In 2007 we examined initiatives to improve throughput of operating theatres in a large teaching hospital, with 52 operating theatres each running at an estimated cost of £4800 per day, and performing 50-60,000 operations per year.
While it is undesirable to increase the speed with which clinicians perform procedures, it is possible to shorten downtime by improving support processes. Our historical data suggested an average turnaround time of 25 minutes between procedures, and we have been able to reduce this to an average of four minutes.
Whereas on conventional lists, four total joint replacements (TJR) filled the whole operating list (0830 – 1700), with the new scheme, it was possible to complete five TJR and finish by 1530.
Our optimal theatre list included some key areas to improve utilisation:
- Dedicated porter for list
- Additional floor nurse
- Senior anaesthetic nurse
- Senior recovery nurse
Some modifications to the normal practice standard were required. Two patients must be admitted the day before surgery so they can be sent for early enough to start the list promptly at 8.30am. The remaining patients can then be seen by anaesthetic and surgical teams prior to the start of the list.
Crucial to improving theatre efficiency is reducing turnaround time between cases. To this end the recovery nurse must collect the patient from theatre, rather than the anaesthetist “portering” the patient from theatre to recovery. Increased use of regional anaesthetic techniques facilitates this smooth transition to recovery.
Review of efficiency
Having established a system to collect theatre timing we retrospectively reviewed logged data to look at:
- Start time
- Turnaround time (from being ready to transfer to recovery, to start of next anaesthetic)
- Procedure time (anaesthetic + surgical time)
- Number of procedures performed
- Total time used
We compared eight earmarked optimised “fastrack” lists with five TJR and compared with 17 non-optimised lists (four TJR standard). Three of the optimised lists were performed by staff grade or a senior SpR in anaesthetics.
Throughput of cases for the optimised lists was higher than non-optimised lists (4.63 cases vs. 4 cases p <0.01), and this was further improved with consultant only lists (4.9) –Table 1. Analysis of the case mix between the lists revealed similar numbers of knee arthroplasty, hip arthroplasty and hip resurfacing procedures.
Procedural time was reduced, together with turnaround time and this resulted in a reduction in mean case time. Start delay was reduced from a mean of 14 to 4 minutes (p=0.007).
Some of the lists were staffed with a non-consultant anaesthetist, and in some of the non-optimised lists the lead surgeon was an SpR. Further analysis of the non-consultant grade difference showed that non-consultants had a significant effect on the turnaround time, but a very limited effect on the procedural time.
Our experience demonstrates that more cases can be done in the same theatre time with an improvement in non-procedural gap time. Of all the projects we have trialled for improving theatre efficiency this has demonstrated the greatest potential for maximising throughput. The increased staffing costs we estimated at a maximum of £530 per list which is low relative to the additional tariff for TJR.
We saw reduced procedural time as a result of: a more senior anaesthetic nurse reducing anaesthetic time, an additional floor nurse in theatre which reduces setup time and limits delays during the procedure.
We cannot be confident, however, there was no difference in the complexity of cases, and the positive mindset of staff may also reduce procedure time. As our best performance was with direct consultant involvement then these lists may be more suitable to be earmarked as non-training lists, with training lists or complex cases scheduled on alternative sessions.
A significant part of the success of this project is engaging the staff from differing disciplines to co-operate, drive people out of their comfort zones and instil a sense of crisis.
In addition feedback of improved performance and minor incentives, for example allowing staff home early at the end of the list, are crucial to bring about a new system approach in theatre. Some staff will respond better to this theatre arrangement, and can improve job satisfaction for those where working within a more efficient environment is rewarding.
We have had difficulty ingraining this new system, and until it becomes “the way we do things around here” the traditional method of running theatre lists will prevail.
Jonathan Loughead is specialist registrar orthopaedics, Nigel Brewster is a consultant orthopaedic surgeon and Digby Roberts is a consultant anaesthetist clinical director Peri-operative care all at the Freeman Hospital, Newcastle upon Tyne.