ANALYSIS OF ORTHOPEADIC THEATRE TIME UTILIZATION AT KENYATTA NATIONAL HOSPITAL
Trauma is the leading causes of admission in Kenyatta National Hospital and often these patients require surgery. The trauma burden unpredictability usually mismatches demand and supply of the hospital thus posing challenge for systems improvement and streamlining.
Utilization is defined as the ratio of time that an asset is used, against its capacity.
For uniformity among the OR team, it is extremely important to developing a precise definition of turnaround time. For the purpose of this paper, turnaround time is defined as the time between incision close of patient n and incision open of patient n+1. This definition captures the surgeon’s, anaesthetist and nurse perspective of turnaround time and allows us to see the delay between the most expensive value-added times in the theatre.
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Previous study from KNH reported high rate of cancellation of elective list on the day of surgeries (20.6%)1. One of the causes attributed to these delays was inefficient utilization of OR time, mainly due to delay in starting time and long turnaround time within the OR. It was noted that 70.9% of non clinical cancellation was due to list overrun/lack of time. It was also the leading cause of cancellation in KNH at (43.8%). Three specialty were identified to have recorded the highest cancellation rate were Cardiothoracic surgeries 38%, Neurosurgeries 37.8% and Orthopedic surgeries 32.6%1. Cancellation generally increases waiting list and the risk of further cancellation, which may cause patient dissatisfaction and compromise patient’s safety2.
Poor scheduling of operations can result in cancellation of operation which is costly to both the patient and the hospital3. With the escalating cost of healthcare, quality of care fails to meet expectation of our patients and therefore, the health care organization should look on strategies to improve quality while reducing cost of running hospitals.
The efficiency of operating room can be measured in variety of ways4. Efficiency is defined in term of ability to translate available time into earning5–8. Computer simulation and mathematical models, both of which essentially idealizations that the practical capacity for OR to be between 80-90%9.
Theatre complex is a high cost department with the hospital and therefore considerable resources are wasted if operating room if not used effectively. Improving the performance of operating room is key to achieving shorter waiting time for surgery, reducing cancellation for operations and more so achieving the implementation of booking of elective surgery in our hospital. Increased utilization of operating room improves patients flow and reduces the waiting list time. Improving theatre utilization would lead to a reduction in cost recovery from each patients10. 4 in their study in South African concluded that private operation theatre utilization rates were higher than public operation theatres due to commercial nature of private healthcare and absent consequent cost drivers in public health sector10. Utilization rate in South Africa was found to be 48% which was significantly lower than the globally bench mark of between 70-80%4. 11 concluded that the delay in starting list, under schedule, interruption due to emergency surgeries, administrative reasons, induction of anesthesia and recovery police are the main factor that account for inefficient use of operating room facilities in India hospitals
Operating room utilization rate is usually an indicator used in measuring efficiency in use of hospital resources. It is argued that high utilization is cost effective and improves quality of care10,12–15.
Brief Description of KNH Main Theatre
KNH Main theatre is located in the first floor of the tower block adjacent to Critical Care Unit (CCU), Renal and Burns Unit. It has twelve operating rooms out of which two are allocated to Prime Care Center; one is dedicated for emergency surgeries 24 hours a day. The remaining nine are allocated to different specialty in a week. The specialties are General surgery, Urology surgery, Maxillofacial surgery, ENT surgery, Pediatrics surgery, Plastic surgery, Ophthalmology surgery, Orthopedic surgery, Cardiothoracic surgery, Neurosurgical and Obstetrics and Gynecology surgery.
Within the OR the following equipments are found, Operating table in the center of the room, Operating lights directly over the table to provide bright light during surgery, Anaesthesia machine is at the head of the operating table equipped with Electronic monitor machine which records the heart rate and respiratory rate by adhesive patches called chest leads placed on patient’s chest, it has also the Pulse oximeter which is attached to the patient’s finger with an elastic band aid. Pulse oximeter measures the amount of oxygen contained in the blood, an automated blood pressure measuring machine that automatically inflates the blood pressure cuff on patient’s arm continuously recording blood pressure, there is the diathermy machine which uses high frequency electrical signals to cauterize blood vessels and cut through tissue with a minimal amount of bleeding. Other specialized machines may be brought in depending on the nature of surgery.
In a week there are 45 theatre space slot allocated to different specialty, out of which orthopedic surgeries have 12 slots and the remaining 33 slot are allocated among the remaining 10 specialty. The orthopedic department is located on the sixth floor of the tower block and has four wards namely 6A, 6B, 6C and 6D. Ward 6B serves as a joint admission for all pediatric cases from 6A, 6C and 6D. Each ward has four days in a week to do the elective surgeries.
Each ward is expected to submit its operation list to main theatre reception before 15:00 hours on the day before its assigned operation day. In the evening before the surgery, anaesthetists visit the wards to do a pre-anesthetic assessment on patients who had been scheduled for surgery. They are expected to re-assure these patients, assess their fitness for surgery, and also confirm the necessary investigation are done which they document in the pre-anesthetic check list.
On the day of surgery porters are sent to the ward to bring the patients who are then received by a designated theatre nurse at the receiving area, the Receiving Area nurse check to confirm the identity of the patient, see that consent for the surgery had been given and all necessary investigation have been done. Thereafter, the patient is wheeled to waiting bay where he/she is kept on-hold until the theatre room is ready. All other procedures like intravenous access and induction of anaesthesia are done in theatre. After surgery, the patient is taken to Post Anesthesia Care Unit (PACU) while the operating room is cleaned in preparation for the next patient.
Economic considerations also suggest that it is desirable to keep operating rooms fully used. Thus, it is imperative that areas of time wastage in the theatre time flow be recognized and their causes identified. This will assist theatre managers take necessary steps to correct the problem14.
To identify areas of, and causes of operating room time delay, and suggest solution based on the identified deficiencies.
Operating theatre represents an area of considerable expenditure in a hospital budget. Consequently, hospital administrators are so concerned with maximizing utilization of OR. This can only be made possible by knowing how much time is spent on which activity and there by identify the factors resulting in under utilization of OR16.
KNH theatre complex is being managed by Assistant Chief Nurse (ACN) with the help of Administrative Officer. The two are answerable to the Head of Department (HOD) Theatre, TSSU and CSSD. The staff within each OR includes Surgeons, Anesthetist, 1- circulating nurse , 1- scrub nurse and 1- theatre sterile assistant (TSA). The general theatre activities are overseen by a Theatre Users Committee (TUC), with HOD as the chairperson. Other members are from Nursing, Surgery, Anaesthesia, Administration and Technical departments.
I will survey the timing of events in the Orthopedic OR using their elective operating lists available from Monday to Friday at theatre front office desk for a period of one month. I will use a designed proforma based on established operating theatre process steps to record the following;
- Patient sent-for (PS): Time when porter leave R/A to the ward for the patient
- Patient available (PA): Time the patient arrives at theatre R/A
- Patient in room (PIR): time when patient enters OR
- Anesthesia/Induction start time (AIT): time induction of anesthesia starts
- Surgery start time (ST): time cleaning of surgical area
- Surgery finish (SF): time dressing is put on the incision site
- Patient out OR (POR): Time at which patient leaves the OR
From the above times, I will derive the following:
Ward to theatre transfer interval: the interval between PS and PA (b-a). This interval is prolonged when it is greater than 20 minutes.
R/A waiting time: It is the interval between patient available (PA) and when patient is transferred to OR (c-b). It is prolonged if it is greater than 10 minutes.
Pre-anesthetic waiting time: the difference between patient’s in room (PIR) and anesthesia/induction start time (AIT) (d-c). It is prolonged when it is greater than 20 minutes.
Anaesthesia admission time (AAT): the interval between AIT and ST (e-d) and it is prolonged when it is greater than 20 minutes.
Surgery duration: the interval between ST and SF (f-e).
Anesthesia reversal time (ART): the interval between SF and POR (g-f)
Turnaround time (TAT): the interval between incision close of patient n and incision open of patient n+1.
There will be a one week pilot study to set the cut-off point for the intervals between normal and delayed time. This will be based on the mean time observed in the pilot study and for convenience it will be rounded-up to the nearest number divisible by five. In case of delay outside theatre the officer involved will be interviewed to determine the cause of the delay. However, delays that occures in the theatre will be observed directly by the research assistant filling the proforma.
The data was entered into SPSS 11.5 which was used to calculate the time intervals and for statistical analysis
Efficiency means the management of theatre time, costs resources and staff to undertake as many procedures as possible within given levels of resources, or doing the same number of procedures using a lesser amount of resources
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