Original Article

Audit of the Functioning of the Elective Neurosurgical Operation Theater in India: A Prospective Study and Review of Literature Amrit Kumar Saikia1, Kamath Sriganesh2, Manish Ranjan1, Marie Claire3, Mohit Mittal2, Paritosh Pandey1

BACKGROUND: Knowledge about the utilization of the operation theater (OT) is essential to improve its efficiency. This study evaluated the neurosurgical operation theater utilization in a neurosciences teaching hospital.

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METHODS: Data collected included OTstart time, delay in start, anesthesia induction time, surgical preparation time, anesthesia recovery time, operating time, time between cases, and theater closing time.

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RESULTS: Five hundred thirty-seven surgeries were performed during the study period. The percentage of time used for anesthesia induction, actual surgical procedure, recovery from anesthesia, and theater preparation between the two cases were 8%, 70%, 6% and 5%, respectively. Fourteen percent of scheduled cases were cancelled. On 220 occasions (70.51%), theater was over-run. Late start contributed to loss of 8370 minutes (140 hours) of theater time.

hospital. An important aspect of maximizing the utilization of an OT is to know how much time is spent on each activity and there by identify factors resulting in inappropriate utilization of the facility. Very little data are available about the utilization of operating time in a neurosurgical theater (8) despite literature in other operative specialties. (9, 18, 19) This study therefore aimed at analyzing the utilization pattern of neurosurgery OT time at a tertiary neurosciences center and to identify measurable activities for optimal OT utilization.

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CONCLUSIONS: This study identified the proportion of time spent on each activity in the neurosurgical OT. This knowledge is likely to facilitate better planning of neurosurgical theater schedule and result in optimal utilization.

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INTRODUCTION

O

peration theater (OT) consumes significant expenditure of a hospital budget (17). Despite this, not much focus is placed on optimization of the scarce health care resources in hospital policy and research, especially in the developing nations. Inefficient use of OT can lead to considerable losses in terms of revenue and manpower for the

Key words Audit - Cancellation - Operation theater - Utilization -

Abbreviations and Acronyms NIMHANS: National Institute of Mental Health and Neuroscience OT: Operation theater

METHODS This was a prospective observational study in which data were reviewed of patients undergoing elective neurosurgical procedures at National Institute of Mental Health and Neuroscience (NIMHANS), Bangalore, a tertiary care government teaching hospital. After NIMHANS ethics committee approval, consecutive patients were prospectively studied during a period of 4 months. There are 4 OT suites allotted for scheduled elective neurosurgery. The elective OT timing is from 9 AM to 5 PM with no scheduled break. The OT functions 5 days a week throughout the year except on government holidays. The proportion of work done by consultants and residents is variable and depends on the nature of scheduled cases. Each OT has a separate team of anesthesiologists. The surgical wards are on different floors and ward staff are responsible for transferring patients to and from the wards to the OT. Patients who are listed for elective surgery the previous day were included in the study. The data collection were undertaken prospectively for each patient on a detailed form by an independent staff nurse for each OT who was not involved in this study or in nursing care. This was done to minimize errors and bias. OT utilization was studied with respect to starting and closing time of the operation room and the interval between surgical procedures. The various time periods in this study were defined as follows:

Form the Departments of 1Neurosurgery and 2Neuroanaesthesia; and 3Senior Nursing Staff, Operation Theater Services, National Institute of Mental Health and Neuroscience, Bangalore, India To whom correspondence should be addressed: Paritosh Pandey, M.Ch. [E-mail: [email protected]] Citation: World Neurosurg. (2015). http://dx.doi.org/10.1016/j.wneu.2015.03.031 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.

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AUDIT OF OPERATION THEATER UTILIZATION

OT start time: actual time at which patient is taken inside the OT. Delay in start: difference between “scheduled start time” and “time when patient is shifted to OT.” Anesthesia induction time: difference between “time at which patient is taken to OT00 to “time at which the patient is handed over to the surgeon.” Surgical preparation time: the difference between the “time patient is handed over to surgeon” to “time at start of surgery.” Surgical time: difference between “time of beginning of surgery” to “time of end of surgery.” Anesthesia recovery time: difference between “time at which patient is handed over to anesthesiologist” to “time of shifting the patient out of OT.” Operating time: difference between “time at which patient is taken to OT00 to “time of shifting of patient out of OT.” Time between cases: difference between “time of shifting of patient out of OT00 to “time at which next patient is wheeled into the OT.” OT closing time: time at which the last patient is shifted out of the OT. Data Analysis Data were tabulated for analysis and various time intervals were calculated as a percentage of the total time spent in OT to ascertain the time spent on various activities. The analysis of the data was done by an independent statistician who was not part of the data collection or this study. Mean, 80th percentiles, 95% confidence interval, and minimum and maximum time was calculated for various neurosurgical operations. OT utilization was studied with respect to starting and closing time of the OT and time between the cases.

(2724 hours). OT was overrun by 13,682 minutes (228 hours). There was a delay in start from the scheduled time of 8370 minutes (140 hours). On 84 occasions (26.92%) OT was closed earlier than 5 PM with average early finish time of 36.28 minutes. On 220 occasions (70.51%) theater was closed later than 5 PM with average late finish time of 107.56 minutes. Only in 8 occasions (2.56%) theater was closed on time. Five hundred thirty-seven operations were performed during the study period, with 87 (13.94%) cases being canceled. Of these, 63 (72.41%) cases were canceled due to lack of time and the rest 24 (27.59%) cases were canceled, as emergency surgery was performed in-lieu of elective cases. No surgery was canceled because of lack of fitness for anesthesia/surgery, lack of consent, or nonarrival of patient. Table 1 and Figure 1 show the time taken for various activities in the OT as a proportion of the total OT time. Various neurosurgical procedures performed during the study period and time for various activities for each type of neurosurgery is shown in Table 2. On statistical analysis of the different time components for 10 neurosurgical procedures that we classified, we observed that there was a significant difference for anesthesia induction, surgical duration, and total operation theater time between different neurosurgical procedures. Furthermore, on post-hoc analysis, we observed that there was a significant difference in the surgical times between shunt procedures and epilepsy surgery (P ¼ 0.01), reconstructive procedures (P ¼ 0.02), functional neurosurgical procedures (P ¼ 0.004) and infratentorial (P ¼ 0.001), and supratentorial surgeries (P ¼ 0.003). The actual operative time was longest for the functional neurosurgery and shortest for the shunt procedures. OT starting and closing time is shown in Table 3.

DISCUSSION RESULTS The OT functioned for 78 days during the study period. The OT did not function for 44 days due to Saturdays/Sundays and holidays. The total effective available OT time was 149,760 minutes or 2496 hours (9 AM to 5 PM in 4 OTs). During this period, the total OT time utilization (time between wheeling of first patient into the OT and the last patient being shifting out of OT) was 163,442 minutes

Ideally, an OT should start on time, no operation should be canceled, and the theater should be closed on time. This ensures optimal usage of the OT time and time of the stakeholders like patient, surgeon, anesthesiologist, and nursing, technical, and assisting staff involved in the patient care in the OT. This can, in turn, lead to better quality of health care delivery for hospitalized patients and also for those waiting for surgery. In addition to safe

Table 1. Amount of Time Used for Anesthetic Induction, Surgical Preparation, Actual Operation, Dressing After Surgery, Anesthesia Recovery, and Time Between Cases in the Neurosurgery OT in Minutes (hours) Activity in OT

Minimum

Maximum

Mean

80th Percentile

SD

Total Minutes (hours)

Anesthesia induction

5

65

24.9

30

10

13,363 (223)

8%

Surgical preparation

10

105

27.6

35

11.3

14,826 (247)

9%

Actual operation

25

640 (10.6)

212.5 (3.5)

310 (5.2)

116.1

5

25

5.8

7

Dressing after surgery

% of OT Time

113,952 (1,899)

70%

2.9

3,451 (58)

2%

Anesthesia recovery

5

90

16.9

20

9.9

9,095 (152)

6%

Time between cases

15

180

41.6

55

22.6

8,755 (146)

5%

Total OT time

163,442 (2,724)

100%

OT, operation theater; SD, standard deviation.

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ORIGINAL ARTICLE AMRIT KUMAR SAIKIA ET AL.

Figure 1. Graphic depiction of the neurosurgery operating theater time for various activities.

and effective day-to-day service to patients, it provides health care personnel adequate and quality time for their family. Three decades ago, the OT utilization was only about 40% (3). Subsequent studies showed OT efficiency improving to 77% in 1990 (5) 81% by 1994 (12), and to 91% by 2000 (18), indicating the impact of audit and positive measures in improving OT efficiency during several years. In our study, the actual OT time utilization was 163,442 minutes (2724 hours) as opposed to the scheduled 149,760 minutes (2496 hours) with over-running of OT by 13,682 minutes (228 hours). Similar overutilization of OT was observed in an earlier study (8). The average OT time was 8.7 hours (523.85 minutes) per OT per day in the present study. Anesthesia induction and time for recovery from anesthesia after surgery was 8% and 6%, respectively. In contrast, a higher anesthesia preparation time (5%), induction time (16%), and recovery time (7%) were observed in an earlier study involving neurosurgical patients (8). This shorter anesthesia time in our study could be due to less aggressive invasive monitoring, performance of multiple tasks simultaneously by residents and consultants, and placing additional venous access, arterial line, lumbar drain, or scalp block in parallel with the preoperative surgical preparation (surgical scrubbing and draping of the operative field). Following of this parallel, rather than serial management system resulted in significant reduction in anesthesia induction time. For the same reason, the analysis of the anesthesia times (both induction and recovery time) for 10 neurosurgical procedures in our study did not demonstrate statistical difference between various procedures (P > 0.05). The actual operating time in our study and that of Jan et al. (9) was

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higher (70%) compared with 58% in study by Iyer et al. (8). This could be because both the hospitals are training institutions and the residents perform the beginning and closure part of the procedures. Identifying and delegating surgeons to specific surgeries with expertise in subspecialties (vascular neurosurgeon to neurovascular surgeries), simulation-based skill enhancement for residents and consultants, proper coordination with operating room technicians handling fluoroscopy machines and electrophysiology equipment, having effective intraoperative portable computed tomography scanner, protocolized surgical planning, and use of robotic tools to assist surgical procedures might shorten the duration of surgical time contributing to overall OT time prolongation. **A longer (11.62%) time for OT preparation between the cases was reported in the studies by Jan et al (9) and Iyer et al (8) as compared to 5% in our study reflecting an efficient OT management system in place in our hospital. In contrast, a similar turnaround time of 36 minutes as in our study was observed by Mazzei (11). OT floor and surface disinfection before every surgery reduces the environmental contamination and transmission of health care-associated pathogens. Therefore, this time cannot be compromised. Instead, facilitating recovery in the postanesthesia care unit and preparing the OT for the next patient can be done simultaneously, which might result in reduction of time between the cases. There is not enough data to compare how much time is used for different neurosurgical procedures. Only one previous study evaluated the time involved during various neurosurgical procedures (8) and it is compared with our data (Table 4). Except for the aneurysm surgery, the operative time was longer in our study, whereas the anesthetic time was shorter for all neurosurgical procedures. First, the reason for shorter operative time for neurovascular surgeries in our setup compared with the earlier study is due to some of the neurovascular procedures being revascularization procedures for moyamoya disease and carotid ligation for giant aneurysms. Second, the reason for comparatively shorter operative times for neurovascular surgeries is because these neurovascular procedures were performed only by senior consultants experienced in neurovascular procedures unlike tumor or spine procedures that were performed by surgeons across the range of seniority. The comparison with a different neurosurgical center may not be completely justifiable as physician, patient, and facility characteristics are likely to be different. It, however, provides the overview of OT utilization pattern from two different continents. The details of the operating, anesthetic, and ancillary times, during various neurosurgical operations provide guidance for improvisation in the OT management system. Overall, the OT time utilization in our hospital during the study period appears to be more efficacious compared with earlier studies. However, there are still some areas that if addressed can improve the efficiency of the OT utilization. An earlier study has documented shorter operative time for senior neurosurgeons compared with junior neurosurgeons (13). Prolonged operative duration has been shown to be an important risk factor for postoperative ischemic optic neuropathy after spine surgery (6). Similarly, Korinek (10) demonstrated an increased risk of surgical site infection with operative duration longer than 4 hours. The comparatively longer surgical time in our study is largely due to the training

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Table 2. Mean Times for Various Activities During Neurosurgical Procedures in Minutes (hours) Shunt Surgery (n [ 6)

Time Anesthesia induction

Neuroendoscopy (n [ 22)

Neurovascular Surgery (n [ 48)

Epilepsy Surgery (n [ 13)

Peripheral Nerve Surgery (n [ 12)

24.5

23.7

23.7

20.7

24

Surgical preparation

26

Actual operation

33.9

26.5

28.8

25.6

100.0 (1.7)

179.9 (3)

156.8 (2.6)

256.2 (4.3)

236.3 (3.9)

6.2

6.5

5.8

5.4

5.3

Dressing after surgery Anesthesia recovery

16.2

17.1

16.6

22.4

15.5

Total operating time

172.0 (2.9)

262.0 (4.4)

229.4 (3.8)

336.5 (5.6)

303.6 (5.1)

Time between cases

31.7

39.4

39.8

37.8

35.0

Reconstructive Surgery (n [ 31)

Functional Surgery (n [ 9)

Infratentorial Surgery (n [ 72)

Supratentorial Surgery (n [ 163)

Spine Surgery (n [ 161)

Significance Between 10 Different Neurosurgical Procedures (P Value)

30.2

21.7

29

25.3

23.4

0.01

26.6

24.4

28.5

27.5

27

0.18

281.9 (4.7)

280.0 (4.7)

222.8 (3.7)

189.0 (3.2)

6.5

6

5.8

5.8

0.87

23.1

17.3

17.2

23.4

0.19

367.7 (6.1)

360.7 (6)

300.9 (5)

264 (4.4)

44.3

42.2

42.1

240.1 (4) 7 16.2 320.2 (5.4) 42.5

goal of this teaching hospital. This can be reduced by use of simulators for surgical training (1) and exposure to dedicated workshops to enhance skill and improve speed. Strum et al. (15) noted that the single most important source of variability in surgical procedure times was the surgeon effect. Understanding and acknowledging surgical skills and speed of individual surgeons and planning the OT schedule accordingly will facilitate optimal utilization without the need for cancellation, postponement, and underutilization or overutilization of the OT. Starting the case on scheduled time will facilitate closing of the OT on time and preparing the next case for the day, as well as for the next day’s cases. The cumulative time attributable to delay in starting of the day’s first case in this study was 8370 minutes, with an average delay of 26 minutes per day (range, 5e75 minutes). Late start was observed in 33% and 44% of cases in earlier studies,

Table 3. Operating Theater Starting Time and Closing Time During Study Period Time

Minimum

Maximum

Mean

Starting time

8:50

AM

10:15

AM

9:26

AM

Closing time

3:30

PM

11:10

PM

7:00

PM

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< 0.001

< 0.001

with an average delay of 35 minutes (8, 18). The causes for delay included patient preparation, transporting the patient from ward to OT, and administration of premedication. Unfortunately, the reasons for the delay were not given in that study. Wong et al. (19) demonstrated that a late start (mostly due to equipment failure) has a major impact on OT utilization. Ike-Okoye (7) reported a >50% wastage of ophthalmic OT time due to the late arrival of OT personnel, contributing to a delayed start. Similarly, only 54% of the orthopedic OT time could be used for actual surgery because of a delayed start (16). Adhering to the starting time, therefore, reduces the loss of precious OT time and increases the available duration for productive use and also minimizes overstretching of the OT. In our study, 87 surgeries (14%) were canceled during the study period. Iyer et al. (8) observed a 17% cancellation rate in 810 neurosurgical procedures during a 16-month period. Seventy-four percent of cases were canceled due to lack of investigations, patient refusal, lack of fitness for anesthesia, and emergencies, whereas 26% of cancellations were due to lack of operating time. In contrast, cancellation due to lack of time in our study and that of Vinukondaiah et al. (18) was high at 72% and 65%, respectively. Except for emergencies, other causes for cancellation were not observed in our study, suggesting better preoperative patient workup for surgery, anesthesia, and effective communication regarding surgery among the team members involved, and

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AUDIT OF OPERATION THEATER UTILIZATION

Table 4. Comparison Between the Surgical and Anesthetic Time During Different Neurosurgical Procedures Between our Study and an Earlier Study Title

Surgery

Iyer et al., 2004 (8)

Our Study

Anesthesia Surgery Anesthesia Surgery Time (mean) Time (mean) Time (mean) Time (mean) Minutes Minutes Minutes Minutes

Supratentorial tumor surgery

37

131

25

222

Aneurysm

51

213

24

157

VP shunt

28

60

24

100

Spinal tumor surgery

31

165

23

189

Posterior fossa surgery

55

160

29

280

VP, ventriculoperitoneal.

patients themselves. The high cancellation rate due to lack of time in Indian studies is probably because of overzealous listing of cases due to long waiting lists. This also reflects the high turnover and uneven distribution of expert neurosurgical facilities in our setting and pressure on the existing system to schedule patients for surgery despite the possibility of cancellation. Also, absence of fixed working hours for doctors permits delayed start of the second surgery extending its completion beyond scheduled OT hours and cancellation of cases before scheduled closing time for lack of time. Any surgery is a big event in the life of a patient and family, and the cancellation causes immense psychological distress to the fasting patient, apart from increasing the cost and reducing the bed turnover. The cancellations due to an emergency coming in lieu of the elective cases cannot be prevented; however, cancellations due to lack of time can be prevented by good planning and scheduling and by better OT utilization. One in 7 scheduled cases was canceled in our hospital during the study period, which is significant. The possible steps to minimize such cancellations include appointment of an OT manager, adhering to the starting time of the day, planning and scheduling of the cases by understanding and analyzing the times taken by individual surgeon and anesthesiologist, and scheduling a shorter second procedure after a longer first surgery of the day, as shown by Grote et al. (4). Stone and Bernstein (14) observed that 12.5% of the common errors were related to delay in the neurosurgical OT like waiting for spinelocalizing x-ray. Reduction in delays during surgeries is also likely to reduce errors in neurosurgical OT. Application of lean

REFERENCES 1. Buckley CE, Kavanagh DO, Traynor O, Neary PC: Is the skillset obtained in surgical simulation transferable to the operating theatre? Am J Surg 207:146-157, 2014.

and 6 sigma methodologies may optimize OT efficiency in high volume centers (2). Overall, there is a need to incorporate the relevance of the 4Ps; pathology, patient, paraphernalia (equipment), and physicianrelated factors into the decision-making process for optimal OT time prioritization and utilization. An audit as a follow-up to complete the cycle after implementation of improvements to overcome deficiencies will demonstrate actual benefit of this exercise. There are some limitations of our study. First, we collected and analyzed the data during a short period of time (4 months). Unless there is a significant variation in the 4Ps, these observations are less likely to change with a longer duration of study, given the large sample studied. Second, we did not evaluate the possible causes for delay in the start of the day’s list. The impact of addressing the correctable causes for late start on the OT utilization will be examined during the reaudit. Third, some of the OT time utilization patterns and their findings might not be universally applicable, being local in nature (e.g., turnaround time for frozen section report). Last, we did not evaluate the socioeconomic impact of prolonged OT times. However, our study could serve as a basis for future studies to look at the impact of structured and effective interventions on the OT utilization times. These interventions could be an assessment and implementation of first case on time start or structured simulation-based training before actually performing the surgeries. The impact of these and other interventions on the socioeconomic costs could then be assessed in terms of number of more patients being operated on within the scheduled OT hours and actual costs in rupees being saved by a reduction in overrun times.

CONCLUSION The neurosurgery OT time was well used in our hospital during the study period with a significant proportion (70%) of time spent on actual surgery. Results from this study and from earlier nonneurosurgical operations demonstrate that neurosurgical OT utilization pattern is different from other surgical disciplines. Our findings about operating and anesthetic times for different neurosurgical operations provides a valuable guide for planning operating lists and is likely to help judicious utilization of existing scarce health care resources. Future studies should examine the contribution of physician-specific variability and American Society of Anaesthesiologists physical status and interventions, like anesthetic induction in the induction room, on utilization of OT time.

ACKNOWLEDGMENT The authors thank the entire the nursing staff of the Neurosurgical OT for their support and cooperation.

2. Cima RR, Brown MJ, Hebl JR, Moore R, Rogers JC, Kollengode A, Amstutz GJ, Weisbrod CA, Narr BJ, Deschamps C: Use of lean and six sigma methodology to improve operating room efficiency in a high-volume tertiary-care academic medical center. J Am Coll Surg 213: 83-92, 2011.

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3. Gil AV, Galarza MT, Guerrero R, deVeleez GP, Peterson OL, Bloom BL: Surgeons and operating rooms: underutilized resources. Am J Public Health 73:1361-1365, 1983. 4. Grote R, Sydow K, Walleneit A, Leuchtmann D, Menzel M: Quality of OR planning. Avoiding

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operating room underutilization or utilization. Anaesthesist 59:549-554, 2010.

AUDIT OF OPERATION THEATER UTILIZATION

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5. Haiart DC, Paul AB, Griffith JMT: An audit of the usage of operating theatre time in a peripheral teaching surgical unit. Postgrad Med J 66:612-615, 1990.

11. Mazzei WJ: Operating room start times and turn over times in a university hospital. J Clin Anaesth 6:405-408, 1994.

6. Ho VT, Newman NJ, Song S, Ksiazek S, Roth S: Ischemic optic neuropathy following spine surgery. J Neurosurg Anesthesiol 17:38-44, 2005. 7. Ike-Okoye O: Ophthalmic theatre time utilization in a Nigerian teaching hospital. Niger J Med 15: 285-287, 2006. 8. Iyer RV, Likhith AM, McLean JA, Perera S, Davis CH: Audit of operating theatre time utilization in neurosurgery. Br J Neurosurg 18:333-337, 2004. 9. Jan FA, Tabish SA, Qazi S, Atif MS: Time utilization of operating rooms at a large teaching hospital. J Acad Hosp Adm 15:1-6, 2003. 10. Korinek AM: Risk factors for neurosurgical site infections after craniotomy: a prospective multicenter study of 2944 patients. The French Study Group of Neurosurgical Infections, the SEHP, and the C-CLIN Paris-Nord. Service Epidémiologie

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12. Ricketts D, Hartley J, Patterson M, Harries W, Hitchin D: An orthopaedic theatre timings survey. Ann R Coll Surg Engl 76:200-204, 1994. 13. Riffaud L, Neumuth T, Morandi X, Trantakis C, Meixensberger J, Burgert O, Trelhu B, Jannin P: Recording of surgical processes: a study comparing senior and junior neurosurgeons during lumbar disc herniation surgery. Neurosurgery 67 (2 Suppl Operative):325-332, 2010. 14. Stone S, Bernstein M: Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. Neurosurgery 60:1075-1082, 2007.

17. Tabish SA: Towards development of professional management in Indian hospital. J Manag Med 12: 109-119, 1998. 18. Vinukondaiah K, Ananthakrishnan N, Ravishankar M: Audit of operation theatre utilization in general surgery. Natl Med J India 13: 118-121, 2000. 19. Wong J, Khu KJ, Kaderali Z, Bernstein M: Delays in the operating room: signs of an imperfect system. Can J Surg 5:189-195, 2010.

Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 15 July 2014; accepted 17 March 2015

15. Strum DP, Sampson AR, May JH, Vargas LG: Surgeon and type of anesthesia predict variability in surgical procedure times. Anesthesiology 92: 1454-1466, 2000. 16. Sultan J, Charalambous CP: Theatre time utilisation in elective orthopaedic surgery. J Perioper Pract 22:262-265, 2012.

Citation: World Neurosurg. (2015). http://dx.doi.org/10.1016/j.wneu.2015.03.031 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2015 Elsevier Inc. All rights reserved.

WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2015.03.031

Audit of the Functioning of the Elective Neurosurgical Operation Theater in India: A Prospective Study and Review of Literature.

Knowledge about the utilization of the operation theater (OT) is essential to improve its efficiency. This study evaluated the neurosurgical operation...
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