The Operation Theatre (OT) forms a critical and integral part in delivering surgical health care facilities of any hospital. Various clinical disciples within a multispecialty hospital including orthopaedics, general surgery, cardiac surgery, neurosurgery, gynaecology, obstetrics, ophthalmology, otolaryngology etc. require a well-functioning OT. In addition, effective utilization of an OT is core to the revenue generation of the hospital. As the establishment and maintenance of OT is capital intensive, optimal utilization of the operating room is imperative to manage cost-benefit ratio. Thus it is imperative that every effort should be made to render each OT service efficiently and cost effectively without compromising on patient care and safety.    

The OT functioning depends on a multidisciplinary approach requiring stringent effort amongst surgeons, anaesthetists, resident doctors, nursing staff, orderlies, porters, billing department etc. Each and every individual plays an important part in the smooth functioning of the operating room. One of the many common issues faced is the delay in the start of the first surgery and there by subsequent surgeries, delay in shifting of patients into the OT and cancellation of planned cases. Each of these lead to an increase in the OT turnaround time and decrease in the OT utilization time. It also leads to wastage of human resources, time and facilities. Thus, capitalizing on improving the OT turnaround time, starting cases on time and avoiding cancellations increases the proper usage of OT facilities and resources. This in turn improves the revenue generation of hospital with least wastage of essential services, reduces the waiting time for elective cases and over all better planning.

The aim of this study was primarily to identify and address the causes leading to delay in start of planned surgical cases, cancellation of cases and to analyse the OT turnaround time. The objective was to draw necessary conclusions and recommendations to improve the OT turnaround and utilization time thus increasing the efficiency.

The present study is a prospective observational study conducted in the Orthopaedic OT complex in a 1000 bedded tertiary care teaching hospital in Gujarat in the month of January and February 2021.The orthopaedic OT complex consisted of 2 major, 1 minor and a dedicated operating room for arthroplasty surgeries. The usual working hours for routine elective cases was 9 am to 5 pm on all days except Sundays and public holidays. Emergency OT was beyond 5 pm to next day 9am on all working days and 24 hours on Sundays and public holidays. The same OT complex was used for elective and emergency cases. All the elective planned cases which fulfilled the inclusion criteria were considered for data collection.

The OT turnaround time was taken as the time interval between application of final dressing of the previous patient till the skin incision on the next patient. Thus the present study involved assessment of the following parameters.

1. OT in-time:

This denotes the time when first case was shifted to OT. The in-time was set as 9 am as all the planned elective cases were scheduled at this time. In the event of any case not planned for 9 am but later during the day were not considered as part of the study. The data thus collected was divided into 4 time groups: 1) 8.45-8.59 am, 2) 9.00-9.15 am, 3) 9.16-9.30 am and 4) later than 9.30 am. Shifting of patient to the OT beyond 9.15 am was considered a delay and the reason for it was noted.

2. OT turnaround time:

Here the time was divided into three parts. The data was collected in a prospective manner on every case basis and divided into following groups.

1. Time of shifting patient out of the OT: time taken from after application of final dressing to wheeling the patient out of the OT.
2. Time of shifting patient into the OT: time interval between the previous patient being wheeled out and the next patient being wheeled in.
3. Time to incision: time from patient being wheeled in to the time of skin incision.
4. Total turnaround time: Summation of the above time taken as A+B+C.

3. Any cancellations/ unexpected delay/ rescheduled cases:

This included any planned/ elective case irrespective of the timing which was put up in the elective OT list on the prior day and which got cancelled or rescheduled. Also, the reason for its cancellation or reschedule was documented.

Inclusion criteria:

1. All planned elective cases scheduled for 9 am in Orthopaedic major OT 1 and major OT 2.
2. For OT turnaround time only those cases were considered which were scheduled cases planned immediately after the first case or prior case in the same OT without any time interval gap in between two cases.
3. Causes or reasons for all cancelled or rescheduled cases irrespective of their scheduled time were noted.

Exclusion criteria:

1. Emergency or unplanned or unscheduled cases.
2. Cases with pre planned start time other than 9 am.
3. Cases not scheduled to be not taken successively in the same OT for induction and surgery immediately after prior case.

In the present study, the data was collected from January 01, 2021 to February 28, 2021 prospectively as per our set methodology protocol which included only those cases that fit the inclusion criteria. Total 79 cases fit our inclusion criteria to study the delay in shifting cases and 19 instances were studied to analyse the OT turnaround time. The data collected was analysed using Microsoft Excel Software.

1) OT Start time analysis.

The Start time of all the first planned case of the day was recorded and divided into four groups as shown in Table 1. Out of all the cases scheduled for the day, only 79 cases fulfilled the inclusion criteria of planned elective cases scheduled for 9 am.

Table 1: Table showing Start time groups and number of cases in each group

Out of 79 cases, 47 cases (59 %) were wheeled into the OT at or before 9.15 am. Total 32 cases (41%) i.e. 13 cases and 19 cases were wheeled in between 9.16 and 9.30 and beyond 9.30 am respectively.

The reasons for delay in cases beyond 9.15 were mostly due to post graduate teaching delay, delays in shifting, surgeon related delays, unavailability of orderlies, late shifting to pre-op recovery from wards, pre op anaesthetic assessment in pre op room etc. Out of 79 cases 32 cases were delayed and wheeled into the OT beyond 9.15. The reasons for delay in shifting cases beyond 9.15 are as depicted in Figure 2.

Table 2: Table showing reasons for delay and number of cases in each group

2) OT turnaround time analysis:

There were total 19 instances where back to back cases were scheduled in the same OT. These included 11 cases in January and 8 cases in February. The turnaround time in these 19 instances was divided into the 4 groups and analysed as depicted in Table 3.

Table 3: Table showing the data of turnaround time in the 19 instances (in minutes)

As illustrated in Table 3, the average time taken for shifting the patient out of the theatre post dressing (A) was 12 minutes (SD 4) with minimum time taken being 5 minutes and maximum time 20 minutes. Also, the average time taken to shift the next patient inside the OT (B) was 15 minutes (SD 11) with minimum time taken being 5 minutes and maximum time taken being 40 minutes. The average time to incision time from shifting patient to OT (C) was 54 minutes (SD 20) with minimum time taken being 20 minutes to maximum time taken being 140 minutes. Thus, the average total OT turnaround time (D) taken was 80 minutes (SD 30) with the minimum time taken being 40 minutes and the maximum time taken being 140 minutes.

Remaining 33% (A+B) of the turnaround time consist of time taken after final dressing to shifting patient out (14%) and the time take between shifting the prior patient out of the OT and next patient inside (19%).

We can also deduce that (A +B) gives the time taken from final dressing to shifting the next patient (33%) in and C would include the anaesthetist preparation time, induction time and time for positioning and painting draping of the patient (67%).

The stacked line diagram showing the variations in the time taken in each group as well as total turnaround time taken across all 19 instances is depicted in figure 4. It shows the variations in shifting the patient out of OT was minimal and higher variations in time taken was seen in shifting patient into the operation theatre and induction time till giving the incision. This was corresponding to the standard deviation calculated in each group.

3) Cause for Cancellation / Reschedule of cases:

Out of total 154 routine scheduled cases (77 each in January and February), 26 cases were cancelled/rescheduled. Out of the total 26 cases, 12 in January and 14 in February were cancelled/ rescheduled. The cause of cancellation of planned cases is depicted in Table 4 and Figure 5. The most common cause for planned case cancellation /Rescheduling was the patient being unfit on the day of surgery (38%) followed by non-approval /delay in approval of various schemes(27%) under which the patient was planned to be operated. Out of 26 cancellations, 3 times each (11.5%) the patient would be discharged against medical advice prior to surgery or would not get admitted as planned prior to surgery.

Table 4: Table showing number of cancellations and its causes.

A fully functional operation theatre is an important and necessary part of any hospital or medical centre. To increase the surgical management, efficiency and utilization is one of the key aspects of a good hospital management which can be provided for by providing adequate human resources, equipment, facilities and drugs.

Section 1: Delay of start of cases

Most of the causes for delay in start of cases in our study are avoidable. Scheduling and planning of cases is of prime importance in any OT set up for proper functioning. In our study we found that delay of 8 cases was due to post graduate teaching. In such circumstances the cases can be planned in a way that neither teaching schedule nor start of cases is delayed. Also the patients can be posted after the card /scheme/insurance approvals. Orderlies, porters and ward boys need to be trained or increased in number to avoid shifting delays. Surgeon delays can also be avoided. Patankar R et al.[1] in their 1 month study found surgeon delays were one of the most common causes (22%) for increased turnaround time. Patient fitness issues such as hypertension, anxiety etc. on the day of surgery are non-avoidable during which cases are delayed for a certain time period needed for reassessment.

Talati et.al.[2] in their study found that delay in transfer of patients from ward to OT by the orderlies accounted for delay in 44.6% cases compared to 4% in our study. Ciechanowicz et. al.[3] in their study found 22% cases were delayed compared to 32% in our study. Similarly, Vinukondaiah et.al.[4] and Kumar M. et.al. [5] in their study revealed that 44% and 55.5% of their cases were delayed respectively.

Section 2: OT turnaround time (Average: 80±4 minutes)

A: time taken from final dressing to shifting the patient out of the OT (14%)

This time frame includes multiple variables like post dressing- removal of drapes, positioning of patient to pre-operative position, extubation of patient if given general anaesthesia, checking of vital stats, availability of the stretcher and the orderly to shift patient onto the stretcher and wheel the patient out. Thus there are multiple dynamic variables which are surgeon related, anaesthesia related and support staff dependent.

B: Time taken from shifting previous patient out to shifting the next patient into

the OT (19%).

Being the first step for patients undergoing surgical procedures, it is imperative that patient transportation by support staff, OT orderlies and ward boys is efficient and prompt.[6] This time frame includes the dynamic variables like time taken to clean and sanitize the OT room, shifting the patient from the recovery room to the OT after following the proper checklist protocol and confirmation with the recovery room nurse and the anaesthetist. This time frame requires a good co-ordination amongst the nursing staff, cleaning staff and the shifting orderlies.

1. Time taken from shifting the patient into the OT to incision time (67%).

Many studies and literature may not include this in the definition of turnaround time. But from a surgeon and hospital point of view it is very significant to study this time frame and its management for better efficiency. This time frame includes primarily the role of the anaesthetist and the surgical team. It involves shifting the patient into the OT, pre induction patient vital check by the anaesthetist, connecting of intravenous lines, tubes, ECG leads, and then the induction either by regional or general anaesthesia. Also the time taken across various modalities of anaesthesia also varies from case to case, regional to general and from one anaesthetist to another. Also once induced the surgical team prepares the position of the patient, scrubbing, painting and then draping after which the incision is taken. Certain cases take longer duration in patient preoperative positioning. Thus this time frame includes various dynamic variables which include the anaesthetist and the surgical team, the equipment, machines and drugs/narcotic availability. Our study found that the average time taken was 54 minutes (SD 30). The variability in this time frame is due to the various dynamics involved for example a spinal anaesthesia may take lesser time but a brachial block may take a longer time depending on expertise of the anaesthetist involved. Various studies [7,8] have reported that increase in number of employees such as anaesthesia providers can help reduce OT turnaround time. 

Ang et.al. [9] observed that problems such as delays in sending for patients, patient transport difficulties, conflicts in case scheduling and poor communication contributed to increased turnaround time. They suggested that parallel use of other rooms or OT such as cleaning up the OT whilst the anaesthetists anaesthetizes the next patient can be considered.

Fletcher et.al.[10] in their interventional study found inefficiencies and delays in turnaround time in the elective orthopaedic theatres and successfully identified several areas for improvement and implemented the interventions to get a 45 percent reduction on the mean turnaround time thus increasing the OT efficiency.

Talati et.al.[2] concluded that reasons for increased turnaround time included time spent on supportive services like positioning of patient, catheterization, shifting of outgoing and incoming patient; other reasons included stabilizing medical condition of patient etc.

Naik et.al.[11] concluded that OT turnaround time can be improved by keeping a dedicated theater for emergency procedures which can avoid rescheduling of cases due to last moment entry of emergency cases. They also suggested that adequate staffing and meticulous pre anaesthetic check-up and proper screening of patients preoperatively, checking instruments, blood products and linen can go a long way in avoiding delays and cancellations.

Section 3: Cancellation of cases

With due diligence we can prevent the avoidable cancellations by certain interventions which include detailed previous evening anaesthetic pre-operative check of the patient or scheduling of patients after approval is sought from the card/scheme/insurance companies. Patients not showing up or getting discharged against medical advice are unavoidable but can be counselled at the time of consultation. Checking the implant and surgeon availability prior to scheduling can also be helpful.

4. Kaddoum et.al.[12] found that 4.4 % of the cases in their study were cancelled on the day of surgery of which 71.6 % were judged as potentially avoidable cancellations versus 28.4 % that were judged as unavoidable. Similarly, Garg et al.[13] concluded that most cancellations were avoidable with previous planning and coordination.

Schofield et.al.[14] reported 11.9% cancellations of surgeries while Sanjay et.al. [15] in their study found 14% of their elective operations were cancelled of which 51% were due to patient related reasons.

Jonnalagadd et.al. [16] suggested that a good communication and discussion between the surgeon and the anaesthetist about the case can reduce chances of cancellation due to fitness issues.

Recommendations:

The objective of our study was to draw suitable recommendations based on our findings. On the basis of our findings in our study and other similar studies, following are the recommendations to decrease the delay and cancellation of cases and decrease the OT turnaround time.

1. Teamwork and co-ordination

A “surgery” is a common goal that requires an interdependent co-ordinated team work amongst operating surgeons, anaesthetic team, resident doctors, associates, nursing staff, recovery team, orderlies and ward staff. Beginning from the order for shifting of the patient to the recovery from the ward to back to the ward from the recovery after surgery is a culmination of multiple tasks involving multiple individuals and teams.

2. Checklists and recovery room assessment

We recommend a standard shifting, pre-surgical and post-surgical checklist for verification and streamlining the processes, clearly without the need for multiple checklists, will reduce the delay at various levels. Also the recovery room assessment could include the pre-induction anaesthetic check with intravenous line insertion or catheterization to avoid delay in the OT room.

3. Parallel Processing

This term includes undertaking multiple tasks simultaneously for example:

• The anaesthetist to check the next patient is the recovery room, start the preparation, securing IV access, ECG leads while the previous patient is being shifted out or the OT is being cleaned.
• The next patient may be induced in another OT or minor room if vacant while the previous patient is being wheeled out or OT is being cleaned.
• The OT cleaning may be initiated just as the final dressing is done and drapes are being removed.
• Overlapping of tasks can thus reduce the delay and improve the OT turnaround time.

4. Patient optimization

This includes scheduling of cases only after optimizing the co-morbidities of pre-operative patients which are identified during pre-anaesthetic check-up. Managing these conditions pre operatively before scheduling will reduce the chances of delay and cancellation on the day of surgery. It will thus also reduce the intra- and post- operative complications if the morbidities are optimized beforehand thus reducing the operative time, blood use and possible need for post-op ICU.

5. Pre-operative planning

• Identifying high risk cases beforehand can help in better planning of cases in terms of involving more experienced surgeons, associates and anaesthetists thus reducing the intra-operative and post-operative complications.
• Preoperative reservation and confirmation of blood products can avoid unnecessary delay in procurement
• Arrangement and booking of post-operative ICU in high risk and elderly cases to avoid delay in shifting and recovery room congestion.
• To check, confirm and autoclave the implants/ instruments beforehand to avoid unnecessary hassles and delay.

6. Training of Personnel

• Surgeons and anaesthetists to be sensitized towards being on time and inducing patient without unnecessary delay which may cause inconvenience to the patient or next surgical team /OT personnel.
• Nursing staff, orderlies and ward boys to be trained to act swiftly in shifting of patients, following checklists and to maintain the recovery room with least traffic and congestion.
• Residents and associates to follow up and coordinate the shifting and induction procedures.

7. Staffing

To manage/increase the human resources required to streamline the process either in the form of OT assistants/ anaesthesia technicians, nursing staff, number of orderlies and ward boys to avoid delay in procedures and shifting of patients.

8. Managing logistics

To act swiftly on approval of insurance and other scheme/ card related procedures/ formalities to avoid delay and cancellations and that such cases to be scheduled only if the proposal is approved.

Proper planning and prior scheduling of surgical cases is of prime importance in optimal functioning of any OT complex. Most of the causes of delay in start of scheduled cases, increased OT turnaround time and cancellations are avoidable and requires multidisciplinary contributions. Accordingly recommendations for optimal OT utiization have been suggested in the present study.

1. Patankar R, Jogade A, Patkar D: Case study on delays in the operation theatre; Journal of the Academy of Hospital Administration, Volume 30, No. 1 Jan-June, 2018;47-51.
2. Talati S, Gupta AK, Kumar A: An analysis of time utilization and cancellation of scheduled cases in the main operation theatre complex of a tertiary care teaching institute of North India. J Postgrad Med. 2015;61(1):3-8.
3. Ciechanowicz S, Wilson N. Delays to operating theatre lists: observations from a UK Centre. The Internet Journal of Health. 2010 Volume 13 Number 1.
4. Vinukondaiah K, Ananthakrishnan N, Ravishankar M. Audit of Operation Theatre utilization in General Surgery. Natl Med J India. 2000;13:118-21.
5. Kumar M, Malhotra S, Singla V, Bhatia K. Analysis of Start Time Delay in Operation Theatre Lists. Sch J Appl Med Sci. 2016;4(5):1764-9.
6. Halder R, Gupta D, Pandey H et al. Patient transportation delays and effects on operation theatre’s efficiency: A study for problem analysis and remedial measures. Anesth Essays Res. 2019;13(3):554-559.
7. Lewis MA, Hall RD, Okolo S, Yoong W: How time flies: a prospective analysis of theatre efficiency during elective gynaecology lists. Gynecol Surg. 2012;9:213-17.
8. Stavrou G, Panidis S, Tsouskas J et al. An audit of operating room time utilization in a teaching hospital: Is there a place for improvement? ISRN Surg. 2014;2014:431740.
9. Ang WW, Sabharwal S, Johannsson H et al. The cost of trauma operating theatre inefficiency. Ann Med Surg (Lond). 2016;7:24-29.
10. Fletcher D, Edwards D, Tolchard S et al. Improving theatre turnaround time. BMJ Qual Improv Rep. 2017;6(1):u219831.w8131.
11. Naik S, Dhulked V, Shinde R. A prospective study on OT utilization time. Anaest Essays Res 2018;12:797-802.
12. Kaddoum R, Fadlallah R, Hitti E et al. Causes of cancellations on the day of surgery at a Tertiary Teaching Hospital. BMC Health Serv Res. 2016;16:259.
13. Garg R, Balhotra AR, Bhadoria P. Reasons for surgery cancellation on day of surgery – A prospective study. Indian J Anaesth. 2009;53(1):35-39.
14. Schofield WN, Rubin GL, Piza M et al. Cancellation of operations on the day of intended surgery at a major Australian referral hospital. Med J Aust. 2005;182:612-5.
15. Sanjay P, Dodds A, Miller E, Arumugam PJ, Woodward A. Cancelled elective operations: An observational study from a district general hospital. J Health Organ Manag. 2007;21:54-8.
16. Jonnalagadda R, Walrond ER, Hariharan S, M. Walrond, C. Prasad. Int J Clin Prac. 2005;59(6):716-720.