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Research Article

Causes of elective surgery cancellation and theatre throughput efficiency in an Australian urology unit

[version 1; peer review: 2 approved]
PUBLISHED 19 Aug 2014
Author details Author details
OPEN PEER REVIEW
REVIEWER STATUS

Abstract

Objective:
  • To evaluate our unit’s theatre throughput efficiency, to identify where inefficiencies existed and consequently where the greatest improvement might be made.
  • To identify the causes of day of surgery cancellations and how they might be avoided. 
Patients and Methods:
  • A prospective audit of theatre utilisation was undertaken over a 6 month period between 05/02//2013 and 02/08/2013 at Ipswich General Hospital, QLD, Australia.
  • Times collected were: time of patient arrival in anaesthetic bay, start time of operative procedure, end time of operative procedure, and time of patient leaving theatre.
  • The causative factors for any delays or day of surgery cancellations were identified and recorded where possible.
 Results:
  • In the six month period 26,850 sessional minutes were available for elective operating over 100 operating sessions.
  • 304 elective cases were performed, split between 21 major and 283 minor procedures
  • The sessions ran overtime a cumulative 2114 minutes.
  • Total non-operative minutes totalled 13,209 (50.3% of all available time), split between late starts 499 minutes (1.8%), early list finishes 1894 minutes (7.05%),  changeover time 1869 minutes (6.9%) and anaesthetic time, 8974 minutes (33.4%)
  • Actual operating time only compromised 50.7% of all available elective operating session time (13,614 minutes)
  • Theatre utilisation was 91.8%.
  • 51 procedures were cancelled on the day of surgery during the audit period, representing 14.3% of all scheduled procedures.
  • The most common reason for cancellation was lack of surgical fitness, followed by inadequate operative time.
 Conclusion:
  •  A significant proportion of all elective operative time was consumed by non-operative minutes.
  • Inefficiencies existed in turnover of patients as well as over as well as underbooking of patients on elective lists.
  • An excessive number of cases were cancelled on the day of surgery, wasting valuable operative time.
  • A multi-parametric approach must be taken to improve operation list utilisation.

Introduction

Theatre efficiency is increasingly coming under the spotlight as elective waiting lists continue to increase1. Delays or interruptions during operating lists are associated with dissatisfaction for health care providers and patients alike2. Theatre lists account for a significant proportion of a hospital’s revenue and an even larger fraction of its total expenses36. As operating theatre budgets are already stretched, increased case throughput must come from improved theatre efficiency rather than from more operating sessions.

Efficient use of theatre sessions relies on prompt start times, an appropriately booked theatre case-mix, efficient patient turnover, and finishing on time to reduce overtime costings7,8. Accurate scheduling of elective theatre cases to maximise operating efficiency is extremely complex, as the time required for identical procedures can vary dramatically.

The most cost-efficient method to increase theatre case throughput is by decreasing idle theatre time9,10.

Method

We sought to evaluate our unit’s theatre throughput efficiency so we might identify areas where the most time was wasted during operating sessions, and consequently where the most significant improvements might be made.

To do this we undertook a prospective audit of all elective theatre operating in the Urology unit at Ipswich General Hospital (IGH), a regional secondary referral hospital, over a six month period, between 05/02//2013 and 02/08/2013. The theatre complex at IGH consists of 6 operating suites with a 3 bay arrangement, with each suite having an anaesthetic bay and scrub room in addition to the operating room itself.

Times were extracted from the Operating Room Management Information System (ORMIS) theatre management software (CSC). Versions 5 and subsequently 7 were used, as the software was updated during the audit period. Times extracted from ORMIS were: time of arrival in anaesthetic bay, start time of operative procedure, end time of operative procedure, and time of patient leaving theatre (Table 1). Times were entered into ORMIS by theatre nursing staff as per standard practice.

Table 1. Times extracted from Operating Room Management Information System (ORMIS) theatre management software (CSC) during the audit period, listing the various steps during a patient’s operative journey.

Times RecordedAbbreviation
Time of patients arrival in anaesthetic bayT1
Start time of operationT2
End time of operationT3
Time of patient departure from theatreT4

Where possible the reasons for delays were identified and recorded by both the nursing staff entering the reasons into ORMIS, and by direct recording by a surgical team observer.

The scrub nurses, theatre assistants, and members of the anaesthetic team were not informed that the study was being conducted, so as not to influence their performance. The surgical team were undertaking the audit, and they were never blinded.

Results

In the six month audit period 304 elective cases were performed, split between 21 major (Table 2) and 283 minor procedures (Table 3). Total available operative minutes were 26,850 distributed over 100 elective operating lists. Ordinarily each week consisted of one 3.5 hour, one 8.5 hour and two 3 hour sessions.

Table 2. Breakdown of the major operative procedure performed during the audit period.

Major OperationsNo. Performed
Lap/Open Nephrectomy6
Lap/Open Nephro-ureterectomy1
Lap/Open Pyeloplasty1
Percutaneous Nephrolithotomy (PCNL)2
Ureteric Reimplantation1
Artifical Urinary Sphincter1
E/O skin lesion + skin graft1
Radical Retropubic Prostatectomy (RRP)8
Total21

Table 3. Breakdown of minor operative procedure case-mix during the audit period.

Minor OperationsNo.Minor OperationsNo.
Ureteroscopy58Removal of ureteric stent14
Conduitoscopy1Cystoscopy25
Inguinal Orchidectomy8Cystoscopy + Retrograde
Pyelogram
3
Cystoscopy + biopsy19Cystoscopy + urethral
dilatation
5
Scrotal lesion excision/
abscess drainage
4Incision of ureterocoele2
Continence sling5Cystoscopy + injection of
intravesical botox
2
I/O Ureteric stent29Hydrocoele repair2
Trans-Urethral Resection
of Bladder Tumour (TURBT)
35TRUS biopsy under
sedation
7
Bladder Neck Incision (BNI)4Trans-Urethral Resection
Prostate (TURP)
34
I/O Suprapubic Catheter
(SPC)
1Cystoscopy + diathermy4
Circumcision9Optical urethrotomy5
Open Cystolithotomy1E/O Epididymal Cyst6
Total283

Start time efficiency or late starts (LS) (Table 4), measured from the time the patient entered the anaesthetic bay, was acceptable at 499 minutes or 1.8% of all available list time (Table 5). Significant LS (over 15 minutes late) occurred on only 8 lists. Over all operating lists the mean LS was 5 minutes with a median of 0 minutes, and a range of 0–148 minutes. The total LS time was skewed significantly by a single episode where 6 nursing staff were absent with illness simultaneously, delaying the start of the list by 148 minutes. Only a small number of cases were delayed by the late arrival of anaesthetic or surgical team members. Delay in patients arriving from the day surgery unit or wards were more common but still infrequent.

Table 4. Definitions of times extrapolated from the ORMIS data recorded during the audit period.

Definition of TimesExplanation of Times
Sessional time (ST)All time within the allocated elective
operating session excluding OT +
ES time
Early start time (ES)Scheduled start of ST – T1
Late start time (LS)T1 - scheduled start time of ST
Anaesthetic Time (AT)(T2 – T1) + (T4 – T3)
Changeover Time (CT)T1 (next patient) – T4 (previous
patient)
Procedure Time (PT)T3 – T2
Overtime (OT)PT + AT occurring after end of ST
Non-operative Time (NOT)AT + CT

Table 5. Breakdown of ST usage.

Just over 50% of all available sessional time was used for operating during the audit period.

ActivityTotal
Minutes
Mean
(Overall)
Median
(Overall)
Range
(Overall)
No.
Significant
Mean
(Significant)
Median
(Significant)
Range
(Significant)
% ST
LS499500–148853.3839.5025–1481.80
EF1894N/AN/AN/A2476.254518–4807.05
CT18698.1650–1323131.611416–1326.96
AT897429.5221.502–64N/AN/AN/AN/A33.42
PT1361444.78312–330N/AN/AN/AN/A50.70

1894 minutes were wasted with early finishing (EF) (Table 4) of lists representing 7.05% of all available time (Table 5). Significant EF, considered as lists finishing over 15 minutes early, affected 24 lists and totalled 1830 minutes, with a mean of 76.25 minutes, a median of 45 and a range of 18–480 minutes.

Under booking of theatre lists accounted for a significant proportion of all EF, however, the lion’s share of early list finishes were caused by day of surgery cancellations. 27% of all EF (843 minutes) were accounted for by cancellation of just 3 cases (Table 6). Two radical retro-pubic prostatectomies (RRP) were cancelled due to patients changing their mind on the day of surgery and instead opting for external beam radiation therapy, with a cumulative loss of 363 minutes of scheduled sessional time (ST) (Table 4). The cancellation of a radical cystectomy, which was the only booked case on an all-day operating list, accounted for 480 lost minutes.

Table 6. Breakdown of cases cancelled on the day of surgery and the reasons for their cancellation.

Cancellation reasons are classified as per Argo et al’s cancellation codes 11 .

Cancelled OperationsNo.Reason For
Cancellation
No.
MAJOR
RRP1W52
Radical Cystectomy +
Ileal Conduit Formation
1W11
MINOR
TURBT8W44
W3(UTI)2
F61
P1 (Trauma
witnessed)
1
TURP7W42
W3(UTI)1
F72
F111
A11
Cystoscopy + I/O Ureteric
stent
6P81
W42
W3(UTI)2
P101
Optical Urethrotomy1F71
Cystoscopy6W44
W3(UTI)1
W51
Cystoscopy _ RGP2F61
F71
Ureteroscopy4F72
W3(UTI)1
W43
W21
Hydrocoele Repair2P101
F71
Circumcision3W42
F71
Cystoscopy +/- biopsy6W42
P61
F72
W21

In total, 51 procedures were cancelled on the day of surgery during the audit period, representing 14.3% of all scheduled procedures. The reasons for case cancellation were grouped into 5 categories, and 28 potential cancellation reasons, as per Argo et al’s audit of elective operating in the US Veteran’s Health Administration11 (Table 7). The most common reason for case cancellation was lack of fitness for surgery (W4), with inadequate operative time the second most common (M7) (Table 8).

Table 7. Classification of cancellation codes used to group day of surgery (DOS) cancellations.

Source: Adapted from: Argo JL, Vick CC, Graham LA, Itani KM, Bishop MJ, Hawn MT. Elective surgical case cancellation in the Veterans Health Administration system: identifying areas for improvement. Am J Surg 2009;198:600–6.

PatientFacility
P1 Patient refused or no consentF1 Equipment broken or not
available
P2 VA transportationF2 Implant(s) not available
P3 Patient transportationF3 No Intensive Care Unit
(ICU) beds
P4 Preoperative instructions not
followed or patient not instructed
adequately
F4 No Hospital beds
P5 Patient substanceF5 Scheduling error
P6 Patient cancels, had
procedure performed elsewhere
F6 Staff shortage, other than
surgeons and anaesthesia
providers
P7 Patient cancels, did not have
procedure performed elsewhere
F7 No OR time
P8 Patient deathF8 Emergency case
P9 Case aborted in ORF9 Blood products not
available
P10 Patient is a no-show, no
contact from patient
F10 Facility environment
Work-up F11 Weather/natural disaster
W1 Surgeon-work up needed Anaesthesia
W2 Anaesthesia-work up
needed
A1 Anaesthesia staff not
available
W3 Abnormal test Surgeon
W4 Change in medical statusS1 Surgery staff not available
W5 Change in treatment plan

Table 8. The frequency of individual cancellation classification codes used for day of surgery cancellations during the audit period.

Cancellation reasons are classified as per Argo et al’s cancellation codes11.

Reason for CancellationNumber of
Cancellations
Patient refuses operation2 (P1)
Procedure already performed elsewhere1 (P6)
Patient deceased1 (P8)
Failed to attend2 (P10)
Patient inadequately prepared for surgery
(Not bowel prepped)
1 (W1)
Inadequate anaesthetic workup2 (W2)
UTI on dipstick (Clinically well)6 (W3)
Patient generally unwell17 (W4A)
Patient no longer needs procedure3 (W4B)
Patient no longer wants procedure3 (W5)
List reduced due to staff training2 (F6)
Lack of operative time10 (F7)
Lack of anaesthetic staff1 (A1)
Total 51

2114 minutes were recorded of theatre overtime (OT) (Table 4), measured from the time patients left the operating room. This represented 7.9% overtime over the scheduled ST during the audit period (Table 5). Operative OT, measured from completion of the last operative procedure accounted for 1404 minutes (66.4%), with anaesthetic overtime accounting for the remaining 710 minutes (33.6%). Significant OT affected 37 operating lists, with a mean of 54.59 and median of 37 minutes and a range of 16–105 minutes. The causes of OT during the audit were multifactorial. Any unforeseen delays during the operative list, such as a slow patient changeover, difficult induction of anaesthesia, late start of the operative list, or unexpectedly prolonged operative time all contributed to total overtime.

One of the major contributors that was identified was major cases being booked onto half day operating lists. Two lists each week were of only 180 minutes duration, and on 4 out of 5 occasions when a major case was booked onto such a list, the session ran significantly overtime.

Total patient changeover time (CT) (Table 4), which was defined as the time the patient left the operating room until the subsequent patient on the operating list entered the anaesthetic bay was acceptable at 1869 minutes, representing 6.9% of all available operative list time (Table 5). The mean CT was 8.16 minutes, the median 5 minutes with a range of 0–132 minutes. A significant delay in CT, defined as those taking over 15 minutes, occurred on 31 occasions (13.4% of all changeovers). Late patient arrival or non-arrival at the day of surgery admissions was responsible for a significant proportion of all CT. The next patient was already in the anaesthetic bay before completion of the prior case on 60 occasions (26% of all changeovers), significantly reducing total CT.

Anaesthetic time (AT) (Table 4) which consisted of: patient time spent in the anaesthetic bay, anaesthetic induction time and the time for the patient to leave theatre after the end of the procedure, totalled 9657 minutes. After removing the AT spent in overtime (710 minutes), AT consumed 33.4% of all available operating list time. Mean anaesthetic time over the audit was 29.52 minutes, with a median of 21.5 and a range of 2–64 minutes.

Of all available time, 15018 minutes were spent operating (PT) (Table 4). After excluding the PT occurring after the scheduled end of the operating list (1404 minutes), this meant that only 50.7% of all available sessional time (ST) was spent operating (Table 5).

Theatre utilisation over the entire audit period was 91.8%, however, this number was significantly skewed by the large amount of both OT and early start minutes (ES). ES, measured from entry of the patient into the anaesthetic bay prior to the scheduled start of the operating list, totalled 967 minutes. When these minutes, in addition to the OT (2114 minutes), are subtracted effective theatre utilisation falls to 80.3%.

There were several limitations to our study. While we attempted to blind the theatre assistants, anaesthetic and nursing staff from the ongoing audit, several members of each team became aware of the audit throughout its course. This could have influenced their efforts throughout the audit period. As all times for the study extracted from ORMIS were entered by nursing staff, it is possible that bias could have affected the accuracy of the times if the nurses entering the data were aware of the audit. The surgical team was never blinded to the audit, and this might have influenced the operative urgency of the surgeons involved and their punctuality.

In regards to our case mix, our relatively small proportion of major cases compared to a tertiary referral urology service would certainly increase the ratio of non-operative to operative time compared to an operative case mix with more major cases.

Another factor that influenced our throughput was addition of emergency cases to our elective lists. Ipswich General Hospital has one emergency list daily, which preferentially performs all emergency cases unless elective sessions finish early, or if the patient is medically unstable. During the audit period 4 emergency cases were added to the end of our elective list: 1 drainage of a scrotal abscess and 3 ureteric stents. Total overtime generated by these additional cases totalled 106 minutes. If these additional cases had not been performed, an additional 114 early finishing minutes would have been recorded.

Dataset 1.Raw data files (Excel) for the audit of elective theatre operating in the Urology unit, Ipswich General Hospital, QLD, Australia.
File 1: Elective Operating Session Time Usage.xlsx, Elective operating session time usage as obtained from the ORMIS theatre management software package. File 2: Elective Surgery Cancellation Causes.xlsx, reasons for cancellation of surgery and the ORMIS code allocated to each cancelled procedure. DOS, day of surgery.

Discussion

Our audit has highlighted the complexity of maximising operative efficiency. Optimisation of theatre throughput efficiency starts with careful booking of the operating list. Currently operating lists are booked by ex-clinical staff with a best-guess approach, which while practical, often fails to take into account the myriad variables of the case and staffing mix. In various centres mathematical theories previously applied to the manufacturing industry have been successfully trialled to facilitate more efficient booking of theatre time, however, such methods require significant expertise and staff retraining and are not currently viable options at our institution12.

Day of surgery cancellations affected 14.3% of all scheduled cases during our audit period. Whilst this number is not dissimilar to Argo et al’s analysis of urological cancellations in the Veterans Health Administration (14%), it still represents a significant amount of wasted ST11. Whilst some of these cancellations were unavoidable, such as staff illness, the majority of the 6 cancellations secondary to patient factors (P1, P6, P8, P10) could potentially have been avoided by a phone call to the patient a day or two prior to the operative date, allowing adequate time for replacement cases to be found. The 11 cancellations due to workup and administration factors (W1, W2, W4B, W5, F6) could foreseeably have been avoided by better communication between members of the surgical, anaesthetic and nursing teams. If foreseen early on the day of surgery, these otherwise wasted operative minutes could have been filled with elective patients called in at short notice. Other units have established a “fillbuster” list for just such events9. Whilst there was a significant proportion of our operative time wasted with day of surgery cancellations, we do acknowledge that implementing such a waitlist for elective surgery patients is logistically challenging in a smaller hospital such as ours, and is impractical for many of our patients.

During the audit, CT consumed 6.9% of all available sessional time, and whilst the mean CT was acceptable at 8 minutes, on 31 occasions a significant delay of over 15 minutes occurred. Harders et al. successfully reduced their turnover time by 37% by supplying pagers for all theatre assistants which were triggered 5 minutes prior to completion of the case in addition to standardisation of equipment2. Whilst not an issue in our centre during the course of the audit, Weinbroum et al’s audit has shown that up to 10% of all available operating time is wasted awaiting Post-Anaesthetic Care Unit (PACU) space13. Wasted operative time costs an estimated $US 10–30 per minute or at least $US 600 per hour1315. As the hourly cost of maintaining a single patient in PACU costs $US 110, increased throughput and profitability could both be achieved by increasing the staffing and by physical enlargement of the PACU13,1618.

The greatest gains in terms of surgical throughput efficiency have been seen with implementation of parallel processing. Parallel processing involves preparing patients for theatre concurrently as the prior patient’s procedure is completed, contrasting to the traditional approach of serially processing patients. This approach allows for reduction of both AT and CT. Parallel processing allows intravenous and arterial lines to be inserted, and spinal or even general anaesthesia to be achieved in pre-procedure rooms5,19. Simultaneous processing often requires additional anaesthetic staffing and the consequent increased costs associated. However, the increased cost of implementing parallel processing can be offset by increased throughput and consequent financial gain6.

Parallel processing is most advantageous in operating lists where multiple, small cases are going to be performed, in cases with a consistent operative duration, and on full day operating lists20. These incremental time savings over preceding cases enable the performance of additional cases19,2125. Whilst parallel processing only facilitates added cases on high turnover lists, it has been shown to reduce overtime costings in theatres where fewer, longer cases are performed, however, in this circumstance this might not offset the added costs of increased staffing levels22,26. Sandberg et al. have shown that parallel processing, when used across an entire theatre complex, is cost neutral23. More selective use of parallel processing, such as solely for high turnover lists, would yield the greatest benefit financially without affecting case throughput23.

Conclusion

Our study quantified how much of each theatre session was occupied by non-operative processes in a unit with multiple short-duration operative procedures. Based on the findings of the study, we have implemented process changes to increase our own theatre efficiency. We have recently adopted a high-throughput theatre list one day a month, where multiple small simple cases are booked on an all-day operating list. Additional anaesthetic and nursing staff are rostered on these days to facilitate parallel processing of patients and remove the need for lunch breaks. If these prove to be successful and cost-efficient we would look to increase their frequency.

Whilst we are unable to implement more complex booking algorithms at this stage due to financial constraints, we are still striving to improve our booking efficiency. Efforts are being made to more accurately document predicted operative times on booking forms. Uncomplicated patients are now having blood and urine taken when booked at outpatients. They are then being seen immediately by pre-operative nurses. This enables suitable patients to be prepared for surgery at short notice in the event of cancellations. Booking staff are now making efforts to contact patients several days prior to their surgery and in the event of problems, to liaise with the surgical team, to limit the number of day of surgery cancellations. Assessment of our unit’s theatre throughput is ongoing.

Data availability

F1000Research: Dataset 1. Raw data files (Excel) for the audit of elective theatre operating in the Urology unit, Ipswich General Hospital, QLD, Australia, 10.5256/f1000research.4824.d3276627

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Keller A, Ashrafi A and Ali A. Causes of elective surgery cancellation and theatre throughput efficiency in an Australian urology unit [version 1; peer review: 2 approved]. F1000Research 2014, 3:197 (https://doi.org/10.12688/f1000research.4824.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Current Reviewer Status: ?
Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 1
VERSION 1
PUBLISHED 19 Aug 2014
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Reviewer Report 10 Sep 2014
M. Hammad Ather, Department of Surgery, Aga Khan University, Karachi, 74800, Pakistan 
Approved
VIEWS 16
Operating room space and time is one of the major reasons for long waiting times in elective operative procedures. Improving operating room efficiency is therefore imperative. The authors of the current report attempted to identify lacunae in the operating room ... Continue reading
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HOW TO CITE THIS REPORT
Ather MH. Reviewer Report For: Causes of elective surgery cancellation and theatre throughput efficiency in an Australian urology unit [version 1; peer review: 2 approved]. F1000Research 2014, 3:197 (https://doi.org/10.5256/f1000research.5149.r6092)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Reviewer Report 28 Aug 2014
Levent Turkeri, Department of Urology, Marmara University School of Medicine, Istanbul, Turkey 
Approved
VIEWS 13
 This is a prospective study over a 6 month period to identify the causative factors for delays or cancellations including time of patient arrival in anaesthetic bay, start time of operative procedure, end time of operative procedure, and time of ... Continue reading
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HOW TO CITE THIS REPORT
Turkeri L. Reviewer Report For: Causes of elective surgery cancellation and theatre throughput efficiency in an Australian urology unit [version 1; peer review: 2 approved]. F1000Research 2014, 3:197 (https://doi.org/10.5256/f1000research.5149.r5860)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

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Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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