Can we improve operating room efficiency?

Operating rooms (ORs) are probably among the most important areas of the hospital, contributing to both the workload and the revenue. Efficiency of use of OR time depends on scheduling of cases, allocation of staff, equipment, time required for preparation and induction of anesthesia, performance of surgery, recovery from anesthesia, preparation of the OR for the next patient and other resources. Inefficient OR management can result in case cancellations and long patient waiting lists. A well-managed OR results not only in a high surgical turnover, but also in reduced postoperative complications, improved patient-centered outcomes and greater patient satisfaction. How does one improve OR utilization? The first logical step would be an audit. Several performance parameters relevant to OR utilization have been identified.[1,2] These include 1) accurate case-duration estimate: Measures the percentage of cases where patient-in-room duration is within 15 minutes of the estimated in-room duration. This is a performance parameter for the scheduling of cases. 2) percentage of on-time first case starts: In a good OR, there should be no reason for the patient to be wheeled in late. Delayed starts may reflect inefficiencies in the hospital systems at any level from the wards to receiving the patient in the OR. 3) Pre-admission screening measures the percentage of cases that had a preanesthetic checkup prior to surgery. Inadequate prescreening may be responsible for a proportion of cancellations or delayed starts. 4) Patient-in-to-incision time: Measures the average time that elapsed between the patient entering the operating room and the first incision. This includes the time for induction of anesthesia, positioning, and surgical preparation. This is variable depending on the nature of the anesthetic and the surgery. 5) Average turnover time measures the time that elapsed between the prior patient exiting the room and the next patient entering the OR. There are many factors that drive turnover time. This can include an inefficient central processing of instruments or can be a result of a multidisciplinary problem involving nursing, anesthesia, housekeeping and the turnover team staff not working in co-ordination. Reduction in turnover times may not lead to an increase in surgical throughput unless the number of cases carried out per OR per session is high. Outcomes such as incidence of complications, infection rates, and perioperative mortality are important, but are affected by many factors other than efficiency of OR performance.

Audits of OR utilization have been criticized on several fronts; the lack of standard definitions for various OR processes, differences between studies in terms of methodology used to calculate utilization, lack of validation of these indices as performance indicators and the inability to extrapolate results from one center to another. It is difficult to set universal benchmarks for all ORs as these can vary considerably depending on the patient population, type of hospital as well as the type of surgery and anesthesia. For example, one cannot apply a benchmark set for patient-in-to-incision time for a lipoma excision done as a day-case procedure to a major hip replacement surgery. Hospitals operating on a for-profit basis would be more oriented towards a rapid turnover than academic hospitals with residents in-training. Other limitations of such audits may be a perceived bias in data collection (if surgeons, anesthesiologists or nurses with a potential for bias are responsible for data collection). The Hawthorne effect during the audit may lead to better than expected results. Despite these drawbacks, for want of better alternatives, such audits are being increasingly accepted as tools to improve OR performance.

In this issue of the journal, Talati et al.[3] analyze the utilization of OR time and cancellation of scheduled cases in a tertiary care teaching centre in North India. The principal findings of Talati's study are in keeping with published literature, both from India and elsewhere and have identified potential areas for improvement. With an OR utilization of 86%, 12% of OR time was spent on supportive services (including anesthesia) and 61% on actual surgery. Notably, 22.5% of scheduled cases were cancelled, with lack of operating time being the main factor for cancellation. This seems a rather high figure for an elective surgical list and could represent a key area for change. Unrealistic and inflexible scheduling, hospital and departmental policies and unanticipated delays in anesthetic or surgical procedure could be responsible. The cancellation rate varied from 40% in one OR to 0% in another. This wide range could help identify factors that lead to (or prevented) cancellations. Another interesting finding was that delayed OR starts were fairly common and were due to easily avoidable factors (mostly late shifting of patients from wards).

Several limitations of this study though need to be emphasized. It is unclear why the authors chose to exclude cases which were started after 1400 hrs. It has been shown that list over-runs are an important component of OR performance and contribute to decreased staff morale and delays in start of ORs the next day, due to non-availability of equipment and sterile supplies. Also, since this was a teaching hospital, it would have been interesting to note whether performance of procedures by trainees affected anesthesia and surgery times. The impact of training on OR efficiency is unclear — Eappen et al.[4] found that the administration of anesthesia by residents did not negatively impact anesthesia timings; Urman and colleagues[5] concluded that having anesthesia residents in ORs improved on-time starts but led to increased induction and emergence timings.

A few other studies have examined the appropriateness of use of OR time in the Indian scenario. Vinukondaiah[6] analyzed the utilization of ORs in the department of general surgery in a referral-hospital and identified factors that could possibly improve availability of OR time by as much as 20%. Our own audit of utilization of OR time for 828 surgeries carried out during 407 OR sessions in a tertiary-referral cancer centre.[7] showed that the median time of starting the OR list was 5 min after the scheduled list start time, with 15% (60 out of 407) first cases entering the OR more than 10 min late. Late OR start and finish times, delays in shifting patients out of the OR after recovery from anesthesia, and under-utilization of the anesthesia induction room were identified as potential areas of inefficiency.

Once the problem areas have been identified, the next step is to implement solutions. While it is vital for all concerned departments to be engaged in dialogue and discussion, it is equally important to have strong perioperative leadership.[2] It would be useful to identify an accountable, point person who runs the OR, manages scheduling, and effectively communicates with the surgical, nursing and anesthesia teams and other concerned staff. Often theatres are allocated with a particular surgeon or surgical unit. While it is effective for the first case in each OR, it may be appropriate to schedule subsequent cases into ORs in which there is a greater likelihood of starting and finishing the operation in time, rather than reserve the OR for a particular surgeon. Such flexibility in scheduling can prevent cancellations as well as delayed finishes, and result in better utilization of the OR.

As early as in 1998, Ovedyk and colleagues[8] achieved significant improvements in operating room efficiency by analyzing OR data on causes of delays, devising strategies for minimizing the most common delays, and subsequently measuring delay data. Personal accountability, streamlining of procedures, interdisciplinary teamwork, and accurate data collection were all important contributors to improved efficiency. The importance of audit as a quality improvement tool is beyond doubt. Audits help identify deficits and assess the impact of interventions. Of course, multi-disciplinary changes in practice, processes and attitudes will be needed to bring about improvements in OR utilization and consequently better patient centric outcomes.