Preparatory Time–Related Hand Surgery Operating Room Inefficiency: A Systems Analysis

Abstract

Background: No study exists on preparatory time—from patient’s entrance into the operating room to skin incision—and its role in hand surgery operating room inefficiency. The purpose of this study was to investigate the length and variability of preparatory time and assess the relationship between several variables and preparatory time. Methods: Consecutive upper extremity cases performed for a period of 1 month by hand surgeons were reviewed at 3 surgical sites. Preparatory time was compared across locations. Cases at one location were further analyzed to assess the relationship between preparatory time and several variables. Both traditional statistical methods and Shewhart control charts, a quality control tool, were used for data analysis. Results: A total of 288 cases were performed. The mean preparatory times at the 3 sites were 25.1, 25.7, and 20.7 minutes, respectivley. Aggregated preparatory time averaged 24.4 (range 7-61) minutes, was 75% the length of the surgical time, and accounted for 34% of total operating room time. Control charts confirmed substantial variability at all locations, signifying a poorly defined process. At a single site, where 189 cases were performed by 14 different surgeons, there was no difference in preparatory time by case type, American Society of Anesthesiologists status, or case start time. Preparatory time varied by surgeon and anesthesia type. Conclusions: Preparatory time was found to be a source of inefficiency, independent of the surgical site. Control charts reinforced large variations, signifying a poorly designed process. Surgeon seemingly plays an important, albeit likely indirect, role. Efforts to improve operating room workflow should include preparatory time.

What delays your case start? Exploring operating room inefficiencies

“…Regarding the preparatory duration and variability, Milone et al's study discovered similar findings with Caggiano et al Specifically, they studied the preparation phase of hand-surgery cases, and they found that the mean preparatory time in 3 different surgical sites was 25.1 ± 8.1, 25.7 ± 9.4, and 20.7 ± 8.3 min, respectively [20]. The authors concluded that increased variability signifies a poorly designed process that has room for improvement in the workflow [8].…”

“…Milone et al [20] also identified that the cases with surgeons with more years of experience had lower preparatory duration which is likely due to the fact that their surgeons were present for a high percentage of the preparatory duration in the OR. However, this contrasts our experience where the surgeon was present mainly for the positioning of the patient at the end of the preparatory phase which is the reason we did not elect to use the surgeon experience as a confounder in the multivariable analysis.…”

Strategie per la corretta previsione dei tempi operatori allo scopo di aumentare l'efficienza in sala operatoria: uno studio osservazionale retrospettivo

“…I risultati ottenuti sono stati comparati con la letteratura e risulta evidente come il management dei tempi operatori sia un punto cardine nell'organizzazione del blocco operatorio. In relazione ai tempi pre operatori i dati analizzati non sono del tutto in linea con gli studi pubblicati, infatti al Langone Orthopedic Hospital di New York (USA) il tempo pre operatorio è risultato essere di 24,4 minuti [13] (per loro considerato inefficiente essendo il 34% del tempo totale in sala operatoria), il tempo però non variava in base alla tipologia di intervento ma a seconda del chirurgo o del tipo di anestesia. In relazione ai tempi post operatori invece i risultati si allineano con la letteratura, basti pensare ai 31,09 minuti [14] del tempo di turnover per interventi di Otorinolaringoiatria all'Hospidal Colorado (USA), ai 42,8 [15] minuti del tempo di turnover per interventi eseguiti al MetroHealth Medical Center di Cleveland in Ohio (USA) ridotti a 26,4 minuti dopo alcune modifiche apportate alla pianificazione del processo multidisciplinare, ai 41 minuti [16] di mediana del tempo di turnover per interventi eseguiti all'University Children's Hospital di Loma Linda California (USA) diminuiti a 32 minuti dopo la riprogrammazione delle sale operatorie (che dimostra come modificare i processi multidisciplinari può migliorare significativamente l'efficienza in un ospedale) o infine ai 53 minuti [17] del tempo di turnover per interventi eseguiti all'IRCCS Istituto Ortopedico Galeazzi di Milano nel 2020 durante la pandemia.…”

Supine Elbow Arthroscopy: A decade of results with a vertical humerus and a free forearm

“…However, there has been surprisingly little innovation in the elbow positioning marketplace in the last several decades. Surgical procedural inefficiency and variability in operative time for orthopaedic surgical procedures have been highlighted in the literature recently (DeCook and Statton 2022;Milone et al 2019). Early in my career, I performed elbow arthroscopy with patients in the lateral decubitus, prone, and even supine suspended positions.…”