British Journal of Neurosurgery

ISSN: 0268-8697 (Print) 1360-046X (Online) Journal homepage: http://www.tandfonline.com/loi/ibjn20

Effect of perioperative inefficiency on neurosurgical theatre efficacy: A 15-year analysis Ameya S. Kamat & Andrew Parker To cite this article: Ameya S. Kamat & Andrew Parker (2015) Effect of perioperative inefficiency on neurosurgical theatre efficacy: A 15-year analysis, British Journal of Neurosurgery, 29:4, 565-568, DOI: 10.3109/02688697.2015.1019423 To link to this article: http://dx.doi.org/10.3109/02688697.2015.1019423

Published online: 25 Mar 2015.

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Date: 05 November 2015, At: 23:02

British Journal of Neurosurgery, August 2015; 29(4): 565–568 © 2015 The Neurosurgical Foundation ISSN: 0268-8697 print / ISSN 1360-046X online DOI: 10.3109/02688697.2015.1019423

ORIGINAL ARTICLE

Effect of perioperative inefficiency on neurosurgical theatre efficacy: A 15-year analysis Ameya S. Kamat & Andrew Parker

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Department of Neurosurgery, Wellington Regional Hospital, Wellington South, Wellington, New Zealand

Introduction

Abstract Introduction. Effective utilisation of operating theatre time is an important issue in neurosurgery. There is a commonly held belief amongst surgeons that throughput of theatre is decreasing secondary to worsening perioperative delays. The aim of this paper is to explore some of the factors that lead to delays in the perioperative period by determining whether there has been a trend in the increasing length of case time over a fifteen-year period. Materials and methods. Case notes of all elective patients who consented for surgery between January 1998 and the end of 2012 were reviewed. Only patients who underwent elective surgery were included. Variables recorded included transit time from the ward to theatre, anaesthetic time, surgical time and time spent in recovery. These were compared over the 15-year period to look for apparent trends. Results. The total number of patients who consented for elective surgery at our institution between January 1998 and December 2012 was 6760. The mean anaesthetic time considering all operations performed was 43 mins each over the 15-year period. Anaesthetic time was deemed to be trending upwards from 1998 where the mean time was 27 –60 mins in December 2012, thus reflecting an increase of 33 mins. The mean surgical times over the 15-year period were 131 mins. However in 1998, mean surgical time was 127 mins compared with 133 mins in 2012. Discussion and conclusion. For the operations analysed, anaesthetic time seems to be increasing and has effectively doubled over a 15-year period. Surgical time and non-clinical time are shown to be virtually constant. This delays the overall theatre list and increases the cancellation rate. For compensating this, changes need to be made when allocating resources to both elective and emergency theatres. Staff recruitment needs to be assessed and internal audits need to be conducted within institutions to analyse ways to optimise the throughput of an operation theatre. If these principles are not adhered to, it will have a negative impact as our populations, and hence our case loads increase to instrumental levels. This will in turn have a negative impact on health workers and patients alike.

Effective utilisation of operating theatre time is an important issue in neurosurgery especially in the public sector where resources are limited. Operation theatres therefore must run smoothly and efficiently. As emergency workloads rise, an increasing strain is placed on emergency operating theatre services. This in turn may lead to cancellation of elective cases to accommodate for high acute volumes. Efficient running of theatre lists would allow patients to spend less time exposed to the danger of both their presenting complaints and any hospital-acquired pathology. It would also shorten the length of stay in hospital which in turn has financial ramifications. The efficient utilisation of operating theatre time is important for numerous reasons. Firstly, one must highlight the financial considerations. As of 2012, the costs of running neurosurgical operating theatres at our institution averaged NZ$65 per minute. Additionally, an increase in population and advances in surgery (and hence more surgical options) are resulting in longer waiting lists. No recent study of theatre optimisation by neurosurgeons is available. In light of this we undertook a retrospective study of the timing of perioperative events during elective neurosurgical theatre lists over a fifteen-year period. Our aims were to evaluate the current use of operating theatre time and the reasons for inefficiencies. Efficient use of the emergency operating list is especially important in an acute speciality such as neurosurgery where a large part of the workload results from urgent admissions. If it can be demonstrated that the emergency and semi-elective theatre is overburdened, then additional resources can be directed to maintain safety of the service. There is a commonly held belief amongst surgeons in general that throughput of theatre decreases and the anaesthetic component of cases increases over time. However, other schools of thought blame other factors. In order to help determine the cause, we took advantage of our substantial database which documented multiple events on each patient’s ‘journey’ and examined the changes in surgical and anaesthetic time over a 15-year period. We

Keywords: anaesthesia; delays; neurosurgical operating theatre

Correspondence: Dr Ameya S. Kamat, Department of Neurosurgery, Wellington Regional Hospital, Riddiford St, Wellington South, Wellington, New Zealand. Tel: ⫹ 64 4 385 5999. E-mail: [email protected] Received for publication 25 November 2014; accepted 31 January 2015

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566 A. S. Kamat & A. Parker also analysed other potential causes of operation theatre inefficiency.

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Materials and methods From January 1998, a computerised database entry system known as ‘the Operating Room Scheduling and Office System or ORSOS’ has been operational at our institution. Data entry is performed by the operation theatre nursing staff as each event occurs. This includes the time at which the patient was sent from the ward, arrived at the theatre holding bay (reception), entered the theatre and was induced by the anaesthetic team; and surgical time. It is noted that this system in not errorproof and generally relies on the individual entering the data. Unfortunately, independent validation of the data entry is not feasible at our centre. Six thousand, seven hundred and sixty (6760) consecutive patients who met the study’s inclusion criteria were reviewed from 1998 to the end of 2012. The inclusion criteria selected patients who were admitted for elective surgery. Patients whose operations were performed after working hours were excluded from the study as staffing issues overnight would lead to unavoidable delays and hence add bias. Patients who opted out of surgery before being sent to the theatre were excluded from the study. All the variables recorded are listed in Table I. Anaesthetic time was defined as ‘the time at which the anaesthetic team commenced anaesthetic administration (including intravenous and arterial line insertion) up to the time that the surgeons started preparing the patient for surgery’. Surgical time commenced at the onset of positioning, registration of stereotactic navigation, shaving hair and marking and ended when the dressings were placed. The total time taken for each component over the study period was calculated and recorded in minutes. Recovery time in theatre commenced at the onset of anaesthetic reversal and ended when the patient was wheeled out of the operating theatre. Surgeon seniority was also analysed and operative times were recorded with regard to this. Additionally, our neurosurgical patient database and patient clinical records were searched for negative perioperative outcomes. Emphasis was placed on peri-operative death and inadvertent awareness during anaesthesia.

Table I. Details collected for each patient undergoing neurosurgical procedure in the operation theatre. Recorded variable Description Sending time Arrival time Transit time Anaesthesia time Surgical time Recovery time

Time at which the patient was sent from ward by theatre staff Time at which the patient arrives at the theatre Time taken by the patient from being sent from ward to arrival at the theatre Time taken by the anaesthesia team to induce patient Timescale between starting and finishing an operation (skin to skin) Recovery time in theatre until patient was handed over to recovery room staff

Results The total number of patients who consented for elective surgery at our institution between January 1998 and December 2012 was 6760. In total, 2752 cases were performed by neurosurgical registrars and 4008 by consultant surgeons. The standardised start time was 8:15 am, from Monday to Friday. The designated finishing time was 4:15 pm. The mean anaesthetic time per operation was 43 mins over the 15-year period. Anaesthetic time was deemed to be trend upwards from 1998 where the mean time was 27 mins to 60 mins in December 2012 reflecting an increase of 33 mins. This was statistically significant (p ⫽ 0.011; 95% confidence interval, 25.0–39.0). Mean anaesthetic times for all case when comparing anaesthetist seniority was 27 mins for consultants and 50 mins for neurosurgical registrars (supervised and unsupervised) (Tables II and III). The mean surgical times over the 15-year period were 131 mins. However in 1998, mean surgical time was 127 mins compared with that of 133 mins in 2012. There was no statistically significant trend (p ⫽ 0.175) in time consumed by the surgical team in the analysed 15 years. Mean surgical times for all operations when comparing surgeon seniority was 102 mins for consultants and 137 mins for neurosurgical registrars (Table II). Mean transit time, recovery time in theatre and time between cases are tabulated in Table II. Variations over the 15 years were statistically insignificant in all 3 situations (p ⫽ 0.21, 0.11 and 0.114, respectively). During the entire 15-year study, none of the patients spontaneously woke up during the procedure. There were however 4 intra-operative patient deaths during this period. The surgical cancellation rate was 6% in 1998. This increased to 13.6% in 2012 and was statistically significant, p ⫽ 0.001. The mean cancellation rate over the 15-year period was 8.8%. This translated to 595 cancellations in total. Twelve percent of cancellations were due to patient factors. These included patients’ choice against surgery, change in clinical condition, patients not being optimised/fit for surgery and high emergency caseload volume. One per cent of cancellations were due to environmental factors (power failure, earthquakes and latex allergy) and equipment failure. Three percent of cases were due to lack of necessary equipment. Six per cent of cancellations (36 patients) were due to personnel issues. This contributed to late starts, early finishes and delays between cases. However, 78% of cases were cancelled due to lack of time available to complete the operation on the scheduled list. From this group of 464 cancelled patients, 104 were cancelled as the previous operation was performed Table II. Mean time per recorded variable. Mean time Mean time Recorded variable (overall) (1998) Transit time (Arrival time - Sending time) Anaesthesia time Surgical time Recovery time in theatre Time between cases

Mean time (2012)

18 min

19 min

17 min

43 min 131 min 12 min 22 min

27 min 127 min 14 min 20 min

64 min 133 min 11 min 24 min

Perioperative inefficiency neurosurgical theatre efficacy

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Table III. Mean differences in surgical, anaesthetic and non-clinical time from 1998 to 2012 in minutes. ⫹ indicates an increase in time when comparing 2012 with 1998. – indicates decrease in time. Total no. Mean difference Mean difference Mean difference of cases in surgical time in anaesthetic in non-clinical Operation title (1998–2012) (1998–2012) time (1998–2012) time (1998–2012) Trauma surgery Burr hole surgery for chronic subdural haematoma Vascular neurosurgery Evacuation of intracerebral haematoma Clipping of aneurysm Resection of arteriovenous malformation Spinal Surgery Cervical – Anterior Cervical Discectomy and Fusion (ACDF) Cervical – Decompression Lumbar – Discectomy Lumbar – Decompression Instrumented fusion Spinal Tumour Surgery Functional Neurosurgery Neuro-oncology Craniotomy and debulking/resection of tumour Non-image-guided Biopsy Stereotactic Biopsy Trans-sphenoidal Surgery Hydrocephalus Ventriculo-peritoneal shunt External Ventricular Drain Endoscopic Third Ventriculostomy Pain and Spasticity Microvascular Decompression Cordotomy Balloon Rhizotomy Craniofacial Surgery Miscellaneous Autologous Cranioplasty Titanium Cranioplasty Benign Intracranial Hypertension – shunting Release of Nerve Entrapment Foramen magnum decompression Translabyrinthine Procedures Other/Minor

489

⫹ 2.1

⫹ 6.9

⫹ 1.6

82 476 32

⫹ 11 ⫹ 21.5 ⫺ 3.7

⫹ 13.2 ⫹ 18.5 ⫹ 5.6

⫺ 11.2 ⫹ 1.1 ⫺ 2.3

122 197 132 377 225 11 6

⫹ 2.2 ⫺ 11.2 ⫺ 9.6 ⫺ 8.0 ⫺ 4.6 ⫹ 1.2 ⫹ 2.9

⫺ 0.1 ⫹ 16.2 ⫹ 11.1 ⫹ 8.6 ⫹ 9.4 ⫹ 12.3 ⫹ 1.6

0.0 ⫺ 1.7 ⫺ 1.2 ⫺ 1.8 ⫹ 1.1 ⫹ 0.5 ⫹ 1.1

⫹ 4.5 ⫹ 3.6 ⫹ 2.3 ⫹ 19.1

⫺ 9.0 ⫺ 7.5 ⫺ 6.9 ⫺ 2.3

1423 27 201 666

⫹ 1.7 ⫹ 0.1 ⫺ 0.66 ⫺ 3.4

335 501 151

⫺ 8.9 ⫺ 11.2 ⫺ 7.6

⫹ 2.1 ⫹ 4.5 ⫺ 2.3

⫺ 6.7 ⫺ 4.5 ⫺ 3.6

32 21 226 286

⫺ 10.6 ⫺ 9.6 ⫺ 7.2 ⫹ 13.4

⫹ 13.6 ⫹ 1.1 ⫹ 0.1 ⫹ 22.3

⫹ 1.1 ⫺ 9.4 ⫺ 4.5 ⫹ 1.1

181 61 96 226 102 32 44

⫺ 1.6 ⫺ 4.0 ⫺ 2.9 ⫺ 3.2 ⫺ 4.1 ⫹ 2.1 ⫺ 0.1

⫺ 1.1 ⫺ 2.3 ⫹ 2.4 0.0 ⫺ 0.5 ⫹ 29.3 0.0

0.0 ⫺ 1.0 ⫹ 0.5 ⫺ 1.3 ⫺ 1.1 0.0 ⫺ 0.1

for longer time than anticipated and 360 cancellations resulted from the anaesthetic time of previous cases being higher than expected.

Discussion In the ideal theatre environment, cases should start and finish on time and no operations should be cancelled. This however does not reflect in real-world scenarios. The authors believe that a mean cancellation rate of 8.8% is high although this is considerably lower when compared with that in studies performed in other centres.1 Mean anaesthetic time however has gradually increased over this period despite the data which show that there has not been an increase in negative peri-operative outcomes. From this study, it is difficult to determine whether the increasing anaesthetic time is due to a higher perception of risk or advances in anaesthetic standard of care. When these data were presented in an inter-departmental meeting, most clinicians were unsure of the reasons. However, an internal audit was recommended within other surgical departments to decipher whether this is a global issue. Some interim solutions however could begin with performing anaesthetic reversal of a patient simultaneously

with the preparation of the next patient. Sokolovic et al. concluded that the time between surgical operations decreased significantly and operating room efficiency increased when more number of anaesthesia staff was available to permit induction of anaesthesia before the previous operation was completed.2 Other papers have also highlighted anaesthetic delays. In a paper by Ricketts et al., where an audit of orthopaedic theatre times was conducted, it was noted that 63% of all delayed starts were due to anaesthetic reasons. Delays were less frequent when a senior anaesthetist was present, although this was not statistically significant.3 Therefore, the presence of a senior member of the anaesthetic staff may, however, help ensure that the process of anaesthetising patients begins according to the scheduled start time in the theatre list. In a previously published paper, Kamat et al. have demonstrated the clear increase in caseload, as well as operative volumes.4 However, this rise does not result in an increase in clinical staff numbers to compensate for the larger burden and hence results in compounding of the problem. A growing population, and hence case volume, with no proportional increase in staffing coupled with increasing theatre delays will decrease the overall throughput of the theatre. Caseload

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A. S. Kamat & A. Parker

increases coupled with decreases in throughput can lead to disastrous long-term consequences for health care workers and patients alike. This can affect both efficiency and efficacy of the operation theatres. The mean clinical (surgical and anaesthetic) and nonclinical times disclosed for the various neurosurgical procedures sheds light on how long a given procedure could take. This may be instrumental in resource planning and operation theatre efficiency. Hence, when scheduling the theatre lists, taking this information into consideration would be useful. This would undoubtedly be an invaluable tool with regard to planning staffing levels and allocating resources. Understandably, none of the papers clearly document standard surgical and anaesthetic times in neurosurgical patients. Many variables would exist with regard to clinician’s experience levels, staff resources, availability of equipment and local practice. Other studies that highlight similar issues do exist.1,3,5 However, none of them analyse the trend over such an extended period of time or consist of such a large sample size. Our paper, which by no means defines standard times and is certainly not without its limitations, is the largest reported retrospective analysis and incorporates 15 years of data to demonstrate a trend in worsening operation theatre delays.

Conclusion For a given operation, anaesthetic time seems to be relentlessly increasing and has effectively doubled over a 15-year

period. Surgical time and non-clinical time are shown to be virtually constant. For compensating this, changes need to be made when allocating resources to both elective and emergency theatres. Staff recruitment needs to be assessed and internal audits need to be conducted within institutions to analyse ways to optimise the throughput of operation theatre. If these principles are not adhered to, there may be a negative impact due to a rising population and hence caseload.

Declaration of interest: There were no sources of financial support/grants for this paper, nor are there any conflicts of interest. Both authors contributed equally to the content of the paper.

References 1. Iyer RV, Likhith AM, McClean JA , Perera S, Davis CH. Audit of operating theatre time utilization in neurosurgery. Br J Neurosurg 2004;18:333–7 2. Sokolovic E, Biro P, Wyss P, et al. Impact of the reduction of anaesthesia turnover time on operating room efficiency. Eur J Anaesthesiol 2002;19:560–3. 3. Ricketts D, Hartley J, Patterson M, Harries W, Hitchin D. An orthopaedic theatre timings survey. Ann R Coll Surg Engl 1994; 76:200–204. 4. Kamat AS, Parker A . The evolution of neurosurgery: how has our practice changed? Br J Neurosurg 2013;27:747–51 5. Haiart DC, Paul AB, Griffiths JM. An audit of the use of operating theatre time in a peripheral teaching surgical unit. Postgrad Med J 1990;66:612–15.

Effect of perioperative inefficiency on neurosurgical theatre efficacy: A 15-year analysis.

Effective utilisation of operating theatre time is an important issue in neurosurgery. There is a commonly held belief amongst surgeons that throughpu...
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