The operating room (OR) is one of the most important areas in the modern-day hospital. It is also the biggest revenue generator. Operating room management is a prime focus area for hospitals. Many efforts to improve operating room efficiency focus on reducing OR turnover time (TOT), which is the duration of time between one patient leaving the OR and the next patient entering (including setting up and cleaning).
Several factors cause delays in OR turnover times, some that can be prevented and others that cannot. For instance, there may be issues involving anesthesia, late surgeons, transportation, or even simple lapses in communication that pile up and create inefficiencies. Today, we will be discussing guidelines to improve operating room turnover time, as well as common factors that lead to delays.
Delays in Operating Room Turnover Time
OR turnover times can be broadly classified into poor performance (greater than 40 minutes), medium performance (25-40 minutes), and high performance (less than 25 minutes). A recent study evaluated reasons for delays in turnover times and found that common causes fall under four categories:
- Hospital-related (50.5% of the cases)
- Surgeon-related (22.5% of the cases)
- Patient-related (18% of the cases)
- Anesthetist related (9% of the cases)
The researchers recorded time between wheel-out and wheel-in with the benchmark being 20 minutes. Anything over 20 minutes was classified as a delay. The findings revealed that 15.5 minutes was the average TOT for surgery ORs, with a range of four to 48 minutes. For orthopedics ORs, the average was 17.36 minutes, with a range of five to 60 minutes. More specifically:
- 30% of turnovers were completed within 10 minutes in surgery ORs, and 49% were done in 20 minutes. 79% of turnovers were within benchmark limits.
- 33% of turnovers were completed within 10 minutes in orthopedics ORs, and 44% were done in 20 minutes. 77% of turnovers were within benchmark limits.
When averages for both ORs are combined, a total of 78% of turnovers fell within benchmark limits (22% were delayed), of which 31.5% occurred within 10 minutes. As for delayed turnovers, 14.5% occurred in 30 minutes, 5% in 40 minutes, 2% in 50 minutes, and 0.5% in one hour. As for the causes of delay:
Hospital-related (50.5% of the cases)
- Non-availability of supporting staff like porters, cleaners, and nursing technicians led to delays in six cases.
- Delays in transporting patients (e.g. from pre-operative to OR, OR to recovery) led to delays in six cases.
- Emergency operations led to delays in eight cases.
- Infected cases led to delays in five cases.
- Infrastructure problems led to delays in two cases (e.g. problems with the central sterile services department).
- Equipment failure led to delays in two cases (e.g. cautery not working, C-arm not working).
- Unavailability of OT dress led to delays in one case.
- Gaps in communication and lack of timely OR preparation by staff led to delays in five cases.
Surgeon-related (22.5% of the cases)
- Non-availability of surgeons in the OR led to delays in two cases.
- Scheduling errors or changes in plans (e.g. other cases being given priority) led to delays in two cases.
- Equipment or instrument related issues like non-availability of an implant from the supplier led to delays in two cases.
- Preparation for laparoscopy and other complex surgeries led to delays in two cases.
- Required help from the Senior Surgeon led to delays in two cases.
- A change of surgeon and specialty led to delays in five cases.
Patient-related (18% of the cases)
- Non-availability of informed consent led to delays in two cases.
- Delay in availability led to delays in one case.
- A medical problem like a patient having rhonchi requiring nebulization, antihypertensive not given, respiratory tract infection, ECG to be reviewed, etc. led to delays in six cases.
- Patient apprehension and consultation with family and surgeon led to delays in two cases.
- Non-availability of lab reports led to delays in one case.
Anesthetist related (9% of the cases)
- Anesthetist related factors due to technical reasons like preparations for complicated cases, difficult airways, and invasive monitoring led to delays in six cases.
The study found that avoidable delays in operating room TOT were due to:
- Surgeon unavailability
- Scheduling errors
- Unavailability of supporting staff
- Delays in shifting patients
- Infrastructure problems
- Equipment failure
- Communication Gaps
- Untimely OR preparation by staff
- OT dress unavailability
- Blood unavailability
- Antihypertensive not given
- Consent not given
- Awaited lab reports
Guidelines for Improving Operating Room Turnover Time
Improvements in TOT have positive effects on the operational efficiency of the OR and the financial health of the hospital. However, achieving these improvements requires a careful approach. A single-minded focus on reducing TOT at the expense of other considerations can be dangerous for patients and counterproductive for the OR.
Initial efforts to improve TOT should focus on building a multidisciplinary team that includes members from every relevant area (e.g. surgery, anesthesia, administration, nursing, transport, and admissions). Each member should have an identifiable role that determines their tasks, which should correspond with measurable goals. Additionally, the entire turnover process should be mapped to identify pain points that can be improved.
After the team is established, three strategies can improve TOT. First, ORs can establish parallel processing protocols, in which the following patient is induced while the previous surgery is ongoing. Parallel processing helped reduce TOT to less than 10 minutes in the study outlined above because, apart from cleaning the OR (done during turnover), preparations for the next case had already been made.
Second, surgeons in the OR and use of the same teams positively affects TOT. Actively involved surgeons can motivate and assist staff in their duties. This leads to improved preparation and turnover times.
Finally, instrument availability has a major effect on turnover time; TOT was prolonged when OR staff had to spend time collecting necessary instruments before a patient was brought to the OR. Standardizing equipment, using disposable room turnover kits/hampers and cleaning tools, and storing surgery specific packs close to the ORs where they are frequently used can all help.
Improved turnover saves time, which in turn means surgeons can do more cases on any given day. Driving these improvements requires a multidisciplinary approach with leadership from many different domains. Third-party organizations can also provide strategic expertise and operating room technicians to improve turnover times.