A review of 1241 trauma cases: a study of efficiency in trauma theatres

The opportunity cost of arthroplasty training in orthopaedic surgery

INTRODUCTION

Training the next generation of surgeons is a crucial role fulfilled by consultant orthopaedic surgeons. However we are increasingly constrained by limited time and resources. We sought to compare operative time and length of stay (LOS) for total hip and total knee arthroplasties (THA, TKA) performed by a consultant orthopaedic surgeon with those performed by supervised trainees.

MATERIALS AND METHODS

A prospective database of arthroplasty procedures performed from 2015 to 2018 was collated. Primary surgeon grade was recorded. Patient demographics, ASA grade, LOS and operative time were recorded. For THA both cemented and uncemented arthroplasties were used. SPSS version 23 was used for statistical analysis.

RESULTS

394 arthroplasty procedures were carried out during the study period. Trainee surgeons performed a high proportion of both THA (53.2%, n = 123) and TKA (44.8%, n = 73) surgeries. Trainees performed 57% of cemented THA procedures. LOS did not differ between consultant and trainee surgeons for THA (5.9 ± 4.8 days) or TKA (5.6 ± 4.1 days). Age had a significant effect on LOS (p < 0.001). For THA the mean operative time for trainees was 90.3 ± 19.23 min, 18.2 min longer than the consultant group. For TKA the mean operative time was 89.06 ± 18.87 min for trainees, 24.4 min longer than the consultant group.

DISCUSSION

At our institution trainee surgeons can be expected to take between 18 and 24 min longer to perform arthroplasty procedures. This should be factored into resource planning, as the training of orthopaedic surgeons is crucial to sustaining and improving health service provision.

Orthopaedic Trauma Theatre Efficiency in the COVID-19 Pandemic: Are We Returning to Normality?

Background

Recent studies have shown a decline in theatre efficiency and productivity coinciding with the coronavirus disease 2019 (COVID-19) pandemic. In this study, we evaluate trauma theatre task efficiency in three different time periods (April 2019, April 2020, and November 2020), and analyse if productivity has altered since the start of the pandemic.

Methods

The records of a total of 320 patients who underwent orthopaedic trauma surgery at a large district general hospital in April 2019, April 2020 (during the first wave of the pandemic) and November 2020 (during the second wave of the pandemic) were analysed. Primary outcomes measured include time to get to the theatre, anaesthetic preparation time, the sum of time of anaesthesia and surgical preparation time, duration of surgery and time to transfer to recovery. Patient demographics as well as the type of surgery were also analysed.

Results

The time to get to the theatre and anaesthetic preparation time significantly increased in April 2020 (p<0.05) but fell in November 2020 with no significant difference in comparison to before the pandemic in April 2019 (p>0.05). The duration of surgery and time to transfer to recovery significantly increased in April 2020 (p<0.05) and though reduced in November 2020, was still significantly greater in comparison to April 2019 (p<0.05). In April 2020, the proportion of patients aged 18-65 was just 26% as compared to 35% in April 2019. This figure rose again to 45% in November 2020. The number of hip fracture procedures remained similar during the three time periods, with 32, 32 and 36 hip fracture operations in April 2019, April 2020 and November 2020, respectively.

Conclusion

While operating theatres' efficiency decreased during the first wave of the COVID-19 pandemic, it increased again in the second wave, coming close to the ‘normal’ levels before the pandemic struck.

Impact of COVID-19 Pandemic on Trauma Theatre Efficiency

Introduction

A large transformation in the management of trauma has ensued following the COVID-19 (coronavirus disease 2019) pandemic. There has been an increase in reliance on guidance for decision-making and alterations in the working of the trauma theatre. This has largely been due to the safety measures implemented. Theatre efficiency has gained increasing importance over the years, and with the added pressure of the pandemic, it is essential that trauma theatres operate efficiently. There has been no data analysing the efficiency of trauma theatre during this pandemic.

Methods and Results

We retrospectively analyzed the data at our hospital and looked into the parameters to assess trauma theatre efficiency. It was noted that the operative time and anaesthetic time went up significantly in 2020 in comparison to 2019. Also, the change over time and the late start time was significantly high in 2020. A large proportion of cases did not start on time in 2020. This resulted in a decrease in the efficiency of theatre usage.

Discussion

Reduced productivity of the trauma theatre has been due to several reasons, many of which include implementation of safety measures, such as personal protective equipment (PPE), theatre cleaning, recovery of patients, using designated routes for transfer, and many others. The challenge lies in applying these new measures into our daily practice at the same time while providing efficient care.

Conclusion

Our study highlights the key areas of concern and improvement which need to be addressed in order to render effective trauma care.

Trauma theatre productivity - Does the individual surgeon, anaesthetist or consultant presence matter?

INTRODUCTION

With rising NHS clinical and financial demands, improving theatre efficiency is essential to maintain quality of patient care. Consistent teams and consultant presence have been shown to improve outcomes and productivity in elective orthopaedic surgery. The aim of this study was to investigate the impact on trauma theatre productivity of different surgeons and anaesthetists working together in a Major Trauma Centre. The influence of consultant presence and weekend operating on productivity was also considered.

METHODS

Data relating to a single orthopaedic trauma theatre was gathered retrospectively for a two-year period. Variables including orthopaedic and anaesthetic consultant presence, number and complexity of operations performed and procedure start times were collected for daily trauma lists. Individual anaesthetic and orthopaedic consultants were compared by productivity outcomes. The impact of surgeons operating more frequently with one anaesthetist was also examined.

RESULTS

Data relating to 2384 patients undergoing a total of 2787 procedures was collected. Orthopaedic consultant presence at the first surgical case (p < 0.05) and for 50% or greater of cases (p < 0.05) lead to higher mean number of cases performed per list and reduced turnaround time. Despite working with a significantly higher number of different consultant anaesthetists (p < 0.001) in year two, the productivity of surgeons as judged by list start time, total cases per list and total operating time was not significantly affected. Significantly earlier start times (p < 0.001) and shorter turnaround times (p < 0.001) at weekends led to maintained productivity despite shorter theatre time. No significant difference in productivity was found when comparing individual anaesthetic and orthopaedic consultants. Productivity was not significantly increased by surgeons operating more frequently with one individual anaesthetist.

CONCLUSION

In the setting of an acute trauma theatre, orthopaedic consultant presence led to increased productivity. Furthermore, individual surgeon and anaesthetist pairings had no effect on overall productivity. Future efforts to improve productivity should focus on achieving earlier start times, consultant supervision of lists and reduced turnaround times between cases.

Factors impacting arthroscopic rotator cuff repair operational throughput time at an ambulatory care center

Identifying patient factors influencing operational throughput time is becoming more imperative due to an increasing focus on value and cost savings in healthcare. The primary objective of this study was to determine patient factors influencing throughput time for primary rotator cuff repairs. Demographic information, medical history and operative reports of 318 patients from one ambulatory care center were retrospectively reviewed. Operating room set up, incision to closure and recovery room time were collected from anesthesia records. Univariate analysis was performed for both continuous and categorical variables. A stepwise, multivariable regression analysis was performed to determine factors associated with operating room time (incision to closure) and recovery room time. Of the 318 patients, the mean age was 54.4±10.0 and 197 (61%) were male. Male patients had a significantly longer OR time than females (115.5 vs. 100.8 minutes; P<0.001) Furthermore, patients set up in the beach chair position had a significantly longer OR time than patients positioned lateral decubitus (115.8 vs. 89.6 mins, P<0.0001). Number of tendons involved, and inclusion of distal clavicle excision, biceps tenodesis and labral debridement also added significant OR time. Type and number of support staff present also significantly affected OR time. Recovery room time was significantly longer patients who had surgery in the beach chair position (+9.61 minutes) and for those who had a cardiac-related medical comorbidity (+11.7 minutes). Our study found that patients positioned in a beach chair spent significantly more time in the operating and recovery rooms. While ease of set up has been a stated advantage of beach chair position, we found the perceived ease of set up does not result in more efficient OR throughput.

Effect of switching off unidirectional downflow systems of operating theaters during prolonged inactivity on the period before the operating theater can safely be used

BACKGROUND

Switching off air handling systems in operating theaters during periods of prolonged inactivity (eg, nights, weekends) can produce a substantial reduction of energy expenditure. However, little evidence is available regarding the effect of switching off the air handling system during periods of prolonged inactivity on the air quality in operating theaters during operational periods. The aim of this study is to determine the amount of time needed after restarting the ventilation system to return to a stable situation, with air quality at least equal to the situation before switching off the system.

METHODS

Measurements were performed in 3 operating theaters, all of them equipped with a unidirectional downflow (UDF) system. Measurements (particle counts of emitted particles with a particle size ≥0.5 µm) were taken during the start-up of the ventilation system to determine when prespecified degrees of protection were achieved. Temperature readings were taken to determine when a stable temperature difference between the periphery and the protected area was reached, signifying achievement of a stable condition.

RESULTS

After starting up the system, the protected area achieved the required degrees of protection within 20 minutes (95% upper confidence limit). A stable temperature difference was achieved within 23 minutes (95% upper confidence limit). Both findings lie well within the period of 25 minutes normally required for preparations before the start of surgical procedures.

CONCLUSIONS

Switching off the ventilation system during prolonged inactivity (during the night and weekend) has no negative effect on the air quality in UDF operating theaters during normal operational hours.

How is time used within the orthopaedic trauma theatre?

Theatre efficiency has gained increasing attention though the Productive Operating Theatre (TPOT) initiative from the NHS Institute for Innovation and Improvement. However, literature specifically exploring how time is used within theatre is limited. Running a theatre is expensive and so it is essential to maximise efficiency (NHS III2009). A retrospective review of trauma lists in two district general hospitals has identified areas where time is wasted and highlighted areas for improvement.

Theater Cost Is £16/Minute So What Are You Doing Just Standing There?

The purpose of this study was to measure the time to perform particular activities in the operating room and calculate the cost per minute to perform each activity. We timed how long it takes to perform 15 individual activities carried out by orthopedic trainees during total hip and knee arthroplasty. We developed an algorithm, and then measured the time taken for the preparation of 20 consecutive patients using it. With the algorithm, overall preparation time was reduced by 25.32% for each hip arthroplasty and by 27.60% (P < .0001) for each knee arthroplasty, saving £84.32 and £93.44 per case, respectively. Coordination between surgeons and theater staff is essential to reduce the time spent performing activities, and this will help improve theater efficiency.

A predetermined first patient on the trauma list can improve theatre start times

INTRODUCTION

The concept of the golden patient (GP) was introduced to our busy teaching hospital, in April 2009, with the aim of improving our trauma theatre start times. The GP is a pre-selected first patient on the following day trauma list who is medically fit with a clear surgical plan.

METHODS

This prospective study compared the trauma theatre start times over a two month period following the introduction of the GP, with a similar two month period prior to the introduction of the GP. A two-sided t-test was used to evaluate statistical significance between groups.

RESULTS

Of the 55 planned trauma lists analysed, 42 had a designated GP on it (76%), 37 of which remained first on the actual trauma list (88%). The mean operation start time for the pre-GP lists was 10:03 compared to 09:33 for the actual GP lists (P<0.001). The reception, anaesthetic and operation start times for pre-GP lists compared with lists where no GP was selected were not statistically significant suggesting that the GP was the cause of the significance.

CONCLUSION

The introduction of the GP to our trauma lists has made a significant improvement to theatre start times and consequently surgical theatre efficiency.