ASSESSMENT OF SURGICAL CASE TURNOVER TIME AND FACTORS AFFECTING OPERATION THEATRE EFFICIENCY

Abstract

Background: The operating room (OR) is one of the most resource-consuming and revenue units in any hospital, which makes up about 70% of all hospital revenues. Turnover time (TOT) - the time interval between the completion of one case and the onset of another one- turnover time is a critical non-operative period, the optimization of which is the key to maximizing OR throughput, cost reduction, and preservation of surgical schedules. Regardless of its importance, TOT has a multifaceted interaction of staffing, organizational, patient-related, and time-specific factors which are not fully described in various surgical environments. Objective: To both assess the scale of the TOT delays objectively and examine the most common factors that contribute to these delays, as well as to review how OR team composition, time of the day, and institutional factors affect OR efficiency. Methodology: Evidence synthesis involved a series of observational and retrospective studies that were carried out in academic and teaching hospital environments. There were studies based on prospective observational data observation of TOT in general surgery and orthopaedic theatres, multi-specialty studies of elective cases, and specialty-based studies in hand surgery. Some of the variables that were tested were the identity of the surgeon and continuity, anesthesiologist, nursing team, time of the day, patient ASA status, complexity of the case and institutional/hospital factor. Results: In all studies, most of the turnovers (77-79) included were performed within benchmark ranges and the average ranges of TOT were 15.5 to 96 minutes provided the setting and time of the day. Four major categories of causes that led to delays were surgeon related (22.5%), anesthesia related (9%), patient related (18%), and hospital/institutional related (50.5%), and the latter was the most prevailing. There were also specific identifiable contributors, such as the unavailability of staff, delays in the transportation of patients, the introduction of the emergency cases in the elective lists, equipment problems, and the breakdown of communication. Multivariate analyses continuously showed consecutive surgeon, consecutive anesthesiologist, and same surgical specialty to be independent predictors of lower TOT. Most importantly, time of day proved to be a powerful independent variable- cases that had previously undergone a previous procedure and were terminated after 14:00 had much longer TOT (mean 95.5 vs. 78 min, p<0.001), which coincided with the change of nursing and support staff shifts at 15:00. A dedicated OR staff model was related to a meaningfully lower TOT in hand surgery than a non-dedicated model. Conclusions: Multifactorial determinants that influence the efficiency of TOT and OR include continuity of staffing, institutional infrastructure, time of the day factors, and scheduling of cases. The most influential and adjustable ones are the use of stable surgical, anesthesia teams in the successive cases, the scheduling of staff shift changes in sequence in order to have a time overlap, specialty-specific OR teams, and parallel processing of patient preparation. The most critical interventions to the delay in hospitals are at the hospital level such as the better communication system, standardized turnover practices, and sufficient staffing of support. To maximize the efficiency of the OR, minimize its costs and enhance the overall quality and safety of the delivery of surgical care, it is needed to have a multidisciplinary systems-based approach to its optimization.