Improving Efficiency in the Operating Room

Operating rooms (ORs) are among the most important divisions of a hospital, contributing to both the workload and the revenue. Efficient management of an OR is essential to enhancing patient outcomes and maximizing hospital profits (1). Although the actual percentage varies from country to country, on an average, 50-80% of the public health sector resources – in terms of money and trained personnel – is used in the hospital setting (2). OR efficiency depends on a variety of factors, such as the scheduling of cases, allocation of staff and equipment, time required for preparation and induction of anesthesia, and the preparation of the OR for the next patient. Inefficient OR management can result in case cancellations and long patient waiting lists (1). 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.

There are quite a few parameters relevant to OR utilization that have been identified (1). These include the accurate case-duration estimate, percentage of on-time first case starts, pre-admission screening, patient-in-to-incision time, and average turnover time. The accurate case-duration estimate is a performance parameter for scheduling cases, and measures the percentage of cases where the patient’s actual time spent in the OR is within 15 minutes of the estimated in-room duration. The percentage of on-time first case starts, as implied by the name of this metric, measures how many first cases of the day occur on time. It is important to have a high percentage of on-time first case starts, as delayed starts may reflect inefficiencies in the hospital systems at any level from the wards to receiving the patient in the OR (1). Pre-admission screening measures the percentage of cases that had a pre-anesthetic checkup prior to surgery. Inadequate pre-screening may be responsible for a proportion of cancellations or delayed starts. Patient-in-to-incision time measures the average time that elapsed between the patient entering the operating room and the first incision. This parameter can change, depending on the nature of the anesthetic and the surgery. Last but not least, the 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 can lead to higher than expected average turnover time. For example, inefficient central processing of instruments or a lack of coordination between the nursing, anesthesia, housekeeping and the turnover team staff (1).

In 2015, Talati et al. analyzed OR utilization and the cancellation of scheduled cases at a tertiary care teaching center in North India. They found an overall OR utilization of 86%, with 12% of OR time spent on supportive services (including anesthesia) and 61% on actual surgery (3). Notably, 22.5% of scheduled cases were cancelled, with a lack of operating time being the main factor for cancellation. Unrealistic and inflexible scheduling, hospital and departmental policies and unanticipated delays in anesthetic or surgical procedure could be responsible. 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) (3).

With this in mind, there are some ways in which OR utilization can be improved. For instance, in 1998, Ovedyk et al. achieved significant improvements in operating room efficiency by analyzing OR data on causes of delays. They devised strategies for minimizing the most common delays, and subsequently measured delay data (4). Personal accountability, streamlining of procedures, interdisciplinary teamwork, and accurate data collection were all important contributors to improved efficiency. Audits can also act as quality improvement tools by helping to identify deficits and assess the impact of interventions (4). Additionally, it would be useful to identify a person accountable for running the OR; someone who would be able to manage scheduling, and effectively communicate with the surgical, nursing and anesthesia teams and other concerned staff. Multi-disciplinary changes in practice, processes and attitudes are all needed to bring about improvements in OR utilization and consequently better patient centric outcomes.

References

1. Divatia, J. V., & Ranganathan, P. (2015). Can we improve operating room efficiency?. Journal of postgraduate medicine, 61(1), 1–2. doi:10.4103/0022-3859.147000
2. Talati, S., Gupta, A. K., Kumar, A., Malhotra, S. K., & Jain, A. (2015). An analysis of time utilization and cancellations of scheduled cases in the main operation theater complex of a tertiary care teaching institute of North India. Journal of postgraduate medicine, 61(1), 3–8. doi:10.4103/0022-3859.147009
3. Urman, R. D., Sarin, P., Mitani, A., Philip, B., & Eappen, S. (2012). Presence of anesthesia resident trainees in day surgery unit has mixed effects on operating room efficiency measures. The Ochsner journal, 12(1), 25–29.
4. Overdyk, F. J., Harvey, S. C., Fishman, R. L., Shippey, F. (1998). Successful Strategies for Improving Operating Room Efficiency at Academic Institutions. Anesthesia & Analgesia, 86(4), 896-906.