAMC, diabetes, smoking, depression, anxiety, or PTSD were statistically significant independent risk factors for these appointments.
Results
A total of 1009 elective soft tissue hand surgeries at MRVAMC were reviewed. The patients median age was 61 years. Patients included 173 women (17.1%) and 836 men (82.9%). Eighty-one patients (8.0%) returned for unplanned visits. Age (P = .82); proximity to MRVAMC (P = .34); and diabetes (P = .60), smoking (P = .55), anxiety (P = .33), or PTSD (P = .37) were not statistically significant predictors of unplanned appointments. Depression diagnosis (P = .04) and female sex (P = .03) were found to be independent risk factors for an unplanned appointment (Table 1). The most common indication for the requested appointment was pain-related, followed closely by noninfectious wound concerns and persistent symptoms (Table 2).
Discussion
Improved access, quality, and efficiency for patients are goals for the VA.1-3 The MRVAMC Plastic and Hand Surgery service provides care for the NFSGVAHS and receives an average of 15 to 20 consultation requests daily. The Veterans Health Administration is frequently challenged by staff shortages, and surgical services struggle to respond to consultation requests and treat patients within reasonable time frames.4,5
The objective of this study was to identify risk factors for unplanned postoperative appointments following elective hand surgery. Unplanned appointments prevent scheduled patients from being seen on time and contribute to backlogs and delays. When patients schedule multiple appointments on the same day, delays in the first clinic’s scheduled appointments create delays for the second and third clinics. Hand surgery clinics can provide a better experience for patients and staff by identifying and mitigating factors prompting unplanned visits.
We anticipated that wound complications would prompt unscheduled visits. Diabetes is a known risk factor for wound healing complications after plastic and hand surgery.6,7 A hemoglobin A1c (HbA1c) screening protocol used by the NFSGVAHS plastic surgery service since 2015 to identify poorly controlled patients with diabetes before surgery may partially explain this finding.8 We did not find a statistically significant difference between patients with diabetes and patients without diabetes for scheduling unplanned appointments. The plastic surgery service does not perform elective hand surgery unless the patient’s HbA1c level is < 9%, or violate the flexor sheath unless HbA1c level is < 8%. However, Zhuang et al found an increase in soft tissue infections after hand surgery with HbA1c levels ≥ 7%.9
Smoking is a potential factor in postoperative hand surgery complications.10,11 Lans et al found an increased incidence of 30-day emergency room visits in current and former smokers after outpatient upper extremity fracture surgery.12 The MRVAMC Plastic Surgery Service counsels patients about the risk of skin necrosis and delayed wound healing, but does not cancel cases or obtain laboratory values to verify abstinence in patients undergoing hand surgery. The VA has multiple resources available for patients interested in smoking cessation through mental health services.13
MRVAMC patients have been known to resist returning for scheduled appointments due to the costs or availability of transportation. We suspected that patients who lived further from MRVAMC would be less likely to return for unscheduled visits. We used the first 3 digits of the patients’ mailing zip code to estimate residential proximity to MRVAMC. An acknowledged limitation to this approach is that some veterans have primary addresses in other regions but still spend significant time in the MRVAMC catchment area and use the facility for their health care during the winter months. These “snowbirds” might reside near the facility despite having official addresses that are more distant. Additionally, there was no increased risk of unplanned visits after hand surgery in patients aged > 61 years (the median age of study participants) (P = .82). Dependence on a third party for transportation in older veterans could impact this finding.
Based on the observation that most patients needed reassurance rather than an intervention when they returned for unscheduled appointments, diagnoses of depression, anxiety, and PTSD were evaluated as separate predictive factors. In previous research, anxiety was found to be a risk factor for problematic recovery following carpal tunnel surgery.14 In the current study, depression was found to be a statistically significant predictor of unscheduled postoperative appointments (P = .04), while anxiety (P = .33) and PTSD (P = .37) were not statistically significant predictors. This is consistent with other studies that have found preexisting depression can predict complications after hand surgery.15,16 Vranceanu et al found that depression predicted pain intensity and disability after elective hand surgery.16 Similarly, Oflazoglu et al found a 12% incidence of depression based on the Patient Health Questionnaire-9 in new and returning hand patients who presented to an academic practice.17 They suggest patients should be assessed at all levels of care and that those with poor responses to surgical or nonsurgical management should be evaluated for depression. MRVAMC has a large mental health service consisting of psychiatrists, psychologists, addiction specialists, social workers, and homeless outreach, and patients tend to already have a diagnosis and mental health practitioner when they present to the clinic.
Recent studies found that wound problems, pain, and stiffness were the most common reasons for return visits.18,19 Shetty et al identified younger age, worse preoperative pain scores, and poor access to transportation as predictors of preventable emergency room visits, which generate higher health care expenditures than an office visit.19 Our study’s top reasons for appointments (pain, wound/scar concerns, persistent symptoms) can be addressed with additional presurgery patient and family education. Additionally, clinicians encourage nonnarcotic pain management strategies including anti-inflammatories, acetaminophen, elevation, splinting, and hand therapy, and the hospital employs experienced, fellowship-trained anesthesia block faculty who help limit perioperative narcotic use. Patients are advised that pain can be used to guide them through the postoperative recovery by preventing overuse and alerting them to a problem that would be masked with narcotics, and long-standing problems such as chronic nerve compressions may continue to cause pain after surgery.
Patients and families can be given consistent and repetitive verbal and written information, instructions, and expectations at the initial consultation, preoperative appointment, and on the day of surgery. Postoperatively, outside their scheduled appointments, patients are encouraged to use the My HealtheVet secure messaging system or call the clinic to access an experienced registered nurse before making a long drive. Access to virtual or phone visits can reduce emergent in-person visits in a VA population.20
Ozdag et al found that 42% of patients who had elective carpal tunnel surgery made unplanned electronic messages or phone contact within 2 weeks postsurgery. The authors point out the uncompensated administrative burden on the staff answering these messages and suggest pre-empting the contacts with more up-front education regarding postoperative pain expectations and management strategies.21
Fisher et al found that attending hand therapy reduced the number of emergency department visits in postoperative infection cases.22 At MRVAMC, a postoperative emergency department visit for a patient prompts an urgent unplanned appointment to the plastic surgery clinic, often on the same day. The MRVAMC occupational therapy clinic employed 3 on-site certified hand therapists during the study period. Because all hand surgery patients at the clinic receive hand therapy on the same day as their first postoperative appointment, attendance at hand therapy was not evaluated as a predictor of unplanned visits. Scheduled hand therapy is another point of contact where the clinic can provide reassurance and patient education.
While females made up 17.1% of the patients in this study, they constituted 12.5% of all veterans in Florida in fiscal year 2023.23 This study found that women were more likely to present for unplanned postoperative appointments (P = .03). This is consistent with existing literature which has found that women are higher users of health care and office-based appointments.24,25 This finding suggests the need for further study into whether our methods of communicating instructions to female patients undergoing plastic surgery may not be optimal.
Strengths and Limitations
As a retrospective review, the authors used information documented by multiple different health care practitioners, including trainees. The electronic medical record problem lists and templates provide consistency of information; however, less seasoned clinicians may interpret what they see and hear differently from more experienced clinicians in the postoperative setting. This study occurred in one part of the country with demographics that may not mirror other VA systems or the general population. The authors hope this study can be a starting point for other health care facilities to investigate ways to minimize the burden of unscheduled appointments. A strength of the study is that it was conducted within a closed system, as patients tend to stay within the VA system and documentation and communication among clinicians, even outside the immediate facility, are easily accessed through the electronic health record.
Conclusions
This study found that depression diagnosis and female sex are statistically significant predictors of unplanned postoperative visits after elective soft tissue hand surgery. More effective patient education during the preoperative period, particularly in patients with depression, may be warranted.
- Apaydin EA, Paige NM, Begashaw MM, et al. Veterans Health Administration (VA) vs. non-VA healthcare quality: a systematic review. J Gen Intern Med. 2023;38:2179-2188. doi:10.1007/s11606-023-08207-2
- Blegen M, Ko J, Salzman G, et al. Comparing quality of surgical care between the US Department of Veterans Affairs and non-Veterans Affairs settings: a systematic review. J Am Coll Surg. 2023;237:352-361. doi:10.1097/XCS.0000000000000720
- Valsangkar NP, Eppstein AC, Lawson RA, et al. Effect of lean processes on surgical wait times and efficiency in a tertiary care veterans affairs medical center. JAMA Surg. 2017;152:42-47. doi:10.1001/jamasurg.2016.2808
- National Association of Veterans Affairs Physicians and Dentists. Physicians remain at top of staffing shortage in VA. NAVAPD. December 20, 2023. Accessed March 16, 2026. https://www.navapd.org/news/physicians-remain-at-top-of-staffing-shortage-in-va
- OIG Determination of Veterans Health Administration’s severe occupational staffing shortages fiscal year 2024. Veterans Affairs Office of Inspector General. August 7, 2024. Accessed February 4, 2026. https://www.vaoig.gov/reports/national-healthcare-review/oig-determination-veterans-health-administrations-severe-0
- Goltsman D, Morrison KA, Ascherman JA. Defining the association between diabetes and plastic surgery outcomes: an analysis of nearly 40,000 patients. Plast Reconstr Surg Glob Open. 2017;5:e1461. doi:10.1097/GOX.0000000000001461 7.
- Cox CT, Sierra S, Egan A, et al. Elevated hemoglobin A1c and the risk of postoperative complications in elective hand and upper extremity surgery. Cureus. 2023;15:e48373. doi:10.7759/cureus.48373
- Coady-Fariborzian L, Anstead C. HbA1c and infection in diabetic elective hand surgery: a Veterans Affair Medical Center experience 2012-2018. Hand (NY). 2023;18:994-998. doi:10.1177/1558944720937363<
- Zhuang T, Shapiro LM, Fogel N, et al. Perioperative laboratory markers as risk factors for surgical site infection after elective hand surgery. J Hand Surg Am. 2021;46:675-684. doi:10.1016/j.jhsa.2021.04.001
- Cho BH, Aziz KT, Giladi AM. The impact of smoking on early postoperative complications in hand surgery. J Hand Surg Am. 2021;46:336.e1-336.e11. doi:10.1016/j.jhsa.2020.07.01411.
- Del Core MA, Ahn J, Golden AS, et al. Effect of smoking on short-term postoperative complications after elective upper extremity surgery. Hand (N Y). 2022;17:231-238. doi:10.1177/1558944720926638
- Lans J, Beagles CB, Watkins IT, et al. Unplanned postoperative emergency department visits after upper extremity fracture surgery. J Orthop Trauma. 2025;39:22-27. doi:10.1097/BOT.0000000000002925
- Tobacco and health - how to quit. US Dept of Veterans Affairs. Updated October 29, 2025. Accessed February 4, 2026. https://www.mentalhealth.va.gov/quit-tobacco/how-to-quit.asp
- Ryan C, Miner H, Ramachandran S, et al. General anxiety is associated with problematic initial recovery after carpal tunnel release. Clin Orthop Relat Res. 2022;480:1576-1581. doi:10.1097/CORR.0000000000002115
- Crijns TJ, Bernstein DN, Ring D, et al. Depression and pain interference correlate with physical function in patients recovering from hand surgery. Hand (N Y). 2019;14:830-835. doi:10.1177/1558944718777814
- Vranceanu AM, Jupiter JB, Mudgal CS, et al. Predictors of pain intensity and disability after minor hand surgery. J Hand Surg Am. 2010;35:956-960. doi:10.1016/j.jhsa.2010.02.00117.
- Oflazoglu K, Mellema JJ, Menendez ME, et al. Prevalence of and factors associated with major depression in patients with upper extremity conditions. J Hand Surg Am. 2016;41:263-269. doi:10.1016/j.jhsa.2015.11.019
- Townsend CB, Henry TW, Lutsky KF, et al. Unplanned office visits following outpatient hand surgery. Hand (N Y). 2022;17:1264-1268. doi:10.1177/15589447211028932
- Shetty PN, Guarino GM, Zhang G, et al. Risk factors for preventable emergency department use after outpatient hand surgery. J Hand Surg Am. 2022;47:855-864. doi:10.1016/j.jhsa.2022.05.012
- Sommers-Olson B, Christianson J, Neumann T, et al. Reducing nonemergent visits to the emergency department in a Veterans Affairs multistate system. J Emerg Nurs. 2023;49:539-545. doi:10.1016/j.jen.2023.02.010
- Ozdag Y, Manzar S, El Koussaify J, et al. Unplanned postoperative phone calls and electronic messages for patients with and without opioid prescriptions after carpal tunnel release. J Hand Surg Glob Online. 2024;6:363-368. doi:10.1016/j.jhsg.2024.02.006
- Fisher AH, Gandhi J, Nelson Z, et al. Immediate interventions after surgery to reduce readmission for upper extremity infections. Ann Plast Surg. 2022;88:S163-S169. doi:10.1097/SAP.0000000000003141
- Florida Department of Veterans Affairs Fast Facts. Florida Department of Veterans Affairs. Accessed February 4, 2026. https://floridavets.org/our-veterans/profilefast-facts/
- Bertakis KD, Azari R, Helms LJ, et al. Gender differences in the utilization of health care services. J Fam Pract. 2000;49:147-152.
- Ashman JJ, Santo L, Okeyode T. Characteristics of office-based physician visits, 2018. NCHS Data Brief. 2021;408:1-8.
Patients make unplanned appointments after elective soft tissue hand surgery for real or perceived complications when they experience pain, anxiety, or fear. Unplanned appointments can create travel and financial burdens for patients and families. These appointments take time away from scheduled appointments and can contribute to late arrivals and delays in other clinics. Unscheduled appointments contribute to poor access when staff are diverted from scheduled appointments. If predictive factors can be identified, unplanned appointments may either be ameliorated or avoided with better perioperative risk management or education.
Methods
The US Department of Veterans Affairs (VA) North Florida/South Georgia Veterans Health System (NFSGVAHS) and University of Florida Institutional Review Board approved a retrospective chart review of all plastic surgery cases performed at the Malcom Randall VA Medical Center (MRVAMC) and Lake City VAMC operating rooms from July 1, 2018, through December 31, 2019, and January 1, 2021, through June 30, 2022 (nonurgent surgeries were discouraged during the COVID-19 pandemic). Elective soft tissue hand surgery cases were identified based on the operative description found in the Surgical Service Surgeon Staffing Report reviewed monthly by the Service Chief. Potential indicators of unplanned visits were recorded, including age; sex; diagnosis of diabetes, depression, anxiety, or posttraumatic stress disorder (PTSD); current smoking status; and residential zip code. We used the first 3 digits of the patients’ zip codes, which indicate region, as an estimate of proximity to the MRVAMC, which has a 50-county catchment area across North Florida and South Georgia. Diagnoses were found on the “problem list” from the electronic health record documented in the history and physical examinations before surgery. Clinic notes were examined for 3 months postsurgery to identify unplanned postoperative visits and the reason for the appointment. A χ2 analysis was conducted using Excel Version 2402. P < .05 was used to determine whether age (> 60 years), sex, proximity to MRVAMC, diabetes, smoking, depression, anxiety, or PTSD were statistically significant independent risk factors for these appointments.
Results
A total of 1009 elective soft tissue hand surgeries at MRVAMC were reviewed. The patients median age was 61 years. Patients included 173 women (17.1%) and 836 men (82.9%). Eighty-one patients (8.0%) returned for unplanned visits. Age (P = .82); proximity to MRVAMC (P = .34); and diabetes (P = .60), smoking (P = .55), anxiety (P = .33), or PTSD (P = .37) were not statistically significant predictors of unplanned appointments. Depression diagnosis (P = .04) and female sex (P = .03) were found to be independent risk factors for an unplanned appointment (Table 1). The most common indication for the requested appointment was pain-related, followed closely by noninfectious wound concerns and persistent symptoms (Table 2).
Discussion
Improved access, quality, and efficiency for patients are goals for the VA.1-3 The MRVAMC Plastic and Hand Surgery service provides care for the NFSGVAHS and receives an average of 15 to 20 consultation requests daily. The Veterans Health Administration is frequently challenged by staff shortages, and surgical services struggle to respond to consultation requests and treat patients within reasonable time frames.4,5
The objective of this study was to identify risk factors for unplanned postoperative appointments following elective hand surgery. Unplanned appointments prevent scheduled patients from being seen on time and contribute to backlogs and delays. When patients schedule multiple appointments on the same day, delays in the first clinic’s scheduled appointments create delays for the second and third clinics. Hand surgery clinics can provide a better experience for patients and staff by identifying and mitigating factors prompting unplanned visits.
We anticipated that wound complications would prompt unscheduled visits. Diabetes is a known risk factor for wound healing complications after plastic and hand surgery.6,7 A hemoglobin A1c (HbA1c) screening protocol used by the NFSGVAHS plastic surgery service since 2015 to identify poorly controlled patients with diabetes before surgery may partially explain this finding.8 We did not find a statistically significant difference between patients with diabetes and patients without diabetes for scheduling unplanned appointments. The plastic surgery service does not perform elective hand surgery unless the patient’s HbA1c level is < 9%, or violate the flexor sheath unless HbA1c level is < 8%. However, Zhuang et al found an increase in soft tissue infections after hand surgery with HbA1c levels ≥ 7%.9
Smoking is a potential factor in postoperative hand surgery complications.10,11 Lans et al found an increased incidence of 30-day emergency room visits in current and former smokers after outpatient upper extremity fracture surgery.12 The MRVAMC Plastic Surgery Service counsels patients about the risk of skin necrosis and delayed wound healing, but does not cancel cases or obtain laboratory values to verify abstinence in patients undergoing hand surgery. The VA has multiple resources available for patients interested in smoking cessation through mental health services.13
MRVAMC patients have been known to resist returning for scheduled appointments due to the costs or availability of transportation. We suspected that patients who lived further from MRVAMC would be less likely to return for unscheduled visits. We used the first 3 digits of the patients’ mailing zip code to estimate residential proximity to MRVAMC. An acknowledged limitation to this approach is that some veterans have primary addresses in other regions but still spend significant time in the MRVAMC catchment area and use the facility for their health care during the winter months. These “snowbirds” might reside near the facility despite having official addresses that are more distant. Additionally, there was no increased risk of unplanned visits after hand surgery in patients aged > 61 years (the median age of study participants) (P = .82). Dependence on a third party for transportation in older veterans could impact this finding.
Based on the observation that most patients needed reassurance rather than an intervention when they returned for unscheduled appointments, diagnoses of depression, anxiety, and PTSD were evaluated as separate predictive factors. In previous research, anxiety was found to be a risk factor for problematic recovery following carpal tunnel surgery.14 In the current study, depression was found to be a statistically significant predictor of unscheduled postoperative appointments (P = .04), while anxiety (P = .33) and PTSD (P = .37) were not statistically significant predictors. This is consistent with other studies that have found preexisting depression can predict complications after hand surgery.15,16 Vranceanu et al found that depression predicted pain intensity and disability after elective hand surgery.16 Similarly, Oflazoglu et al found a 12% incidence of depression based on the Patient Health Questionnaire-9 in new and returning hand patients who presented to an academic practice.17 They suggest patients should be assessed at all levels of care and that those with poor responses to surgical or nonsurgical management should be evaluated for depression. MRVAMC has a large mental health service consisting of psychiatrists, psychologists, addiction specialists, social workers, and homeless outreach, and patients tend to already have a diagnosis and mental health practitioner when they present to the clinic.
Recent studies found that wound problems, pain, and stiffness were the most common reasons for return visits.18,19 Shetty et al identified younger age, worse preoperative pain scores, and poor access to transportation as predictors of preventable emergency room visits, which generate higher health care expenditures than an office visit.19 Our study’s top reasons for appointments (pain, wound/scar concerns, persistent symptoms) can be addressed with additional presurgery patient and family education. Additionally, clinicians encourage nonnarcotic pain management strategies including anti-inflammatories, acetaminophen, elevation, splinting, and hand therapy, and the hospital employs experienced, fellowship-trained anesthesia block faculty who help limit perioperative narcotic use. Patients are advised that pain can be used to guide them through the postoperative recovery by preventing overuse and alerting them to a problem that would be masked with narcotics, and long-standing problems such as chronic nerve compressions may continue to cause pain after surgery.
Patients and families can be given consistent and repetitive verbal and written information, instructions, and expectations at the initial consultation, preoperative appointment, and on the day of surgery. Postoperatively, outside their scheduled appointments, patients are encouraged to use the My HealtheVet secure messaging system or call the clinic to access an experienced registered nurse before making a long drive. Access to virtual or phone visits can reduce emergent in-person visits in a VA population.20
Ozdag et al found that 42% of patients who had elective carpal tunnel surgery made unplanned electronic messages or phone contact within 2 weeks postsurgery. The authors point out the uncompensated administrative burden on the staff answering these messages and suggest pre-empting the contacts with more up-front education regarding postoperative pain expectations and management strategies.21
Fisher et al found that attending hand therapy reduced the number of emergency department visits in postoperative infection cases.22 At MRVAMC, a postoperative emergency department visit for a patient prompts an urgent unplanned appointment to the plastic surgery clinic, often on the same day. The MRVAMC occupational therapy clinic employed 3 on-site certified hand therapists during the study period. Because all hand surgery patients at the clinic receive hand therapy on the same day as their first postoperative appointment, attendance at hand therapy was not evaluated as a predictor of unplanned visits. Scheduled hand therapy is another point of contact where the clinic can provide reassurance and patient education.
While females made up 17.1% of the patients in this study, they constituted 12.5% of all veterans in Florida in fiscal year 2023.23 This study found that women were more likely to present for unplanned postoperative appointments (P = .03). This is consistent with existing literature which has found that women are higher users of health care and office-based appointments.24,25 This finding suggests the need for further study into whether our methods of communicating instructions to female patients undergoing plastic surgery may not be optimal.
Strengths and Limitations
As a retrospective review, the authors used information documented by multiple different health care practitioners, including trainees. The electronic medical record problem lists and templates provide consistency of information; however, less seasoned clinicians may interpret what they see and hear differently from more experienced clinicians in the postoperative setting. This study occurred in one part of the country with demographics that may not mirror other VA systems or the general population. The authors hope this study can be a starting point for other health care facilities to investigate ways to minimize the burden of unscheduled appointments. A strength of the study is that it was conducted within a closed system, as patients tend to stay within the VA system and documentation and communication among clinicians, even outside the immediate facility, are easily accessed through the electronic health record.
Conclusions
This study found that depression diagnosis and female sex are statistically significant predictors of unplanned postoperative visits after elective soft tissue hand surgery. More effective patient education during the preoperative period, particularly in patients with depression, may be warranted.
Patients make unplanned appointments after elective soft tissue hand surgery for real or perceived complications when they experience pain, anxiety, or fear. Unplanned appointments can create travel and financial burdens for patients and families. These appointments take time away from scheduled appointments and can contribute to late arrivals and delays in other clinics. Unscheduled appointments contribute to poor access when staff are diverted from scheduled appointments. If predictive factors can be identified, unplanned appointments may either be ameliorated or avoided with better perioperative risk management or education.
Methods
The US Department of Veterans Affairs (VA) North Florida/South Georgia Veterans Health System (NFSGVAHS) and University of Florida Institutional Review Board approved a retrospective chart review of all plastic surgery cases performed at the Malcom Randall VA Medical Center (MRVAMC) and Lake City VAMC operating rooms from July 1, 2018, through December 31, 2019, and January 1, 2021, through June 30, 2022 (nonurgent surgeries were discouraged during the COVID-19 pandemic). Elective soft tissue hand surgery cases were identified based on the operative description found in the Surgical Service Surgeon Staffing Report reviewed monthly by the Service Chief. Potential indicators of unplanned visits were recorded, including age; sex; diagnosis of diabetes, depression, anxiety, or posttraumatic stress disorder (PTSD); current smoking status; and residential zip code. We used the first 3 digits of the patients’ zip codes, which indicate region, as an estimate of proximity to the MRVAMC, which has a 50-county catchment area across North Florida and South Georgia. Diagnoses were found on the “problem list” from the electronic health record documented in the history and physical examinations before surgery. Clinic notes were examined for 3 months postsurgery to identify unplanned postoperative visits and the reason for the appointment. A χ2 analysis was conducted using Excel Version 2402. P < .05 was used to determine whether age (> 60 years), sex, proximity to MRVAMC, diabetes, smoking, depression, anxiety, or PTSD were statistically significant independent risk factors for these appointments.
Results
A total of 1009 elective soft tissue hand surgeries at MRVAMC were reviewed. The patients median age was 61 years. Patients included 173 women (17.1%) and 836 men (82.9%). Eighty-one patients (8.0%) returned for unplanned visits. Age (P = .82); proximity to MRVAMC (P = .34); and diabetes (P = .60), smoking (P = .55), anxiety (P = .33), or PTSD (P = .37) were not statistically significant predictors of unplanned appointments. Depression diagnosis (P = .04) and female sex (P = .03) were found to be independent risk factors for an unplanned appointment (Table 1). The most common indication for the requested appointment was pain-related, followed closely by noninfectious wound concerns and persistent symptoms (Table 2).
Discussion
Improved access, quality, and efficiency for patients are goals for the VA.1-3 The MRVAMC Plastic and Hand Surgery service provides care for the NFSGVAHS and receives an average of 15 to 20 consultation requests daily. The Veterans Health Administration is frequently challenged by staff shortages, and surgical services struggle to respond to consultation requests and treat patients within reasonable time frames.4,5
The objective of this study was to identify risk factors for unplanned postoperative appointments following elective hand surgery. Unplanned appointments prevent scheduled patients from being seen on time and contribute to backlogs and delays. When patients schedule multiple appointments on the same day, delays in the first clinic’s scheduled appointments create delays for the second and third clinics. Hand surgery clinics can provide a better experience for patients and staff by identifying and mitigating factors prompting unplanned visits.
We anticipated that wound complications would prompt unscheduled visits. Diabetes is a known risk factor for wound healing complications after plastic and hand surgery.6,7 A hemoglobin A1c (HbA1c) screening protocol used by the NFSGVAHS plastic surgery service since 2015 to identify poorly controlled patients with diabetes before surgery may partially explain this finding.8 We did not find a statistically significant difference between patients with diabetes and patients without diabetes for scheduling unplanned appointments. The plastic surgery service does not perform elective hand surgery unless the patient’s HbA1c level is < 9%, or violate the flexor sheath unless HbA1c level is < 8%. However, Zhuang et al found an increase in soft tissue infections after hand surgery with HbA1c levels ≥ 7%.9
Smoking is a potential factor in postoperative hand surgery complications.10,11 Lans et al found an increased incidence of 30-day emergency room visits in current and former smokers after outpatient upper extremity fracture surgery.12 The MRVAMC Plastic Surgery Service counsels patients about the risk of skin necrosis and delayed wound healing, but does not cancel cases or obtain laboratory values to verify abstinence in patients undergoing hand surgery. The VA has multiple resources available for patients interested in smoking cessation through mental health services.13
MRVAMC patients have been known to resist returning for scheduled appointments due to the costs or availability of transportation. We suspected that patients who lived further from MRVAMC would be less likely to return for unscheduled visits. We used the first 3 digits of the patients’ mailing zip code to estimate residential proximity to MRVAMC. An acknowledged limitation to this approach is that some veterans have primary addresses in other regions but still spend significant time in the MRVAMC catchment area and use the facility for their health care during the winter months. These “snowbirds” might reside near the facility despite having official addresses that are more distant. Additionally, there was no increased risk of unplanned visits after hand surgery in patients aged > 61 years (the median age of study participants) (P = .82). Dependence on a third party for transportation in older veterans could impact this finding.
Based on the observation that most patients needed reassurance rather than an intervention when they returned for unscheduled appointments, diagnoses of depression, anxiety, and PTSD were evaluated as separate predictive factors. In previous research, anxiety was found to be a risk factor for problematic recovery following carpal tunnel surgery.14 In the current study, depression was found to be a statistically significant predictor of unscheduled postoperative appointments (P = .04), while anxiety (P = .33) and PTSD (P = .37) were not statistically significant predictors. This is consistent with other studies that have found preexisting depression can predict complications after hand surgery.15,16 Vranceanu et al found that depression predicted pain intensity and disability after elective hand surgery.16 Similarly, Oflazoglu et al found a 12% incidence of depression based on the Patient Health Questionnaire-9 in new and returning hand patients who presented to an academic practice.17 They suggest patients should be assessed at all levels of care and that those with poor responses to surgical or nonsurgical management should be evaluated for depression. MRVAMC has a large mental health service consisting of psychiatrists, psychologists, addiction specialists, social workers, and homeless outreach, and patients tend to already have a diagnosis and mental health practitioner when they present to the clinic.
Recent studies found that wound problems, pain, and stiffness were the most common reasons for return visits.18,19 Shetty et al identified younger age, worse preoperative pain scores, and poor access to transportation as predictors of preventable emergency room visits, which generate higher health care expenditures than an office visit.19 Our study’s top reasons for appointments (pain, wound/scar concerns, persistent symptoms) can be addressed with additional presurgery patient and family education. Additionally, clinicians encourage nonnarcotic pain management strategies including anti-inflammatories, acetaminophen, elevation, splinting, and hand therapy, and the hospital employs experienced, fellowship-trained anesthesia block faculty who help limit perioperative narcotic use. Patients are advised that pain can be used to guide them through the postoperative recovery by preventing overuse and alerting them to a problem that would be masked with narcotics, and long-standing problems such as chronic nerve compressions may continue to cause pain after surgery.
Patients and families can be given consistent and repetitive verbal and written information, instructions, and expectations at the initial consultation, preoperative appointment, and on the day of surgery. Postoperatively, outside their scheduled appointments, patients are encouraged to use the My HealtheVet secure messaging system or call the clinic to access an experienced registered nurse before making a long drive. Access to virtual or phone visits can reduce emergent in-person visits in a VA population.20
Ozdag et al found that 42% of patients who had elective carpal tunnel surgery made unplanned electronic messages or phone contact within 2 weeks postsurgery. The authors point out the uncompensated administrative burden on the staff answering these messages and suggest pre-empting the contacts with more up-front education regarding postoperative pain expectations and management strategies.21
Fisher et al found that attending hand therapy reduced the number of emergency department visits in postoperative infection cases.22 At MRVAMC, a postoperative emergency department visit for a patient prompts an urgent unplanned appointment to the plastic surgery clinic, often on the same day. The MRVAMC occupational therapy clinic employed 3 on-site certified hand therapists during the study period. Because all hand surgery patients at the clinic receive hand therapy on the same day as their first postoperative appointment, attendance at hand therapy was not evaluated as a predictor of unplanned visits. Scheduled hand therapy is another point of contact where the clinic can provide reassurance and patient education.
While females made up 17.1% of the patients in this study, they constituted 12.5% of all veterans in Florida in fiscal year 2023.23 This study found that women were more likely to present for unplanned postoperative appointments (P = .03). This is consistent with existing literature which has found that women are higher users of health care and office-based appointments.24,25 This finding suggests the need for further study into whether our methods of communicating instructions to female patients undergoing plastic surgery may not be optimal.
Strengths and Limitations
As a retrospective review, the authors used information documented by multiple different health care practitioners, including trainees. The electronic medical record problem lists and templates provide consistency of information; however, less seasoned clinicians may interpret what they see and hear differently from more experienced clinicians in the postoperative setting. This study occurred in one part of the country with demographics that may not mirror other VA systems or the general population. The authors hope this study can be a starting point for other health care facilities to investigate ways to minimize the burden of unscheduled appointments. A strength of the study is that it was conducted within a closed system, as patients tend to stay within the VA system and documentation and communication among clinicians, even outside the immediate facility, are easily accessed through the electronic health record.
Conclusions
This study found that depression diagnosis and female sex are statistically significant predictors of unplanned postoperative visits after elective soft tissue hand surgery. More effective patient education during the preoperative period, particularly in patients with depression, may be warranted.
- Apaydin EA, Paige NM, Begashaw MM, et al. Veterans Health Administration (VA) vs. non-VA healthcare quality: a systematic review. J Gen Intern Med. 2023;38:2179-2188. doi:10.1007/s11606-023-08207-2
- Blegen M, Ko J, Salzman G, et al. Comparing quality of surgical care between the US Department of Veterans Affairs and non-Veterans Affairs settings: a systematic review. J Am Coll Surg. 2023;237:352-361. doi:10.1097/XCS.0000000000000720
- Valsangkar NP, Eppstein AC, Lawson RA, et al. Effect of lean processes on surgical wait times and efficiency in a tertiary care veterans affairs medical center. JAMA Surg. 2017;152:42-47. doi:10.1001/jamasurg.2016.2808
- National Association of Veterans Affairs Physicians and Dentists. Physicians remain at top of staffing shortage in VA. NAVAPD. December 20, 2023. Accessed March 16, 2026. https://www.navapd.org/news/physicians-remain-at-top-of-staffing-shortage-in-va
- OIG Determination of Veterans Health Administration’s severe occupational staffing shortages fiscal year 2024. Veterans Affairs Office of Inspector General. August 7, 2024. Accessed February 4, 2026. https://www.vaoig.gov/reports/national-healthcare-review/oig-determination-veterans-health-administrations-severe-0
- Goltsman D, Morrison KA, Ascherman JA. Defining the association between diabetes and plastic surgery outcomes: an analysis of nearly 40,000 patients. Plast Reconstr Surg Glob Open. 2017;5:e1461. doi:10.1097/GOX.0000000000001461 7.
- Cox CT, Sierra S, Egan A, et al. Elevated hemoglobin A1c and the risk of postoperative complications in elective hand and upper extremity surgery. Cureus. 2023;15:e48373. doi:10.7759/cureus.48373
- Coady-Fariborzian L, Anstead C. HbA1c and infection in diabetic elective hand surgery: a Veterans Affair Medical Center experience 2012-2018. Hand (NY). 2023;18:994-998. doi:10.1177/1558944720937363<
- Zhuang T, Shapiro LM, Fogel N, et al. Perioperative laboratory markers as risk factors for surgical site infection after elective hand surgery. J Hand Surg Am. 2021;46:675-684. doi:10.1016/j.jhsa.2021.04.001
- Cho BH, Aziz KT, Giladi AM. The impact of smoking on early postoperative complications in hand surgery. J Hand Surg Am. 2021;46:336.e1-336.e11. doi:10.1016/j.jhsa.2020.07.01411.
- Del Core MA, Ahn J, Golden AS, et al. Effect of smoking on short-term postoperative complications after elective upper extremity surgery. Hand (N Y). 2022;17:231-238. doi:10.1177/1558944720926638
- Lans J, Beagles CB, Watkins IT, et al. Unplanned postoperative emergency department visits after upper extremity fracture surgery. J Orthop Trauma. 2025;39:22-27. doi:10.1097/BOT.0000000000002925
- Tobacco and health - how to quit. US Dept of Veterans Affairs. Updated October 29, 2025. Accessed February 4, 2026. https://www.mentalhealth.va.gov/quit-tobacco/how-to-quit.asp
- Ryan C, Miner H, Ramachandran S, et al. General anxiety is associated with problematic initial recovery after carpal tunnel release. Clin Orthop Relat Res. 2022;480:1576-1581. doi:10.1097/CORR.0000000000002115
- Crijns TJ, Bernstein DN, Ring D, et al. Depression and pain interference correlate with physical function in patients recovering from hand surgery. Hand (N Y). 2019;14:830-835. doi:10.1177/1558944718777814
- Vranceanu AM, Jupiter JB, Mudgal CS, et al. Predictors of pain intensity and disability after minor hand surgery. J Hand Surg Am. 2010;35:956-960. doi:10.1016/j.jhsa.2010.02.00117.
- Oflazoglu K, Mellema JJ, Menendez ME, et al. Prevalence of and factors associated with major depression in patients with upper extremity conditions. J Hand Surg Am. 2016;41:263-269. doi:10.1016/j.jhsa.2015.11.019
- Townsend CB, Henry TW, Lutsky KF, et al. Unplanned office visits following outpatient hand surgery. Hand (N Y). 2022;17:1264-1268. doi:10.1177/15589447211028932
- Shetty PN, Guarino GM, Zhang G, et al. Risk factors for preventable emergency department use after outpatient hand surgery. J Hand Surg Am. 2022;47:855-864. doi:10.1016/j.jhsa.2022.05.012
- Sommers-Olson B, Christianson J, Neumann T, et al. Reducing nonemergent visits to the emergency department in a Veterans Affairs multistate system. J Emerg Nurs. 2023;49:539-545. doi:10.1016/j.jen.2023.02.010
- Ozdag Y, Manzar S, El Koussaify J, et al. Unplanned postoperative phone calls and electronic messages for patients with and without opioid prescriptions after carpal tunnel release. J Hand Surg Glob Online. 2024;6:363-368. doi:10.1016/j.jhsg.2024.02.006
- Fisher AH, Gandhi J, Nelson Z, et al. Immediate interventions after surgery to reduce readmission for upper extremity infections. Ann Plast Surg. 2022;88:S163-S169. doi:10.1097/SAP.0000000000003141
- Florida Department of Veterans Affairs Fast Facts. Florida Department of Veterans Affairs. Accessed February 4, 2026. https://floridavets.org/our-veterans/profilefast-facts/
- Bertakis KD, Azari R, Helms LJ, et al. Gender differences in the utilization of health care services. J Fam Pract. 2000;49:147-152.
- Ashman JJ, Santo L, Okeyode T. Characteristics of office-based physician visits, 2018. NCHS Data Brief. 2021;408:1-8.
- Apaydin EA, Paige NM, Begashaw MM, et al. Veterans Health Administration (VA) vs. non-VA healthcare quality: a systematic review. J Gen Intern Med. 2023;38:2179-2188. doi:10.1007/s11606-023-08207-2
- Blegen M, Ko J, Salzman G, et al. Comparing quality of surgical care between the US Department of Veterans Affairs and non-Veterans Affairs settings: a systematic review. J Am Coll Surg. 2023;237:352-361. doi:10.1097/XCS.0000000000000720
- Valsangkar NP, Eppstein AC, Lawson RA, et al. Effect of lean processes on surgical wait times and efficiency in a tertiary care veterans affairs medical center. JAMA Surg. 2017;152:42-47. doi:10.1001/jamasurg.2016.2808
- National Association of Veterans Affairs Physicians and Dentists. Physicians remain at top of staffing shortage in VA. NAVAPD. December 20, 2023. Accessed March 16, 2026. https://www.navapd.org/news/physicians-remain-at-top-of-staffing-shortage-in-va
- OIG Determination of Veterans Health Administration’s severe occupational staffing shortages fiscal year 2024. Veterans Affairs Office of Inspector General. August 7, 2024. Accessed February 4, 2026. https://www.vaoig.gov/reports/national-healthcare-review/oig-determination-veterans-health-administrations-severe-0
- Goltsman D, Morrison KA, Ascherman JA. Defining the association between diabetes and plastic surgery outcomes: an analysis of nearly 40,000 patients. Plast Reconstr Surg Glob Open. 2017;5:e1461. doi:10.1097/GOX.0000000000001461 7.
- Cox CT, Sierra S, Egan A, et al. Elevated hemoglobin A1c and the risk of postoperative complications in elective hand and upper extremity surgery. Cureus. 2023;15:e48373. doi:10.7759/cureus.48373
- Coady-Fariborzian L, Anstead C. HbA1c and infection in diabetic elective hand surgery: a Veterans Affair Medical Center experience 2012-2018. Hand (NY). 2023;18:994-998. doi:10.1177/1558944720937363<
- Zhuang T, Shapiro LM, Fogel N, et al. Perioperative laboratory markers as risk factors for surgical site infection after elective hand surgery. J Hand Surg Am. 2021;46:675-684. doi:10.1016/j.jhsa.2021.04.001
- Cho BH, Aziz KT, Giladi AM. The impact of smoking on early postoperative complications in hand surgery. J Hand Surg Am. 2021;46:336.e1-336.e11. doi:10.1016/j.jhsa.2020.07.01411.
- Del Core MA, Ahn J, Golden AS, et al. Effect of smoking on short-term postoperative complications after elective upper extremity surgery. Hand (N Y). 2022;17:231-238. doi:10.1177/1558944720926638
- Lans J, Beagles CB, Watkins IT, et al. Unplanned postoperative emergency department visits after upper extremity fracture surgery. J Orthop Trauma. 2025;39:22-27. doi:10.1097/BOT.0000000000002925
- Tobacco and health - how to quit. US Dept of Veterans Affairs. Updated October 29, 2025. Accessed February 4, 2026. https://www.mentalhealth.va.gov/quit-tobacco/how-to-quit.asp
- Ryan C, Miner H, Ramachandran S, et al. General anxiety is associated with problematic initial recovery after carpal tunnel release. Clin Orthop Relat Res. 2022;480:1576-1581. doi:10.1097/CORR.0000000000002115
- Crijns TJ, Bernstein DN, Ring D, et al. Depression and pain interference correlate with physical function in patients recovering from hand surgery. Hand (N Y). 2019;14:830-835. doi:10.1177/1558944718777814
- Vranceanu AM, Jupiter JB, Mudgal CS, et al. Predictors of pain intensity and disability after minor hand surgery. J Hand Surg Am. 2010;35:956-960. doi:10.1016/j.jhsa.2010.02.00117.
- Oflazoglu K, Mellema JJ, Menendez ME, et al. Prevalence of and factors associated with major depression in patients with upper extremity conditions. J Hand Surg Am. 2016;41:263-269. doi:10.1016/j.jhsa.2015.11.019
- Townsend CB, Henry TW, Lutsky KF, et al. Unplanned office visits following outpatient hand surgery. Hand (N Y). 2022;17:1264-1268. doi:10.1177/15589447211028932
- Shetty PN, Guarino GM, Zhang G, et al. Risk factors for preventable emergency department use after outpatient hand surgery. J Hand Surg Am. 2022;47:855-864. doi:10.1016/j.jhsa.2022.05.012
- Sommers-Olson B, Christianson J, Neumann T, et al. Reducing nonemergent visits to the emergency department in a Veterans Affairs multistate system. J Emerg Nurs. 2023;49:539-545. doi:10.1016/j.jen.2023.02.010
- Ozdag Y, Manzar S, El Koussaify J, et al. Unplanned postoperative phone calls and electronic messages for patients with and without opioid prescriptions after carpal tunnel release. J Hand Surg Glob Online. 2024;6:363-368. doi:10.1016/j.jhsg.2024.02.006
- Fisher AH, Gandhi J, Nelson Z, et al. Immediate interventions after surgery to reduce readmission for upper extremity infections. Ann Plast Surg. 2022;88:S163-S169. doi:10.1097/SAP.0000000000003141
- Florida Department of Veterans Affairs Fast Facts. Florida Department of Veterans Affairs. Accessed February 4, 2026. https://floridavets.org/our-veterans/profilefast-facts/
- Bertakis KD, Azari R, Helms LJ, et al. Gender differences in the utilization of health care services. J Fam Pract. 2000;49:147-152.
- Ashman JJ, Santo L, Okeyode T. Characteristics of office-based physician visits, 2018. NCHS Data Brief. 2021;408:1-8.
Predictors of Unplanned Postoperative Visits in a Veterans Affairs Hand Surgery Practice
Predictors of Unplanned Postoperative Visits in a Veterans Affairs Hand Surgery Practice
Stretcher vs Table for Operative Hand Surgery
Stretcher vs Table for Operative Hand Surgery
US Department of Veterans Affairs (VA) health care facilities have not recovered from staff shortages that occurred during the COVID-19 pandemic.1 Veterans Health Administration operating rooms (ORs) lost many valuable clinicians during the pandemic due to illness, relocation, burnout, and retirement, and remain below prepandemic levels. The staffing shortage has resulted in lost OR time, leading to longer wait times for surgery. In October 2021, the Malcom Randall VA Medical Center (MRVAMC) Plastic Surgery Service implemented a surgery-on-stretcher initiative, in which patients arriving in the OR remained on the stretcher throughout surgery rather than being transferred to the operating table. Avoiding patient transfers was identified as a strategy to increase the number of procedures performed while providing additional benefits to the patients and staff.
The intent of the surgery-on-stretcher initiative was to reduce OR turnover time and in-room time, decrease supply costs, and improve patient and staff safety. The objective of this study was to evaluate the new process in terms of time efficiency, cost savings, and safety.
METHODS
The University of Florida Institutional Review Board (IRB) and North Florida/South Georgia Veterans Health System Research and Development Committee (IRB.net) approved a retrospective chart review of hand surgery cases performed in the same OR by the same surgeon over 2 year-long periods: October 1, 2020, through September 30, 2021, when surgeries were performed on the operating table (Figure 1), and June 1, 2022, through May 31, 2023, when surgeries were performed on the stretcher (Figure 2). Time intervals were obtained from the Nurse Intraoperative Report found in the electronic medical record. They ranged from “patient in OR” to “operation begin,” “operation end” to “patient out OR,” and “patient out OR” to next “patient in OR.” The median time intervals were obtained for the 3 different time intervals in each study period and compared.
A Mann-Whitney U test was used to determine statistical significance between the groups. We queried the Patient Safety Manager (Jason Ringlehan, BSN, RN, oral communication, 2023) and the Employee Health Nurse (Ivan Cool, BSN, RN, oral communication, June 16, 2023) for reported patient or employee–patient transfer injuries. We requested Inventory Supply personnel to provide the cost of materials used in the transfer process. There was no cost for surgeries performed on the stretcher.
RESULTS
A total of 306 hand surgeries were performed on a table and 191 were performed on a stretcher during the study periods. The median patient in OR to operation begin time interval was 25 minutes for the table and 23 minutes for the stretcher. The median operation end to patient out OR time was 4 minutes for the table and 3 minutes for the stretcher. Time savings was statistically significant (P < .001) for both ends of the surgery. The median room turnover time was 27 minutes for both time periods and was not statistically significant (P = .70). There were no reported employee or patient injuries attributed to OR transfers during either time period. Supply cost savings was $111.28 per case when surgery was performed on the stretcher (Table).
DISCUSSION
The new process of doing surgery on the stretcher was introduced to improve OR time efficiency. This improved efficiency has been reported in the hand surgery literature; however, the authors anticipated resistance to implementing a new process to seasoned OR staff.2,3 Once the idea was conceived, the plan was reviewed with the Anesthesia Service to confirm they had no safety concerns. The rest of the OR staff, including nurses and surgical technicians, agreed to participate. No resistance was encountered. The anesthesia, nursing, and scrub staff were happy to skip a potentially hazardous step at the beginning and end of each hand surgery case. The anesthesiologists communicated that the OR bed is preferred for intubating, but our hand surgeries are performed under local or regional block and intravenous sedation. The table was removed from the room to avoid any confusion with changes in staff during the day.
Compared with table use, surgery on the stretcher saved a median of 3 minutes of in-room time per case, with no significant difference in turnover time. The time savings reported here were consistent with what has been reported in other studies. Garras et al saved 7.5 minutes per case using a rolling hand table for their hand surgeries,2 while Gonzalez et al reported a 4-minute reduction per case when using a stretcher-based hand table for carpal tunnel and trigger finger surgeries.3 Lause et al found a 2-minute time savings at the start of their foot and ankle surgeries.4
Although 3 minutes per case may seem minimal, when applied to a conservative number of 5 hand cases twice a week, this time savings translates to an additional 15-minute nursing break each day, a 30-minute lunch break each week, and 26 extra hours each year. This efficiency can reduce direct costs in overtime. Consistently ending the day on time and allowing time for scheduled breaks can facilitate retention and improve morale in our current environment of chronically short-staffed surgical services. Recent literature estimates the cost of 1 OR minute to be about $36 to $46.5,6
Lateral transfers, in which a patient is moved horizontally, take place throughout the day in the OR and are a known risk factor for musculoskeletal disorders among the nursing staff. Contributing factors include patient obesity, environmental barriers in the OR, uneven patient weight distribution, and height differences among surgical team members. The Association of periOperative Registered Nurses recommends use of a lateral transfer device such as a friction-reducing sheet, slider board, or air-assisted device.7 The single-use Hover- Sling Repositioning Sheet is the transfer assist device used in our OR. It is an inflatable transfer mattress that reduces the amount of force used in patient transfer. The mattress is inflated with air from a small motor. While the HoverSling is inflated, escaping air from little holes on the underside of the mattress acts as a lubricant between the patient and transfer surface. This air reduces the force needed to move the patient.8
Patient transfers are a known risk for both patient and staff injuries.9,10 We suspected that not transferring our surgical patients between the stretcher and bed would improve patient and staff safety. A review of Patient Safety and Employee Health services found no reported patient or staff injuries during either timeframe. This finding led to the conclusion that effective safety precautions were already in place before the surgery-on-stretcher initiative. The MRVAMC routinely uses patient transfer equipment and the standard procedure in the OR is for 5 people to participate in 1 patient transfer between bed and table. The patient transfer device plus multiple staff involvement with patient transfers could explain the lack of patient and staff injury that predated the surgery-on-stretcher initiative and continued throughout the study period.
The inventory required to facilitate patient transfers at MRVAMC cost on average $111.28 per patient based on a search of the inventory database. This amount includes the HoverSling priced at $97 and the Medline OR Turnover Kit (table sheet, draw sheet, arm board covers, head positioning cover, and positioning foam strap) priced at $14.28. The Plastic Surgery Service routinely performs a minimum of 10 hand cases per week. If $111.28 per case is multiplied by the average of 10 cases each week over 52 weeks, the annualized savings could be about $57,866. This direct cost savings can potentially be applied to necessary equipment expenditures, educational training, or staff salaries.
Hand surgery literature has encouraged initiatives to reduce waste and develop more environmentally responsible practices.11-13 Eliminating the single-use patient transfer device and the turnover kit would avoid generating additional trash from the OR. Fewer sheets would have to be washed when patients stay on the same stretcher throughout their surgery day, which saves electricity and water.
Strengths and Limitations
A strength of this study is the consistency of the data, which were obtained from observing the same surgeon performing the same surgeries in the same OR. The data were logged into the electronic medical record in real time and easily accessible for data collection and comparison when reviewed retrospectively. A weakness of the study is the inconsistency in logging the in/out and start/end times by the OR circulating nurses who were involved in the patient transfers. The OR circulating nurses can vary from day to day, depending on the staffing assignments, which could affect the speed of each part of the procedure.
CONCLUSIONS
Hand surgery performed on the stretcher saves OR time and supply costs. This added efficiency translates to a savings of 26 hours of OR time and $57,866 in supply costs over the course of a year. Turnover time and staff and patient safety were not affected. This process can be introduced to other surgical specialties that do not need the accessories or various positions the OR table allows.
- Hersey LF. COVID-19 worsened staff shortages at veterans’ medical facilities, IG report finds. Stars and Stripes. October 13, 2023. Accessed February 28, 2025. https:// www.stripes.com/theaters/us/2023-10-13/veterans-affairs-health-care-staff-shortages-11695546.html
- Garras DN, Beredjiklian PK, Leinberry CF Jr. Operating on a stretcher: a cost analysis. J Hand Surg Am. 2011;36(12):2078-2079. doi:10.1016/j.jhsa.2011.09.006
- Gonzalez TA, Stanbury SJ, Mora AN, Floyd WE IV, Blazar PE, Earp BE. The effect of stretcher-based hand tables on operating room efficiency at an outpatient surgery center. Orthop J Harv Med Sch. 2017;18:20-24.
- Lause GE, Parker EB, Farid A, et al. Efficiency and perceived safety of foot and ankle procedures performed on the preoperative stretcher versus operating room table. J Perioper Pract. 2024;34(9):268-273. doi:10.1177/17504589231215939
- Childers CP, Maggard-Gibbons M. Understanding costs of care in the operating room. JAMA Surg. 2018;153(4):e176233. doi:10.1001/jamasurg.2017.6233
- Smith TS, Evans J, Moriel K, et al. Cost of operating room time is $46.04 dollars per minute. J Orthop Bus. 2022;2(4):10-13. doi:10.55576/job.v2i4.23
- Waters T, Baptiste A, Short M, Plante-Mallon L, Nelson A. AORN ergonomic tool 1: lateral transfer of a patient from a stretcher to an OR bed. AORN J. 2011;93(3):334-339. doi:10.1016/j.aorn.2010.08.025
- Barry J. The HoverMatt system for patient transfer: enhancing productivity, efficiency, and safety. J Nurs Adm. 2006;36(3):114-117. doi:10.1097/00005110-200603000-00003
- Apple B, Letvak S. Ergonomic challenges in the perioperative setting. AORN J. 2021;113(4):339-348. doi:10.1002/aorn.13345
- Tan J, Krishnan S, Vacanti JC, et al. Patient falls in the operating room setting: an analysis of reported safety events. J Healthc Risk Manag. 2022;42(1):9-14. doi:10.1002/jhrm.21503
- Van Demark RE Jr, Smith VJS, Fiegen A. Lean and green hand surgery. J Hand Surg Am. 2018;43(2):179-181. doi:10.1016/j.jhsa.2017.11.007
- Bravo D, Gaston RG, Melamed E. Environmentally responsible hand surgery: past, present, and future. J Hand Surg Am. 2020;45(5):444-448. doi:10.1016/j.jhsa.2019.10.031
- Tevlin R, Panton JA, Fox PM. Greening hand surgery: targeted measures to reduce waste in ambulatory trigger finger and carpal tunnel decompression. Hand (N Y). 2023;15589447231220412. doi:10.1177/15589447231220412
US Department of Veterans Affairs (VA) health care facilities have not recovered from staff shortages that occurred during the COVID-19 pandemic.1 Veterans Health Administration operating rooms (ORs) lost many valuable clinicians during the pandemic due to illness, relocation, burnout, and retirement, and remain below prepandemic levels. The staffing shortage has resulted in lost OR time, leading to longer wait times for surgery. In October 2021, the Malcom Randall VA Medical Center (MRVAMC) Plastic Surgery Service implemented a surgery-on-stretcher initiative, in which patients arriving in the OR remained on the stretcher throughout surgery rather than being transferred to the operating table. Avoiding patient transfers was identified as a strategy to increase the number of procedures performed while providing additional benefits to the patients and staff.
The intent of the surgery-on-stretcher initiative was to reduce OR turnover time and in-room time, decrease supply costs, and improve patient and staff safety. The objective of this study was to evaluate the new process in terms of time efficiency, cost savings, and safety.
METHODS
The University of Florida Institutional Review Board (IRB) and North Florida/South Georgia Veterans Health System Research and Development Committee (IRB.net) approved a retrospective chart review of hand surgery cases performed in the same OR by the same surgeon over 2 year-long periods: October 1, 2020, through September 30, 2021, when surgeries were performed on the operating table (Figure 1), and June 1, 2022, through May 31, 2023, when surgeries were performed on the stretcher (Figure 2). Time intervals were obtained from the Nurse Intraoperative Report found in the electronic medical record. They ranged from “patient in OR” to “operation begin,” “operation end” to “patient out OR,” and “patient out OR” to next “patient in OR.” The median time intervals were obtained for the 3 different time intervals in each study period and compared.
A Mann-Whitney U test was used to determine statistical significance between the groups. We queried the Patient Safety Manager (Jason Ringlehan, BSN, RN, oral communication, 2023) and the Employee Health Nurse (Ivan Cool, BSN, RN, oral communication, June 16, 2023) for reported patient or employee–patient transfer injuries. We requested Inventory Supply personnel to provide the cost of materials used in the transfer process. There was no cost for surgeries performed on the stretcher.
RESULTS
A total of 306 hand surgeries were performed on a table and 191 were performed on a stretcher during the study periods. The median patient in OR to operation begin time interval was 25 minutes for the table and 23 minutes for the stretcher. The median operation end to patient out OR time was 4 minutes for the table and 3 minutes for the stretcher. Time savings was statistically significant (P < .001) for both ends of the surgery. The median room turnover time was 27 minutes for both time periods and was not statistically significant (P = .70). There were no reported employee or patient injuries attributed to OR transfers during either time period. Supply cost savings was $111.28 per case when surgery was performed on the stretcher (Table).
DISCUSSION
The new process of doing surgery on the stretcher was introduced to improve OR time efficiency. This improved efficiency has been reported in the hand surgery literature; however, the authors anticipated resistance to implementing a new process to seasoned OR staff.2,3 Once the idea was conceived, the plan was reviewed with the Anesthesia Service to confirm they had no safety concerns. The rest of the OR staff, including nurses and surgical technicians, agreed to participate. No resistance was encountered. The anesthesia, nursing, and scrub staff were happy to skip a potentially hazardous step at the beginning and end of each hand surgery case. The anesthesiologists communicated that the OR bed is preferred for intubating, but our hand surgeries are performed under local or regional block and intravenous sedation. The table was removed from the room to avoid any confusion with changes in staff during the day.
Compared with table use, surgery on the stretcher saved a median of 3 minutes of in-room time per case, with no significant difference in turnover time. The time savings reported here were consistent with what has been reported in other studies. Garras et al saved 7.5 minutes per case using a rolling hand table for their hand surgeries,2 while Gonzalez et al reported a 4-minute reduction per case when using a stretcher-based hand table for carpal tunnel and trigger finger surgeries.3 Lause et al found a 2-minute time savings at the start of their foot and ankle surgeries.4
Although 3 minutes per case may seem minimal, when applied to a conservative number of 5 hand cases twice a week, this time savings translates to an additional 15-minute nursing break each day, a 30-minute lunch break each week, and 26 extra hours each year. This efficiency can reduce direct costs in overtime. Consistently ending the day on time and allowing time for scheduled breaks can facilitate retention and improve morale in our current environment of chronically short-staffed surgical services. Recent literature estimates the cost of 1 OR minute to be about $36 to $46.5,6
Lateral transfers, in which a patient is moved horizontally, take place throughout the day in the OR and are a known risk factor for musculoskeletal disorders among the nursing staff. Contributing factors include patient obesity, environmental barriers in the OR, uneven patient weight distribution, and height differences among surgical team members. The Association of periOperative Registered Nurses recommends use of a lateral transfer device such as a friction-reducing sheet, slider board, or air-assisted device.7 The single-use Hover- Sling Repositioning Sheet is the transfer assist device used in our OR. It is an inflatable transfer mattress that reduces the amount of force used in patient transfer. The mattress is inflated with air from a small motor. While the HoverSling is inflated, escaping air from little holes on the underside of the mattress acts as a lubricant between the patient and transfer surface. This air reduces the force needed to move the patient.8
Patient transfers are a known risk for both patient and staff injuries.9,10 We suspected that not transferring our surgical patients between the stretcher and bed would improve patient and staff safety. A review of Patient Safety and Employee Health services found no reported patient or staff injuries during either timeframe. This finding led to the conclusion that effective safety precautions were already in place before the surgery-on-stretcher initiative. The MRVAMC routinely uses patient transfer equipment and the standard procedure in the OR is for 5 people to participate in 1 patient transfer between bed and table. The patient transfer device plus multiple staff involvement with patient transfers could explain the lack of patient and staff injury that predated the surgery-on-stretcher initiative and continued throughout the study period.
The inventory required to facilitate patient transfers at MRVAMC cost on average $111.28 per patient based on a search of the inventory database. This amount includes the HoverSling priced at $97 and the Medline OR Turnover Kit (table sheet, draw sheet, arm board covers, head positioning cover, and positioning foam strap) priced at $14.28. The Plastic Surgery Service routinely performs a minimum of 10 hand cases per week. If $111.28 per case is multiplied by the average of 10 cases each week over 52 weeks, the annualized savings could be about $57,866. This direct cost savings can potentially be applied to necessary equipment expenditures, educational training, or staff salaries.
Hand surgery literature has encouraged initiatives to reduce waste and develop more environmentally responsible practices.11-13 Eliminating the single-use patient transfer device and the turnover kit would avoid generating additional trash from the OR. Fewer sheets would have to be washed when patients stay on the same stretcher throughout their surgery day, which saves electricity and water.
Strengths and Limitations
A strength of this study is the consistency of the data, which were obtained from observing the same surgeon performing the same surgeries in the same OR. The data were logged into the electronic medical record in real time and easily accessible for data collection and comparison when reviewed retrospectively. A weakness of the study is the inconsistency in logging the in/out and start/end times by the OR circulating nurses who were involved in the patient transfers. The OR circulating nurses can vary from day to day, depending on the staffing assignments, which could affect the speed of each part of the procedure.
CONCLUSIONS
Hand surgery performed on the stretcher saves OR time and supply costs. This added efficiency translates to a savings of 26 hours of OR time and $57,866 in supply costs over the course of a year. Turnover time and staff and patient safety were not affected. This process can be introduced to other surgical specialties that do not need the accessories or various positions the OR table allows.
US Department of Veterans Affairs (VA) health care facilities have not recovered from staff shortages that occurred during the COVID-19 pandemic.1 Veterans Health Administration operating rooms (ORs) lost many valuable clinicians during the pandemic due to illness, relocation, burnout, and retirement, and remain below prepandemic levels. The staffing shortage has resulted in lost OR time, leading to longer wait times for surgery. In October 2021, the Malcom Randall VA Medical Center (MRVAMC) Plastic Surgery Service implemented a surgery-on-stretcher initiative, in which patients arriving in the OR remained on the stretcher throughout surgery rather than being transferred to the operating table. Avoiding patient transfers was identified as a strategy to increase the number of procedures performed while providing additional benefits to the patients and staff.
The intent of the surgery-on-stretcher initiative was to reduce OR turnover time and in-room time, decrease supply costs, and improve patient and staff safety. The objective of this study was to evaluate the new process in terms of time efficiency, cost savings, and safety.
METHODS
The University of Florida Institutional Review Board (IRB) and North Florida/South Georgia Veterans Health System Research and Development Committee (IRB.net) approved a retrospective chart review of hand surgery cases performed in the same OR by the same surgeon over 2 year-long periods: October 1, 2020, through September 30, 2021, when surgeries were performed on the operating table (Figure 1), and June 1, 2022, through May 31, 2023, when surgeries were performed on the stretcher (Figure 2). Time intervals were obtained from the Nurse Intraoperative Report found in the electronic medical record. They ranged from “patient in OR” to “operation begin,” “operation end” to “patient out OR,” and “patient out OR” to next “patient in OR.” The median time intervals were obtained for the 3 different time intervals in each study period and compared.
A Mann-Whitney U test was used to determine statistical significance between the groups. We queried the Patient Safety Manager (Jason Ringlehan, BSN, RN, oral communication, 2023) and the Employee Health Nurse (Ivan Cool, BSN, RN, oral communication, June 16, 2023) for reported patient or employee–patient transfer injuries. We requested Inventory Supply personnel to provide the cost of materials used in the transfer process. There was no cost for surgeries performed on the stretcher.
RESULTS
A total of 306 hand surgeries were performed on a table and 191 were performed on a stretcher during the study periods. The median patient in OR to operation begin time interval was 25 minutes for the table and 23 minutes for the stretcher. The median operation end to patient out OR time was 4 minutes for the table and 3 minutes for the stretcher. Time savings was statistically significant (P < .001) for both ends of the surgery. The median room turnover time was 27 minutes for both time periods and was not statistically significant (P = .70). There were no reported employee or patient injuries attributed to OR transfers during either time period. Supply cost savings was $111.28 per case when surgery was performed on the stretcher (Table).
DISCUSSION
The new process of doing surgery on the stretcher was introduced to improve OR time efficiency. This improved efficiency has been reported in the hand surgery literature; however, the authors anticipated resistance to implementing a new process to seasoned OR staff.2,3 Once the idea was conceived, the plan was reviewed with the Anesthesia Service to confirm they had no safety concerns. The rest of the OR staff, including nurses and surgical technicians, agreed to participate. No resistance was encountered. The anesthesia, nursing, and scrub staff were happy to skip a potentially hazardous step at the beginning and end of each hand surgery case. The anesthesiologists communicated that the OR bed is preferred for intubating, but our hand surgeries are performed under local or regional block and intravenous sedation. The table was removed from the room to avoid any confusion with changes in staff during the day.
Compared with table use, surgery on the stretcher saved a median of 3 minutes of in-room time per case, with no significant difference in turnover time. The time savings reported here were consistent with what has been reported in other studies. Garras et al saved 7.5 minutes per case using a rolling hand table for their hand surgeries,2 while Gonzalez et al reported a 4-minute reduction per case when using a stretcher-based hand table for carpal tunnel and trigger finger surgeries.3 Lause et al found a 2-minute time savings at the start of their foot and ankle surgeries.4
Although 3 minutes per case may seem minimal, when applied to a conservative number of 5 hand cases twice a week, this time savings translates to an additional 15-minute nursing break each day, a 30-minute lunch break each week, and 26 extra hours each year. This efficiency can reduce direct costs in overtime. Consistently ending the day on time and allowing time for scheduled breaks can facilitate retention and improve morale in our current environment of chronically short-staffed surgical services. Recent literature estimates the cost of 1 OR minute to be about $36 to $46.5,6
Lateral transfers, in which a patient is moved horizontally, take place throughout the day in the OR and are a known risk factor for musculoskeletal disorders among the nursing staff. Contributing factors include patient obesity, environmental barriers in the OR, uneven patient weight distribution, and height differences among surgical team members. The Association of periOperative Registered Nurses recommends use of a lateral transfer device such as a friction-reducing sheet, slider board, or air-assisted device.7 The single-use Hover- Sling Repositioning Sheet is the transfer assist device used in our OR. It is an inflatable transfer mattress that reduces the amount of force used in patient transfer. The mattress is inflated with air from a small motor. While the HoverSling is inflated, escaping air from little holes on the underside of the mattress acts as a lubricant between the patient and transfer surface. This air reduces the force needed to move the patient.8
Patient transfers are a known risk for both patient and staff injuries.9,10 We suspected that not transferring our surgical patients between the stretcher and bed would improve patient and staff safety. A review of Patient Safety and Employee Health services found no reported patient or staff injuries during either timeframe. This finding led to the conclusion that effective safety precautions were already in place before the surgery-on-stretcher initiative. The MRVAMC routinely uses patient transfer equipment and the standard procedure in the OR is for 5 people to participate in 1 patient transfer between bed and table. The patient transfer device plus multiple staff involvement with patient transfers could explain the lack of patient and staff injury that predated the surgery-on-stretcher initiative and continued throughout the study period.
The inventory required to facilitate patient transfers at MRVAMC cost on average $111.28 per patient based on a search of the inventory database. This amount includes the HoverSling priced at $97 and the Medline OR Turnover Kit (table sheet, draw sheet, arm board covers, head positioning cover, and positioning foam strap) priced at $14.28. The Plastic Surgery Service routinely performs a minimum of 10 hand cases per week. If $111.28 per case is multiplied by the average of 10 cases each week over 52 weeks, the annualized savings could be about $57,866. This direct cost savings can potentially be applied to necessary equipment expenditures, educational training, or staff salaries.
Hand surgery literature has encouraged initiatives to reduce waste and develop more environmentally responsible practices.11-13 Eliminating the single-use patient transfer device and the turnover kit would avoid generating additional trash from the OR. Fewer sheets would have to be washed when patients stay on the same stretcher throughout their surgery day, which saves electricity and water.
Strengths and Limitations
A strength of this study is the consistency of the data, which were obtained from observing the same surgeon performing the same surgeries in the same OR. The data were logged into the electronic medical record in real time and easily accessible for data collection and comparison when reviewed retrospectively. A weakness of the study is the inconsistency in logging the in/out and start/end times by the OR circulating nurses who were involved in the patient transfers. The OR circulating nurses can vary from day to day, depending on the staffing assignments, which could affect the speed of each part of the procedure.
CONCLUSIONS
Hand surgery performed on the stretcher saves OR time and supply costs. This added efficiency translates to a savings of 26 hours of OR time and $57,866 in supply costs over the course of a year. Turnover time and staff and patient safety were not affected. This process can be introduced to other surgical specialties that do not need the accessories or various positions the OR table allows.
- Hersey LF. COVID-19 worsened staff shortages at veterans’ medical facilities, IG report finds. Stars and Stripes. October 13, 2023. Accessed February 28, 2025. https:// www.stripes.com/theaters/us/2023-10-13/veterans-affairs-health-care-staff-shortages-11695546.html
- Garras DN, Beredjiklian PK, Leinberry CF Jr. Operating on a stretcher: a cost analysis. J Hand Surg Am. 2011;36(12):2078-2079. doi:10.1016/j.jhsa.2011.09.006
- Gonzalez TA, Stanbury SJ, Mora AN, Floyd WE IV, Blazar PE, Earp BE. The effect of stretcher-based hand tables on operating room efficiency at an outpatient surgery center. Orthop J Harv Med Sch. 2017;18:20-24.
- Lause GE, Parker EB, Farid A, et al. Efficiency and perceived safety of foot and ankle procedures performed on the preoperative stretcher versus operating room table. J Perioper Pract. 2024;34(9):268-273. doi:10.1177/17504589231215939
- Childers CP, Maggard-Gibbons M. Understanding costs of care in the operating room. JAMA Surg. 2018;153(4):e176233. doi:10.1001/jamasurg.2017.6233
- Smith TS, Evans J, Moriel K, et al. Cost of operating room time is $46.04 dollars per minute. J Orthop Bus. 2022;2(4):10-13. doi:10.55576/job.v2i4.23
- Waters T, Baptiste A, Short M, Plante-Mallon L, Nelson A. AORN ergonomic tool 1: lateral transfer of a patient from a stretcher to an OR bed. AORN J. 2011;93(3):334-339. doi:10.1016/j.aorn.2010.08.025
- Barry J. The HoverMatt system for patient transfer: enhancing productivity, efficiency, and safety. J Nurs Adm. 2006;36(3):114-117. doi:10.1097/00005110-200603000-00003
- Apple B, Letvak S. Ergonomic challenges in the perioperative setting. AORN J. 2021;113(4):339-348. doi:10.1002/aorn.13345
- Tan J, Krishnan S, Vacanti JC, et al. Patient falls in the operating room setting: an analysis of reported safety events. J Healthc Risk Manag. 2022;42(1):9-14. doi:10.1002/jhrm.21503
- Van Demark RE Jr, Smith VJS, Fiegen A. Lean and green hand surgery. J Hand Surg Am. 2018;43(2):179-181. doi:10.1016/j.jhsa.2017.11.007
- Bravo D, Gaston RG, Melamed E. Environmentally responsible hand surgery: past, present, and future. J Hand Surg Am. 2020;45(5):444-448. doi:10.1016/j.jhsa.2019.10.031
- Tevlin R, Panton JA, Fox PM. Greening hand surgery: targeted measures to reduce waste in ambulatory trigger finger and carpal tunnel decompression. Hand (N Y). 2023;15589447231220412. doi:10.1177/15589447231220412
- Hersey LF. COVID-19 worsened staff shortages at veterans’ medical facilities, IG report finds. Stars and Stripes. October 13, 2023. Accessed February 28, 2025. https:// www.stripes.com/theaters/us/2023-10-13/veterans-affairs-health-care-staff-shortages-11695546.html
- Garras DN, Beredjiklian PK, Leinberry CF Jr. Operating on a stretcher: a cost analysis. J Hand Surg Am. 2011;36(12):2078-2079. doi:10.1016/j.jhsa.2011.09.006
- Gonzalez TA, Stanbury SJ, Mora AN, Floyd WE IV, Blazar PE, Earp BE. The effect of stretcher-based hand tables on operating room efficiency at an outpatient surgery center. Orthop J Harv Med Sch. 2017;18:20-24.
- Lause GE, Parker EB, Farid A, et al. Efficiency and perceived safety of foot and ankle procedures performed on the preoperative stretcher versus operating room table. J Perioper Pract. 2024;34(9):268-273. doi:10.1177/17504589231215939
- Childers CP, Maggard-Gibbons M. Understanding costs of care in the operating room. JAMA Surg. 2018;153(4):e176233. doi:10.1001/jamasurg.2017.6233
- Smith TS, Evans J, Moriel K, et al. Cost of operating room time is $46.04 dollars per minute. J Orthop Bus. 2022;2(4):10-13. doi:10.55576/job.v2i4.23
- Waters T, Baptiste A, Short M, Plante-Mallon L, Nelson A. AORN ergonomic tool 1: lateral transfer of a patient from a stretcher to an OR bed. AORN J. 2011;93(3):334-339. doi:10.1016/j.aorn.2010.08.025
- Barry J. The HoverMatt system for patient transfer: enhancing productivity, efficiency, and safety. J Nurs Adm. 2006;36(3):114-117. doi:10.1097/00005110-200603000-00003
- Apple B, Letvak S. Ergonomic challenges in the perioperative setting. AORN J. 2021;113(4):339-348. doi:10.1002/aorn.13345
- Tan J, Krishnan S, Vacanti JC, et al. Patient falls in the operating room setting: an analysis of reported safety events. J Healthc Risk Manag. 2022;42(1):9-14. doi:10.1002/jhrm.21503
- Van Demark RE Jr, Smith VJS, Fiegen A. Lean and green hand surgery. J Hand Surg Am. 2018;43(2):179-181. doi:10.1016/j.jhsa.2017.11.007
- Bravo D, Gaston RG, Melamed E. Environmentally responsible hand surgery: past, present, and future. J Hand Surg Am. 2020;45(5):444-448. doi:10.1016/j.jhsa.2019.10.031
- Tevlin R, Panton JA, Fox PM. Greening hand surgery: targeted measures to reduce waste in ambulatory trigger finger and carpal tunnel decompression. Hand (N Y). 2023;15589447231220412. doi:10.1177/15589447231220412
Stretcher vs Table for Operative Hand Surgery
Stretcher vs Table for Operative Hand Surgery
