Patient Transportation Delays and Effects on Operation Theatres' Efficiency: A Study for Problem Analysis and Remedial Measures.

BACKGROUND AND AIMS: Delay in patients' transportation to the operating theater (OT) is a globally recognized phenomenon, leading to delay in the subsequent processes (anesthesia induction, surgery, and patient turnover). This observational study was conducted to evaluate the common reasons for delay in transporting patients to the neurosurgery OT complex and its consequent effects and how the elimination of these reasons by application of feasible measures can influence the after effects. SETTINGS AND
DESIGN: This was an anesthesiologist-based audit of transportation process of patients to the OT complex of a tertiary care teaching hospital to identify the impediments and effects of delay, suggest and implement remedial measures, and assess the outcomes.
MATERIALS AND METHODS: The movement process of successive 551 patients was studied. In the evaluation phase, common reasons for transportation delays were identified. The incidences of consequent effects such as second-case cancellations and overrunning of OTs beyond scheduled hours were noted. In the implementation phase, corrective measures were instituted and the incidences of delays and the consequent effects were again noted. STATISTICAL ANALYSIS: Statistical analysis was performed using SPSS 17.0.
RESULTS: In the evaluation phase (303 patients), common reasons for delays included porter-associated delays (15), unavailable lifts (7), and pediatric patients (6). The incidences of case cancellation (20) and overrunning of OTs (9) were high. In the implementation phase, after remedial measures were enforced, the incidences of delays due to porter, lifts, and pediatric patients dropped to 1, 6, and 0, respectively. Simultaneously, a decrease in second-case cancellation (2) and overrunning of OTs (7) also reduced. As an additional finding, a significant reduction in OT turnover times was also observed (16.31 ± 9.29 min vs. 11.70 ± 5.78 min).
CONCLUSIONS: Analysis of common reasons of patient transportation delays and removal of these impediments can markedly improve the efficiency in OT functioning. Copyright:

INTRODUCTION

Efficient running of operation theaters (OTs) has traditionally been the area of interest of health-care managers as increased efficiency promotes more operations to be performed at the same cost.[1] In efficient theater, time utilization is a global problem and had been previously addressed in studies conducted in North America and Australia.[2345678] Prior studies have reported an incidence of above 90% delays in beginning of the first case attributed to interruptions during patient transportation, anesthesia induction, surgical preparation and procedures or during the turnover (when the previous case is being shifted out and the next one is being wheeled in).[910] These unwanted delays are detrimental as they can cause wastage of health-care resources. Moreover, they cause serious physical and psychological harm to the patients in the form of anxiety, frustration, and inconvenience to relatives and needless prolongation of the mandatory fasting periods.

Among the various reasons attributed for causing unwanted delays in OTs, transportation delay has been recognized as an important reason.[91112] These delays are ascribed to causes such as the distance of the wards from the OTs, in coordination between OT nurses and ward nurses, and incomplete handovers among the nurses.

The neurosurgery OT complex of our tertiary care superspecialty institute has four functional OTs where, on an average, two cases per table per day are conducted. We had been observing that the arrivals of the patients from the wards or intensive care unit (ICU) (either the first one of the day or the second one) were getting delayed on a regular basis. This resulted in inappropriate delays in beginning of the cases, resulting in the OTs running beyond scheduled hours or cancellation of second cases.

Therefore, we planned this study to identify impediments causing these transportation delays, evaluate its effects, suggest measures to remove them, and, thereafter, implement the feasible ones and assess the improvement if any which resulted from adoption of these measures.

MATERIALS AND METHODS

This prospective observational study employed a qualitative approach using in-depth analysis of patient transportation system, related factors, and their effects on operation room time utilization. The participants of this study were hospital staffs involved in patient care and transportation and OT staffs. These participants were purposively selected based on their roles affecting neurosurgical OT utilization which was being studied to participate. Because this study dealt with the quality assurance of existing systems and processes and did not involve any interventions on human subjects, ethical approval was exempted; however, informed consent was obtained from the patients.

For this prospective observational study, the inclusion criteria were the patients undergoing neurosurgical procedures within the routine surgical hours on weekdays between May 15, 2017, and November 15, 2017. The study was conducted in two phases. In the initial 3 months (evaluation phase), the existing processes were observed. In the next 3 months (implementation phase), the remedial measures were imposed. Patients operated at night or on weekends and holidays and emergency cases (beyond routine hours or within routine hours) were excluded from the study.

Evaluation period

In the first 3 months of the study, we observed the transportation processes and recorded the data diligently. Based on this, we listed the common reasons for transportation delays.

Implementation period

After ascertaining the reasons for the unwanted delays, we zeroed down to implementation of the feasible corrective measures. Regular compliance was ensured by periodically instructing the porters and nursing staff to adhere to the prescribed measures. We again reevaluated the patient transportation system after assuring implementation of the corrective measure in subsequent 3 months of the study.

Data were collected by an independent observer not involved in patient management who noted the following sequence of the patient transportation:

Summoning the patient telephonically from the ward/ICU to the OT and their arrival to OT, i.e. the shifting time (ST)

Tv: Time interval between the arrival of the patient to the OT and completion of identity and consent verification

Ta: Time interval between completion of verification and beginning of anesthesia induction.

Tc: Time interval between shifting of the first case and anesthesia induction of the second case (turnover time), i.e. the time when cleaning of the OT and equipment were taking place and the OT remained vacant.

If a patient arrived later than 35 min during transportation, this case was labeled as a delayed case; the porter, attendants of the relatives, and the nursing staffs were enquired about the reasons. Furthermore, the outcome of the delay in the form of next-case cancellation or overrunning of the routine cases beyond scheduled time was noted in each of the phases.

Statistical analysis

Statistical analysis was performed using SPSS 17.0 (Statistical analysis was performed using Statistical Program for Social Science, IBM Corporation (SPSS 17.0)). Demographic data such as age of patients and genders of the patients were compared using independent Student's t-test. Other variables such as different time intervals were expressed in mean ± standard deviation and were compared using independent Student's t-test. Other nonparametric variables such as reasons for delay and effects of delays were compared using Pearson's Chi-square test. P ≤ 0.05 was considered statistically significant.

RESULTS

In the period between May 15, 2017, and November 15, 2017, a total of 551 cases were conducted during the routine hours in the neurosurgical OT of our tertiary care center, of which 303 cases were observed in the evaluation phase and 268 cases were observed in the implementation phase. The demographic data including age, gender, and originating stations were similar in both the groups [Table 1].

Table 1

Demographic distributions in both the phases

Parameters	Groups		P
	Evaluation phase (n=303)	Implementation phase (n=268)
Age (years)	35.90±17.77	34.85±18.49	0.371
Gender (male vs. female)	183 versus 120	154 versus 114	0.266
Originating stations
Ward	281	248	0.783
ICU	5	7	0.783
Pediatric ward	17	13	0.783

Data are presented as mean±SD or number. Independent t-test was used to compare the means between the groups and Chi-square test for the proportions. ICU=Intensive care unit

The ST (i.e., summoning the patient telephonically from the ward/ICU to the OT and their arrival to OT) in the evaluation phase was 28.059 ± 9.820 min. In the evaluation phase, the ST increased to 31.436 ± 8.296 min (P = 0.001) (95% confidence interval [CI]: 1.8722–4.8818) [Table 2]. Verification times (Tv, i.e. the time interval between the arrival of the patient to the OT and completion of identity and consent verification by OT nurses) were similar in both the groups (P = 0.383) (95% CI: −0.3900–0.1500) [Table 2]. Time interval between completion of verification and anesthetic induction of the patients (Ta) in the two phases were found to be similar (P = 0.586) (95% CI: 0.7539–1.333) [Table 2].

Table 2

Shifting times, verification times, time interval between completion of verification and anesthetic induction of the patients, and incidences of delay in arrival

Parameters	Groups		P
	Evaluation phase (n=303)	Implementation phase (n=268)
ST (min)	28.059±9.820	31.436±8.296*	<0.001
Tv (min)	4.26±1.73	4.14±1.53	0.383
Ta (min)	6.43±5.26	6.72±7.37	0.586
Incidences of delay in arrival (%)	34 (11.22)	13 (4.85)*	0.006

Data are presented as mean±SD or number. Independent t-test was used to compare the means between the groups and Chi-square test for the proportions. *Significant difference (P<0.05). SD=Standard deviation, ST=Shifting times, Tv=Verification times, Ta=Time interval between patient verification and anaesthesia induction

The incidence of patients reaching late than their scheduled time was decreased from 11.22% (34/303) during evaluation phase to 4.85% (13/268) during implementation phase (P = 0.006) (95% CI: 1.8785–10.8850] [Table 2]. The main reasons for delays during transportation which could be analyzed during the evaluation phase were recorded, and after implementation of the remedial measures, the reasons were compared [Graph 1]. A significant reduction in the incidences of porter-related delays in the implementation phase was observed (P < 0.001) (95% CI: 2.0047–7.6509). Delays due to transportation lifts not being vacant could not be reduced despite our efforts (P < 0.955) (95% CI: −2.7508–2.7403). Sensitization of the pediatric ward nurses led to delays from pediatric wards dropping to zero in the implementation phase (P = 0.829) (95% CI: −2.0676–2.3548). There was no appreciable effect on factors due to communication errors between OT and ward nursing staffs (P = 0.020) (95% CI: 0.2078–4.2518) and the miscellaneous causes of delays in the implementation phase (P = 0.557) (95% CI: −1.4065–2.6332).

Graph 1

Main reasons for delay in the evaluation phase compared with the same in the implementation phase. (1) Absence of porter during changeover time, (2) transportation lift not free, (3) patient from pediatric ward, (4) miscommunication regarding patients, (5) miscellaneous

There were 97 instances when a first case was followed by a second case in OT list during evaluation phase, whereas 80 similar instances in the implementation phase were observed which was statistically insignificant (P = 0.589) (95% CI: −5.5069–9.6088). This turnover time (Tc) when the OT remained unoccupied was significantly lower in the implementation phase compared to evaluation phase (P < 0.001) (95% CI: −5.9015–−3.3185) [Table 3]. We also analyzed the two main effects of delay, namely routine cases extending beyond scheduled hours and cancellation of the second cases. The incidences of delays beyond scheduled hours in the implementation phase reduced (P < 0.001) (95% CI: 2.8537–9.2675), but no effect on the cancellation of second cases was seen (P = 0.795) (95% CI: −2.6633–3.2651) [Graph 2].

Table 3

Number of instances where the second case was involved and time interval when the operation theater remained unoccupied (Tc)

Parameters	Groups		P
	Evaluation phase (n=303)	Implementation phase (n=268)
Number of instances where second case was involved (%)	97 (32.0)	80 (29.9)	0.589
Tc (min)	16.31±9.29	11.70±5.78	<0.001*

Data are presented as number or mean±SD. Independent t-test was used to compare the means between the groups and Chi-square test for the proportions. *Significant difference (P<0.05). SD=Standard deviation, Tc=Turnover time

Graph 2

Comparison of effects of delays in the evaluation phase versus implementation phase. *P=.001

DISCUSSION

Anesthesiologists are a part of the hospital team who ensure proper functioning of surgical services and thus have to closely adhere to various quality assurance parameters, analyze causes of delays and misuse, and ensure compliance. In our study, we attempted to identify the common reasons of delays in the patient transportation to the OTs in the evaluation phase and their adverse consequences. In the implementation phase, feasible corrective measures were undertaken (increasing the summon times, sensitization of porters and nurses) which decreased these delays and reduced OT turnover times.

In the four OTs of the neurosurgery complex, on an average, one or two elective cases are conducted per table per day before commencement of the cases (either first or second case of the list); the OT nursing staff, approximately 20 min before the beginning of the procedures telephonically informs the ward/ICU nurses to shift the patients. The patients (either the first or second case) were transported from their respective wards or ICU to the OT complex on trolleys/wheelchairs manned by dedicated porters. After their arrival, the OT nursing staff checked the patient's identity, consent forms, and radiological images. Following the completion of the first case till the wheeling in of the second patient, a mandatory pause for cleaning and readying the OT (preparing drugs, cleaning monitoring aids, etc.) for the next case was undertaken.

During the transportation of the patients (either the first or second one) whenever the patient's arrival to the OT had got delayed beyond the expected time (approximately 35 min), we observed certain consequences. If it was the first procedure of the day, it started later (i.e., after 9:00 a.m.) and got completed at such a point of time when the second case had to be canceled. For the second cases of the day, transportation delays excessively prolonged the turnover times (time interval between reversal of the first patient and induction of the second patient) and overshooting beyond routine OT hours (beyond 6:00 p.m.). In both the scenarios, the OTs remained vacant wasting precious time and resources.

The neurosurgery ward being located on the eighth floor required the service of transport lifts (elevators) for patients’ movement. Although four large capacity lifts are present, they were often overcrowded, especially during the morning hours when there is high-volume patient movement for diagnostic/therapeutic procedures and rush of patient's relatives congesting the system. Shifting the wards proximately or installing newer lifts was not feasible.

Pediatric patients resist change of places in unfamiliar hospital settings. They are also prone to tantrums, especially while shaving of parts or being changed into strange OT clothes. This contributed to transportation delays from pediatric wards.

Regarding porters, it was observed that especially during shift changeovers (between 7 a.m–8 a.m. and 1 p.m.–2 p.m.), a reluctance was observed among porters of the previous shifts in finishing their assigned transportation and a tendency to pass the responsibility to the porters from the next shift. This shift changeover time usually coincided with the time when patients were being shifted to the OT.

Miscommunication between the OT nurses and ward nurses in the form of wrong patient, wrong ward, mispronounced names, and patient with similar sounding names became the source of confusion and thus inadvertent delays.

ICU patients also got delayed as shifting patients with infusion and invasive lines (often on ventilator) was cumbersome than ambulatory patients and required supervision of trained staff. Furthermore, no dedicated porter team was stationed at the ICU; therefore, transfer was dependent on ICU staff and cleaners who were often busy attending other patients.

Thus, the above-mentioned problems were identified as the prime reasons for delays, and the following measures were instituted in the implementation phase:

The center of porter services was approached and instructed to ensure that patient transportation should be completed expeditiously as it saves valuable time and resources. The porters were instructed to ensure completion of their assigned task and not to leave stations before the porters of next shift took over

OT nursing staff and the ward/ICU nursing staff were apprised of the problem. Patient summon time was endeavored to be increased from 20 to 40 min to overcome contingencies such as lift unavailability and patient not being ready. Improved coordination and communication regarding patient's names, registration numbers, designated wards, and relieving ICU cleaners from other details for shifting patients were stressed. The nursing staff of pediatric wards were requested to ensure that shaving and changing clothes should be completed before they are summoned from the OT (night before/early morning).

Porter problem (major cause of delay in our setting) was due to tendency of postponing the assigned jobs for people of the next shift and leaving stations before arrival of relievers creating backlogs as majority of the patient transfers overlapped with changeover times. These results were consistent with the findings of Hopkins et al. who concluded that one-third (32%) of the delays result from problems of portering.[13]

Oluwadiya et al. highlighted the problem of delays in transferring patients to OTs in approximately one third of the cases.[12] They blamed the layout of the hospital which necessitated 15 min for patient transfer. Similarly, in our setting, physical distance was an important factor as transporting patients involved moving them from the eighth floor using transport lifts requiring about 20 min. Similarly, location of the pediatric ward was such that there was no transport lift and patient movement involved moving patients on trolley requiring similar time. This simple act of approaching the central porter service and apprising them of the necessity and advantages of quick and efficient patient transfers brought a dramatic decrease in this problem.

Lack of adequate number of patient transportation lifts was also a key problem. Installation of additional lifts was time- and resource-consuming process. Hence, we attempted to increase our summon time to 40 min instead of 20 min which was the routine practice, for both the first and second cases of the day. This created a buffer of additional time to iron out any impediments which might appear during the shifting process (e.g. patient not being ready, congested lift, and wrong patient). This ensured that patients reached the OT complex well in time before beginning of their scheduled procedures. Previous studies have similarly suggested calling for the next patient and to be kept in the waiting area if estimated time for completion of the previous surgery is 30–60 min to compensate for delayed transfers.[1415]

Additional buffer of time created by early summoning expedited the transfer of pediatric patients too (often the first cases of lists). Their transfer was also hastened when preparatory measures (part shaving, changing into OT clothes) were done earlier than conventionally practiced. Radical improvements were observed following implementation of these measures.

Miscommunication among the nursing staff of OT and wards/ICU has been previously stressed.[14] Proper education and sensitization about error-free communication was imparted during the latter part of the evaluation phase. However, observers in the study did not interrupt them during the study to avoid introducing any bias. In spite of our measures, negligible changes were observed in communication errors. This may be improved if such training and education regarding error-free communication is continued over a considerably long period observed in a larger cohort of patients. Deputing one nurse exclusively for ensuring summoning, identification, and tracking of patients’ movement can reduce communication-related deficiencies further. Documentation of communication and reporting of errors will enforce further accountability. These errors should be addressed in subsequent education programs. Prioritization of patient transfer was also emphasized to mitigate the miscellaneous causes of delays of ICU patients.

Patient transfer reflects the working architecture of hospital administration demonstrating the intricate interrelationship of task force, infrastructure, communication, policies, working culture, and the training and education levels of the health-care workers and its continuous upgradation. Transportation imperfections alone cannot be blamed for the adverse effects such as case cancellations and overshooting beyond scheduled hours as multiple steps are involved (anesthesia induction, positioning, sterile draping, and surgery). However, once the first link of the chain gets disrupted, the entire sequence of events gets affected.

Saha et al. calculated that the median waiting time for the anesthesiologist was 7 min.[15] In the evaluation phase, the mean duration of time when the OT remained vacant between the first and second case (Tc) was 16.31 ± 9.29 min. Assuming approximately 10 min was needed for cleaning the OT, equipment, machine recalibration, and drug preparation by dedicated cleaners and technicians, the anesthesiologists in our OTs also had to wait for approximately similar period before they could begin their procedures. Our measures reduced this period significantly to 11.70 ± 5.78 min. Consequently, subtracting 10 min for the cleaning period, the OT remained vacant/unoccupied for just about 1 min. Although it was not strictly an objective of the study, improving the transportation system flaws expedited patient turnover. In majority of the facilities, OT turnover represents 10%–20% of the total case times.[16] A review of four academic institutions calculated average turnover times between 34 and 66 min.[17] Other authors reported turnover times ranging from 10 to 25 min.[1819] Probably, in our case, prior arrival of the patient geared the OT staff to quicken their activities. Faster turnaround times also motivated the other health-care providers to speed up their share of jobs, ultimately resulting in finishing cases on time. However, as a cautionary note, attempts to decrease OT turnover times excessively can raise concerns regarding cleanliness, sterility, machine calibration, and drug errors.

In our study, we attempted to increase the summon time of the patient to the OT approximately 40 min which earlier was about 20 min. Although we could not achieve it to that level (31.436 ± 8.296 min), it brought the required changes by reducing incidences of overrunning of the OTs and cancellation of the second cases significantly. Inability to achieve a significant difference in the ST between the evaluation and implementation phases may be attributed to the small sample size (571) and small period of the study (6 months). However, certain drawbacks of increasing summon time also exist. In the absence of a dedicated and staffed holding area, patients will remain unmonitored. The presence of relatives decreases anxiety, especially in children, which can be affected when the patients are summoned too early.

OT delays not only cost financially but also affect the quality, safety, and efficiency of health-care services. It also generates frustration and conflict between colleagues,[2021] affecting the morale of all involved. In addition to the measures suggested in our study, time being mentioned in the case sheet at each level of handover authenticated with signatures mentioning reasons for delay at each level would further strengthen the system of reducing delays.

Any study of operating room processes, including this one, is subjected to inherent methodological limitations. Our study too was not devoid of such limitations. First, it was conducted in a single OT complex of a single hospital. However, we strongly believe that similar strategy would be effective in other settings too where patient turnover is more than 1–2 cases per day. Higher sample sizes and longer periods of study would have ensured more validity of results and higher levels of statistical significances. Finally, the Hawthorne effect (the fact that any process is observed and documented can entail marked differences in performance) might have occurred, especially during the implementation phase, thereby increasing the efficiency and speed of all involved, leading to overall speeding up of the system.

CONCLUSIONS

Being the first step for patients undergoing surgical procedures, it is imperative that patient transportation to the OT is completed efficiently and promptly. Appreciation of the common reasons for delays in patient transportation to OTs and their consequent effects can improve OT time utilization and can result in dramatic decrease in transportation delays, their after effects, and turnover times.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.