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 Chawla Quality Assurance Manager Jaipur Golden Hospital Rohini, New Delhi

1


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, Chawla, Quality Quality Assurance Assurance Manager, without whose support and guidance, 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 Hospit Hospital, al, New Delhi. Delhi. for their their support support and consta constant nt encoura encouragem gement ent through throughout out 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, Coordi Coordinat nator, or, Placem Placement ent cell, cell, for provid providing ing me an opport opportuni unity ty to associ associate ate with 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)

2


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, Chawla, Quality Quality Assurance Assurance Manager, without whose support and guidance, 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 Hospit Hospital, al, New Delhi. Delhi. for their their support support and consta constant nt encoura encouragem gement ent through throughout out 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, Coordi Coordinat nator, or, Placem Placement ent cell, cell, for provid providing ing me an opport opportuni unity ty to associ associate ate with 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)

2


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 ob jective 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 op eration 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.

3


Contents

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

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

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

2.

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

Project Outline...............................................................17 4


2.1

Problem Definition,17

2.2

Objectives, 17

3.

2.2.1

Secondary Research,17

2.2.2

Primary Research,18

2.2.3

Key Issues and Recommendations,18

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

3.1

Research Methodology,19 3.1.1 3.1.2

4

Research Objectives,19 Response rate

3.1.3

Sample Size, 20

3.1.4

Method of Research,

3.1.5

Data Analysis,

Operation Theatre ……………………………………

4.1

Introduction 4.1.1

Operating Rooms 5


4.1.2

4.2

Physical Infrastructure – Operation Theatre

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

5.

Administration of anaesthesia

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:

6


5.6.2

6.

Flow Process of Activities of Operation Theatre 5.6.2. a

Phase I

5.6.2.b

Phase II (Operation Theatre Utilization Study)

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

6.1

Overview

6.2

Objectives

6.3

Data analysis

6.4

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)

RESULTS 6.4.1 Phase I

7.

Data Analysis Phase – II……………………………….

7.1

Overview

7.2

Objectives

7.3

Data Analysis 7


7.3.1 7.4

RESULT 7.4.1

8.

Calculation of O.T. utilisation

Phase II

Results……………………………………..

8.1

Overview

8.2

Cancellations

8.3

Late Start

8.4

Operating Time

9.

Recommendations & Key Messages……………

9.1

9.3

Overview 9.2.1

Low theatre utilization

9.2.2

Cancellations

9.2.3

Late Start

9.2.4

Operating Time

The suggestions for improving O.T. Utilization 8


9.4

Key Messages

9.5

Conclusion

Bibliography………………………………. APPENDIX

9


Chapter 1 1.1

Introduction

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 acc reditation.

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

10


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 qua lity 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.

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:

11


-

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

-

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. 1.2

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 Psychiatry

Ultrasound / CT Scan K.T.U.

12


Diagnostics

Laboratory • • • • •

Clinical Pathology Microbiology Histopathology Biochemistry Cytology

Imaging Services • • • •

X-Ray CT Scan MRI Ultrasound

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) LDR (deluxe)

13

We care… with care •

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 modu lar 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.

•

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

14


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

patients. Special discounts can be availed under this scheme.

1.7 S. No.

WORK LOAD DETAILS (of the current quarter)

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

13.

Average monthly emergency surgeries

4.03

4.78

5.00

Diagnostics

15


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)

In the first phase, the records of Main Operation Theatre (MOTC) and records relating to MOTC in Medical Records Department and were perused.

16


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 patientout"

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.

•

To identify reasons for cancellation of cases

17


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

18


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.

3.1.5

DATA ANALYSIS

19


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, 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 20


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 antistatic 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) 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.

21


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 (7501000) 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. 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 22


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.

23


FEATURES LOCATION

SPECIFICS Visibility

REMARKS Fair

ENTRANCE

Reception

Not available

Waiting area

Available but inadequate

Changing area

Available

PRE-ANAESTHETIC EXAMINATION ROOM

Availability

Available

Suites

Walls

Furnished and under good repair Clean and light in colour

Floor Ceiling

INTERIORS

Piped gas system

Furnished and under good repair Available

Gas scavenging system

Available

Pendants

Available

Door width

Adequate

Walls

Clean and under good repair

Dado

Not Available

Ceiling

Clean and under good repair

Flooring

Marble, light colour

Colour

24


FEATURES

DOORS

LIGHTING

DIMENSION FOR POST OPERATIVE WARD

SIGNAGE

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

Clear width

Adequate

Self closure Natural

Available, wherever necessary Inadequate

Artificial

Adequate

Inter bed distance

Adequate

Foot end to foot end

Adequate

Bed to wall

Adequate

Head end width

Adequate

Area

Adequate

Fire dept. norm exit signs

Available

Fire dept. norm exit maps with current location

Not Available

25


NOISE WASTE MANAGEMENT, HYGIENE & CLEANLINESS

Cloth towels Paper towels

Available Not Available

Disinfectant liquid/gel

Not Available

Exterior noise penetration Echogenecity

Low Low

Coloured bin

Available(waste segregation is not compiled by staff)

Coloured bags

Available

Sharp cutters

Available

Use of designated spaces for Available waste disposal FIRE SAFETY

Fire alarm system

Available

Fire sprinklers

Available

Fire extinguishersavailability Fire extinguishersserviceability Fire hose

Available Expiry date 2008

Partition

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

Fire door width

Adequate

Fire door colour

Not marked

ZONING

Available / Not Available

Not Available

SECURITY

Electronic surveillance

Not Available

Manual surveillance

Available

Gen. set UPS

Available Available

Emergency lights

Available

POWER BACK UP

26


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.

•

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 27


•

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 e mergency 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 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.

28


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:

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). 29


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 H ospital 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 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. 30


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, latexfree, 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. 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. 31


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 •

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. 32


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.

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 33


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 •

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 theeconomic 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 34


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. 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 Time 2. 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.

35


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

•

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.

36


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. 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.

37


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?

•

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 38


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)

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-fordischarge 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


40


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. 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

41


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.

6.3

•

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 patientout"

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)

6.3.1

Average cases per day (Dept. wise)

42


6.3.2

Operated cases (Dept. wise)

(JANUARY 2009- JUNE 2009)

6.3.3

(Table 1)

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

43


6.3.4

6.4

RESULTS

6.4.1 •

Conversion Of Admissions into Surgeries

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 30 TH 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. 44


•

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.

45


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.

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 46


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 = [( 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 47


= 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

= 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

48


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.

=

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.

=

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

•

Total Requirement of O.T. in Percentage (Emg. Cases) 49


=

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

=

= 23% 12600 x 100 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.

=

34348 x 54692

100

= 62.8%

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 54692

= 46%

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

50


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.

•

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 54692

100

= 10.38%

TOTAL O.T. UTILIZATION FOR ANAESTHESIA IN PERCENTAGE

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

51


= 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 = Total no of working min.

5438 x 100 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 (min.) + Shifting to recovery

time(min.) + Reversal of Anaesthesia Time

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. 54692 31578 x 100 54692

X 100

= 57.73%

Total Percentage of Adjusted Utilization were = 57.73%

52


7.4

•

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%

RESULT 7.4.1

Phase II

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) 53


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 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%.

54


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.

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.

55


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

•

OBSERVED AVERAGE TIME FOR DIFFERENT PROCEDURES DONE BY DIFFERENT DEPARTMENTS

56


•

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:

57


OT functioning

Surgeon

Anaesthetist

Nurses/Technician

(n=20) 90%

(n=20) 100%

(n=20) 75%

all all the the proc proced edur ures es star startt on the the (60 %) scheduled time delay due to the staff nurse 10%

70%

55%

10%

5%

delay due to other staff 0% delay due to non part preparation 0% delay in shifting of the patient in to 25% the OT

0% 0% 35%

20% 25% 50%

dela delay y in shi shiftin fting g of prev previious ous 15% patient out of the OT delay due to lack of sterile supplies 15%

10%

45%

5%

15%

dela delay y in the the read readin ines esss of othe other r 25% equipment dela delay y due due to late late arri arriva vall of the the 5% impl mplant ant(like like DHS, DHS, Hip/ Hip/Kn Knee ee replacement)

15%

35%

20%

30%

delay due to break down of critical 5% equipment(C-ARM) delay by the Anaesthetist 20%

5%

15%

10%

20%

dela delay y due due to lat late PAC PAC by the 50% Anaesthetist delay due to Surgeon 80%

5%

15%

90%

80%

delay delay due to physic physician ian cleara clearance nce 35% (like Cardiac/Neuro) delay due to posting of an 65% emergency case

30%

45%

80%

85%

delay due to an ongoing case in 75% OT dela delay y due due to non non depo deposi siti tion on of 70% payment by the attendants delay due to lack of approval(in 70%

50%

75%

75%

70%

70%

50%

OT start on time in the morning

58


case of TPA’s) delay due to lack of consent by the 60% patient/attendant delay due to late reporting of the 90% patient to the hospital delay due to critical condition of 45% the patient (like serious patient)

60%

45%

80%

75%

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

59


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 single most most import important ant factor factor for cancel cancellat lation ionss of cases. cases. This This was mainly mainly becaus becausee 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.

60


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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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 63


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 w asted. 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)

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There are large delays between cases.

•

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

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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.

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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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. 2. MaCaulay, HMC and Davies LL. Hospital planning and Administration. WHO 1966. 3. Donham RT, Mazzei WJ, Jones RL. Procedural times glossary. Am Anesthesiol 1996:23 (suppl):5. 4. Breslawski S and Hamilton D: Operating room scheduling. Choosing the best system, AORN J 53 (5): 1229-1237, 1991. 5. Committee on Plan Projects (COPP, 1964). 6. Kaiser share ambulatory surgery benchmarks. Health Care Benchmarks 1998;Jan:5-6. 7. Lacqua MJ, Evans JT. Cancelled elective surgery - An evaluation. Am Surg 1994;60:809-11. 8. K. Vinukkondaiah, N. Ananthakrishanan, et al. Audit of operation theatre utilization in gernal surgery NMJI 2000.13:3-118-121. 9. Dexter F, Macario A, Traub RD. Which Algorithm for scheduling Add-on Elective Cases maximizes Operating Room Utilization- Anesthesiology 1999 91(15): 1491-500. 10. Narain P, TackleyR, Lee M, Clyne CAC. A computer audit of the use of theatre time by a surgical team. Surgical Audit 1998.13:3-118-121. 11. National Audit Office. Use of operating theatres in the National Health Service. London: HMSO, 1987 (Report 143). 68

Ot Utilization Project 642

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