Theatre time utilisation in elective orthopaedic surgery.
Abstract: 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%.

KEYWORDS Theatre time / Operative time / Anaesthetic time / Turnover time
Authors: Sultan, J.
Charalambous, CP
Pub Date: 08/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: August, 2012 Source Volume: 22 Source Issue: 8
Accession Number: 309315278
Full Text: Introduction

Efficient utilisation of theatre time is important for efficient cost-effective theatre running. Better theatre utilisation means shorter waiting lists and less waiting on the wards. For surgeons, theatre utilisation is often used as an index of the surgeon's performance, and this may become a tool of appraisal in the future (Opit 1991, Faiz 2008). Theatre time is an expensive and limited resource, with an average hourly cost of about [pounds sterling]500 (O'Keefe 2010, BTHF Trust 2010, WHH Trust 2009/2010). In addition, theatre time utilisation is one of the indicators of hospital performance (Faiz 2008). Improving theatre utilisation is imperative to maintaining the financial viability of NHS trusts, through reducing cost and increasing theatre throughput as well as meeting waiting list targets.

Previous studies in other surgical specialties, including general surgery and neurosurgery, have indicated that only between 49 and 60% of available theatre time was utilised in actual operating, with the rest spent on other activities such as patient turnover and anaesthetic time (Haiart et al 1990, Lyer et al 2004). A study in 1994 showed similar findings in elective orthopaedic surgery (Ricketts et al 1994). Whilst these studies served to identify the percentage of theatre time used for operating, they failed to detail different parts of the turnover time where efficiency could be improved.

The aim of this study was to assess theatre time utilisation at a teaching district general hospital in the UK and to identify areas for potential improvement in the efficacy of using theatre time.

Materials and methods

The study was carried out in a teaching district general hospital, which had eight orthopaedic consultant teams, two daily elective orthopaedic theatres and one daily trauma theatre list. A prospective review of the timing of events in theatre was carried out for the elective theatre lists of the senior author over a period of ten consecutive weeks. Approval was granted by the Research and Development department as a service evaluation project. Only routine elective cases were surveyed and no distinction was made between day-cases and overnight admissions. Data were collected in real time by the first author using a pre-designed pro forma. Apart from the authors, all theatre staff, including scrub nurses and the anaesthetist, were unaware of the data collection.

Data collected included:

* date of surgery

* scheduled start time

* grade of the operating surgeon

* presence or absence of a supervising consultant

* time for sending for the patient

* time of arrival to theatre reception

* time of arrival into the anaesthetic room

* type of anaesthesia

* grade of the anaesthetist

* time at which the patient was anaesthetised and ready for transfer into theatre

* time the patient was transferred into theatre

* time for positioning and draping

* knife to skin time

* procedure performed

* time of sending for next patient on the list

* time of finishing the procedure and transferring patient out of theatre

* identifiable causes of delays.

Documented times were then used to calculate:

* any delays in starting the list

* time for transportation from the ward to theatre

* time from arrival to theatre reception to transfer to the anaesthetic room (theatre preoperative checks)

* the anaesthetic time

* time from completion of anaesthesia to transferring the patient into theatre

* time for positioning and draping

* the operative time.

Delays in starting the list, the operative time, and total available theatre time were also calculated (Table 1).

Data collection and analysis was carried out using Microsoft[R] Office Excel[R] 2007. Statistical analysis was carried out using SPSS[R] (version 16.0; SPSS Inc., Chicago, Illinois). Student's t-test was used for group comparisons, and statistical significance was established at the p <0.05 level.

Results

Fifteen lists with 41 cases were examined, constituting 5,194 minutes of utilised theatre time. Each list had at least one procedure scheduled. There were no cancellations during the study period. Nine lists were half-day lists, from 08:30 to 12:30, and six lists were full-day, from 08:30 to 17:00. The total planned theatre time was 5,220 minutes, giving a theatre-occupancy of 99.5%. Five (33.3%) of the half-day lists over-ran by five minutes or more. The operative time was 2,804 minutes, constituting 54.0% of total theatre time. Details of the procedures performed are listed in Table 2.

The trainee registrar performed 31 cases (75.6%), 12 (29.2%) of which were supervised by the consultant and 19 (46.3%) were performed independently (mean operative theatre time 51.5 [+ or -] 40.5 minutes, range 5-207). The consultant performed 10 cases (24.4%) with a mean operative time of 120.9 [+ or -] 73.2 minutes (range 43-268).

The total delay in the start time, calculated as the time from the scheduled session start time to sending for the first patient, was 355 minutes (6.8%), with a mean delay of 23.7 [+ or -] 28.0 minutes (range 0 - 100). In two cases, there were identifiable causes for the delay: a problem with the theatre airflow caused a 60 minute delay, and a lack of appropriate equipment for the case caused a 20 minute delay.

The time used for transferring patients from the ward to the theatre was 461 minutes. However, only 281 minutes (5.4%) were spent awaiting patients and the remainder of time overlapped with the operative procedures. This is because on average, patients were sent for 13.9 [+ or -] 8.8 minutes (range 0 - 45) prior to finishing the preceding procedure.

The time used for transferring the patient from theatre reception to the anaesthetic room (used for preoperative checks) was 387(7.4%) minutes (mean 9.4 [+ or -] 6.9, range 2 - 30). There was no overlap between the preoperative checks and the preceding operative procedure on table.

The total anaesthetic time was 623 minutes (12.0%, mean 16.8 [+ or -] 11.5, range 8 - 59). This included 33 general and 4 spinal anaesthetics. Four local anaesthetic cases administered by the surgeon were included under the operative rather than anaesthetic time. A consultant anaesthetist was present in 32 out of 37 cases. Anaesthesia was administered by the consultant anaesthetist in 19 cases (mean 15.4 [+ or -] 7.7, 8 - 20 minutes), and by a trainee/staff grade in 18 cases (mean 17.3 [+ or -] 15.4, 8 - 59 minutes) (p=0.02). Once anaesthetised, there was a total delay of 169 minutes (3.3%) in transferring the anaesthetised patient from the anaesthetic room into theatre.

Table 3 summarises the times spent in the various activities and Table 4 lists the documented causes of delays.

Discussion

Theatre time is an expensive and limited resource. Hospital managements usually assess theatre utilisation as the time spent doing any activity in theatre. This represents theatre occupancy, and is calculated as the percentage of theatre time used for carrying out activities divided by the total available theatre time. This figure does not highlight any inefficiencies in utilising the occupancy time. Theatre occupancy time can be utilised efficiently to perform a higher number of procedures using the same available time, thereby cutting cost and improving theatre throughput. At the same time, understanding how theatre time is spent is important in planning theatre lists and in allocating appropriate time to each case so as to avoid cancellations due to theatre over-running.

In this study, we found that only 54.0% of theatre occupancy time was used for performing surgical procedures, anaesthetic time was 12.0%, and time for positioning and draping was 9.3%. The remainder 24.7% was used for patient turnover, including delays in starting the list, patient transportation, and preoperative theatre checks at theatre reception.

A prompt start on the scheduled time will provide an extra 6.8% theatre time. Despite some overlap between on-going surgical procedures and patient transport (39% of the total transportation time), there remains a large scope for improvement. If patients are sent for early enough during the preceding surgical procedure, most of the time for transportation and preoperative checks can be overlapped with the operative time therefore saving approximately 13% of extra theatre time. Adding the mean times required for transportation (11.2 minutes) and for preoperative checks (9.4 minutes), it may be possible to overlap the turnover time with the operative procedure by sending for patients around 20 minutes prior to finishing the procedure being performed on the operating table.

A reorganisation of how anaesthetist assistants work can serve to save more time, by allowing the anaesthetist assistant to do preoperative checks for the next patient whilst the anaesthetist is recovering the previous patient with the help of recovery staff. A second anaesthetist, possibly a trainee, may provide an extra 12% operative time by overlapping the anaesthetic and operative times; however, this may require increased capacity and staff in the holding area. In total, these measures could provide an extra 30% of the available theatre time that could be utilised to perform surgical procedures.

A common cause of delays was faulty and unavailable surgical equipment, which is of particular relevance to orthopaedics, a very technical surgical sub-specialty. This problem could be reduced through better planning and checking of the availability of required equipment for the procedures on the list and by including any special equipment needed on the listing form when the patient is listed for surgery. This should then be picked up by theatre staff prior to the day of surgery, and any problems highlighted.

Whilst previous studies had similar findings, with between 49 and 60% of theatre time utilised in operating (Haiart et al 1990, Ricketts et al 1994, Lyer et al 2004), this study went further by looking into the details of turnover time and identifying areas for potential improvement. Furthermore, previous studies calculated available theatre time as the time between the scheduled start and scheduled end of a session. In this study, theatre utilisation was calculated as a percentage of the theatre occupancy time, between the scheduled start-time and the end of the last case. This is because theatre lists do not and should not be expected to run for an exact length of time. Flexibility should be allowed for unexpected complications during surgery.

A limitation of this study is that it was carried out in one hospital with one operating surgeon and the results therefore potentially cannot be generalised. In addition, there is a potential researcher bias. Nevertheless, the results of this study were in line with previous literature. Furthermore, the prospective nature of this study and the detailed data collection provided an accurate breakdown of theatre time utilisation and suggested ways in which to improve its efficacy.

Conclusion

This study shows that in our setting, despite a theatre-occupancy of 99.5%, only 75% of theatre time was utilised in clinical activity that directly contributed to the procedure being performed. The remaining 25% was turnover time. Better resourcing and organisation of the theatre list may allow greater overlap of the turnover and anaesthetic times with the operative time, and hence more efficient theatre time utilisation. Careful coordination between theatre staff and the surgeon can reduce delays due to faulty or unavailable equipment. In addition, when planning theatre lists, the time spent for anaesthesia, positioning and draping and turnover must be taken into account along with time needed for actual operating. This will help better utilise the available theatre time, and prevent lists from over-running or finishing too early.

References

Blackpool Teaching Hospitals NHS Foundation Trust 2010 Disclosure ID 24534 - operating theatres

Available from: www.bfwh.nhs.uk/about/foi/show_foi.asp?id=319 [Accessed May 2011]

Faiz O, Tekkis P, McGuire A, Papagrigoriadis S, Rennie J, Leather A 2008 Is theatre utilisation a valid performance indicator for NHS operating theatres? BMC Health Service Research 8 (28)

Haiart D, Pail A, Griffiths J 1990 An audit of the usage of operating theatre time in a peripheral teaching surgical unit Postgraduate Medical Journal 66 (778) 612-5

Lyer R, Likhith A, McLean J, Perera S, Davis C 2004 Audit of operating theatre time utilisation in neurosurgery British Journal of Neurosurgery 18 (4) 333-7

O'Keefe S 2010 Theatre productivity tool overview [Online]. Available from: www.google.co.uk/url?sa=t&source=web&cd=3&ved=0CDQQFjAC&url=http%3A%2F%2Fwww.wales.nhs.uk%2Fsitesplus%2F829%2Fopendoc%2F163866%26AFBAF244-1143-E756-5CEFBAE866570896&rct=j&q=theatre%20time%20cost%20per%20hour%20in%20NHS&ei=iXvRTc70PIzB8QPWs7naDQ&usg=AFQjCNHPnUlnWX0cBN-ErIE3ifPvKpZamw [Accessed May 2011].

Opit L, Colloins R, Campbell G 1991 Use of operating theatres: the effect of case mix and training in general surgery Annals of the Royal College of Surgeons of England 73 (6) 389-93

Ricketts D, Hatley J, Patterson M, Harries W, Hitchin D 1994 An orthopaedic theatre timings survey Annals of the Royal College of Surgeons of England 76 (3) 200-4

West Hertfordshire Hospitals NHS Trust 2009/2010 Re: Freedom of information request Available from: www.westhertshospitals.nhs.uk/foi_publication_scheme/disclosure_log/2010/december/documents/170%20-%20140111.pdf [Accessed May 2011]

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by J Sultan and CP Charalambous

Correspondence address: J Sultan, Specialty Registrar, Trauma and Orthopaedics, Blackpool Victoria Hospital, Whinney Heys Road, Blackpool, FY3 8NR.

Email: jawad.sultan@gmail.com

About the authors

J Sultan

MBBS, MRCS (Ed), MSc Orth Eng

Specialty Registrar, Trauma and Orthopaedic Surgery, NHS North Western Deanery, Orthopaedic Training Rotation

C P Charalambous

BSc MBCHB MSc MD FRCS (Tr&Orth)

Consultant Orthopaedic Surgeon, Blackpool Victoria Hospital

No competing interests declared

Provenance and Peer review: Unsolicited contribution, Peer reviewed, Accepted for publication April 2012.
Interval                             Calculation

Delays in start  Time between scheduled start until sending for the
time             first patient

Operative time   Time from knife-to-skin until the patient has left
                 theatre (for each procedure)

Total available  Time between the scheduled starting time to the
theatre time     time when the last patient on the list left
                 theatre (rather than the planned end of session
                 time)

Table 1 Calculations of delays in starting the list, the operative
time and total available theatre time


Procedure                          No of cases (%)

Knee arthroscopy                        15 (36.6%)

Shoulder arthroscopy                    10 (24.4%)

Minor upper limb surgery                 8 (19.5%)

Total knee arthroplasty                   3 (7.3%)

ACL reconstruction (arthroscopic)         2 (4.9%)

Elbow replacement                         1 (2.4%)

Others                                    2 (4.9%)

Total                                    41 (100%)

Table 2 List of procedures performed


Activity                     Time minutes (%)    Mean (+ or -) SD

Operative time                  2,804 (54.0%)  68.4 (+ or -) 57.8

Anaesthetic time                  623 (12.0%)  16.8 (+ or -) 11.5

Positioning and draping            481 (9.3%)   11.7 (+ or -) 8.5

Theatre preoperative               387 (7.4%)    9.4 (+ or -) 6.9
checks

Delays in start time               355 (6.8%)  23.7 (+ or -) 28.0

Extra time for patient             281 (5.4%)  4.0 (+ or -) 12.07
transfer from ward to
theatre

Delays in transfer from the        169 (3.3%)    4.5 (+ or -) 4.7
anaesthetic room to
theatre

Time unaccounted for                94 (1.8%)                   -

Total                            5,194 (100%)                   -

Table 3 Theatre time utilisation for various activities

Cause                     Number of cases

Faulty/missing equipment                6

Delays in the ward                      2

Faulty theatre airflow                  1

Nerve block failed                      1

Theatre staff not ready                 1

Total                          11 (26.8%)

Table 4 Documented causes for unexpected delays
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