Every two or three years, someone, usually a hospital administrator, decides that delays in operating room turnover time need to be looked into. A committee of 20 or 30 stakeholders (love that term) is appointed and assigns someone the job of measuring the time between cases and identifying reasons for delays. In years when turnover time is not being studied, first case starting delays are on the agenda.
In my nearly 24 years as a surgical department chair, one or the other of these issues was investigated at least ten times. We were never able to conclusively determine the exact causes of delays or solutions to the problem, and we returned to business as usual.
An article in Anesthesiology News about a paper that looked at causes of operating room delays in over 15,500 cases at a single hospital got my attention.
The number one reason for delays was that the nurses did not have the operating room ready for the patient. Nursing also was responsible for the third most common cause “preop prep (IVs, meds, etc.).”
Surgeons were the reason for the second most common problem, “notes, consent, patient marking not complete.” A few more of the top 10 included surgeons running two rooms, surgeon unavailable, and my favorite, ” the last case ended early.” I’m not sure how a case ending early causes a delay in starting the next case. Usually, we are blamed for underestimating the length of time we need to do an operation.
Anesthesiologists were cited for only one of the ten most common reasons for delays — placement of an IV line or regional block.
Not surprisingly, the study was done by anesthesiologists using data they collected.
When I expressed skepticism about this on Twitter, I was accused of implying the research was fraudulent. Not so. Some of my best friends are anesthesiologists. In fact, two of my medical school roommates became anesthesiologists. Fraud is not the issue. It’s a matter of perspective.
For example, when the nurses investigate OR delays, the problem never seems to be nursing.
I’m not saying that surgeons don’t cause delays. A task force once found that one of my surgeons was late for his first case every time he operated because he had to take his kids to school.
Another surgeon would disappear between cases and was always late for his next one. No one knew where he went. Some thought he may have been calling his broker or perhaps having an affair.
Here’s what the anesthesiologist researchers may have overlooked.
In effort to avoid delays, I would often ask for an anesthesia consult on complicated inpatients booked for surgery a day or two later. On nearly every occasion, the anesthesiologist who saw the patient was not the one assigned to do the case. The consulting anesthesiologist never said a certain lab test was necessary, but in the holding room, the one who was going to put the patient to sleep said it was. A spirited discussion, phone calls, and a delay ensued.
Sometimes a day surgery patient who arrived 2 hours ahead of schedule wasn’t interviewed by anesthesia until the scheduled time of the case.
Then there was my patient whose operation was postponed for 6 hours because she had a piece of hard candy in her mouth when she got to OR. The anesthesiologist said it was the equivalent of having a full stomach.
Can delays be shortened by working together? A 2014 paper in the Journal of Surgical Research by a surgeon and four anesthesiologists found that “various events and organizational factors created an environment that was receptive to change.” The authors were able to decrease their general surgery OR turnaround times from 48.6 minutes to 44.8 minutes, a statistically significant (p < 0.0001) but hardly clinically important difference.
Let me hear your experiences with OR delays.
“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.
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