Theatre Efficiency Research Articles

Introducing magnetic seed localisation for impalpable breast cancer; A pioneering Scottish experience

Background & Aims: Breast conservation surgery for patients with impalpable breast cancer requires tumour localisation. Localisation is performed on the day of surgery using ultrasound(US) or stereotactic wire placement, although this negatively impacts theatre utilisation and efficiency and requires radiological capacity on the day of surgery. The innovative metallic seed (MagSeed®) may circumvent these limitations. We piloted using these seeds in our surgical practice to evaulaute surgical feasibility, clinical effectiveness and patient safety.

The introduction of play specialists as operating department escorts for children.

Attending theatre for a surgical procedure can be a very stressful time for both children and their parents and guardians, with ward staff accompanying patients to the operating department to provide support. A local Trust proposed a change from the deployment of registered nurses to the utilisation of play specialists as escorts for children on their journey to theatre and during the induction of anaesthesia to improve patient experience, levels of registered staff remaining on the children’s ward and theatre efficiency. It was found that in children who had not received premedication, this substitution can be completed successfully, providing that the play specialists receive sufficient training to carry out this role effectively.

Karydakis procedure can be effectively performed in the lateral position.

Karydakis published a large pilonidal series in 1992, reporting a recurrence rate of less than 1% and complication rate of 8.5%. The aim of this study was to compare the outcomes of Karydakis procedure (KP) performed in the lateral versus the prone position in a consecutive series. Ninety-seven consecutive patients undergoing a KP between March 2000 and February 2018 were retrospectively assessed. Patients with disease sinuses or fistulas extending from the midline to either left or right sides only were considered for KP in the contralateral side position. Surgery was carried out for primary pilonidal disease in 71 patients (73%) and for recurrent disease in 26 patients (27%). The majority (62%) of pilonidal tracts veered off from the midline to either the left or right side only. Wound complications, mostly minor skin separation, occurred in 37 patients (38%). Disease recurrence occurred in eight patients (8%). There was no difference between patients who had KP in a lateral position compared with those operated in a prone position regarding wound complications (41% versus 35%, P = 0.675), disease recurrence (9% versus 7%, P = 1.000), mean operating time (64.6 min versus 66.6 min, P = 0.259) and mean length of hospital stay (1 day for both groups). Pilonidal surgery in the lateral position has potential benefits for patient safety, patient comfort and theatre efficiency. The clinical results of this series show that the KP can be performed safely and effectively with the patient in the lateral position for most cases of pilonidal disease.

Patient-related reasons for late surgery cancellations in a plastic and reconstructive surgery department

SummaryLate cancellations of scheduled operations cause direct and indirect costs for a hospital and economic and emotional stress for the patient. Previously, late cancellation rates for scheduled operations in plastic surgery have been shown to be attributable to patient-related causes in the majority of cases.In this retrospective study, we sought to examine specifically the patient-related reasons for the late cancellations in a plastic surgery operating theatre at Helsinki University Hospital in Finland from 2013 to 2014. We calculated latency between the date of decision for surgery and the scheduled operation day. In cases where the surgery was rescheduled and performed before 31 December 2015, the rescheduled waiting time latency was calculated. We aimed to improve our knowledge of the causes of late cancellations to further optimise the operating theatre efficiency and propose a strategic algorithm to avoid late cancellationsDuring the study period, 327 (5.5%) of all the scheduled operations were recorded as late cancellations. Of these, 45.3% were because of patient-related issues. Acute infection, change in medical condition not noticed before and operation no longer necessary were by far the most common causes of cancellation, comprising 63.5%. Sixty-six per cent of patient-related cancelled operations were performed later, especially when the specific reason was patient's acute illness. Root-cause analysis shows that most of the underlying reasons for the cancellations can be attributed to a failure in communication. The majority of these cancellations were considered to be preventable, thus emphasising the importance of communication and skilful multi-professional planning of the operating theatre list.

Introduction of a mandatory pre-block safety checklist into a regional anaesthesia block room service: a quality improvement project.

Wrong-side block is an uncommon yet potentially preventable complication of regional anaesthesia. One strategy for reducing the incidence of wrong-side block is to introduce an additional check into the pre-block workflow in the form of a block 'time out' or 'stop before you block'. In the aftermath of a wrong-side block incident at our institution, the mandatory use of a pre-block safety checklist was successfully introduced into the workflow of the block room. Compliance with the checklist rose from 31% in the six-month pre-intervention phase to over 90% in the six-month post-intervention phase. This was achieved without any negative effect on block efficacy, theatre efficiency, complication rates or patient satisfaction. The high rate of checklist utilisation was associated with an increased rate of ultrasound video documentation. This suggests that there may be collateral benefit to using a pre-block safety checklist in addition to merely reducing the risk of wrong-side block.

Quantifying capacity for burn care in South Africa

The Lancet Commission on Global surgery has highlighted the fact that the vast majority of surgical care is delivered and consumed in high income countries (HIC’s) yet about two thirds of the burden of surgical disease is in low and middle income countries (LMIC) where resources are grossly inadequate. In light of this we set out to audit the current resources available to treat burns in South Africa to quantify the extent of the resource deficit which needs to be addressed if we wish to close the gap in outcomes between South Africa and the developed world. Data was collected for seven out of the nine provinces. There are a total of 17 burn units with 511 beds and 8140 admissions per year across the country.Although there are some deficits in the infrastructure and staffing available to treat burn injuries in South Africa, for example access to isolation, after hours cover, dedicated temperature controlled theatres, this is difficult to alter without government buy in and the current fiscal environment. It would appear that process of care (what you do with what you have) is lacking and needs more development for example establishment of a national registry to facilitate data collection and audit, as well as the introduction of outreach programs, protocols and improving theatre efficiency.

Knife to skin: An audit of emergency theatre efficiency

Knife to skin: An audit of emergency theatre efficiency

The impact of distractions and interruptions during Cesarean Sections: a prospective study in a London teaching hospital.

During Cesarean Sections, distractions which interrupt task specific activities include auditory, equipment, theatre traffic, and irrelevant communication. Aims of this study were to investigate frequency and types of distractions and to assess impact on patient safety and theatre efficiency. Prospective observational study in a London hospital in women undergoing elective and emergency Cesarean Sections. Distractions were recorded prospectively in primiparous women having uncomplicated elective and emergency Cesarean Sections over a 4 week period. Level of distraction is categorized as I: no noticeable impact on surgical team; II: ≥ 1 team member affected; and III: all members affected. Safety outcomes assessed included perioperative complications such as postpartum hemorrhage, organ injury, postsurgical pyrexia (first 48h), return to theatre, readmissions, and postdelivery anemia < 7g/dl. Data from 33 elective and 23 emergency cases were collected. Mean number of level II/III distractions/case was 13.20 (± 6.93) and number of level II/III distracting events was greater during elective compared to emergency cases (mean 14.91 vs 12.00, p = 0.04). In total, 17.89% of distractions occurred during crucial part of surgery between skin incision and delivery of baby, while delays resulting from level II/III distractions accounted for 11.25% of total operating time. There were no intra- or postoperative complications observed in the cohort of cases. Distractions did not culminate in perioperative complications, but disrupted surgeons' task activity, prolonging mean procedure duration by 26.8%. Recognising sources and effects of distractions will enable measures to be taken to improve theatre productivity and patient safety.

Trauma theatre productivity – Does the individual surgeon, anaesthetist or consultant presence matter?

IntroductionWith rising NHS clinical and financial demands, improving theatre efficiency is essential to maintain quality of patient care. Consistent teams and consultant presence have been shown to improve outcomes and productivity in elective orthopaedic surgery. The aim of this study was to investigate the impact on trauma theatre productivity of different surgeons and anaesthetists working together in a Major Trauma Centre. The influence of consultant presence and weekend operating on productivity was also considered. MethodsData relating to a single orthopaedic trauma theatre was gathered retrospectively for a two-year period. Variables including orthopaedic and anaesthetic consultant presence, number and complexity of operations performed and procedure start times were collected for daily trauma lists. Individual anaesthetic and orthopaedic consultants were compared by productivity outcomes. The impact of surgeons operating more frequently with one anaesthetist was also examined. ResultsData relating to 2384 patients undergoing a total of 2787 procedures was collected. Orthopaedic consultant presence at the first surgical case (p < 0.05) and for 50% or greater of cases (p < 0.05) lead to higher mean number of cases performed per list and reduced turnaround time. Despite working with a significantly higher number of different consultant anaesthetists (p < 0.001) in year two, the productivity of surgeons as judged by list start time, total cases per list and total operating time was not significantly affected. Significantly earlier start times (p < 0.001) and shorter turnaround times (p < 0.001) at weekends led to maintained productivity despite shorter theatre time. No significant difference in productivity was found when comparing individual anaesthetic and orthopaedic consultants. Productivity was not significantly increased by surgeons operating more frequently with one individual anaesthetist. ConclusionIn the setting of an acute trauma theatre, orthopaedic consultant presence led to increased productivity. Furthermore, individual surgeon and anaesthetist pairings had no effect on overall productivity. Future efforts to improve productivity should focus on achieving earlier start times, consultant supervision of lists and reduced turnaround times between cases.

The effect of handover location on trauma theatre start time: An estimated cost saving of £131000 per year.

The National Health Service was estimated to be in £2.45 billion deficit in 2015 to 2016. Trauma theatre utilization and efficiency has never been so important as it is estimated to cost £15/minute. Structured questionnaires were given to 23 members of staff at our Trust who are actively involved in the organization or delivery of orthopaedic trauma lists at least once per week. This was used to identify key factors that may improve theatre efficiency. Following focus group evaluation, the location of the preoperative theatre meeting was changed, with all staff involved being required to attend this. Our primary outcome measure was mean theatre start time (time of arrival in the anaesthetic room) during the 1month immediately preceding the change and the month following the change. Theatre start time was improved on average 24minutes (1month premeeting and postmeeting change). This equates to a saving of £360 per day, or £131040 per year. Changing the trauma meeting location to a venue adjacent to the trauma theatre can improve theatre start times, theatre efficiency, and therefore result in significant cost savings.

The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy

BackgroundThe ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations.MethodsData collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves.ResultsAfter exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45–85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p < 0.001), with the proportions of operations lasting > 90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score.ConclusionThe scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care.

The effectiveness of regional anaesthesia before and after the introduction of a dedicated regional anaesthesia service incorporating a block room.

Dedicated regional anaesthesia services incorporating block rooms and/or block teams may facilitate theatre efficiency and improve training in regional anaesthesia. Currently, it is unknown if a dedicated regional anaesthesia service improves the effectiveness of regional anaesthesia. In November 2013, the Royal Brisbane and Women's Hospital established a dedicated regional anaesthesia service comprising a block team and a block room. Pre-intervention (conventional model of care) registry data was retrospectively compared with post-intervention (dedicated regional anaesthesia service) audit data, with regard to pain and opioid requirement in the post-anaesthesia care unit (PACU). The primary outcome was inadequate analgesia, defined as a numerical rating scale (NRS; 0, no pain; 10, worst pain imaginable) for pain >5 in the PACU. Pre- and post-intervention, 43.7% and 27.7% of patients respectively reported a NRS >5 (<i>P</i> <0.001). A difference in the type of blocks and surgery performed may have accounted for the improved outcome seen post-intervention. After adjustment for American Society of Anesthesiologists physical status, block type and surgery type, the odds ratio of having inadequate analgesia (NRS >5) was 0.54 (95% confidence interval 0.39 to 0.76) for post-intervention compared to pre-intervention. Secondary outcomes examined pre- and post-intervention were the absence of pain (39.3% and 55.1% of patients, respectively, <i>P</i> <0.001), systemic opioid analgesia requirement (48.6% and 30.5% of patients respectively, <i>P</i> <0.001) and median maximum NRS (4 [interquartile range (IQR) 0 to 8] and 0 [IQR 0 to 6] respectively, <i>P</i> <0.001). A dedicated regional anaesthesia service was associated with improved effectiveness of regional anaesthesia.

National Theatre Quality Improvement Programme (TQIP) Ireland

In late 2016, a collaborative between the HSE Integrated Care Programme for Patient Flow, National Clinical Programme for Anaesthesia (NCPA), National Clinical Programme in Surgery (NCPS), supported by the HSE Quality Improvement division and the RCSI’s Quality & Process Improvement Centre (QPIC) was established to oversee a sustainable theatre quality improvement programme. Building on the learning from the experience of introducing The Productive Operating Theatre (TPOT) in Ireland, TQIP aims to support hospitals and multidisciplinary perioperative teams who are committed to quality and process improvement to deliver sustainable improvements in: patient experience and outcomes; safety, quality & reliability of care; improved team effectiveness and staff wellbeing; value and improved efficiency; organisational Quality Improvement (QI) capability, enabling a culture of continuous improvement. Implementation of the programme at scale will improve patient flow and value for money through improved theatre efficiency (e.g. reduction in delays in start times, improved utilisation, reduced over runs and inventory costs), increased capability in the application of quality improvement tools with perioperative teams in the selected sites and increased uptake in other hospitals through demonstrated improvements in waiting lists and performance metrics. Furthermore a central repository and QI knowledge sharing network for perioperative teams will be developed including HSE Perioperative Teams certified in QI methodologies following an accredited programme. The Programme Governance and team have been established and agreement reached on a programme plan. The programme includes a QI training programme for perioperative teams in selected sites and on-going support from the QPIC Quality Improvement Advisors and Nurse Leads. Site selection is based on agreed readiness assessment criteria. Outcome measures will be specific to projects in sites but a target of 10% theatre efficiency improvement is expected by the end of year 1. Two sites, one of which has already begun introducing TPOT, and a new site have been identified as pioneers for the new programme. Specific projects in both sites will be agreed and commenced in early 2017. Early results are expected in the next 6-12 months.

Development and implementation of a theatre booking form and morning briefing meeting to improve emergency theatre efficiency.

The aim of this study was to improve emergency theatre efficiency via the introduction of a theatre booking form and morning briefing meeting. Process mapping was used to engage staff and consider if the emergency theatre may benefit from the application of a structured process of communication. A theatre booking form and morning briefing meeting were implemented to promote change. Efficiency was measured by theatre utilisation and characterised into neutral time, efficient time and inefficient time. The results demonstrated a 12.9% increase in efficient time, 3.3% fall in inefficient time and 9.6% fall in neutral time post-implementation, during the high volume work period of 08:00 to 17:59 on weekdays. No improvement in efficiency was demonstrated outside these hours or on weekends during lower volume workloads. Utilisation of a theatre booking form and morning briefing meeting improved emergency theatre efficiency during high volume work periods by the application of a structured process of communication.

Knowledge and perceptions of the NMSA role in Australia: A perioperative staff survey

In Australia, the role of the Non- Medical Surgical Assistant (NMSA) lacks recognition and professional regulation. This paper reports the findings of a recent survey of Australian perioperative staff [n=ri6] to determine their knowledge and perceptions of the NMSA role. The survey findings confirm that the role is not well established across the Australian health care system. Of concern is that perioperative staff are required to fill the role of surgical assistant on an impromptu basis. NMSAs with no post-graduate qualifications are perceived by perioperative staff to be less equipped in mentoring, leadership, theatre efficiency, safety and procedural knowledge. There was evidence that some perioperative praxes necessitate the role of the NMSA to avoid practices that compromise patient safety.

Re-evaluation of three-session theatre efficiency

How does it compare with the 2S system?

Operating efficiency of an emergency Burns theatre: An eight month analysis

BackgroundThe efficient use of operating theatres is important to insure optimum cost-benefit for the hospital. We used the emergency Burns theatre as a model to assess theatre efficiency at our institution. MethodsData was collected retrospectively on every operation performed in the Burns theatre between 01/04/15 and 30/11/15. Each component of the operating theatre process was considered and integrated to calculate values for surgical/anaesthetic time, changeover time and ultimately theatre efficiency. ResultsA total of 426 operations were carried out over 887h of allocated theatre time (ATT). Actual operating time represented 67.7%, anaesthetic time 8.8% and changeover time 14.2% of ATT. The average changeover time between patients was 30.1min. Lists started on average 27.7min late each day. There were a total of 5.8h of overruns and 9.6h of no useful activity. Operating theatre efficiency was 69.3% for the 8 month period. ConclusionOur study highlights areas where theatre efficiency can be improved. We suggest various strategies to improve this that may be applied universally.

Improving theatre turnaround time

The NHS Institute for Innovation and Improvement has determined that a £7 million saving can be achieved per trust by improving theatre efficiency. The aim of this quality improvement project...

The cost of trauma operating theatre inefficiency

The National Health Service (NHS) is currently facing a financial crisis with a projected deficit of £2billion by the end of financial year 2015/16. As operating rooms (OR) are one of the costliest components in secondary care, improving theatre efficiency should be at the forefront of efforts to improve health service efficiency. The objectives of this study were to characterize the causes of trauma OR delays and to estimate the cost of this inefficiency. A 1-month prospective single-centre study in St. Mary's Hospital. Turnaround time (TT) was used as the surrogate parameter to measure theatre efficiency. Factors including patient age, ASA score and presence of surgical and anaesthetic consultant were evaluated to identify positive or negative associations with theatre delays. Inefficiency cost was calculated by multiplying the time wasted with staff capacity costs and opportunity costs, found to be £24.77/minute. The commonest causes for increased TT were delays in sending for patients (50%) and problems with patient transport to the OR (31%). 461 min of delay was observed in 12 days, equivalent to loss of £951.58/ theatre/day. Non-statistically significant trends were seen between length of delays and advancing patient age, ASA score and absence of either a senior clinician or an anaesthetic consultant. Interestingly, the trend was not as strong for absence of an anaesthetic consultant. This study found delays in operating TT to represent a sizable cost, with potential efficiency savings based on TT of £347,327/theatre/year. Further study of a larger sample is warranted to better evaluate the identified trends. © 2016 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Neurosurgical operation theatre utilization and efficiency: A retrospective audit

Neurosurgical operation theatre utilization and efficiency: A retrospective audit