• Rahul K Shah, Justin Cohen, Anju Patel, and Craig Derkay.
• Division of Otolaryngology, Children's National Medical Center, Washington, DC 20010, USA. rshah@cnmc.org
• Arch. Otolaryngol. Head Neck Surg. 2012 Jul 1;138(7):624-7.

ObjectiveTo study pediatric direct laryngoscopy and bronchoscopy operative flow.DesignObservational quality improvement initiative.SettingTwo freestanding tertiary care children's hospitals.PatientsPediatric patients undergoing direct laryngoscopy and bronchoscopy.Main Outcome MeasuresTrained medical students observed direct laryngoscopy and bronchoscopy operative flow. An audit tool containing 144 fields was completed during each encounter for the following domains: timing of the case, preoperative preparation, operative flow, and operating room personnel assessment.ResultsForty-one cases were observed. The mean time between the patient entering the operating room and the beginning of the case was 12 minutes. In all the patients, a complete history was obtained, and a physical examination was performed. The equipment was ready for 31 cases (76%) and was checked before 32 cases (78%). Anesthesia equipment was checked before 36 cases (88%). Issues with intravenous access were recorded for 19 cases (46%). The operating room orientation needed to be changed to accommodate the procedure in 11 cases (27%). Preoperative preparation of the patient proceeded smoothly in 16 cases (39%), and the operative flow proceeded without disruption in 19 cases (46%). The scrub nurse left the operating room in 2 cases (5%), the circulating nurse left in 15 cases (37%), and the anesthesiologist left in 9 cases (22%).ConclusionsAlthough a common pediatric otolaryngology procedure, direct laryngoscopy and bronchoscopy operative flow is ideal in less than half the cases. Areas for improvement include obtaining intravenous access, reducing operating room personnel turnover, verifying equipment, and educating staff on operating room setup. To our knowledge, this is the first observational quality improvement initiative in otolaryngology to study the operative flow of a specific procedure and provide insight into areas of patient risk and opportunities for improvement in efficiency.

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