Monday, 13 October 2014


The largest study of theatre cancellations was performed in 2006 at 123 VHA facilities with 9 surgical specialties. Of 329,784 cases, 12.4% were canceled, and investigators assigned cancellations to 1 of 6 broad categories of cancellation reasons (Table 3).

These 6 cancellation categories are similar to another study, which grouped cancellations into: (1) patient; (2) capacity constraints; (3) work-up; and (4) required specialized personnel unavailable. Unless a predetermined and accepted classification system is used prospectively, cancellation data obtained from administrative databases may not provide enough meaningful explanation to understand root causes.

The VHA study found that patient factors, including "no-show," were the most common reasons for cancellation of elective surgical cases, comprising 35% of all cancellations. Work-up issues or medical condition change (28%), facility issues (20%), surgeon issues (8%), anesthesia issues (1%), and miscellaneous issues (8%) were the next most common explanations for cancellations. Possible remedies for the problem of cancellations may differ for each facility, and must involve a determination of how many of the facility's cancellations were preventable (eg, resulted from an administrative error or a foreseeable circumstance).

When an operation is canceled, the associated cost is always discussed by theatre staff. This cost should be measured by the opportunity cost: What would the facility have done if it had known about the cancellation earlier? This is analogous to a restaurant trying to assess the cost of someone canceling a reservation; it depends on whether the restaurant would be able to fill the seat anyway. If the theatre suite can perform another case without too much idle time, then the cost is small. However, if the theatre suite can't fill that slot with another case, then the hospital incurs a larger cost because it must pay staff who don't have a case to do.

Table 3.

PACU admission delays. A term often used for postanesthesia care unit (PACU) admission delays is "theatre holds," which may be defined as the percentage of workdays with at least 1 delay of 10 minutes or longer in a PACU admission because the PACU is full. It is important to adjust PACU nurse staffing around the times of PACU admissions. The times of PACU admissions are usually more important in predicting staffing needs than other factors, such as discharge delays or prolonged patient stays related to nausea and vomiting. Algorithms exist that use the number of available nursing hours to find the staffing solution with the fewest number of understaffed days.

Profitability of cases. The contribution margin per hour of theatre time is computed as follows: The numerator is hospital revenue generated by a surgical case minus all the variable costs from the patient's hospitalization. The denominator is the length of time in hours that the patient is in the theatre. Variable costs, such as implants, vary directly with the volume of cases performed.

Theoretically, any case with a contribution margin greater than zero that can be done safely is, to a facility, financially worth doing. This is because fee-for-service hospitals have a positive contribution margin for almost all elective cases, mostly as a result of a large percentage of theatre costs being fixed. Contribution margin is, of course, insurance mix dependent. Thus, hospitals with poor contracts may score poorly here despite the theatre being highly efficient in other ways.

Turnover times. Cost reduction from reducing turnover times (because theatre workload is reduced) can only be achieved if theatre allocations and staffing are also reduced. Despite this, turnover time receives much attention from theatre managers because it is a key satisfier for surgeons. Theoretically, if a lot of short cases are scheduled, with many short turnover times, an additional case can be performed within the same staffed workday. However, this has been found to be difficult to achieve consistently in actual practice.

Sometimes the theatre suite reduces turnover times -- by providing more staff to clean the room, for example -- but new problems are exposed (not enough time for sterilizing instruments for the new case, no bed for the patient in PACU) that were previously "hidden" by long turnover times.

Prolonged turnovers (delays). A length of time between cases that is longer than a defined interval (eg, 1 hour) should be considered a delay, not a turnover. Prolonged turnover times peak in the middle of the workday because that is when most turnovers occur. Fewer than 10% of prolonged turnovers (delays) should last longer than 60 minutes in well-functioning theatre suites.

For example, imagine that a case scheduled for 3 hours finishes after 30 minutes because the patient has widespread metastases. The surgeon for the to-follow case is not available for 2 hours, because he is operating at another facility. That 2-hour delay should not contribute to calculations of turnover times.

Prediction bias. Prediction bias is the bias in case-duration estimates per 8 hours of theatre time. Prediction bias indicates whether the estimate of case times is consistently too high or too low. Efficient theatre suites should aim for bias in case-duration estimates of less than 15 minutes per 8 hours of theatre time.

Some surgeons consistently shorten their case-duration estimates because they have too little theatre time allocated and need to "fit" their list of cases into the theatre time that they do have. In contrast, other surgeons purposely overestimate case durations to maintain control and access of their allocated theatre time, so that if a new case appears, their theatre time is not given away.

Changing Workflow in the Surgical Suite

Anyone who has spent time in the theatre knows that the greater the parallel processing, the more cases can be done on a given day. Examples of parallel processing are putting the patient to sleep while the theatre nurse and technician get the surgical tray ready. In Europe, a separate induction room is used for the concurrent induction of anaesthesia, and in the United States, block rooms are often available as a physical space away from the theatre to place epidural or peripheral nerve blocks before bringing the patient into the theatre. These options require additional personnel and a different physical layout of the suite.

Several parallel induction and processing workflow models can increase theatre throughput. For example:
  • Four theatres each with its own induction room and additional personnel:
    • One anaesthetist and 1 instrument technician are added to each of the 4 theatres. The aanesthesia of the first patient of the day is induced in the theatre, and by the end of that case, the additional induction team performs anesthesia induction for the to-follow patient. The team takes care of that particular patient until the end of the case while the original team prepares for the next patient, alternating cases
  • Circulating 1 anaesthesia team among the 4 theatres and 4 induction rooms:
    • One anesthetist and 1 instrument technician move from one induction room to another, performing only anesthesia inductions. Other resources of the 4 theatres remain the same as in the traditional model
  • A centralized induction room for the 4 theatres:
    • A centralized induction room with 3 beds and additional personnel prepares patients for all 4 theatres
  • Four teams in 4 theatres for 3 surgeons -- no induction rooms:
    • Four theatres with personnel (each with an anesthetist) are available for procedures scheduled in 3 rooms and 3 surgeons. The personnel of the empty room prepare for the patient of the surgeon expected to finish next.
Which parallel workflow models are economically favorable will depend on variables, such as:
  • The cost of the additional space and equipment required to allow the parallel processing to occur;
  • The utilization of the theatre and induction room;
  • The cost of each additional person, whether it be physician, nurse, or technician; and
  • The duration of cases: Short procedures benefit the most from individual induction rooms. In contrast, if a surgery suite has longer cases with fewer turnovers, a single centralized induction room serving several multiple theatres may be the way to go.
Revenues gained by parallel processing would need to offset any increased costs. Success for such parallel processes may be best achievable with a select patient population and a small, highly committed group.


Getting the right case into the right room at the right time is the goal for every theatre director. For anaesthesiologists, goals of increasing anaesthesia group productivity are the same as increasing the efficiency of use of theatre time. Examples of possible theatre efficiency benchmarks have been provided and in time may become generally accepted industry standards.

A question often asked is: "Do you have any first-step recommendations to increase theatre efficiency? Among all the different areas of inefficiency, what are the low-hanging fruit? Often, this is institution specific and depends on the local culture, leadership, and financial pressures. Using a survey of the theatre personnel as provided in the Figure is a logical place to start and a low-cost way to identify areas of inefficiency.

Superhuman effort, for example, rushing around on the day of surgery trying to reduce turnover times, can be dangerous and stressful with little financial justification. On the day of surgery, the best way to proceed is by simply taking care of each patient in a relaxed, cheerful, and supportive manner, having done most of the thoughtful planning ahead of time.

Sources: MedScape Anesthesiology, Alex Macario MD, MBA.

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