Waiting for Godot

Editor, Surgical theatre time is precious, and waiting time between surgical procedures is seen as wasted time. Thus, hospital managers increasingly intervene to minimise it.1,2 Most often, the start of the first procedure is the focus of interest.3–5 Less often, waiting times between operations (changeover time) are analysed. The first waiting time of the day is time taken to prepare the operating room, followed by multiple turnover times, which include resupply logistics, cleaning, disinfection and patient transfer, which need to be orchestrated. Are first and following turnover times influenced by the same factors, or are they independent factors? Analysing 2622 changing times (first waiting time and turnover times) in a 310-bed hospital between 1 January 2012 and 4 April 2012, we focused on ‘suture-to-cut’ times, also addressed as ‘nonoperative time’, which depict a longer interval than the Anglo-Saxon ‘wheel-in-wheel-out time’. We found that the mean turnover time was 0.63 ± 0.42 h (range 0 to 3.9). Forty six percent of all turnover times were less than 30 min, 65% were less than 36 min and 75% were less than 42 min (median 34 min). There was no extended waiting time in complex surgical procedures, refuting any anaesthesiological ‘tubing-and-wiring’ delay. There was no significant additional further delay following timely procedures up to 1.5 h owing to increased tiredness of either surgeon or anaesthetist, tested by correlating duration of surgical procedure with the nonoperative time following the procedure, indicating a steady and efficient workflow (Spearman r = 0.17; increase = 0.018). If this effect was compared for the 10 surgeons who performed most operations with procedures more than 1.5 h, there was a small, though significant, prolonged waiting time compared with shorter operations (median, 5.5 min; P = 0.0027). Waiting time before and after surgery correlated in a highly significant manner (P < 0.0001), indicating an ‘operation room consistency factor’ attributable to factors not analysed here. Communication is of paramount importance in turnover times. If the next operation does not need a surgical change (same surgeon), waiting time between operations is lowest. If a change of surgeon occurs within a department, waiting time is significantly higher. Even longer waiting times occurred when a surgeon from a different department undertook the next procedure (P < 0.0001, Kruskal–Wallis). Larger surgical teams needed a longer time to prepare (0.54 to 0.87 h with 1 to 4 surgeons; P < 0.0001 Kruskal–Wallis). Time of day seemed to be an important (if not the most powerful) factor concerning turnover time (Fig. 1). While morning waiting and turnover times were 0 to 0.4 h, they increased over the day up to 0.7 to 0.9 h in the afternoon (P = 0.0025; two-tailed). It may be speculated that this effect is because of increasing tiredness, fatigue or skills being worn out. There was no obvious time step around shift change of nurses. A similar ‘fatigue’ effect during the week between Monday and Friday was not seen. Interestingly, turnover times seem to decrease with operation volume per department, but this small tendency was far outweighed by interdepartmental differences.Fig. 1: No captions available.Turnover times are expensive, but to a certain extent they are inevitable and unavoidable, enabling anaesthesiological, surgical and nursing preparations. Our brief study, analysing 2622 datasets, showed that there are periodic changes during daytime that have not been described before. Indeed, Masursky et al.6 found that an increased turnover time occurred in the afternoon, and that this could be attributed to nurse shift changes. These effects of nurse shift changes were not seen in our small dataset. Nevertheless, we expected to find a similar effect because of change from septic operations at the end of the operating lists to clean operations that were scheduled later during the day, creating a need for operating room disinfection before continuing. Interestingly, turnover time around 4 p.m. was shorter than the turnover time at 2 and 3 p.m. (Fig. 1). Is it the proximity to the approaching leisure time which enhances efficiency? Comparing our crude turnover time numbers with those of Masursky et al.,6 their median operating room turnover time was 33 min. This compares well with our median turnover time of 34 min, although their turnover time was the difference between wheel-out and wheel-in. We used the suture-to-cut time traditionally used in Germany, which included all procedures between skin closure of one patient to incision in the next patient (dressing the patient, cleaning and kitting up the operating room, scrubbing and draping the patient). The influence of patient characteristics, anaesthetists, surgeons and nursing personnel has not been included in our investigation; thus, a lot of potential cofactors still remain to be unveiled. Nevertheless, this small study provides an interesting insight into turnover times and the characteristics they seem to follow. The daily increase of turnover time due to tiredness does not continue after a night of recovery, and begins at a lower level, as turnover times for the next day are seen starting small again. Otherwise, an increase in turnover time over the week would have been seen. It seems that overnight regeneration is sufficient even after a hard working day. Turnover times are neither evil nor good, as they seem to follow certain principles. Some of these have been outlined in this small study. Short turnover times and speed need communication to complete a large surgical team, change surgeons or change departments (P < 0.0001; Kruskal–Wallis; Fig. 2). Small departments are not slower and they do not lack routine. Motivation seems to be pivotal, as incentives like money have no positive influence on turnover times.7 Waiting times for a single surgeon or the surgical team can be minimised with a simple trick, that teams should be planned for consecutive operations as far as possible on the same day.8 A respected operating room manager could fill in if communication gaps arise, which can be intradepartmental or between departments.Fig. 2: No captions available.Turnover times mirror a complex teamwork effort, and thus indicate how effective and team-orientated wards, anaesthesiology, nursing and technical staff, and surgeons are willing to work together. With motivation and communication, turnover times can be kept low within the limits of the outlined periodic changes. Acknowledgements related to this article Assistance with the letter: none. Financial support and sponsorship: none. Conflicts of interest: none.