https://www.infirmiere-canadienne.com/blogs/ic-contenu/2024/02/20/reduire-le-temps-de-rotation
Team-based approach includes parallel processes, better perioperative communication, effective use of runners and induction rooms
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Operating room nurses, through education, motivation, the efficient use of resources and personnel, and changes to processes, have the ability to significantly improve not only turnover time but also staff morale throughout the hospital.
Takeaway messages
- Reducing turnover time — how long it takes for one patient to leave an operating room before a new one enters — can help alleviate Canada’s overburdened health-care system.
- There are many factors contributing to high turnover time, including increased complexity of cases, high staff turnover, and the pandemic backlog.
- Solutions are multidisciplinary and include completing multiple tasks concurrently, adding induction rooms, using “runners,” addressing perioperative considerations and, most importantly, having a well-trained, motivated health-care workforce that is open to change.
What is turnover time — and why is it important?
Turnover time is the measure between one patient leaving the operating room (OR) and the next patient entering it, including the time it takes to clean, collect additional equipment and complete the surgery setup.
With the increasing demand on health-care systems in general, and on operating procedures in particular, there is a clear need for reducing turnover times. Lack of efficiency between patients increases the backlog of surgical cases and, with it, the potential for cancellations. Delays are caused by poor communication, staff shortages, new nursing staff, cases overrunning, surgeon unavailability and additional OR-cleaning procedures that have been implemented following the pandemic. Furthermore, incomplete procedure and blood product administration consents, unmarked surgical sites and non-compliant patients, among other factors, all contribute to delays in the arrival of a surgical patient to the OR.
In this article, I describe the challenges that are contributing to delays and propose solutions that can be put into practice.
Challenges
Advances in surgical procedures and equipment
With the rise in technological development, upgraded surgical techniques and the added complexity of procedures, surgical cases today demand extra staff and added training, more time to set up, and, possibly, additional equipment (Mangum & Cutler, 2002). It is not uncommon for hospital staff to suffer from the effects of personnel shortages, commonly due to sick calls or multiple vacant positions. With insufficient staff, there is often a lack of support when preparing for rare or complex cases, learning new equipment and organizing implants. This has the potential to lengthen turnover times as nurses may need additional time to fulfil their roles during unfamiliar procedures.
High staff turnover and novice learners
As nurses continue to leave their units and, in some cases, the profession altogether, the need for specialty-trained OR nurses is increasing. This results in hiring new graduate nurses with little to no experience and their prompt enrolment into an accelerated OR training program. In ideal circumstances, nurses would have cultivated and honed the necessary clinical, critical thinking, and decision-making skills through experience on an acute care ward before transitioning into a specialty field. However, the global OR nursing shortage cannot cater to such ideals.
Health-care facilities that welcome new learners tend to be regarded positively by new staff. Fresh faces, optimism, the hunger for knowledge and the expectation of success not only bring excitement to the workplace; they also emphasize the importance of ongoing education and patience from all team members.
With that said, we cannot ignore the fact that such novice nurse learners may not display the same level of efficiency and independence as that of senior nurses, contributing to further procedural delays. For example, this may result in lengthy patient check-ins, slower documentation and the need for assistance when performing basic nursing skills. When the circulating nurse is called upon to help a novice nurse with these skills, they are interrupted from completing their duties.
COVID-19 catch-up
At the start of the pandemic, to prevent the spread of COVID-19 and to protect health-care staff, all COVID-19-positive patients, known or suspected, were treated as positive when in the OR (Prakash, Dhar, & Mushtaq, 2020). This called for an increase in staff, thorough room cleaning and additional delays. Having to wait about one hour for the necessary air exchange to occur, the lack of available cleaning personnel and enhanced cleaning protocols, all contributed to the prolonged disinfection of the OR between cases (Prakash et al., 2020). One study found that providing care to COVID-19-positive patients increased turnover time by 32 minutes (Andreata, Faraldi, Bucci, Lombardi, & Zagra, 2020).
COVID-19-positive patients often had high viral loads and a long infectious period, which meant that despite strict infection control measures, countless health-care providers fell ill (Prakash et al., 2020).5 This led to increasing numbers of staff on sick leave and casual employees fearing having to pick up extra shifts. These patients also presented new challenges during intubation, where the virus harbouring in patients’ respiratory tracts became airborne. The strict donning and doffing of personal protective equipment was mandatory, inevitably taking up time.
Because of COVID-19, non-emergent surgeries were cancelled or postponed, which in turn created an extensive surgical backlog (Wang et al., 2020). With lengthy surgical wait-lists, limited OR time, a lack of staffing and increased cleaning protocols, it is important that surgical staff, both direct and non-direct providers, reduce turnover time between surgical cases. We must maximize OR time as we aim to clear the surgical backlog while also completing the usual scheduled surgeries (Olson et al., 2018).
Resistance to change
Unfortunately, resistance to change is not uncommon within health care, and implementing strategies to target change may receive pushback from employees. With advancements in technology, greater day-to-day expectations and a strong push for efficiency, many health-care professionals feel overwhelmed and become reluctant to adopt new processes.
Health-care providers must be offered adequate support, guidance, patience and encouragement throughout any change process.
Approaches and strategies
In order to mitigate turnover delays, health-care professionals should be aware of variables that either support or halt change efforts. A multidisciplinary approach, the integration of parallel processes, enhanced perioperative communication, the use of induction rooms, and the efficient use of a “runner” (an extra nurse or support person) during a COVID-19-positive case all have the potential to significantly reduce turnover time.
Take a multidisciplinary approach
All operating personnel can help control turnover time (Olson et al., 2018). Decreasing excess time between surgical cases has the potential to enhance positive feelings among surgeons and anesthesiologists (Bhatt, Carlson, & Deckers, 2014), which means that doctors may be more willing to assist with tasks that they may not routinely perform (e.g., initiating IV lines, clearing and cleaning, and gathering positioning equipment).
Although some reasons are multifactorial, interdisciplinary and unavoidable (Olson et al., 2018) and cannot be entirely eliminated, it is important that interventions to improve turnover time promote teamwork and the development of trusting relationships (Bhatt et al., 2014). With a multidisciplinary approach, team members can assist each other to complete certain tasks. For example, any employee can tie off the linen and garbage bags while the housekeeping personnel are wiping down the bed. Or perhaps the surgeon can grab the positioning equipment while the nurse is checking in the next patient.
Implement parallel processes
Parallel processes allow two tasks to be completed concurrently — for example, overlapping the next patient check-in and transportation to the OR with the room setup (Kodali, Kim, Bleday, Flanagan, & Urman, 2014). However, nurses may be resistant to this, in part because of the need for additional staff. It may be beneficial to allow the housekeeping teams to enter the OR when it is safe to do so, overlapping cleaning and transferring of the patient to the post-anesthesia care unit (PACU) (Kodali et al., 2014).
Implementing parallel processes calls for a shift in culture, a need for enhanced communication between intraoperative and housekeeping personnel, and support from leadership teams. This allows roles to be clearly defined and efficiency increased, thus making turnover time more predictable. This predictability means that cases were more likely to start and end on time (Kodali et al., 2014).
Interestingly, implementing parallel processes even in the face of resistance has been shown to still be successful at reducing turnover times (Kodali et al., 2014).
Enhance perioperative communication
Clear communication is needed for any team to run effectively. The perioperative team must communicate needs and provide updates to all members of the health-care team. In addition, a system should be in place that allows real-time communication between the charge nurse, OR nurses and the sterile processing department (Bhatt et al., 2014). This would allow the timely preparation of the next case cart and availability of supplies and equipment, as well as ensuring adequate staffing to replace employees nearing the end of their shifts.
Communicating incomplete tasks such as absent orders, missing or incomplete consents, and necessary patient site marking to physicians helps the room run smoothly. For example, the surgeon may check in with the next patient, answer their questions, have them sign the consent form, and so on, while the room is being prepared.
Notifying managers and leaders of factors that delay turnover time can result in positive changes (Bhatt et al., 2014). They are more likely to be engaged in and committed to finding a solution when they are aware of the problems.
Consider the addition of induction rooms
The use of induction rooms depends on the size and funding of the health-care institution. In some settings, induction rooms are the norm, facilitating the aestheticization of the next patient while the surgeon is closing the wound of the previous case. In ultra-efficient units, while the anesthesiologist is escorting the patient to the recovery unit and speaking to relatives, the surgeon is helping with cleaning so that the now-anesthetized patient in the induction room is wheeled into the OR with minimal delay.
This does, however, involve the use of a separate room, extra nursing and anesthetic personnel, and additional cleaning for the housekeeping staff, all of which add costs. For this reason, induction rooms may be more suited for new hospital developments that are wanting to significantly invest in OR infrastructure (Bhatt et al., 2014).
Use runners effectively
The COVID-19 pandemic illustrated the benefit of having an extra nurse or support person during an airborne surgical case. This runner can promptly collect the items and equipment needed throughout the procedure. However, the runner should be used effectively. Not having extra supplies and equipment in the room, for example, may lead to additional delays as the runner fetches necessary items (Prakash et al., 2020). When surgery on a COVID-19-positive case is under way, a nurse from another OR is often pulled from their assignment to fulfil the role of a runner. This increases the workload of the nurses in the other OR, causing delays, missed breaks and insufficient room staffing. In an effort to have minimal staff in the OR dealing with the COVID-19 case, breaks are often postponed until the case is completed. With numerous nurses needing well-deserved breaks, it is no wonder that subsequent cases are further delayed.
Perioperative considerations
There are factors beyond the health-care worker’s control that cause delays within the perioperative area — for example, the distance patients and personnel have to travel from the preoperative area to the OR, the status of the patient (e.g., mobility or cognitive deficits, obesity, anxiety or behavioural issues), and pre- and postoperative staffing levels (Kodali et al., 2014).
Nursing plays an integral role in decreasing turnover times. However, this is dependent on the nurse’s ability to be proactive and efficient and to demonstrate an overall willingness to help (Olson et al., 2018). It is important to review surgical cases ahead of time so that the necessary equipment is collected, surgical steps/instruments can be reviewed, and questions clarified with the surgeon. Nurses should have an overall understanding of general surgical flow so that they can have items nearby in case they are needed (e.g., dressings, drainage systems, bed/stretcher), page the house cleaners in advance, coordinate with recovery nurses regarding transport to the PACU, and facilitate efficient check-in processes with subsequent patients. They should schedule their coffee and lunch breaks accordingly and try to avoid taking them during room turnover.
Kodali et al. (2014) discovered that nurses and OR aides “had the potential to have a broader impact on OR practices because these team members routinely floated to other ORs as necessary. In other words, these stakeholders had a much larger range of influence in the context of process change” (p. 409).
Engaging in a morning team huddle enhances staff morale, efficiency and preparedness. Introducing team members can help clarify roles and limitations and establish an overall sense of teamwork. During the huddle, the team should clarify implants and equipment as needed, anesthetic concerns, sutures and dressings, and the postoperative care plan.
It is important to recognize that poor retention of auxiliary surgical staff (e.g., nursing aides, house cleaners and secretaries) directly impacts the efficiency of a hospital. Health-care personnel have to be empowered, supported and rewarded throughout change processes.
Conclusion
OR nurses, through education, motivation, the efficient use of resources and personnel, and changes to OR processes, have the ability to significantly improve not only turnover time but also staff morale throughout the hospital. By showing leadership and proactivity in enhancing efficient use of ORs, other teams will be drawn in, and in this way we can play a crucial role in setting standards for and enhancing patient care throughout the hospital. With efforts to prevent and solve delays, health-care personnel can enjoy predictable workdays where they start and end their shifts appropriately, and patients can benefit from not having their cases postponed or cancelled. We should aim to accomplish a balance of OR efficiency, patient safety and improved quality of life of health-care staff (Kodali et al., 2014).
References
Andreata, M., Faraldi, M., Bucci, E., Lombardi, G., & Zagra, L. (2020). Operating room efficiency and timing during coronavirus disease 2019 outbreak in a referral orthopaedic hospital in Northern Italy. International Orthopaedics, 44(12), 2499–2504. doi:10.1007/s00264-020-04772-x
Bhatt, A. S., Carlson, G. W., & Deckers, P. J. (2014). Improving operating room turnover time: A systems based approach. Journal of Medical Systems, 38(12), 148. doi:10.1007/s10916 014-0148-4
Kodali, B. S., Kim, D., Bleday, R., Flanagan, H., & Urman, R. D. (2014). Successful strategies for the reduction of operating room turnover times in a tertiary care academic medical center. Journal of Surgical Research, 187(2), 403–411. doi:10.1016/j.jss.2013.11.1081
Mangum, S. S., & Cutler, K. (2002). Increased efficiency through OR redesign and process simplification. AORN Journal, 76(6), 1041–1046. doi:10.1016/s0001-2092(06)61006-5
Olson, S., Jaross, S., Rebischke-Smith, G. S., Chivers, F., Covel, S. K., & Millen, C. E. (2018). Decreasing operating room turnover time: A resource neutral initiative. Journal of Medical Systems, 42(5), 96. doi:10.1007/s10916-018-0950-5
Prakash, L., Dhar, S. A., & Mushtaq, M. (2020). COVID-19 in the operating room: A review of evolving safety protocols. Patient Safety in Surgery, 14(1), 30.
Wang, J., Vahid, S., Eberg, M., Milroy, S., Milkovich, J., Wright, F. C., ... Irish, J. (2020). Clearing the surgical backlog caused by COVID-19 in Ontario: A time series modelling study. Canadian Medical Association Journal, 192(44), E1347–E1355. doi:10.1503/cmaj.201521
Mallory Browne, RN, works as a travel nurse in operating rooms in British Columbia.
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