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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
2. Project Outline...............................................................17
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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
4.1.1 Operating Rooms
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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.
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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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.
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:
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- 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 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)
LDR (deluxe)
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• 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.
• 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
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• 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
13. Average monthly emergency surgeries 4.03 4.78 5.00
Diagnostics
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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.
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• 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
2.2.3 KEY ISSUES & RECOMMENDATIONS
• To optimize the utilization of operation theatre in the hospital.
• To identify reasons for cancellation of cases
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• 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.
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Chapter 3 | Research Methodology
3.1 Research Methodology
3.1.1 RESEARCH OBJECTIVES
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• 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.
3.1.5 DATA ANALYSIS
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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
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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)
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.
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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.
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
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We care… with care 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.
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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
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
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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
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
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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
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
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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
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• 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
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.
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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).
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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
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.
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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.
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.
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• 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.
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• 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
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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 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
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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 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.
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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.
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• 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.
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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
We care… with care 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-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.
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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
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• 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)
6.3.1 Average cases per day (Dept. wise)
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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)
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6.3.4 Conversion Of Admissions into Surgeries
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.
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• 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.
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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
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
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• 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.
We care… with care 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
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= 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
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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.
= 7744 x 100 = 14.16% 54692 Non usage of O.T. In Percentage= 14.16%
• Total Requirement of O.T. in Percentage (Emg. Cases)
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= 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.
= 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%
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• 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 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
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We care… with care = 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.) + 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%
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• 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
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)
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We care… with care 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%.
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We care… with care 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.
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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
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• 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:
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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 OT
75% 50% 75%
delay due to non deposition of payment by the attendants
70% 75% 70%
delay due to lack of approval(in 70% 70% 50%
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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.
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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.
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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)
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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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We care… with care
• 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).
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12. National Centre for Health Statistics. Health, United States, 1999 with health and
aging chartbook (DHSS Publication No. PHS99-1232). Hyattsville, MD: National
Centre for Health Statistics, 1999.
13.Facilities planning and management by G D Kunders 10th edition 2008.258-262.
14.Principles of Hospital Administration & Planning by BM Saharkar 2nd edition
15.A study on utilization effectiveness of the operating theatres at Queen Mary
Hospital Leung MP Date April 1999 HSRC Report # 512018
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