Operation theatre utilization and efficiency

Sir,

We have read both the audit study[1] and the accompanied editorial[2] aimed at improving operating room (OR) efficiency. Both the articles have emphasized that a delayed start in the first case (Wheel in) and increased turn over time (Wheel out) for any case of the day will have a ripple effect on the subsequent cases leading to poor OR performance. However, there is a substantial difference in terminology used to describe the “Wheel in” time. Talati et al.[1] defined this as the “Time spent on supportive service”; whereas Divatia et al.[2] defined this as “Patient-in-to-incision time”. Though both the definition included time taken for anaesthesia induction and surgical preparation they don’t reemphasize the time spent on preparing the patient for anaesthesia induction. This preparation for anaesthesia induction may include but not limited to placement of invasive arterial and central venous catheter for monitoring and medicament infusion in a major surgical procedure before attempting actual anaesthesia induction and positioning of an epidural catheter for perioperative analgesia. One of the reason for delayed starting time in Talati et al.[1] study was, need for nebulisation before wheeling the patient to OR table. This preparation time vary widely between teaching and non-teaching hospitals. In a teaching hospital with ongoing resident training program, anaesthetic preparation time is inversely proportional to the skill acquired by the trainee resident. In case of Talati et al.,[1] the average room turn over time (5.39%) is about 45% of time taken for providing supportive services (12.02%). We believe that, if, parallel anaesthetic preparation of the second case is allowed during the room turn over time, then, we can at least avoid a major delay in start of the second case. Similarly if we can make “Wheel in” time inclusive of anaesthetic preparation time and receive the patient in the pre-operative anaesthetic room/holding area at an appropriate time before the actual defined “Table start time”, then, we can even start the first case on time. To achieve this the nature of surgery, anaesthetic preparation needed and available skilled hand (depending on procedure complexity) should be taken into consideration.

From a surgeon's point of view, the time taken to complete the surgery will be different with regular and new surgical assistants respectively. Use of staplers, clips and better suture material will improve the time taken for surgery but it will increase the cost of surgery. And when frozen sections are required to proceed further, then efficiency of OR staff in handling and transporting the tissues, to a different facility plays an important role.

We are also of the belief “In a good OR, there should be no reason for the patient to be wheeled in late”[2] but for this we need to incorporate time for preparation and induction of anaesthesia along with time for positioning, and surgical preparation to define “Wheel in”. Parallel anaesthetic preparation of the following case in the anaesthetic room during turnover time instead of sequenced preparation and induction in the OR will certainly improve the OR efficiency and productivity.

As stated by Divatia et al.,[2] personal accountability, streamlining of procedures, interdisciplinary teamwork, and accurate data collection including regular audit are all important contributors to improve OR efficiency. For improvements in OR utilization and patient centric outcomes multi-disciplinary changes in practice, processes and attitudes are desirable.