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| ORIGINAL ARTICLE |
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| Year : 2013 | Volume
: 59
| Issue : 4 | Page : 281-283 |
Utilization of operating room time in a cancer hospital
P Ranganathan, P Khanapurkar, JV Divatia
Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
| Date of Submission | 20-Jul-2013 |
| Date of Decision | 13-Aug-2013 |
| Date of Acceptance | 02-Oct-2013 |
| Date of Web Publication | 17-Dec-2013 |
Correspondence Address:
P Ranganathan
Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Parel, Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0022-3859.123155
Background: Appropriate usage of operating room (OR) time can improve efficiency of utilization of resources and help to decrease surgical waiting lists. Aims: This study was conducted to evaluate the pattern of usage of OR time in a tertiary referral cancer hospital. Setting and Design: This was a prospective audit carried out over 2 months in 11 major ORs in a cancer hospital. Materials and Methods: OR anesthesiologists filled a standard form for all patients undergoing elective surgery and documented the following times: entry into OR, start of anesthesia, handover to surgeon, incision, start of reversal, end of anesthesia, and shifting out of patient. Statistical Analysis: Median time utilized for various OR processes was calculated. Results: An average of two surgeries were performed per OR session (828 surgeries in 407 OR sessions). Anesthesia and surgery-related processes contributed to 17% and 79%, respectively, of total OR time, with turnover time between cases accounting for the remaining 4%. Fifteen percent (60 out of 407) OR sessions started more than 10 min later than the planned start time, and 17% (70 of 407) of OR sessions ended more than 2 h after the scheduled finish time. An anesthesia procedure room was utilized in only 15% of cases where it could potentially have been used. Conclusion: This audit identified patterns of OR usage in a cancer hospital and helped to detect areas of inefficient utilization. Anesthesia-related processes contributed to 17% of the total OR time.
Keywords: Medical audit, operating room, utilization review
How to cite this article:
Ranganathan P, Khanapurkar P, Divatia J V. Utilization of operating room time in a cancer hospital. J Postgrad Med 2013;59:281-3 |
| :: Introduction | |  |
Efficient management of operating room (OR) time is important for optimum utilization of manpower and resources, to maximize the cost-effectiveness and to decrease surgical waiting lists. This is particularly important in the setting of cancer surgery where any delay can impact disease staging and patient outcomes. Audits of OR utilization have been shown to have a role in identifying deficiencies and improving inefficient OR utilization. [1],[2],[3],[4],[5],[6] The objectives of this audit were to study the pattern and efficiency of use of OR time in elective surgical lists in a tertiary referral cancer hospital.
| :: Materials and Methods | | |
This was a prospective audit carried out over 2 months from 1 April 2011 to 31 May 2011 in a tertiary cancer center. During this period, elective surgical procedures were carried out in 11 ORs in the hospital. Despite being a teaching hospital, there are no vacation periods in the hospital and the pattern of functioning of the ORs is consistent throughout the year. Surgical and anesthesia procedures were performed either by the senior permanent staff or by the trainees working under supervision. One fully equipped anesthesia procedure room was available for the performance of regional anesthesia procedures in conscious patients; general anesthesia was administered only in the main ORs. We included all consecutive elective surgical procedures carried out under general or regional anesthesia. Emergency cases, cases performed on weekends, and cases performed under local anesthesia were excluded. OR anesthesiologists filled a proforma for each patient, including the following timings: entry into OR, start and end of anesthesia procedures [regional anesthesia, general anesthesia, invasive monitoring, specialized airway devices (fiberoptic intubation, lung isolation)], handover to surgeon, incision, end of surgery, recovery from anesthesia, shifting out of OR and entry of next patient. A record of preoperative regional anesthesia procedures carried out in the induction room was also maintained. Completeness of data was verified by cross-checking a random sample of cases with the OR record book.
The following definitions were used for the purpose of this audit:- OR start time: Time of entry of first patient into the OR
- Total anesthesia time: This included the following:
- Pre-anesthesia time: Time from patient entry into the OR till the start of anesthesia (general or regional) - This represented the time taken to confirm patient identity, attach monitors, and secure intravenous access.
- Anesthesia time: This included the following:
- Induction time: Time taken for administration of anesthesia until handover to surgeon
- Reversal and recovery time: Time from end of surgery till shifting out of the patient, i.e. time taken for reversal of anesthesia and for immediate postoperative recovery
- Total surgery time: This included the following:
- Surgical preparation time: Time from handover of patient till incision. This represented the time taken to position, prepare, and drape the patient.
- Surgery time: Time from the first incision to the time when last incision was closed. This was the actual time taken for the surgical procedure and included the time taken for application of dressings, splints, etc.
- Turnover time: Time from when one patient exited the OR till the next patient entered the OR. This represented the time taken to clean and prepare the OR between cases.
- OR end time: Time of exit of last patient from the OR
- Total OR time: Time between OR start time and OR end time
- End-utilization: Percentage of total OR time that was used in anesthesia or surgery-related activity = (total anesthesia time + total surgery time)/(total OR time)
Statistical analysis
Data were entered into a statistical software program SPSS 18.0 (SPSS Inc., Chicago, USA). Time taken for various processes was expressed as median (with interquartile ranges).
| :: Results | | |
Data were obtained for 828 surgeries carried out during 407 OR sessions in the study period (average of two cases per OR per day). The total OR time was 214,320 min. The median time of starting the OR list was 5 min after the scheduled list start time, with 15% (60 out of 407) first cases entering the OR more than 10 min late. The median OR end time was 60 min after the scheduled OR end time, with 17% (70 of 407) last cases leaving the OR more than 2 h after the scheduled finish time. [Table 1] lists the time taken for various processes in the OR. Surgical procedures included all types of cancer surgeries such as mastectomy, mandibular resection with reconstruction, laryngectomy, esophagectomy, lung resection, radical hysterectomy, radical prostatectomy, pelvic bone resections, pancreatectomy, gastrectomy, and colonic resections. Sixty percent of cases had a total surgical time exceeding 2 h [Figure 1].
[Figure 2] shows the contribution of various processes to the total OR time. End-utilization was 96%. Turnover time between cases accounted for only 4% (145 h, 33 min) of the total OR time. Anesthesia time contributed to 17% (598 h, 23 min) of the total OR time; of this, the time between recovery from anesthesia till the actual shifting out of the patient was 100 h, 19 min (3% of the total OR time). The anesthesia procedure room was utilized in only 15% of cases where it could have been used potentially.
| :: Discussion | | |
This audit of usage of OR time in a tertiary referral cancer hospital identified some areas of inefficiency such as delayed start of OR, inadequate utilization of the procedure room, and delays in shifting the patients out of the OR after immediate recovery from anesthesia.
Delayed starts have been implicated as a significant component of unutilized OR time in several studies. [1],[2],[3],[4],[5],[6] In our study, while some delays were due to unavoidable reasons (spillover of emergency cases from the previous night, non-availability of recovery room beds), other reasons that were identified included delayed shifting of patient from wards, issues with patient fitness, late arrival of consultant doctors, and problems with OR equipment. These problems are potentially avoidable and need to be dealt with. Another area for improvement of OR utilization is the use of the anesthesia procedure room; the main reason given for non-utilization was lack of manpower, which is in keeping with the findings of other authors. [3],[6] Our usage of the procedure room is currently restricted to performance of preoperative regional anesthesia procedures; however, even this could potentially lead to saving around 20 min per OR per session. The turnover time between cases accounted for only 4% of the total OR time, which is much less than that of other studies. [1],[2],[4],[5] As a result, the end-utilization was 96% which was very high. This could be due to the complex nature of surgical cases performed at our hospital - almost 60% of the cases had a total surgical time more than 2 h and the median number of cases per OR session was just two. However, we did find some delay during recovery from anesthesia and shifting out of OR, and this could possibly be corrected.
Our study has certain limitations. The study forms were filled by anesthesiologists who were aware of the background for the study and there may have been some bias in recording, especially for anesthesia-related delays. We looked at the average timings for OR processes across a variety of surgical procedures - it is possible that for short-duration surgeries, turnover times may contribute to a larger percentage of the total OR time and decrease the end-utilization. Delays during anesthetic induction can occur due to various reasons - genuine difficulty with the procedure, inexperienced junior staff performing the procedure, and time spent in teaching - and some of these delays could perhaps be minimized. However, there are no guidelines on "acceptable" target time limits for various processes in the OR, including anesthesia as well as surgical procedures. Therefore, we could not comment on delays in anesthesia or surgery-related procedures. In particular, if the start of anesthesia was delayed after shifting the patient into the OR, this was reflected as a prolonged pre-anesthesia time. Also, considering that ours is an academic institute with trainee doctors working under supervision, some amount of delay has to be accepted in the interest of teaching.
The results of this audit may not be applicable to other settings with a different case-mix, varying levels of experience of surgeons and anesthesiologists, and separate working patterns. However, this study may help to reinforce the role of audits in identifying and correcting deficiencies in OR utilization.
Considering that many of the surgeries at our hospital are extensive procedures, it is possible that even with correction of all these shortcomings, the number of cases performed per OR session may not actually increase. However, it needs to be recognized that anesthesia-related activity accounts for 17% of the total theater time. Thus, optimizing anesthesia-related time could potentially reduce delays in OR finish time.
| :: Conclusion | | |
This audit identified some areas of inefficiency in OR utilization, such as late starts, inadequate utilization of induction room, and delay in shifting of patients from the OR. While some of these are easily correctible, other factors are dependent on availability of manpower and resources. Multidisciplinary interventions may be needed to bring about the final change.
| :: References | | |
| 1. | Haiart DC, Paul AB, Griffiths JM. An audit of the usage of operating theatre time in a peripheral teaching surgical unit. Postgrad Med J 1990;66:612-5. 
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| 2. | Ricketts D, Hartley J, Patterson M, Harries W, Hitchin D. An orthopaedic theatre timings survey. Ann R Coll Surg Engl 1994;76:200-4.
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| 3. | Saha P, Pinjani A, Al-Shabibi N, Madari S, Ruston J, Magos A. Why we are wasting time in the operating theatre? Int J Health Plann Manage 2009;24:225-32.
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| 4. | Delaney CL, Davis N, Tamblyn P. Audit of the utilization of time in an orthopaedic trauma theatre. ANZ J Surg 2010;80:217-22.
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| 5. | Overdyk FJ, Harvey SC, Fishman RL, Shippey F. Successful strategies for improving operating room efficiency at academic institutions. Anesth Analg 1998;86:896-906.
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| 6. | Vinukondaiah K, Ananthakrishnan N, Ravishankar M. Audit of operation theatre utilization in general surgery. Natl Med J India 2000;13:118-21.
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[Figure 1], [Figure 2]
[Table 1]
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Case-Mix
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