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Journal of the Academy of Hospital Administration

Time Utilization of Operating Rooms at a Large Teaching Hospital

Author(s): Farooq Ahmad Jan*, Syed. A. Tabish**,Shigufta Qazi***, M.S. Atif****

Vol. 15, No. 1 (2003-01 - 2003-06)

Key Messages:

  • Time utilization in operation theatres is maximally for actual surgery (66%).
  • Supportive services consume 21% and preparatory phase consumes 13% of time.
  • There are strategies available to improve time utilization.

Abstract

Background. Hospitals consume the largest share of government spending on health. The operation theatre represents an area of considerable expenditure in a hospital budget. Considering the magnitude of current costs, hospital administrators are more than casually concerned with maximum utilization of the facility. In order to maximize the utilization of operation theater it is essential to know how much time is spent on which activity and there by identify the factors resulting in under utilization of the facility.

Methods

An observational study of operations done in operation suite of Sher-I Kashmir Institute of Medical Sciences was carried out for a period of one and a half year. Various operating rooms were observed for a period of three months each; by simple random sampling taking a sample size of 30%. (30% of weekdays were studied out of three months for each speciality) Times at which various activities and events took place in operating room were recorded and data analysed.

Results. Out of the utilized time, time spent on actual surgery was found to be 66.02%, time spent on supportive services was found to be 21.06% and time spent on making room ready was found to be 12.91%. Mean idle time of 128.47 minutes per day was recorded. Room turn around time was on an average 14.1 minutes.

Conclusion

Utilization of theatre can be increased by avoiding delayed starts, avoiding cancellation of cases, proper scheduling of surgeries, by anaesthetizing the patient in anaesthesia room instead of operating room and by laying of sterile trolleys in lay-up room instead of operating room.

Keywords: Time Utilization, Operating Room

Introduction

Hospitals consume the largest share of government health resources, yet until recently they have not been a focus of health policy and research in developing countries1. Hospitals in developing countries absorb more resources than any other kind of recurrent government spending on health1. Although the actual percentage varies from country to country, it is on an average 50-80% of public health sector resources in money and trained personnel to be used in hospitals1. Review of the health sector in many countries suggests that these large expenditures on hospital involve a great waste of resources because of the technical and managerial inefficiency, management and role of hospitals in health sector, there is a need to introduce professionalization in hospital management1.

The operation theatre complex of a hospital represents an area of considerable expenditure in a hospital budget and requires maximal utilization to ensure optimum cost-benefit2. There is paucity of data in India on the use of available operating time and the reasons for less than optimal utilization have not been studied2. The efficient use of operating time is also important to clear waiting lists3. In order to improve the utilization of operating room it is essential to know how much time is spent on which activity.

A study was conducted at Sher-I-Kashmir Institute of Medical Sciences which would go a long way in improving the utilization of operating room. Sher-I-Kashmir Institute of Medical Sciences is a 600 bedded teaching hospital which besides teaching and research has been imparting quality patient care in various branches of medicine including superspecialities.

Specific aims of the study are to find out the time spent on actual surgery, time spent on supportive services and time waiting while operating room was being made ready for surgery. The average idle time (unproductive time) needs to be calculated. Reasons for under utilization of operating rooms, if any need to be identified to improve its efficiency.

Methods

An observational study of operations performed in the main operation suite of Sher-I-Kashmir Institute of Medical Sciences was carried out for a period of one and half year (15-7-99 to 14-1-2001).

Gastrointestinal surgery, Neurosurgery, Cardiovascular and thoracic surgery, plastic and reconstructive surgery, Urology and Paediatric surgery operating rooms were observed for a period of three months each; by simple random sampling taking a sample size of 30%. Total of 108 operating days were studied. (30% of the weekdays i.e. 18 days were studied out of three months for each speciality. Weekend and night surgeries are a separate entity and were not included in our study).

A proforma was developed, prestested and standardized to record following observations of each operating rooms:

  • time at which room is ready for first usage
  • time at which first supply package is opened for that patients care.
  • time at which patient is received in operation theatre
  • time at which induction of patient is done
  • time at which surgery starts
  • time at which surgery ends [close of wound]
  • time at which first patient leaves operating room.
  • turn around time [time from one patient out and second in]
  • time at which operating room is ready for starting second patient
  • time at which operating room is ready for the patient and time at which surgery starts
  • last case finished at what time
  • any change in the operation schedule and time of such change
  • any cancellation of operation schedule or a case
  • effective time not utilized for conducting surgery

Table No.I: Time spent on actual surgery, supportive services and making room ready in different surgical specialities.

Speciality Time spent

Time spent

Time spent

on actual surgery  

on supportive services

on making room ready

  S.D. Range   S.D. Range   S.D. Range
Gastrointestinal Surgery 60.18% 8.68 44.26 to 73% 29.95% 8.72 17.50 to 45.94% 9.87% 2.06 5 to 14%
Plastic Surgery 71.11% 9.62 52 to 88.73% 17.35% 6.29 5.67 to 29% 11.49% 3.87 5.60 to 19%
Neurosurgery 70.40% 11.19 47.61 to 80% 17.97% 6.88 10.70 to 29.3% 11.62% 5.49 5.40 to 23%
Urology 61.07% 12.77 40% to 86% 21.41% 8.46 5.70 to 37% 17.51% 5.09 8.30 to 24%
CVTS 81.88% 7.59 66.15 to 89% 9.70% 5.19 4 to 20% 8.50% 3.47 4.47 to 15.3%
Paediatric Surgery 55.2% 7.81 48.60 to 75% 26.22% 5.73 11.6 to 35% 18.57% 4.92 6.4 to 25%
Overall 66.02% 12.76 40 to 89% 21.06% 9.5 4 to 45.9% 12.91% 5.55 4.47 to 25%

Note: Time spent on actual surgery: Preparing the part to close of wound.
Time spent on supportive services: time spent on anaesthetizing the patient, laying of sterile trolleys, Sponges etc.
Time spent on making room ready: Cleaning the room, disposing off the used lineen, removed tissues, Sponges etc.
S.D: Standard deviation.

Time spent on actual surgery {preparing the part to close of wound} was noted. Time spent on supportive services {time which is spent on laying of sterile trolleys, sponges and also time spent on anaesthetizing the patient} was recorded. Time spent on making room ready {time which is spent on cleaning the room, disposing off the used linen, removed tissues, sponges etc both at the start of day and between cases} was also recorded. Time which is not spent on any of the above activity {idle time} was recorded.

Results

The data obtained has been analysed and summarized in the form of tables I and II.

Analysis of variance showed that the difference in the time spent on actual surgery in different surgical specialities is statistically significant. P<.05.

Analysis of variance showed that the difference in the time spent on actual surgery in different specialities is statistically significant.P<.05.

Analysis of variance showed that the difference in the time spent on making room ready in different surgical specialities is significant.p<.05.

Table No. II: Idle time and room turn around time of different surgical specialities

Speciality   Idle time     Room turn around time
    S.D. Range   S.D. Range
Gastrointestinal surgery 86.5 min50.68 0 to 170 min 6.8 min 5.39 2 to 20 min
Plastic surgery 108.75 min 109.91 10 to 360 min 13.90 min 10.77 5 to 35 min
Neurosurgery 150.88 min 98.59 45 to 360 min 23 min 18.93 10 to 45 min
Urology 172.69 min 131.67 25 to 360 min 17 min 8.91 8 to 35 min
CVTS 114 min 118.51 0 to 360 min 23.4 min 23.40 17 to 65 min
Paediatric surgery 159.38 min 104.86 15 to 360 min 10.43 min 3.60 8 to 13 min
Overall 128.47 min 104.83 0 to 360 min 14.1 min 11.81 2 to 65 min

Note: Idle time: Unproductive time
Room turn around time: time from first patient out and second in.
S.D: Standard deviation.

Analysis of variance showed the difference in the idle time of different surgical specialities not to be statistically significant.p>.05. It is not out of place to mention here that main operation theatre in the hospital under study is scheduled for six hours a day.

Discussion

In our study out of the utilized time 66% was spent on actual surgery; 21% on supportive services and 12.9% on making room ready for operation. In one study which has been in some other hospital 54% of time was spent on actual surgery, 31% on supportive services and 15% waiting while operation room was being made ready for operation4. In Central Middle-Sex Hospital, London an orthopaedic theatre timing survey showed that 60% of elective list time was used for operating, 21% for turnover and no useful activity occurred during the remaining 19% of theatre times3. Of the general surgery session time in the same hospital 49% is used for performing operations3. In our study great variation was observed in the percentage of time spent on actual surgery, supportive services and on making room ready for surgery in different surgical specialities. Analysis of variance showed this difference to be significant (p<.05). Thus difference is not by chance but depends on the type of the surgeries performed e.g. case lengths are shorter in general surgery, paediatric surgery and urology whereas they are longer in plastic surgery, neurosurgery and cardiovascular and thoracic surgery; therefore time spent on actual surgery in plastic, neuro and cvts are longer. The productivity in an operation theatre can be defined as surgical time divided by the total work hours of the operation room staff5. This productivity factor is normally reduced in the case of operations that take only a short time to perform, since the time interval between operations is usually not reduced correspondingly5. In the unit for outpatient surgery at Akershus Central hospital, 4.6 operations were performed daily in 206 days in 1993, with a productivity factor of 42% and an operating theatre utilization of 66% Operating theatre time spent on specific patients/total operating theatre time)5. The mean interval from the time the surgeons finished one operation until they could start the next was 33 minutes (confidence interval 32-34) with a mean operating time of 44 minutes (42-46)5.

The mean idle time in our study was 128.49 minutes/day. This amounts to utilization rate of 64.31%. Analysis of variance in the idle time of different surgical specialities showed no significance p>.05, which means that this unproductive time has nothing to do with the type of the surgery being performed; rather the causes of this idle time need to be identified and corrected. Main causes of idle time in our study were unplanned scheduling of operations, delayed starts and cancellation of cases. In a study conducted in a large teaching hospital idle time of 105 minutes on an average has been recorded6. Researchers have found operating room utilization rates to be low overall 40 to 60% in widely varying settings in Chicago7, Columbia8, United States Department of veteran affairs7. In another study utilization was found to be ranging from 44% to 113%6. Audit of surgical theatre utilization at Jawaharlal Institute of Postgraduate Medical Education and Research Pondicherry, India which was done prospectively over a period of 12 months with respect to the starting and closing of the operation theatre, interval between surgical procedures and cancellation of surgical procedures showed that theatre was functional for 279 days during the year of the study, and 1773 cases were operated (6.3 cases/day).2 The total operating time utilization was 91.5%. The major reasons for cancellation of a total of 310 cases were lack of operating time (65.2%), emergency surgery during the elective cases (13.9%) and preoperative lack of fitness (11.3%).2 Among all the lists, 43.6% started late and 63.6% of lists finished well before the scheduled closing time2. Absence of monitoring equipment and non availability of additional qualified anaesthetists necessitated induction of anaesthesia in the main operating room and accounted for 11% of the total operating time2. An audit of the usage of operating theatre in Eastern General Hospital Edinburgh found that twenty five percent of theatre sessions were not allocated for use, twenty three percent of general surgical lists were cancelled and of the lists which did take place, a further twenty three percent of theatre time was not utilized9. A report by the National audit office UK showed only 50% to 60% of weekday operating time was being used9. This report was examined by the committee of public accounts and much of the blame for underutilization of operation theatres was attributed to poor working practices among surgeons9. A study at Central Middle Sex Hospital London showed only 9/151 (6%) of lists started within 5 minutes of the scheduled time3. Of unnecessary delays contributing to this, 63% involved anaesthetic staff and 24% theatre staff. Surgeons were implicated in 10% of start delays3. There were less start delays if senior anaesthetic staff were present3. In a study patients seen at assessment clinics within two months before admission had a significantly higher operation rate than those admitted from a routine waiting list; 97% V 62% p<.00510. Patients on long waiting lists for surgery need to be reassessed before admission to avoid wasting theatre opportunities by cancellation of cases10.

Turn around time of 14 minutes was recorded on an average in our study. In studies conducted in other hospitals room turn around time was almost uniformly 36 minutes11. In our study it was seen that most of the time is wasted at the start of the day and at the end rather than between cases. Shorter turn around times may also sometimes indicate compromise on the cleanliness of the theatre. In one study turn around times were quicker if a consultant surgeon was present (p=.0022)3.

Intervention Strategies

More effective use of theatre time is possible if delays in starting lists is minimized, proper scheduling of surgical lists is done, if more detailed preparation was undertaken by the anaesthetic, theatre and surgical staff, patients on long waiting lists are reassessed before admission to avoid cancellation of cases, by anaesthetizing the patient in anaesthesia room instead of operating room which would reduce the time spent on supportive services and by laying of sterile trolleys in lay-up room instead of operating room which would again reduce the time spent on supportive services. The time spent on making room ready can be reduced but at the same time proper attention needs to be given to the aseptic precautions both at the start of day and in between cases.

References

  1. Syed.A.Tabish. Towards development of professional management in Indian hospital. Journal of management in Medicine 1998. 12(2): 109-119.
  2. Vinukondaiah.K, Ananthakrishnan.N, Ravishankar.M. Audit of operation theatre utilization in general surgery. Natl Med J India 2000; 13(3): 118-21.
  3. Ricketts.D, Hartley.J, Patterson.M, Harries.W, Hitchin.D. An orthopaedic theatre timing survey. Ann R Coll Surg Engl 1994; 76(3): 200-4.
  4. Sakharkar.B.M: Operation theatre Suite; In Principles of Hospital Adminsitration and Planning. First edition. Jaypee Bros, New Delhi; 1998: 14; 197-207.
  5. Anestesiavdelingen, Sentralsydehuset I Akershios, Nordbyhagen. Utilization of a unit of ambulatory surgery. Tdsskr Nor Laegeforen 1996; 116(3): 376-8.
  6. Sinha R.K. A study to assess staffing requirement of doctors in surgical unit of a large hospital. Tehesis for M.H.A, AIIMS, 1987. (unpublished observations)
  7. Mc Quarrie DG. Limits to efficient operating room scheduling: Lessons from computer ? use models. Arch Surg 1981; 116: 1065-1071.
  8. Gil AV, Galarza MT, Guerrero R, deVeleez GP, Peterson OL, Bloom B.L. Surgeons and operating rooms: underutilized resources. Am J Public Health 1983; 73: 1361-1365.
  9. 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(780): 612-5.
  10. Mangan JL, Walsh C, Kernohan Wg, Murphy JS, Mollan RA, Mc Millen R, Beverland DE. Total Joint replacement: implication of cancelled operations for hospital costs and waiting list management. Qual Health Care 1992; 1(1):34-7.
  11. Mazzei W.J. Operating room start times and turn over times in a university hospital. J clin Anaesth 1994: 405-8.

* Senior Resident Hospital Administration
** Additional Professor and Head Accident and Emergency.
*** Professor of Anaesthesiology
**** Senior Resident

Address for correspondence:
Farooq Ahmad Jan, Senior Resident, Department of Hospital Administration, Sher-I-Kashmir Institute of Medical Sciences Srinagar, Kashmir. 190011,
E-mail: [email protected]

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