Audit of operating theatre time utilization in neurosurgery

Prospective Elective Neurosurgical Theater Utilization Audit in Pakistan: Problems in a Public Tertiary Care Hospital and Proposed Solutions from Lower-Middle-Income Country

Background In lower-middle-income countries such as Pakistan, public hospitals provide free healthcare but suffer from poor management and misgovernance, negatively impacting service provision. One aspect of this is operating theater time (OTT) utilization. In a 1,600-bed hospital with a 22 million catchment population, we noticed significant delays and inadequate OTT efficiency at the neurosurgery department of Jinnah Hospital, Lahore, Punjab, Pakistan. This audit aimed to analyze the neurosurgical OTT utilization, identify delays, and highlight managerial deficiencies and areas for improvement while comparing our workflow with contemporary international literature.

Materials and Methods We prospectively audited OTT utilization at the neurosurgical department. All elective surgeries from January to April 2021 were included to identify delays concerning patient transfer, anesthesia team arrival, preparation and intubation time, operative time, and anesthesia extubation time.

Results Fifty-six per cent of OTT was utilized operating. Sources of delay included the delayed arrival of anesthesia team (4.7%) and the delay in transferring patients to OT (9.7%). Anesthesia intubation and preparation time accounted for 23% of OT utilization and was significantly longer than the comparable international studies. Extubation time accounted for 5.7% of OT utilization. The issues surrounding transfer delays and prolonged anesthesia time were discussed, with strategies to address them developed with close vital input from our anesthesia colleagues and ward staff.

Conclusion Gross delays relatively simple in nature were identified due to poor management and less than ideal interspecialty coordination. Most delays were avoidable and can be addressed by proper planning, optimization of patient transfer and resources, and, most importantly, improved communication between surgeons, anesthetists, and ward staff. This can ensure optimal use of theater time and benefit all specialties, including ancillary staff, and, most importantly, the patient. A reaudit is warranted to assess the impact of interventions on OTT utilization.

The Direct Costs of Microsurgical Resection of Vestibular Schwannomas

OBJECTIVE

To determine and itemize surgical costs associated with the translabyrinthine (TL), retrosigmoid (RS), and middle cranial fossa (MCF) approaches for microsurgical excision of vestibular schwannoma (VS).

STUDY DESIGN

Retrospective cost analysis study.

SETTING

Tertiary referral center.

PATIENTS

Thirty consecutive adult patients underwent microsurgical excision of VS by either TL, RS, or MCF approach (10 per approach).

INTERVENTIONS

Microsurgical excision of VS by one of the three major approaches. Medical and financial data were collected.

MAIN OUTCOME MEASURES

Total operating room time (minutes), skin-to-skin time (minutes), operating room cost ($US), and surgical supplies cost ($US).

RESULTS

The MCF approach was associated with the shortest skin-to-skin time (230.3 min, p < 0.001). Mean overall nonsurgical room time was 94.7 minutes and not significantly different among approaches (p = 0.55). Mean total surgical supplies cost was $5,028 and was the highest for the RS ($7,116; p < 0.001) but not significantly different between TL and MCF. Mean operating room services charges were $68,417 overall and were the lowest for the MCF group ($53,306; p = 0.01). Tumor size was not correlated with surgical supplies cost (p = 0.74). The items associated with the highest average cost per case were the surgical aspirator ($1,062), drill burs ($928), and titanium implants ($575). There was redundancy in multiple surgical items such as drill burs, hemostatic agents, and sutures.

CONCLUSION

This study is the first to provide a detailed itemization of the surgical expenses specific to VS resection. Elevated nonsurgical room time and supply redundancy provides the opportunity for decreasing surgical costs and waste.

The Criterion Validity, Reliability, and Feasibility of an Instrument for Assessing the Nursing Intensity in Perioperative Settings

Patient classification systems generate information for staff allocation based on a patient's care needs. This study aims to test further the instrument for assessing nursing intensity (NI) in perioperative settings. Nine operating departments from five university hospitals were involved. The perioperative nurses gathered data from patients (N = 876) representing different fields of surgery. Reliability was tested by parallel classifications (n = 144). Also, the users' (n = 40) opinions were surveyed. The results support the predictive validity and interrater reliability of the instrument. The nurses considered the instrument feasible to use. The patients' low ASA class did not automatically signify low NI; however, high ASA class was more frequently associated with high intraoperative NI. Intraoperative NI indicated the length of the postanaesthesia care and the type of the follow-up unit. Parallel classifications ensured the homogenous use of the instrument. The use of the instrument is recommended.

Analysis of neuro-theatre utilisation and reasons for cancellation to improve efficiency and productivity

In neurosurgery, much emphasis has recently been placed on theatre cancellation and time utilization as a key hospital management performance indicator. We sought to evaluate our unit's theatre throughput efficiency and identify the causes of elective surgery cancellations. We retrospectively audited all scheduled elective neurosurgical procedures over a period of nine months. Mean theatre utilization time was 47.0%. The common causes of cancellations were lack of theatre time (32%), non-availability of beds in recovery room (18.6%), and insufficient preoperative patient preparation (5.5%). Inefficiencies were noted in turnover of patients and inaccurate prediction of operative time. Our theatre utilization time is consistent with available literature; however, cancellations of elective surgery waste valuable operative time and resources. The study concludes that a multi-dimensional approach must be taken to improve theatre utilization and reduce cancellation rates. A pre-assessment clinic has been introduced in order to reduce cancellation rates.

How can we maximize the use of our operating lists? An analysis of factors influencing theatre efficiency in oculoplastic day surgery

Operating theatre utilization has become the principal measure of NHS operating theatre service performance. We analysed data from oculoplastic theatres in a tertiary centre to identify factors influencing theatre efficiency. We conducted three audits on operating theatre utilization in 2011, 2014 and 2015. Data was collected from real time information entered into the hospital database, including time of arrival, induction, first cut and close of operation. The primary outcome measure was the operating list utilization rate, a combined value of anaesthetic and surgical time as a proportion of the total planned session time. The initial 2011 audit recorded an operating list utilization rate of 81.2%. However, this dropped to 64.5% in 2014 following new management and a move to a new theatre suite. Analysis of the factors contributing to poor theatre efficiency led to changes that streamlined the patient pathway, including standardized case scheduling and reducing staggered patient arrival. A 2015 reaudit analyzing the effects of these changes demonstrated an increase in the operating list utilization rate to 78%. It was significantly higher (p < 0.01) for whole-day lists (85%) compared to half-day lists (75%), suggesting that whole-day lists were more efficient. Operating theatres are a valuable resource and the factors affecting theatre efficiency within our unit are common and will be relevant to units elsewhere. Correcting them can lead to significant improvements in patient care. Data from this study may provide a benchmark for other units in the United Kingdom.

Audit of the Functioning of the Elective Neurosurgical Operation Theater in India: A Prospective Study and Review of Literature

BACKGROUND

Knowledge about the utilization of the operation theater (OT) is essential to improve its efficiency. This study evaluated the neurosurgical operation theater utilization in a neurosciences teaching hospital.

METHODS

Data collected included OT start time, delay in start, anesthesia induction time, surgical preparation time, anesthesia recovery time, operating time, time between cases, and theater closing time.

RESULTS

Five hundred thirty-seven surgeries were performed during the study period. The percentage of time used for anesthesia induction, actual surgical procedure, recovery from anesthesia, and theater preparation between the two cases were 8%, 70%, 6% and 5%, respectively. Fourteen percent of scheduled cases were cancelled. On 220 occasions (70.51%), theater was over-run. Late start contributed to loss of 8370 minutes (140 hours) of theater time.

CONCLUSIONS

This study identified the proportion of time spent on each activity in the neurosurgical OT. This knowledge is likely to facilitate better planning of neurosurgical theater schedule and result in optimal utilization.

Effect of perioperative inefficiency on neurosurgical theatre efficacy: A 15-year analysis

INTRODUCTION

Effective utilisation of operating theatre time is an important issue in neurosurgery. There is a commonly held belief amongst surgeons that throughput of theatre is decreasing secondary to worsening perioperative delays. The aim of this paper is to explore some of the factors that lead to delays in the perioperative period by determining whether there has been a trend in the increasing length of case time over a fifteen-year period.

MATERIALS AND METHODS

Case notes of all elective patients who consented for surgery between January 1998 and the end of 2012 were reviewed. Only patients who underwent elective surgery were included. Variables recorded included transit time from the ward to theatre, anaesthetic time, surgical time and time spent in recovery. These were compared over the 15-year period to look for apparent trends.

RESULTS

The total number of patients who consented for elective surgery at our institution between January 1998 and December 2012 was 6760. The mean anaesthetic time considering all operations performed was 43 mins each over the 15-year period. Anaesthetic time was deemed to be trending upwards from 1998 where the mean time was 27 -60 mins in December 2012, thus reflecting an increase of 33 mins. The mean surgical times over the 15-year period were 131 mins. However in 1998, mean surgical time was 127 mins compared with 133 mins in 2012.

DISCUSSION AND CONCLUSION

For the operations analysed, anaesthetic time seems to be increasing and has effectively doubled over a 15-year period. Surgical time and non-clinical time are shown to be virtually constant. This delays the overall theatre list and increases the cancellation rate. For compensating this, changes need to be made when allocating resources to both elective and emergency theatres. Staff recruitment needs to be assessed and internal audits need to be conducted within institutions to analyse ways to optimise the throughput of an operation theatre. If these principles are not adhered to, it will have a negative impact as our populations, and hence our case loads increase to instrumental levels. This will in turn have a negative impact on health workers and patients alike.

Is percentage theatre utilisation data an accurate predictor of cost-effectiveness and performance in urology?

Objective:

The current economic and political climate demands a focus on efficiency and productivity, whilst delivering quality, across all aspects of the National Health Service (NHS). Operative theatres act as a critical, yet costly resource. The Audit Commission employs the use of percentage theatre utilisation as a principal measure of NHS operating theatre service and efficiency performance. We analysed theatre utilisation data in a five-consultant, high turnover, urology department within a NHS University Teaching Hospital. Our aim was to examine the relationship between theatre utilisation data, cost effectiveness and income generated.

Patients and methods:

Data on the usage of a dedicated urology theatre was collected over 251 hours for a full calendar month. A total of 176 consecutive procedures were performed. Linear regression analysis was performed to assess the correlation between number of operating hours, cases per hour, utilisation percentages and income generated.

Results:

There was no correlation between percentage theatre utilisation and income ( R2=0.0191, p=0.82). No relationship was identified between percentage theatre utilisation and total number of cases performed ( R2=0.0001, p=0.99). Although there appeared to be a positive correlation between the number of cases performed and income generated, this was not statistically significant ( R2=0.725, p=0.067). Furthermore, there was no association between the number of cases performed per hour and income generated ( R2=0.3184, p=0.32).

Conclusion:

Our data identifies no correlation between percentage theatre utilisation, income generated and number of cases performed. Utilisation percentages are not a reliable performance indicator when used in isolation, and therefore should be used as part of a more global picture when assessing cost effectiveness and efficiency performance.

Theatre time utilisation in elective orthopaedic surgery

A prospective review of theatre time utilisation of the senior author's elective orthopaedic lists was carried out over a period of 10 weeks. A total of 41 cases were included. Only 54.0% of theatre time was utilised for operating. The anaesthetic time was 12.0%, and 9.3% of theatre time was used for positioning and draping. Delays in starting the list and turnover time accounted for the remaining 25%.

A review of 1241 trauma cases: a study of efficiency in trauma theatres

BACKGROUND

Our trauma department has recently moved to a newly built University hospital. Its geographic situation and the fact that all surgical sub-specialties are represented make it a very busy level 1 trauma centre. Our aim was to assess our activity and efficiency in trauma looking at 1241 consecutive trauma operations over a period of 6 months. Furthermore we evaluate the impact of the move to the new hospital on our activity.

METHOD

A total of 1241 consecutive trauma operations were reviewed, looking at transit times of patients to theatre, the duration of induction of anaesthesia, time to prepare and drape the patients and duration of surgery. Daily starting and finishing times were also analysed. We looked at operations done from April 2006 to July 2006 in our old site and compared the timings to the first 2 months in the new University hospital. In addition, we looked at the most recent 2 months in our new hospital.

RESULTS

The mean number of cases done daily and the distribution of time in trauma theatre were not significantly different in the 2 hospitals. A mean of 4.9 trauma operations are done per day with a mean of 18.6% of trauma lists starting on time. Furthermore, only around 55% of total theatre time is spent operating. The efficiency of trauma theatre utilisation is far from optimal but seems to correspond with the findings in the general literature.

CONCLUSION

Activity and theatre utilisation in trauma should be monitored regularly in order to assess the time distribution of surgical cases. This monitoring enables the department to highlight causes of inefficiencies and has been shown to improve the activity in trauma theatres.

Is theatre utilization a valid performance indicator for NHS operating theatres?

Background

Utilization is used as the principal marker of theatre performance in the NHS. This study investigated its validity as: a managerial tool, an inter-Trust indicator of efficient theatre use and as a marker of service performance for surgeons.

Methods

A multivariate linear regression model was constructed using theatre data comprising all elective general surgical operating lists performed at a NHS Teaching hospital over a seven-year period. The model investigated the influence of: operating list size, individual surgeons and anaesthetists, late-starts, overruns, session type and theatre suite on utilization (%).

Results

7,283 inpatient and 8,314 day case operations were performed on 3,234 and 2,092 lists respectively. Multivariate analysis demonstrated that the strongest independent predictors of list utilization were the size of the operating list (p < 0.01) and whether the list overran (p < 0.01). Surgeons differed in their ability to influence utilization. Their overall influence upon utilization was however small.

Conclusion

Theatre utilization broadly reflects the surgical volume successfully admitted and operated on elective lists. At extreme values it can expose administrative process failure within individual Trusts but probably lacks specificity for meaningful use as an inter-Trust theatre performance indicator. Unadjusted utilization rates fail to reflect the service performance of surgeons, as their ability to influence it is small.