The impact of late-starts and overruns on theatre utilisation rates.
Abstract: The NHS Management Executive recommends that hospitals should aim to use 90% of planned theatre time and that theatre utilisation should be used as a key performance indicator. This study aims to investigate the impact of latestarts and overruns on theatre utilisation rates. Data were retrieved from a prospectively updated theatre database for all elective plastic surgical main theatre operating sessions carried out over a one year period. Theatre list utilisation was calculated as the percentage of the total allocated session time that was used for anaesthesia and operating. A total of 2,944 elective main theatre operations were performed in one year. Total theatre utilisation was 90.9%. Utilisation of lists starting less than one hour after the scheduled start time was similar to the utilisation of sessions starting more than one hour late (90.1% versus 91 7% respectively, p=0.527). In contrast, overrunning lists demonstrated much higher utilisation rates than those that finished before the end of the session (96.7 % versus 76.6% respectively, p<0.001). The study shows that late-starts and overruns represent obvious sources of theatre inefficiency yet their impact on utilisation is misleading: overruns exaggerate theatre usage and late-starts have little impact upon it. We conclude that the use of utilisation as a marker of theatre performance requires caution.

KEYWORDS Operating rooms / Utilisation / Organisational efficiency / Theatre utilisation / Delivery of healthcare
Subject: Medical care, Cost of (Analysis)
Surgery (Health aspects)
Medical care (Utilization)
Medical care (Analysis)
Author: Al-Benna, Sammy
Pub Date: 07/01/2012
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: July, 2012 Source Volume: 22 Source Issue: 7
Product: Product Code: 8000410 Surgical Procedures NAICS Code: 62 Health Care and Social Assistance
Geographic: Geographic Scope: Germany Geographic Code: 4EUGE Germany
Accession Number: 300545545
Full Text: Health services worldwide are currently undergoing a period of economic turbulence (Al-Benna 2010). Healthcare providers, in both public and private sectors, are facing increasing pressure to improve cost efficiency and productivity (Al-Benna 2010, 2012). Clinical activity in the hospital is closely monitored and the target is to provide high quality of care at the lowest possible costs. It has been estimated that 29% of all healthcare outlays are related to surgical expenditure, therefore the efficient use of operating theatres in hospitals has assumed a great importance in healthcare cost (Munoz et al 2010).

Surgical costs are related to supplies used, cost of equipment, inventory volume and operating room utilisation (Munoz et al 2010). A critical task in these services is planning the operating theatres so that hospital resources are efficiently allocated and patient satisfaction is assured (Gilmour 2009, Munoz et al 2010, OECD 2010, Al-Benna 2010, 2011, Bloodworth 2011).

This problem of allocating a given amount of resources in the best way possible is not new from an economic point of view. Theatre utilisation has long been used in the UK as an indicator to measure the efficiency of the use of hospital resources such as the operating rooms (NHS Management Executive 1989, Audits Commission for Scotland 1999, Audit Commission 2003, Northern Ireland Audit Office 2003, NHS Institute for Innovation and Improvement 2009). Researchers often argue that high utilisation equals cost-effectiveness and goes hand in hand with high quality of health care (Evans 2009, Al-Benna 2010, Munoz et al 2010). In these studies utilisation is typically considered as an absolute measure that can be used to resolve the perceived efficiency problem in healthcare (Faiz et al 2008, OECD 2010).

In accordance with this trend, UK governmental institutions have produced key reports on theatre utilisation, and offered programmes to improve theatre utilisation (NHS Management Executive 1989, Audits Commission for Scotland 1999, Audit Commission 2003, Northern Ireland Audit Office 2003, NHS Institute for Innovation and Improvement 2009)The reports showed that theatres were being used for only about 70-88% of scheduled time and recommended that hospitals should aim to use 90% of planned theatre time. The publications from these governmental institutions have served to enhance the profile of this performance indicator in the public setting, but there has been little research to date investigating its validity as a performance indicator. The aim of this study was to investigate the impact of late-starts and overruns on theatre utilisation rates.

Methods

Data were collected retrospectively from the operating theatre database of St. John's Hospital, Howden, Livingston, Scotland which contained records of each operation performed. To ensure a large enough sample size, data were collected from all elective plastic surgical main theatre operating sessions carried out over a one year period. Only elective plastic surgery was included. Those cases performed on weekends and public holidays were excluded as there was no scheduled plastic surgery theatre on these days. Each operation record stored on the database provides a summary of the procedure performed, the staff involved and the times at which certain events occurred. For each operation during the one year period, the following times were recorded:

* Time patient sent for Time in theatre reception

* Time in anaesthetic room

* Time anaesthetic starts

* Time of first incision

* Time out of theatre

The data were collected and entered onto a Microsoft Excel spreadsheet. Based on these times, the following was calculated for each procedure:

* Time patient sent for - Time in theatre reception

* Time in theatre reception - Time into anaesthetic room

* Time into anaesthetic room - Time anaesthetic starts

* Time anaesthetic starts - Time of first incision

* Time anaesthetic starts - Time out of theatre

Operating theatre schedules were also collected during this one year period, enabling the start time and the allocated theatre time for each elective plastic surgery list to be recorded. Late-starts were calculated as the time that anaesthesia commenced on the first case minus the scheduled start time. Overruns occurred where the last case finished after the scheduled end of the session. Theatre list utilisation was calculated as the percentage of the total allocated session time that was used for anaesthesia and operating. All of the above recorded times were rejected as being normally distributed (Kolmogorov-Smirnov test), and hence, median values were calculated and analysed with Mann-Whitney U-tests (MINITAB[TM] Statistical Software, Release 13.1, Minitab Inc., State College, PA, USA).

Results

In total, 2,944 operations within elective plastic surgery sessions during the one-year period fitted the criteria for inclusion into this study. In each case, the operative records were complete, and the required data was recorded for analysis.

The median Time patient sent for - Time in theatre reception was 11 min (range 1-75 min). The median Time in theatre reception - Time into anaesthetic room was 11 min (range 1-190 min). The median Time into anaesthetic room - Time anaesthetic starts was 6 min (range 1-53min). The median Time anaesthetic starts room - Time of first incision was 10 min (range 1-58min). The median Time anaesthetic starts room - Time out of theatre was 63 min (range 5-688min).

Only 20.4% of elective lists started less than one hour after the scheduled start. Overall, 79.6% of lists started over one hour late and 17.9% overran their intended session duration. The theatre utilisation when lists started less than one hour after the scheduled start time was similar to the utilisation when lists started more than one hour late (90.1% versus 91.7% respectively, p=0.527). In contrast, overrunning lists demonstrated much higher utilisation rates than those that finished before the end of the session (96.7 % versus 76.6% respectively, p < 0.001).

Conclusions

In a theoretically efficient operating system, the theatre should start on time, no operation should be cancelled and the theatre should finish on time. Increased elective throughput through improved utilisation of the operating theatre allows scheduling of more elective surgery.

The aim of this study was to determine the theatre utilisation rate over a one year period, with data available for all consecutive elective plastic surgery operations done during this period. More importantly, the study investigated the impact of late-starts and overruns on utilisation rates.

In the current survey of 2,988 elective plastic surgery operations theatre utilisation was 90.9%. The mean theatre utilisation when lists started less than one hour after the scheduled start time was similar to the mean utilisation when lists started more than one hour late. However, overrunning lists demonstrated much higher utilisation rates than those that finished before the end of the session (see Figure 1).

This study demonstrates that late-starts and overruns represent obvious sources of theatre inefficiency, yet their impact on theatre utilisation rates is misleading as overruns exaggerate theatre usage whereas late-starts have little impact upon it. Therefore, sceptiscism regarding the validity of a 'target' utilisation rate for theatres should be maintained.

In the future, quantitative measures of surgical service workload, such as human resource group tariffs, are likely to prevail over theatre utilisation rates. Definition of an actual service 'output' in hospitals has aided political and strategic as well as operational decision-making. Irrespective however of the validity of a specific tool that quantifies theatre effectiveness, improving elective theatre efficiency demands a broad perspective over the entire surgical pathway.

Looking at ways of decreasing theatre time wastage, it appears that nothing can be done about anaesthetic and operating times, which will vary depending on the needs of the individual patient. This supposition could be challenged as it is widely accepted that an increase in operating times contributes to increased morbidity. However, it is difficult to define the cut-off for an 'acceptable' time for anaesthesia and surgery, as there is always a fine balance between speed and safety.

At present, although '90% theatre efficiency' is regarded as a goal, the term is incompletely defined and variously interpreted, making it an almost redundant aspiration. In addition this study demonstrates that factors beyond occupancy of theatre time are important in running an efficient theatre service. This has important consequences for hospital expenditure, hospital income and the clearing of waiting lists.

Activity and theatre utilisation should be monitored regularly to assess the time distribution of surgical cases. This monitoring enables the department to highlight causes of inefficiencies and has been shown to improve the activity in elective theatres. Given that hospitals incur costs regardless of whether theatre time is used, the avoidance of wasted time and maximisation of operating time should help to reduce the pressure on waiting lists It is easy to measure when a list starts and finishes but that is a remarkably poor measure of whether the time in between was used efficiently.

The Productive Operating Theatre is a comprehensive package of support that has been coproduced and tested by the NHS Institute for Innovation and Improvement (2009) working with NHS theatre teams. It has been designed to enable organisations in the NHS to improve the patient experience and the outcomes of care by pursuing three main goals:

a) increase the safety and reliability of care

b) improve team performance and staff wellbeing

c) add value and improve efficiency.

Many NHS trusts have focused on theatre efficiency metrics, but it is important to have developed integrated measures that include clinical quality, safety, patient experience and service reliability - as well as productivity (Al-Benny 2010).

Late-starts and overruns represent obvious sources of theatre inefficiency yet their impact on utilisation is misleading as overruns exaggerate theatre usage and late-starts have little impact upon it. Studies such as this may help to identify areas in which time may be more efficiently used and may confirm best practice. Late starts and unutilized time between cases is an area where improvement is possible. This is especially true of starting on time. Therefore, the use of theatre utilisation as a marker of theatre performance requires caution.

Theatre 1 has one case scheduled that starts and finishes on time, therefore theatre utilisation is 100%.

Theatre 2 has five cases that start and finish on scheduled time, all five cases overlap as the next patient was in the anaesthetic room before the current patient left theatre, therefore theatre utilisation is greater than 100%.

Theatre 3 has four cases that start and finish on scheduled time, all cases are serial, therefore theatre utilisation is less than 100%.

Theatre 4 has four serial cases that start on time but overrun If the theatre is utilised for over 8 hours the total may be greater than 100%.

Theatre 5 has one case that starts late and overruns, but if the total time for 'Time anaesthetic starts room - Time out of theatre' is over 8 hours, theatre utilisation is greater than 100%.

References

Al-Benna S 2010 A discourse on the contributions of evidence-based medicine to wound care Ostomy Wound Management 56 (6) 48-54

Al-Benna S 2011 Perioperative management of morbid obesity Journal of Perioperative Practice 21 (7) 225-33

Al-Benna S 2012 Construction and use of wound care guidelines Ostomy Wound Management In press

Audit Commission 2003 Operating theatres: Review of national findings London, HMSO

Audits Commission for Scotland 1999 Full house-theatre utilisation in Scottish hospitals Edinburgh, Audit Scotland

Bloodworth K 2011 The productive ward and the productive operating theatre Journal of Perioperative Practice 21 (3) 97-103

Evans J, Lipp A 2009 Health economics: what value to the theatre practitioner? Journal of Perioperative Practice 19 (3) 88-92

Gilmour D 2009 The productive operating theatre programme Journal of Perioperative Practice 19 (7) 196

Faiz 0, Tekkis P, McGuire A, Papagrigoriadis S, Rennie J, Leather A 2008 Is theatre utilisation a valid performance indicator for NHS operating theatres? BMC Health Services Research 31 (8) 28

Munoz E, Munoz W 3rd, Wise L 2010 National and surgical health care expenditures 2005-2025 Annals of Surgery 251 (2) 195-200

NHS Institute for Innovation and Improvement 2009 The Productive Operating Theatre Available from: www.institute.nhs.uk/qualityand_value/productive_operating_theatre/get_started.html (Accessed November 2011)

Northern Ireland Audit Office 2003 The use of operating theatres in the Northern Ireland Health and Personal Social Services Belfast, HMSO

Organization for Economic Cooperation and Development 2010 OECD Health Data 2010 Paris, IRDES

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Correspondence address: Sammy Al-Benna, Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Buerkle-de-la-Camp-Platz 1, 44789 Bochum, Germany. Email: sammy.al-benna@ruhr-uni-bochum.de.

About the author

Sammy Al-Benna

MB ChB, PhD, MRCS, PGCNano

Plastic Surgeon, Department of Plastic Surgery, BG University Hospital, Germany

No competing interests declared
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