Ot Utilization Project 642

We care… with care

Summer Training Project

Jaipur Golden Hospital

Title

Operation Theatre: Time Efficiency Study

Project By

Dr. Vivek Ahuja

Summer Trainee (May-July’09)

Project Guide

Dr. Kiran ChawlaQuality Assurance Manager

Jaipur Golden Hospital

Rohini, New Delhi

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Acknowledgement

I would begin my acknowledgements by thanking the Medical Superintendent,

Dr. Ashish Chandra, for initiating this study. I am also grateful to my guide, Dr. Kiran

Chawla, Quality Assurance Manager, without whose support and guidance, this project

would not have been possible. It was a great learning experience to work with such an

experienced and knowledgeable mentor.

I would also like to thank the management and all the employees of Jaipur Golden

Hospital, New Delhi. for their support and constant encouragement throughout the

project

Special thanks to Dr.Ishwar Singh, Dr.Khushali Ratra, Dr. Ajay Singhal for going

out of their way to help me with my project.

Due thanks to my Institute UIAMS, Chandigarh and Dr. Jagandeep Singh,

Coordinator, Placement cell, for providing me an opportunity to associate with an

esteemed organization like Jaipur Golden Hospital, New Delhi. and constant guidance

during the project with time, support and the much needed enthusiasm and inspiration.

Special thanks to our Director, Prof. A.K. Saihjpal for his constant guidance and support.

And my final thanks to my family and friends for their great moral support at all

times during the project.

(Vivek Ahuja)

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Executive Summary

Jaipur Golden Hospital, multispecialty hospital dedicated for Care of patients with tower

specialties and related illnesses for the past two decades. The services have state of the art

technology and equipment, highest level of environmental controls and fully trained and

experienced staff who are dedicated to the care of patients.

A study was carried out at a tertiary care hospital with objective of assessment of

Operation Room Time Utilization analysis and identification of bottlenecks, if any for

optimum utilization. It is essential to assess the existing workload as well as to optimize

facility functioning and patient scheduling for surgical operations. The operation time

utilization varies in different healthcare settings. Optimum utilization of the OT time has

always been a priority area for hospital administrators. It also aids in allocating reserve

time for emergency operations, asepsis measures and procedures, and provides decision

making information for augmentation or downsizing of the facility. The study revealed

that the utilization though satisfactory could be further maximized by increasing the

operational timing of OT, functioning one shift of 08 hours and performing minor

procedures in minor OTs of the OPD. The study identified the main bottlenecks as the

non adherence to OT timings.

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Contents

Acknowledgment.....................................................................2

Executive Summary..................................................................3

Introduction.....................................................................10

1.1 Jaipur Golden Hospital- Overview,10

1.2 Vision,11

1.3 Mission,11

1.4 Quality Policy,12

1.5 Scope and Facilities,13

1.6 Work Load Details- Current Quarter,15

1.7 Special Initiatives,16

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We care… with care 2. Project Outline...............................................................17

2.1 Problem Definition,17

2.2 Objectives, 17

2.2.1 Secondary Research,17

2.2.2 Primary Research,18

2.2.3 Key Issues and Recommendations,18

3. Research Methodology....................................................19

3.1 Research Methodology,19

3.1.1 Research Objectives,19

3.1.2 Response rate

3.1.3 Sample Size, 20

3.1.4 Method of Research,

3.1.5 Data Analysis,

4 Operation Theatre ……………………………………

4.1 Introduction

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4.1.1 Operating Rooms

4.1.2 Physical Infrastructure – Operation Theatre

4.2 Protocols for operation theatre settings

4.2.1 Visitor’s protocol for OT setting

4.2.2 Protocol for personnel

4.2.3 Other Protocols

4.3 Preparation of surgical procedure

4.4 Policy for invasive/surgical procedures

4.5 Administration of anaesthesia

5. Operation Theatre Utilization………………………………

5.1 Overview

5.2 Existing theories

5.3 Definition

5.3.1 O.T./OR utilization

5.4 Methods of O.T./OR utilization

5.5 Aims and Objectives:

5.6 Methods

5.6.1 Points kept in mind while analyzing theatre utilization, ask:

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5.6.2 Flow Process of Activities of Operation Theatre

5.6.2. a Phase I

5.6.2.b Phase II (Operation Theatre Utilization Study)

6. Data Analysis Phase – I…………………………….....

6.1 Overview

6.2 Objectives

6.3 Data analysis

6.3.1 Average cases per day (Dept. wise)

6.3.2 Operated cases (Dept. wise)

6.3.3 Comparative Study of Six Monthly Operated cases (Dept. wise)

6.4 RESULTS

6.4.1 Phase I

7. Data Analysis Phase – II……………………………….

7.1 Overview

7.2 Objectives

7.3 Data Analysis

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7.3.1 Calculation of O.T. utilisation

7.4 RESULT

7.4.1 Phase II

8. Results……………………………………..

8.1 Overview

8.2 Cancellations

8.3 Late Start

8.4 Operating Time

9. Recommendations & Key Messages……………

9.1 Overview

9.2.1 Low theatre utilization

9.2.2 Cancellations

9.2.3 Late Start

9.2.4 Operating Time

9.3 The suggestions for improving O.T. Utilization

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9.4 Key Messages

9.5 Conclusion

Bibliography……………………………….

APPENDIX

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Chapter 1 | Introduction

1.1 THE JAIPUR GOLDEN HOSPITAL

Jaipur Golden Hospital is a 256 bedded, ISO 9001-2000 certified, multispecialty hospital

dedicated for Care of patients with tower specialties and related illnesses for the past two

decades.

The Hospital provides high end tertiary care in Medicine, Plastic Surgery, Dermatology,

General Surgery, Dentistry, Cardiology, CTVS, Orthopedics, Pediatrics, Neonatology,

Obstetrics and Gynaecology, Neurosciences including Neurology and neurosurgery. Also

covered under the scope are the departments of Gastroenterology and Pulmonology. The

laboratory is NABL accredited. The Hospital provides complete services for treatment of

emergency, acute and follow up care for patients of all age groups.

The services have state of the art technology and equipment, highest level of

environmental controls and fully trained and experienced staff who are dedicated to the

care of patients.

Jaipur Golden Hospital is in the process of NABH accreditation.

1.2 VISION

To deliver world-class healthcare with a service focus, by creating an institution

committed to the highest standards of medical and service excellence, patient care,

scientific knowledge and medical education

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1.3 MISSION

To develop a Quality Management program that is systematic, organization-wide

and consistent with our Mission, vision, values and strategic plan.

To provide a system to monitor, evaluate and improve care for the Hospital

Customers so as to ensure high standards of quality and safety for patients.

To further ensure protection of patient rights and ethical practices across.

To define the accreditation roadmap of the organization.

Review quality measurement reports from departments and services as well as

benchmark data from external sources.

Ensure that staff education training plans are in accordance with quality

improvement priorities.

To evaluate patient satisfaction and the quality of patient care through objective

and systematic monitoring of services and to recommend and oversee corrective

action when problems are identified.

1.4 QUALITY POLICY

We at Jaipur Golden Hospital, New Delhi abide by our mission statement to bring

healthcare of international standards within the reach of every individual.

We are committed to the achievement and maintenance of excellence in education and

healthcare for the benefit of humanity.

We would also strive to be a patient focused organization exhibiting good leadership and

teamwork.

In order to achieve this we shall:

- Work together to ensure strict compliance to our policies and ethics.

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- Respect quality, integrity, confidentiality and patient satisfaction

- Deliver prompt and courteous service emphasizing on systems and processes for

continual improvement in services provided through motivation and training.

We are committed to benchmark with the national and other recognized quality

management systems by adopting good professional practices.

Health care services also ensure that it is the individual responsibility of the entire staff to

ensure compliance in all their activities.

1.5 SCOPE AND FACILITIES

Specialties

Medicine Paediatrics

Ophthalmology Paediatric Surgery

Gynae &Obs. Oncology

Surgery Gastro-Enterology

Dermatology Gastro surgery

Plastic Surgery Nephrology

Haematology Urology

Orthopaedics Respiratory Medicine

Cardiology ENT

Neurosurgery Anaesthesia

Neurology Ultrasound / CT Scan

Psychiatry K.T.U.

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Diagnostics

Laboratory Imaging Services

Clinical Pathology X-Ray Microbiology CT Scan Histopathology MRI Biochemistry Ultrasound Cytology

Critical care units Wards

Surgical ICU Deluxe suite

Medical ICU Super deluxe

Pediatrics ICU Deluxe room

Nursery I Single room

Nursery II 2 bedded

CCU Semi-private (AC)

Respiratory ICU Economy (Non AC)

Casualty beds Economy ( AC)

Free ward (P)

Free ward (F)

Free ward (M)

NCC

LDR (suite)

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LDR (deluxe)

Total number of complement beds (beds on which patients are kept overnight): 256

Total number of non-complement beds: 11

SURGERY

The Hospital’s main thrust areas in surgery are minimal access surgery, Neurosurgery,

Cardiothoracic surgery and Orthopaedic surgery. Operation theatres (O.T) are dedicated

for these surgeries. Operation theatre is ultramodern and complete with modular units and

attached recovery room, seminar air flow, total environment control and an alert team of

trained medical and nursing staff. An Acute Post Operative Pain Service managed by the

Anaesthetists is also available.

OPERATING SUITES

S. No. Designation of Operation theatre and Endoscopic suites

Number

1. Major OT Complex 6

2. Minor OT 1

3. Endoscopic Suite 2

1.6 SPECIAL INITIATIVES

At Jaipur Golden Hospital, 10% of the total beds have been reserved for poor

patients.

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The hospital has a instituted a special programme, SMILE TRAIN, in

collaboration with an international NGO, for the children suffering from cleft

palate, hare lips etc

Senior Citizen Initiative Programme (SCIP) has been started for the elderly

patients. Special discounts can be availed under this scheme.

1.7 WORK LOAD DETAILS (of the current quarter)

S. No. PARTICULARS APRIL MAY JUNE

IPD indices

1. Bed occupancy rate 63.07 68.60 70.18

2. Average length of stay 4.27 4.21 4.25

3. Average daily surgeries (major) 11.38 12.60 13.25

4. Average daily surgeries (minor) 6.09 5.39 6.59

5. Average daily deliveries 2.12 2.64 1.83

6. Average daily admissions 36.70 41.35 41.77

7. Average daily discharges 37.06 41.17 41.45

OPD indices

8. Average daily OPD attendance 291.5 342.5 372.36

9. Average daily new patients

registration

219.88 257.79 285.6

10. Average daily follow up patients 71.61 84.95 86.76

11. Average daily day care patients 2.00 1.35 1.70

Emergency indices

12. Average daily emergency attendance 33.90 36.64 40.54

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13. Average monthly emergency

surgeries

4.03 4.78 5.00

Diagnostics

14. Average daily Laboratory tests 1066.67 1223.57

15. Average daily Radiological tests 63.80 74.67 73.32

Chapter 2 | Project Outline

2.1 Problem Definition

“To Study Operation room time utilization, identification of bottlenecks

and to Recommend optimum utilization.”

2.2 Objectives

To examine the utilization of operation theatre in the Main Operation Theatre

Complex of Jaipur Golden Hospital in relation to work load.

To identify the bottle neck, if any, in proper and efficient utilization of Operation

Theatre time and based on that, suggest remedial measures for improving the

Operation Theatre Utilization.

To fulfill these objectives research was undertaken A biphasic approach was used in

the study.

• SECONDARY RESEARCH (Phase I)

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In the first phase, the records of Main Operation Theatre (MOTC) and records

relating to MOTC in Medical Records Department and were perused.

• PRIMARY RESEARCH(Phase II)

In the second phase, observation study by the analyst was done in the MOTC was

done. (Operation Theatre Time Utilization Study)

2.2.1 SECONDARY RESEARCH

To identify the workload of the Main O.T. and also the seasonal

variations/fluctuations if any.

To distinguish between different type of operations and identify the respective

departments.

To know about MOTC staff, their timing and workload.

To understand the process for scheduling of the OT procedures.

To study the different phases involved in MOTC from "patient in to patient out"

2.2.2 PRIMARY RESEARCH

Observed time utilized for different procedure in MOTC from "patient in to

patient out".

Analyzing the reasons for delay in OT functioning with the help of

questionnaire.

2.2.3 KEY ISSUES & RECOMMENDATIONS

To optimize the utilization of operation theatre in the hospital.

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To identify reasons for cancellation of cases

Chapter 3 | Research

Methodology

3.1 Research Methodology

3.1.1 RESEARCH OBJECTIVES

To analyze time utilization for different phases involved in MOTC from

"patient in to patient out"

To categorize opinion regarding the reasons for delay in OT functioning &

Delay In OT procedures

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3.1.2. SAMPLE SIZE

For analyzing average time utilization for different phases involved in MOTC

total of 150 surgical procedures were monitored.

For categorizing opinion regarding the reasons for delay in OT functioning &

Delay in OT procedures total of 60 questionnaires were filled by Surgeon,

Anesthetist and Technician/nursing staff 20 each.

A total data of 397 cases during the period of study was examined.

3.1.3 RESPONSE RATE

The questionnaire formulated to examine the reasons for delay in OT procedures was

given to surgeons, anaesthetists, OT technicians.

The response rate was 100% as all 20 Surgeons, 20 Anaesthetists and 20

Technician/nursing staff obliged by answering the questionnaire.

3.1.4 TIME TAKEN

The time taken to examine one surgical procedure was approx 60 min.

The filling of a questionnaire took 5 mins.

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3.1.5 DATA ANALYSIS

The data obtained from the observation was of a pre-dominantly intuitive nature

and thus MS-Excel proved to be sufficient.

Chapter 4 | Operation Theatre

4.1 Introduction

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-

benefit. The surgical suite typically consumes 9-10% of the hospital budget2. Surgical

suites once needed only 20% utilization to produce a positive bottom line. However,

economics of the OR environment have changed dramatically in the past 25 years.

Technological advances like minimally invasive surgery which need costly equipment,

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We care… with care payments based on diagnosis related groups, captivated payment and discounted fee-for

service have all significantly reduced margins in the surgical business.

The surgical suite of a modern general hospital and everything that goes with it makes a

very complex workshop. Present day surgical procedures involving more people and

highly sophisticated and larger equipment have rendered operating rooms of some what

obsolete. Even more complicated is the question how to make the functioning of

operating rooms over tense hours smooth and comfortable.

4.1.1 Operating Rooms

The major decision centers round the number and type of operating rooms. While

planning and equipping each operating room, a series of questions need to be answered.

The relate to size, usage, lightening (surgical and gen. illumination), intercommunication

and signal systems, electronic equipment and monitoring system, medical gas

system(suction, oxygen, nitrous oxide and compressed air) and other service lines,

fixtures, safety precautions such as grounding for X-ray, TV camera, and against static

electricity, storage, supply cabinets, environmental control, etc.

Operating room should have walls and floor of impervious semi-matt surface with anti-

static flooring. Tiles are not recommended due to crevices formed between them. Static

electricity, which is produced due to friction of floor with shoes or wheels or moving

equipment, is major problem. A mosaic floor with the least possible joints and with brass

or copper stripes six inches apart both ways carries away static electricity.

In general hospitals, the tendency is to have all major operating rooms as nearly identical

as possible(except in specialty hospitals where provision is made in some of them for

special procedures) so the scheduling of various kinds of surgery is possible. Operating

rooms must have minimum clear area of 33.44 sq.metres (360sq.ft) = 5.48*6.10 meters

(18*20 ft) excluding fixed cabinets and built in shelves. Many surgeons, however,

recommend larger space- 6010 by 7.31 meters (20*24 ft) =44.60 sq. meters (480 sq. ft)

for major operating rooms and 7.31*7.62 meters (24*25 ft)= 55.70 sq.meters (600 sq. ft)

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We care… with care for special procedure rooms. Each operating room should have X- ray film illuminator

which should hold at least two films at a time, and an emergency communicating system

that can be activated without the use of hands for contact with the surgical suit control

station or frozen section laboratory.

An orthopedic surgery room should have, in addition, an enclosed storage space for

splints and tractions. If this storage is outside the operating room, it should be easily

accessible. If plaster of Paris is used for cast work, a plaster sink should be provided.

The rapidly advancing cardiac and neurosurgery units in specialty hospitals requires

extra large operating rooms as these type of surgeries need a larger team of surgeons,

nurses and technicians in addition to a great deal of extra equipment such as heart- lung

machine. They also need electronic devices like ECG.EEG etc for measuring bodily

functions. One way of accommodating such equipment is by providing an

instrumentation room adjacent to or between two extra large operating rooms with a floor

approximately 3 feet higher than the operating rooms. Glass panels permit vision into the

operating rooms. David porter, a renowned and experienced hospital architect of

America, recommended that major operating rooms be size 20ft * 24 ft= 480 sq.

ft(approx. 6.10 * 7.13 meters = 44.60 sq. meters) and special procedure rooms 24 ft* 30ft

=720 sq.ft (approx. 7.31 * 9.14 meters = 66.88 sq. meters). In the author’s opinion 600

square feet should be adequate.

A more scientific way of estimating/ calculating the required number of operating rooms

is by dividing the estimated number of procedures per year by the number of procedures

that can be performed in one operating room in a year. It has been that an average

primary and secondary hospitals(of approx. 400 beds), with a balanced mix specialties’,

can perform 1000 to 1300 procedures per operating room in a tear(total of major, minor

and cystology procedures.). a major tertiary hospital, however, averages fewer (750-

1000) procedures per room because the procedures themselves are more complicated. In

anew and upcoming hospital, forecasting the number of surgeries is easier said than done.

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We care… with care However, in a running hospital that is to be upgraded, it can be calculated on basis of

previous years performance.

4.1.2 Physical Infrastructure – Operation Theatre

While planning and equipping each operating room, a series of questions need to be

answered. The relate to size, usage, lightening (surgical and gen. illumination),

intercommunication and signal systems, electronic equipment and monitoring system,

medical gas system(suction, oxygen, nitrous oxide and compressed air) and other service

lines, fixtures, safety precautions such as grounding for X-ray, TV camera, and against

static electricity, storage, supply cabinets, environmental control, etc.

FEATURES SPECIFICS REMARKS

LOCATION Visibility Fair

ENTRANCE Reception Not available

Waiting area Available but inadequate

Changing area Available

PRE-ANAESTHETICEXAMINATION ROOM

Availability Available

Suites Walls Furnished and under good repair

Floor Clean and light in colour

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Ceiling Furnished and under good repair

Piped gas system Available

Gas scavenging system Available

Pendants Available

Door width Adequate

INTERIORS Walls Clean and under good repair

Dado Not Available

Ceiling Clean and under good repair

Flooring Marble, light colour

Colour

FEATURES SPECIFICS REMARKS

Clean Available

Sterile Available

Disposal Available, but utilization process may increase the risk of infection control,Segregation and storage area and practices do not follow the standard practices

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DOORS Clear width Adequate

Self closure Available, wherever necessary

LIGHTING Natural Inadequate

Artificial Adequate

DIMENSION FOR POST OPERATIVE WARD

Inter bed distance Adequate

Foot end to foot end Adequate

Bed to wall Adequate

Head end width Adequate

Area Adequate

SIGNAGE Fire dept. norm exit signs Available

Fire dept. norm exit maps with current location

Not Available

Cloth towels AvailablePaper towels Not Available

Disinfectant liquid/gel Not Available

NOISEWASTE MANAGEMENT, HYGIENE & CLEANLINESS

Exterior noise penetration LowEchogenecity Low

Coloured bin Available(waste segregation is not compiled by staff)

Coloured bags Available

Sharp cutters Available

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Use of designated spaces for waste disposal

Available

FIRE SAFETY Fire alarm system Available

Fire sprinklers Available

Fire extinguishers- availability

Available

Fire extinguishers- serviceability

Expiry date 2008

Fire hose Available(no one is trained, keys not readily available for the use)

Partition Available

Fire door width Adequate

Fire door colour Not marked

ZONING Available / Not Available Not Available

SECURITY Electronic surveillance Not Available

Manual surveillance Available

POWER BACK UP Gen. set AvailableUPS Available

Emergency lights Available

4.2 Protocols for operation theatre settings

4.2.1 VISITOR’S PROTOCOL FOR OT SETTING

Visitors entry for patients in Post operative area is restricted to one

Children below 12 years are not allowed inside the OT complex.

Visitors suffering from contagious disease (cough and cold etc) are not allowed to

enter.

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Only OT chappals / slipper are allowed. Chappals or shoes are allowed only with

shoe covers.

Visitors are not allowed to bring materials such as food, flowers and other

materials, which can be a potential source of infections.

4.2.2 PROTOCOL FOR PERSONNEL

All personnel’s including housekeeping staff will wear clean OT attire while

entering OT.

No personnel are allowed to move outside the complex with clean OT attire and

come back except in emergency situation.

Surgeons for surgeries of 4 hours or more will use double gloves.

Doctors, nurses and technical staff use proper hand wash techniques before

handling any patient to prevent cross infection.

4.2.3 OTHER PROTOCOLS

All cleaning and disinfection procedures are completed at least 1 hour before the

schedule of surgery in OT.

4.3 Preparation of surgical procedure

There should be a documented list of surgical procedure in the hospital

Surgical patients are first assessed by the surgeons and a provisional diagnosis is

made prior to surgery which is documented in the case sheet.

Provisional diagnosis is to be made in both emergency or routine surgery.

An informed consent is obtained by the surgeon prior to the procedure and details

are written in the consent which is understandable by the patient/ attendant in

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their language. Consent should also contain type of anaesthesia to be used during

the procedure.

Patient identification procedure is used to identify the patient. Two levels-

- wrist band with complete information.

- Case file with complete information.

To prevent wrong site surgery in case of bilateral similar organs. Mark the site

before procedure and it is confirmed from the file & the patient also if

unconscious.

From the file provisional diagnosis is confirmed before proceeding for the surgery

to avoid the error of wrong surgery.

A brief operative notes are written about the procedure performed , post operative

diagnosis and the status of the patient before shifting.

They should be countersigned by the chief Surgeon.

Post operative plan of care is documented All the post operative patients shall be

screened for SSI rates.

4.4 Policy for invasive/surgical procedures

Purpose:

To promote patient safety by providing guidelines for verification of correct site, correct

procedure, and correct patient for invasive/surgical procedure(s). This policy applies to

all invasive/surgical procedures including bedside invasive procedures performed at the

facility. This policy does not apply to venipuncture, peripheral IV placement, and

insertion of Nasogastric tube or insertion of a Foley catheter.

Scope:

All the patients undergoing invasive / surgical procedure

Responsibility:

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We care… with care All the clinical & non clinical staff involved in invasive / surgery patients

Policy:

Scheduling

1. The verification process for correct site procedure/surgery begins with scheduling.

2. The following information is required when scheduling an invasive/surgical

procedure:

a. The correct spelling of the patient's full name;

b. Medical Record number (Date of birth is used when a medical record

number is unavailable)

c. Procedure to be performed

3. Scheduled procedures that involve anatomical sites that have laterality, the

word(s) right, left, or bilateral will be written out fully on the procedure/operating

room schedule and all relevant documentation (e.g., consents).

4. Any discrepancies in data should be clarified with the physician.

Pre-procedure/Preoperative Verification

If the patient is a minor, incompetent or sedated; has a language barrier; or is a

trauma/emergency victim, accurate communication may be impeded. In such

cases, the patients' family, health care proxy agent, interpreter, or legal guardian)

should complete the identifiers and verify site mark as per Hospital Informed

Consent Policy.

The patient responses will be verified with hospital ID, posted schedule,

consent(s), radiographic films, site mark (if applicable), and information in the

medical record including history and physical.

In an emergency situation, consent for treatment is implied, allowing treatment to

proceed without obtaining written patient consent. Emergency situation is

defined as: a medical condition manifesting itself by acute symptoms of sufficient

severity (including severe pain, psychiatric disturbances and/or symptoms of

substance abuse) such that the absence of immediate medical attention could

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reasonably be expected to result in placing the health of the individual in serious

jeopardy, serious impairment of bodily functions, or serious dysfunction of a

bodily organ.

SITE MARK— Preferably, completed before patient enters procedure/operating room a

site mark is required for all patients having an invasive/surgical procedure that involves:

Procedures for Site Marking:

a. Pens used for site marking shall be single patient use

b. Prior to marking the site(s), the physician performing the procedure/surgery

verifies the patient's identify, consent(s), medical record data including history

and physical, and radiographs (as applicable) to confirm accuracy. .

c. A site mark will be made at or adjacent to the incision site, and must be

visible after the patient is prepped and draped.

d. Adhesive markers must only be used as an adjunct to the site marking.

e. The physician performing the procedure will definitely mark the procedure

site prior to induction of anaesthesia, using an indelible, hypoallergenic, latex-

free, skin marker. The marking shall be clear and unambiguous. It is

unacceptable to mark with an "X" or use the word "No". It is recommended that

SSSS be used to mark the procedure site(s).

f. A sterile indelible marker may be placed on the prep tray. In the event the site

mark is removed during the surgical/procedure prep, the qualified RN in the

presence of the physician performing the procedure.

g. Patient Refusal Procedures for Site Marking - If a patient refuses to have the

site marked, the patient's physician will review with the patient the rationale for

site marking.

Special Site Marking Requirements:

Multiple sides or sites - If the procedure involves multiple sites/ sides during the same

operation, each side and site must be marked.

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We care… with care Spine Surgery-Preoperatively, the skin is marked in the general spinal region; and

Laparoscopic surgery - The surgical site will be marked for laparoscopic cases that

involve operating on organs that have laterality. The marking must be done near the

proposed site or near the proposed incision/insertion site and will indicate the correct

side. The mark must be visible after draping.

Dental Surgery -Teeth do not need to be marked. The skin mark will not be placed on an

open wound or lesion.

Emergency Procedure - Site marking may be waived in critical emergencies at the

discretion of the operating physician.

Procedure for Managing Discrepancies

A discrepancy at any point must stop the case from proceeding until resolved.

All team members and patient (if possible) must agree on the resolution(s) to the

identified discrepancy.

Removal of the Site Mark - At the end of the case, staff should attempt to remove the site

mark in the event that the patient will be having subsequent surgical/invasive procedures

4.5 Administration of anaesthesia

SCOPE

All patients who need to have anaesthesia.

STEPS

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All patients for anaesthesia have a pre-anaesthesia assessment by a qualified

anaesthetist. After the PAC, the anaesthetist writes the patient is fit for surgery or

not.

Type of anaesthesia is planned which will be given

Informed consent for administration of anaesthesia is taken.

An immediate preoperative reevaluation is done.

During anaesthesia monitoring is done of

regular and periodic recording of heart rate.

cardiac rhythm

respiratory rate.

blood pressure

O2 Saturation

airway Security

potency & level of anaesthesia.

Patients post anaesthesia status is monitored & documented.

Patient is transferred from the post operative area as per criteria for transfer from

recovery area.

If the patients’ condition is unstable and he/ she requires ICU care the same shall

be monitored there.

A qualified individual applies defined criteria to transfer the patient from the

recovery area.

All adverse anaesthesia events are recorded monitored for the purpose of taking

corrective and preventive actions.

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Chapter 5 | Operation Theatre

Utilization

5.1 Overview

Operating Room utilization is a measure of the use of an operating room that is properly

staffed with people needed to successfully deliver a surgical procedure to a patient.

It is obvious that optimum utilization of operating rooms is possible if they are not

reserved rigidly for use by a particular department or surgeon as a rule. The operating

rooms should further be similar in design and character to make it easy for all surgeons to

use them without a new set of conditions. In some of the hospitals where a few operating

rooms are allotted to Neurology, Urology, ENT, etc and others room to General Surgery,

the use coefficient of the operating rooms of latter category was low as compared to that

of rooms shared by more departments. Reason for demand of separate OT suits for

different specialties’ should be thoroughly debated. There will always be a conflict of

interest between the administrative and specialists point of view.

Nevertheless, most surgeons and administrators agree that one operating room should be

earmarked for endoscopic surgery and a separate room for emergency surgery of accident

cases both potentially septic.

5.2 Existing theories

According to the existing theories on OT utilization

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The classic definition of OR utilization is the sum of the time it takes to perform

each surgical procedure (including preparation of the patient in the OR, anesthesia

induction, and emergence) plus the total turnover time, divided by the time

available. As an example, if the average "patient in to patient out" time for a

herniorrhaphy is 45 min and the average turnover time is 15 min, then 10

herniorrhaphy cases can be performed in a 10-h period in that OR, for an OR

utilization of 100%. With this definition, if cases extend beyond the scheduled end

of the day, the time used after the scheduled end of the day is counted as

utilization, even though the hospital may be paying overtime to provide the

staffing.

Strum et al. (1) defined the concepts "overutilization" and "underutilization."

Underutilization is defined as time during the scheduled hours of operation that is

not used, and overutilization is defined as the time used by scheduled cases past

the end of the scheduled time. With these concepts we can estimate the economic

efficiency of an OR suite

The standard definition produces the actual utilization—the time that is actually

used. Because it is necessary to know the actual case times to perform the

calculation, utilization can never be known in advance. In this analysis, we also

refer to the scheduled utilization, that is, the predicted utilization obtained when

cases are scheduled.

OR utilization is defined by Donham and colleagues as the quotient of hours of

OR time actually used during elective resource hours and the total number of

elective resource hours available for use3

5.3 Definition

5.3.1 O.T./OR utilization

It is defined as Anaesthetic plus operating time as a percentage of total actual theatre time.

34

http://www.anesthesia-analgesia.org/cgi/content/full/96/4/1114#R1-121868

We care… with care O.T. utilization is sum total of Anaesthesia induction time, Positioning time , Procedure

time and Reversal of Anaesthesia time as a percentage of total actual theatre time.

5.4 Methods of O.T./OR utilization

O.T. utilization can be calculated on the basis of various parameters. These are

1. Total O.T. utilization Time2. Raw utilization 3. Adjusted utilization

Total O.T. Utilization Time is sum total of Anaesthesia induction time,

Positioning time, Procedure time and Reversal of Anaesthesia Time.

Total O.T. utilization for anaesthesia is sum total of Anaesthesia induction time and Reversal of Anaesthesia Time.

Total O.T. utilization for cleaning the O.T. is sum total of time from patient out of room to room clean-up finished and next case taken.

Raw utilization is the total minutes of elective cases performed within OR time

divided by the minutes of allocated block time.

Raw Utilization = total minutes of cases performed ÷ total minutes of OR time

allocated

Raw Utilization = Total O.T. utilization in Percentage (Routine Cases)

Adjusted utilization uses the total minutes of elective cases performed within

OR block time, including "credit" for the turnover times necessary to set up and

clean up ORs.

Adjusted Utilization is sum total of Pre Op waiting in OT , Anaesthesia induction

time , Positioning time ,Procedure time, Reversal of Anaesthesia Time ,Shifting

to recovery Room, OT clean time and Post Op waiting in OT (last three come

under credit time)

Adjusted Utilization

= [total minutes of cases + "credit time"] ÷ total minutes of OR

time allocated

35


Total working Time of MOTC is equivalent to Number of routine O.T.s

multiplied by per day working hours of O.T. multiplied by Total no. of working

days.

Total O.T. required time is sum total of Pre Op waiting in OT, Anaesthesia

induction time, Delay after induction, Positioning time, Delay after position

ready, Procedure time ,Reversal of Anaesthesia time, Post Op waiting in OT,

Shifting to recovery room and OT clean time.

Procedure Start time is the time the patient’s Anaesthetic commences if having

a general anaesthetic or the time the patient enters the operating room if having a

local anaesthetic. Start time is the time when patient wheeling in of Ist case.

Procedure Finish time is the time the patient leaves the operating room (or the

time the patient enters recovery, as the nearest equivalent). Case End time is the

time when patient wheeling out of last case.

Factors affecting utilization rates include: the accuracy of estimated case times,

cancellation rate, number of add-ons available to fill gaps, whether longest cases

go first, the time of day as utilization typically is highest in the morning and

lowest in the evening, and other constraints (ie, surgeon can only use room 12, or

start at 11am).

5.5 Aims and Objectives:

The study had two objectives:

1. To examine the utilization of operation theatre in the Main Operation Theatre

Complex of JGH in relation to work load.

36


2. To identify the bottle neck, if any, in proper and efficient utilization of

Operation Theatre time and based on that, suggest remedial measures for

improving the Operation Theatre Utilization.

The fundamental aim of this study was to support an assessment the efficiency

and quality of care.

5.6 Methods

This audit was done prospectively over a period of 1 month in the MOTC(major O.T.

complex), Jaipur Golden Hospital, New Delhi. Operation theatre utilization was studied

with respect to the starting and closing of the procedure, interval between surgical

procedures, cancellation of surgical procedures and reasons thereof.

5.6.1 Points kept in mind while analyzing theatre utilization, ask:

Is the flow of patients managed effectively with minimum delays between cases?

Delays may be due to a variety of reasons, such as poor management, delays for

equipment, poor communication between theatres and wards.

Do theatre lists consistently start late and/or finish early? Late starts may be

caused by pre-operative visiting of the patient by the anaesthetist and surgeon.

Are sufficient cases booked to use 100% of the capacity of the major constraint?

If theatres are the main constraint, lists should be booked to use 100% capacity.

Is case mix planned to take account of constraints and availability of essential

resources e.g. C –arm, microscope?

Are too many cases booked, or is the case mix inappropriate to fit into the

allocated theatre time?

37


Are emergency cases added to elective lists that do not have the spare capacity for

these cases?

Is there sufficient capacity to meet demand?

Where theatres are not the constraint, how can resources be used in other ways,

e.g. using spare capacity on inpatient lists for day cases?

Could slots for specialized emergencies be available on appropriate elective lists

to improve efficiency?

Factors affecting utilization rates include: the accuracy of estimated case times,

cancellation rate, number of add-ons available to fill gaps, whether longest cases

go first, the time of day as utilization typically is highest in the morning and

lowest in the evening, and other constraints (ie, surgeon can only use room 12, or

start at 11am).

5.6.2 Flow Process of Activities of Operation Theatre

Study conducted in two phases was used to address the study objectives. A biphasic

approach was used in the study. In the first phase, the records of Main Operation Theatre

(MOTC) and records relating to MOTC in Medical Records Department and were

perused. In second phase, observation regarding Operation Theatre Time Utilization

Study

5.6.2. a Phase I

In the first phase, the Medical Records Department and records of Main Operation

Theatre were perused so as to obtain an overview of the workload of the Main O.T. and

also the seasonal variations/fluctuations if any. The commonest problem of MOT staff,

their timing and workload was studied. In this study 18 months (January 2008-June 2009)

Medical Records and records of Main Operation Theatre were methodically studied.

5.6.2.b Phase II (Operation Theatre Utilization Study)

38

We care… with care A time and motion study of 150 operations was carried out in Phase II. The actual time

patients spent in various activities while in the Operating Theatres were measured such as

Operation time(previously decided), Patient available(floor in), Patient in room(Theater

in), Anaesthesia Start/Anaesthesia induction, Anaesthesia Ready , Position

Start/Surgical preparation, Position Ready/Surgical preparation Ready, Procedure Start

time(Operation start) , Procedure Finish time(Operation End), Patient Out of

Room(Theatre out), Arrival in recovery Room, Anaesthesia Discharge Time/Ready-for-

discharge from O.T.(Anaesthesia Discharge), OT Room Clean up Time and Next

Surgery start time(previous given). In all, 17 stages were identified starting from the time

the patient was entered in MOTC to the time the patient left the MOTC/RR. The

incidence of and reasons for case cancellation/delay were also recorded. As well as

questionnaire for different categories of staff were devised. In last phase, see the

utilization and to make recommendations if any.

39


Chapter 6 | Data Analysis Phase

– I

6.1 Overview

For this study 18 months (January 2008-June 2009) Medical Records and Records of

Main Operation Theatre were methodically studied. Analysis of the data collected from

the Medical Records Department and records of Main Operation Theatre were perused so

as to obtain an overview of the workload of the Main O.T. and also the seasonal

variations/fluctuations were studied.

The MOTC consists of 5 operation rooms of which OT 5 is for emergency cases , OT 1

for septic cases,OT 2 for ortho cases, OT 3 for eye cases OT 4 for plastic cases generally.

40

We care… with care The scheduled elective theatre timings are 8a.m. to 4p.m. Each O.T. works 6 days a week

throughout the year except on public holidays(10 days).There were total of 15

technician,16 Staff Nurse and 2 Nursing Aid . There were total of 5 technician,5 Staff

Nurse and 1 Nursing Aid in the morning shift . There were total of 5 technician, 2 Staff

Nurse and 2 Nursing Aid in the evening shift. There were total of 1 technician, 2 Staff

Nurse and 2 Nursing Aid in the night shift.

6.2 Objectives

To identify workload of the Main O.T. and also the seasonal

variations/fluctuations if any.

To distinguish between different type of operations and identify the respective

departments.

To know about MOTC staff, their timing and workload.

To understand the process for scheduling of the OT procedures.

To study the different phases involved in MOTC from "patient in to patient out"

6.3 Data analysis

In this phase, the records of Main Operation Theatre (MOTC) and records relating to

MOTC in Medical Records Department and were perused. The data thus collected was

used to analyze & calculate departmental utilization/work load.(Table I)

41


6.3.1 Average cases per day (Dept. wise)

6.3.2 Operated cases (Dept. wise)

(JANUARY 2009- JUNE 2009) (Table 1)

6.3.3 Comparative Study of Six Monthly Operated cases (Dept. wise)

42


6.3.4 Conversion Of Admissions into Surgeries

43


6.4 RESULTS

6.4.1 Phase I

The operation theatre was functional for 303 days during the last year (2008), and

13 cases were operated per day. This year till 30TH June the operation theatre was

functional for 181 days, 2300 cases were operated (2009) i.e.13 cases per day.

Percentage of operations done by different departments from 1st January to 30th

June 2009 were GYNEA (23.5%) ORTHO (17%) GEN.SUG. (23%) PLASTIC

(13%) ENT (6%) EYE (4%) URO (3%) NEPHRO (3%) NEURO (3%) PAED

(1%) ANAE (1%) MED (1%) DENTAL (0%). Percentage of operations done

by different departments from 16th May to 15th June 2009 (project time) was

approximately same.

Operations Scheduling

Schedule for the day's work is made by surgeon's themselves, it is very common

occurrence that the operations listed are either cancelled or postponed due to

variety of reasons.

Emergency cases are managed by anaesthetist unit with the help of OT chairman.

There were Division of work between, technician, Staff Nurse and Nursing Aid.

But the number of staff was less in the evening hours.

44


Chapter 7 | Data Analysis Phase – II

7.1 Overview

Data analysis in the second phase, observation study by the analyst was done in the

MOTC was done. (Operation Theatre Time Utilization Study). 150 cases were

observed. A questionnaire was provided to the Operation Theatre staff for analyzing

the reasons for delay in OT functioning.

45


7.2 Objectives

Observed time utilized for different procedure in MOTC from "patient in to

patient out".

Analyzing the reasons for delay OT functioning with the help of

questionnaire.

7.3 Data Analysis

7.3.1 CALCULATION OF O.T. UTILISATION

Total no. of O.T.’s in MOTC =5 (4 for routine cases, 1 for emergency cases)

Total no. of routine cases operated in MOTC = 277

Total no. of emergency cases operated in MOTC =120

Total no. of routine cases operated in O.T. V = 8

Total no. of emergency cases operated in O.T. V = 19

Total no. of emergency cases operated on Sunday = 17

Requirement of OT for Emergency case (Avg. minimum time) =105 min

Requirement of OT for routine case (Avg. minimum time) =124 min

Average O.T. utilization for emergency case = 74 min

Average O.T. utilization for routine case = 91 min (Table 4)

Working hour of O.T. = 8 hr.

No. of Sundays in a month =5

No. of working days in a month=26

Total no of working minutes of MOTC in a month

46

We care… with care = [(No. of routine O.T.s x Per day working hours of O.T. x Total no. of working

days in a month x 60) + (Total no. of routine cases operated in O.T. V x Requirement of

OT for routine case (Avg. minimum time) ) + (Total no. of emergency cases operated in

O.T. V x Requirement of OT for Emergency case (Avg. minimum time))+ (Total no. of

emergency cases operated on Sunday x Requirement of OT for Emergency case (Avg.

minimum time))]

Total no of working minutes of MOTC in a month

= [(4 x 8 x 26 x 60) + (8x 124 + 19 x 105) + (17 x 105)]

= [(49920) + (992 ) + (1995) + (1785) ] = 54692 min.

Total no of working minutes of MOTC in a month = 54692 min.

Requirement of OT for Emergency cases

= Total no. of emergency cases operated in MOTC x Requirement of OT for

Emergency case (Avg. minimum time)

=120 x 105 = 12600 min.

Requirement of OT for Emergency cases = 12600 min.

Requirement of OT for Routine cases

= Total no. of routine cases operated in MOTC x Requirement of OT for routine

case (Avg. minimum time)

= 277x 124 = 34348 min

Requirement of OT for Routine cases = 34348 min

Total Requirement of OT for a month cases

47


= Requirement of OT for Routine cases + Requirement of OT for Emergency

cases

=34348+12600 = 46948min.

Total Requirement of OT for a month cases = 46948 min.

Non usage of O.T.

= Total no of working minutes of MOTC Total Requirement of OT for a month

= 54692 – 46948 = 7744 min.

Non usage of O.T. = 7744 min.

TOTAL O.T. UTILIZATION

TOTAL O.T. UTILIZATION

= (Total no. of emergency cases operated in MOTC x Average O.T. utilization

for emergency case) + (Total no. of routine cases operated in MOTC x Average

O.T. utilization for routine case)

= (120 x 74) + (277 x 91) = 8880 +25207 = 34087 min.

Total O.T. utilization = 34087 min.

Total O.T. utilization in Percentage = Total O.T. utilization in min. x 100 Total no of working min.

= 34087 x 100 54692 = 62.32 % Total O.T. utilization in Percentage = 62.32 %

Total Requirement of OT in Percentage = Total Requirement of OT x 100 Total no of working min.

48


= 46948 x 100 54692

= 85.84%

Total Requirement of OT in Percentage = 85.84%

Non usage of O.T. in Percentage = Non usage of O.T. x 100 Total no of working min.

= 7744 x 100 = 14.16% 54692 Non usage of O.T. In Percentage= 14.16%

Total Requirement of O.T. in Percentage (Emg. Cases) = Requirement of OT for Emergency cases x 100

Total no of working min.

= 12600 x 100 = 23% 54692

Total Requirement of O.T. in Percentage (Emg. Cases) = 23%

Total O.T. utilization in Percentage (EMG. Cases)

= Total O.T. utilization in min (EMG. Cases) x 100 Total no of working min.

= 8880 x 100 = 16% 54692

Total O.T. utilization in Percentage (EMG. Cases) = 16%

Total Requirement of O.T. in Percentage (Routine Cases)

= Requirement of OT for Emergency cases x 100 Total no of working min.

49

We care… with care = 34348 x 100 = 62.8% 54692

Total Requirement of O.T. in Percentage (Routine Cases) = 62.8%

Total O.T. utilization in Percentage(Routine Cases)

= Total O.T. utilization in min. (Routine Cases) x 100 Total no of working min. = 25207 x 100 = 46% 54692

Total O.T. utilization in Percentage(Routine Cases) = 46%

Total Percentage time used for cleaning the O.T.s

Total time used for cleaning the.O.T.s =

Total time used for cleaning the routine O.T.s + Total time used for cleaning

the Emg. O.T.s

Total time used for cleaning the routine O.T.s =

Avg. routine OT clean time x Total no. of routine cases operated in MOTC

14 x 277=3878 min.

Total time used for cleaning the Emg. O.T.s =

Avg. EMG. OT clean time x Total no. of emg.cases operated in MOTC

15 x 120=1800 min.

Total Percentage time used for cleaning the O.T.s =

Total time used for cleaning the routine O.T.s + Total time used for cleaning the

Emg. O.T.s

= (3878 +1800) =5678 min.

Total Percentage time used for cleaning the O.T.s =5678 min.

50


Total Percentage time used for cleaning the O.T.s

= Total time used for cleaning the.O.T.s x 100 Total no of working min.

= 5678 x 100 = 10.38% 54692

TOTAL O.T. UTILIZATION FOR ANAESTHESIA IN PERCENTAGE

Total time used for anaesthesia =Total Anaesthesia induction time + Total Reversal of

Anaesthesia Time

= Anaesthesia induction time of routine cases x Total no. of routine cases operated in

MOTC + Reversal of Anaesthesia Time of routine cases x Total no. of routine cases

operated in MOTC+ Anaesthesia induction time of emg. cases x Total no. of emg. cases

operated in MOTC+ Reversal of Anaesthesia Time of emg. cases x Total no. of emg.

cases operated in MOTC

= 9 x 277+5 x 277+9 x120 +4 x 120 = 5438 min.

= Total time used for anaesthesia x 100 = 5438 x 100 Total no of working min. 54692 min.

=10%

Total O.T. utilization for anaesthesia in percentage=10%

ADJUSTED UTILIZATION

Adjusted Utilization = [total minutes of elective cases performed + "credit time"] ÷ total

minutes of OR time allocated

Adjusted Utilization ={Pre Op waiting in OT(min.) + Anaesthesia induction time(min.) +

Positioning time (min.) + Procedure time(min.) + Reversal of Anaesthesia Time (min.)

51

We care… with care + Shifting to recovery Room(min.) + OT clean time (min.) + Post Op waiting in OT

(last three come under credit time)} x Total no. of routine cases operated in MOTC

÷ Total no of working min.

= (9+8+69+5+5+4+14) x 277. X 100 54692 = 31578 x 100 = 57.73% 54692

Total Percentage of Adjusted Utilization were = 57.73%

Total Requirement of OT in Percentage = 85.84%

Total Requirement of O.T. in Percentage (Routine Cases) = 62.8%

Total Requirement of O.T. in Percentage (Emg. Cases) =23%

Total O.T. utilization in Percentage = 62.32 %

Total O.T. utilization in Percentage (Routine Cases) = 46%

Total O.T. utilization in Percentage (Emg. Cases) = 16%

Total O.T. utilization for anaesthesia in Percentage =10%

Total Percentage time used for cleaning the O.T.s = 10.38%

Non usage of O.T. In Percentage= 14.16%

Total Percentage of Adjusted Utilization were = 57.73%

7.4 RESULT

7.4.1 Phase II

52

We care… with care A time-motion study established the baseline times for various stages of operating theatre

activity. Standard benchmark time deviations were also derived. Operating theatre time

utilization overall, and by individual departments was also calculated. While the actual

surgery remained the most time consuming part of the process 54%, other activities took

up considerable time some almost as much as 46% of the operating time. Anaesthetic

activities accounted for 10% of the time the operating table was actually occupied. The

overall theatre time utilization was 62.32% for elective operations and 23% for

emergency operations. The Total Requirement of OT was 85.84%. The Non usage of

O.T. was 14.16%.The Total Requirement of O.T. (Routine Cases) was 62.8%. The Total

Requirement of O.T. (Emg. Cases) was 23%. The Total O.T. utilization (Routine Cases)

was 46%. The Total O.T. utilization (Emg. Cases) was 16%. The Total O.T. utilization

for anaecthesia was 10% .The Total time used for cleaning the O.T.s was 10.38%. The

Total Adjusted Utilization was 57.73%. There were no significant differences in waiting

times found between departments.

Total number of cancelled operations.=28

Number of operations cancelled by patients. =16 (57%)

Number of operations cancelled by the hospital for non-clinical reasons=10(36%)

Number of operations cancelled by the hospital for clinical reasons.=2(7%)

Number of ‘last minute’ cancelled operations =1(4%)

Elective theatre performance

Total inpatient anaesthetic plus operating time as 46% of total actual theatre time.

Emergency theatre performance

Total emergency anaesthetic plus operating time as 16% of total actual theatre time.

Emergency operations out of hours

Number of operations in between 4pm and 8am (next day). =50(41.66%)

Total anaesthetic plus operating time in between 4pm and 8am (next day). =6.76%

The operation theatre was functional for 303 days during the year, and cases were

operated 13 cases per day (2008). This year till 30TH June the operation theatre was

53

We care… with care functional for 181 days, 2300 cases were operated (2009) i.e.13 cases per day. The total

operating time utilized was 62.32%. The Total Requirement of OT was 85.84%.The Non

usage of O.T. Was 14.16% .Total Percentage time used for cleaning the O.T.s were

10.38%. Total Requirement of O.T. in Percentage (EMG. Cases) were 23%.Total O.T.

utilization in Percentage (EMG. Cases) were 16%.Total Requirement of O.T. in

Percentage (Routine Cases) were 62.8%. Total O.T. utilization in Percentage (Routine

Cases) was 46%. Total O.T. utilization for anaesthesia in Percentage were10%.Total

Adjusted Utilization were57.73%.

The major reasons for cancellation of a total of 28 cases were patient not admit (57 %),

surgeon cancelled due to some problem (39%), due to patient expire (4 %),and

preoperative lack of fitness(0%) . Among all the lists, 6.66% started late, 17.33% cases

finished well after the scheduled closing time, 13.33% of lists finished well before the

scheduled closing time, 22% surgeon reached late for planned case, 2.66% cases were

postponed, 5.33% cases were preponded, under-scheduling, interruption due to

emergency surgeries, surgeon want to operate cases back to back (6.66%), previous case

finished late (17.33%) were main factors that account for inefficient use of operating

facilities. The correction of these factors would increase the available operating time by

nearly 20%.

Analysis of the data collected from various O.T.'s. with regard to O.T. utilization

revealed that by and large all the O.T.s are adequately utilized as per the current working

schedule. The overall O.T. Utilization % of M.O.T. Complex was 62.32%. The average

O.T. case start time was 8.25 a.m., case end time was 3.25 p.m. and theatre closure time

was 4 p.m. In the prospective phase of the study, a questionnaire was designed to assess

individual opinion of O.T. users like Surgeons, Anaesthetists and Nursing staff regarding

resource, utilization pattern and workload.

54

We care… with care Room Clean up time - time from patient out of room to room clean-up finished and next

case taken. The clean up time ranged from 13 minutes as in O.T.-3 (ENT/EYE cases).

O.T.-2 for lengthy cases (Ortho) department so had clean up time 15 minutes, O.T.-1 for

HCV and HbsAg positive and complicated cases and General Surgery were usually taken

up. O.T.-4 used by Plastic department so had clean up time 16 minutes. The average

clean up time of all OTs 15 minutes which is within the acceptable range Thus, it can be

seen that not much time is wasted for cleaning the operation theatres.

Avg. OT clean time=15 min

Avg. OT I clean time=14 min

Avg. OT II clean time=15 min

Avg. OT III clean time=13 min

Avg. OT IV clean time=16 min

Avg. OT V clean time=14 min

55


OBSERVED AVERAGE TIME FOR DIFFERENT PROCEDURES DONE BY DIFFERENT DEPARTMENTS

Opinion regarding delay in start of OT and the reasons for the delay

In the prospective phase of the study, a questionnaire was designed to assess individual

opinion of O.T. users like Surgeons, Anaethetists and Nursing staff regarding resource,

utilization pattern and workload. Analysis of this data gave the following findings:

56


OT functioning Surgeon

(n=20)

Anaesthetist

(n=20)

Nurses/Technician

(n=20)

OT start on time in the morning 90% 100% 75%

all the procedures start on the scheduled time

(60 %) 70% 55%

delay due to the staff nurse 10% 10% 5%

delay due to other staff 0% 0% 20%

delay due to non part preparation 0% 0% 25%

delay in shifting of the patient in to the OT

25% 35% 50%

delay in shifting of previous patient out of the OT

15% 10% 45%

delay due to lack of sterile supplies 15% 5% 15%

delay in the readiness of other equipment

25% 15% 35%

delay due to late arrival of the implant(like DHS, Hip/Knee replacement)

5% 20% 30%

delay due to break down of critical equipment(C-ARM)

5% 5% 15%

delay by the Anaesthetist 20% 10% 20%

delay due to late PAC by the Anaesthetist

50% 5% 15%

delay due to Surgeon 80% 90% 80%

delay due to physician clearance (like Cardiac/Neuro)

35% 30% 45%

delay due to posting of an emergency case

65% 80% 85%

delay due to an ongoing case in 75% 50% 75%

57

We care… with care OTdelay due to non deposition of payment by the attendants

70% 75% 70%

delay due to lack of approval(in case of TPA’s)

70% 70% 50%

delay due to lack of consent by the patient/attendant

60% 60% 45%

delay due to late reporting of the patient to the hospital

90% 80% 75%

delay due to critical condition of the patient (like serious patient)

45% 30% 60%

Although none of the Anaesthetist felts that there is delay in start of Operation Theatre,

yet 10% of the consultants and 25% of the nurses felt that O.T.'s are starting late and

commonest reason stated were delay due to Surgeon, delay due to late reporting of the

patient to the hospital, delay due to non deposition of payment by the attendants, delay

due to an ongoing case in OT,delay due to posting of an emergency case.

Non availability of staff nurses/other staff or sterile supplies / part preparation/ break

down of critical equipment(C-ARM) was an infrequent reason for delay in starting O.T.

Majority of consultants felt that if additional inputs are given in minor O.T.'s (in the

OPDs), main O.T. time can be utilized better. However, it would necessitate up gradation

of the minor O.T.'s with respect to infrastructure, staffing and equipments. It was thought

that an interval of 10-15 minutes was an appropriate interval in between two surgeries.

58


Chapter 8 | Results

8.1 Overview

Lacqua and Evans prospectively reviewed 1,068 elective cases that resulted in 184 (17%)

cancellations6.They concluded that cancellation of cases could be decreased by improved

preoperative patient evaluation, improved communication between the physician and the

patient and a modified schedule design.

Brewer evaluated the utilization of operation theatres in an academic 2,000 bed hospital

and found a cancellation rate of 8%7. K. Vinukondaiah, et al in their study found, a total

of 310 (14.9%) cases cancelled during one year period lack of operating time was the

single most important factor for cancellations of cases. This was mainly because surgeons

took longer than the estimated duration of surgery8.

8.2 Cancellations

Inefficient scheduling of operation theatre time often results in delay or cancellation of

surgical procedures. This increases the cost of patient care in the hospital and also results

in monetary loss to the patient as he/she is away from work. Cancellation due to Surgeon

non clinical motive also results in psychological trauma to patients, as they have to

undergo the preoperative mental and clinical preparation again.

59

We care… with care 8.3 Late Start

Late starts and unutilized time between cases is an area where improvement is possible.

This is especially true of starting on time. Although none of the Anaesthetist felt that

there is delay in start of Operation Theatre, yet 10% of the consultants and 25% of the

nurses felt that O.T.'s are starting late and commonest reason stated were delay due to

Surgeon, delay due to late reporting of the patient to the hospital, delay due to non

deposition of payment by the attendants, delay due to an ongoing case in OT, delay due

to posting of an emergency case. none of the case was Delay due to readiness of the

equipment.

Attention to this problem would increase the utilization of available operating time. Non

availability of staff nurse/other staff or sterile supplies was an infrequent reason for delay

in starting OT. Undue delay between cases did not account for any wastage of operating

time. Healthcare Benchmarks reported average turnover times of 21 minutes for main

OR's and It was19 min in JGH.

8.4 Operating Time

The operating time at this hospital vis-a-vis other centers in India and abroad is restricted.

Also, the number of public holidays decreases the period of availability of the operating

room. The causes cited for low OT utilization were varied. Surgeons felt that non

availability of anesthetic services was major reason, whereas anesthetist felt that wrong

or over scheduling of cases by the surgeons was the prime cause. However, all the OT

users agreed that non availability of nursing orderlies for shifting the patients and

sweepers for cleaning of OR after completion of the surgery was most annoying cause for

delay between cases and subsequent delay in completion of list.

In a report by Narian et al, the total operating time found to be 82.5% of the total

available time10 According to the National Audit Office study, only 50% to 60% of the

total time was utilized in performing surgery11. Our figure are better than this average.

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We care… with care All the respondents agreed that no O.T. manual or guidelines exist in any department or

the hospital and felt strongly the need for such a manual. Most of the respondents were

not satisfied with the O.T.discipline in our hospital, which may be due to lack of defined

guidelines. The major causes cited for delay in OT was ,Surgeons wanted to Operate

cases back to back wrong or over scheduling of cases by surgeons was the prime cause

This study demonstrates that 7 per cent of elective operations are cancelled, all are within

24 hours of surgery. The cancellation rates could be significantly improved by directing

resources to address patient-related causes and hospital non-clinical causes.

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Chapter 9 |

Recommendations & Key Messages

9.1 Overview

Optimum utilization of the OT time has always been a priority area for Hospital

Administrator’s. Baker had opined that accurate records, weekly analysis of recorded

data, establishment of operating room rules and regulations and strict adherence to and

enforcement of approved policies and procedures are essential ingredients for an efficient

operating of an operating room. Thus it is clear that study of operating room records can

provide means of assessment of the degree of utilization of operation theatres.

A prospective survey was conducted over a 1-month period to identify cancelled day case

and in-patient elective operations were major causes for Low theatre utilization. To

ensuring that the reasons for cancellation and the timing in relation to surgery were

identified. The reasons for cancellation were grouped into patient-related reasons,

hospital clinical reasons and hospital non-clinical reasons. Cancelled operations are a

major drain on health resources: 8 per cent of scheduled elective operations are cancelled

nationally, within 24 hours of surgery. The aim of this study was to define the extent of

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We care… with care this problem in the Organization, and suggest strategies to reduce the cancellation rate

and increase efficiency.

9.2 Recommendations

In total, 397 operations were undertaken during the research period and 28 (7 per cent)

cancellations were recorded, of which 16 were day cases and 12 in-patients of

cancellations were within 24 hours of surgery; 57 per cent of cancellations were due to

patient-related reasons; 39 per cent were cancelled for non-clinical reasons; and 4 per

cent for clinical reasons. The common reasons for cancellation were due to patient not

admitted ( 57 per cent).

9.2.1 Policy on Anaesthesia

As a policy, general anaesthesia was also administered on the main operating table.

Considering that induction of and recovery from anaesthesia are as important as the

surgery itself, the time utilized for this should not be considered as wasted.

However, this time could have been gained for performing operations if the

induction/recovery from anaesthesia had been performed in the anaesthesia room. This

should be weighed against the need for two qualified anesthetists to alternate between

cases and proper monitoring equipment being available in the anaesthesia

induction/recovery room.

9.2.2 Low theatre utilization rates should be investigated to

determine why optimum usage is not being achieved.

Further investigation may identify that:

Cancellation due to non admission of patient (day cases)

There are large delays between cases.

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Lists procedures consistently start late.

9.2.3 Cancellations

Inefficient scheduling of operation theatre time often results in delay or

cancellation of surgical procedures.

The single most important cause for the cancellation was found to be "patient not

admit" .For this problem protocol should be made that Payment should be

deposited by the attendants before booking a O.T.And protocol should be made

that patient should admit on time(day cases) as advised by Consultant

Another way to increase efficiency is to have variable-length shift to handle he

non standardized routine of a typical OR suite. "Longest cases first" results in the

highest utilization rate, lowest amount of overtime, and largest number of delayed

cases being transferred to another room to be done in the most timely fashion.

Protocol should be made for operations cancelled by the Surgeon for non-clinical

reasons and wrong or over scheduling of cases by surgeons.

9.2.4 Late Start

Late starts and unutilized time between cases is an area where improvement is

possible. This is especially true of starting on time. Attention to this problem

would increase the utilization of available operating time.

The OT should adopt flexible scheduling of OT session between departments.

The IT system should be used for OT scheduling.

Surgeons, Anaesthetists and Nurses should work together to set OT lists, with a

view to maximize the utilization of theatre

Up gradation of the minor O.T.'s with respect to infrastructure, staffing and

equipments. Payment should be deposited by the attendants before booking an

O.T.

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9.2.5 Operating Time

The elective OT sessions should be reallocated on the basis on the waiting times and number of urgent cases.

Up gradation of the minor O.T.'s with respect to infrastructure, staffing and equipments.

Number staff be in adequate number during evening shift.

If too many cases booked, then by using case mix achieve maximum O.T.

utilisation

9.3 The suggestions for improving O.T. Utilization are as follows:-

Recommendations First case should reach O.T. in time from the ward, to allow the O.T. to be started

on time. The anaesthesia and other equipments must be made ready by the assisting staff so

that the O.T. starts on time.

A proper work culture needs to be established in the OTs. Accountability should be fixed for any delay.

Need for availability of "Operating Room Manual" for ready referral was strongly felt. This manual should clearly mention the job description and responsibility of all the operating room personnel.

Discipline should be inculcated by organizing periodic in service training and workshops.

Performing all the minor procedures in minor O.T.'s attached to the OPD.

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We care… with care 9.4 Key Messages

There is marked difference in utilization of operation theatres between the

perception of surgical consultants and reality.

The common reasons for cancellation were due to patient not admitted

Improper utilization of time between two surgeries and late starting of OTs are

important areas needing attention of Hospital Administrator's to improve

utilization.

9.5 Conclusion

Thus it can be summarized that even with certain existing lacunae and constraints; the OT

utilization of MOTC is optimum as per the literature. However, in spite of optimum

utilization MOTC, there was dissatisfaction and discontentment among the doctor’s.

Even with the existing bed strength and number of OTs, one way of solving this problem

is increasing the number of C- arms and state of art operation theatres.

Restructuring the reorganization of O.T. personnel should be done so that adequate

numbers of staff are available in each shift. It also needs to be ensured that this step

would not in any way downgrade the academic standards. This system can be tried on

experimental basis for a short period to test its feasibility. National Health Services

Management Board has pointed out that full utilization of operation theaters would

involve the recruitment of considerable numbers of staff, the provision of substantial

numbers of extra beds as well as a substantial amount of extra funding12.

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BIBLIOGRAPHY

1. OR Manager May 1996, 12:9-10.

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6. Kaiser share ambulatory surgery benchmarks. Health Care Benchmarks

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7. Lacqua MJ, Evans JT. Cancelled elective surgery - An evaluation. Am Surg

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time by a surgical team. Surgical Audit 1998.13:3-118-121.

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11. National Audit Office. Use of operating theatres in the National Health Service.

London: HMSO, 1987 (Report 143).

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Ot Utilization Project 642

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