Patient Safety Tip of the Week
August 26, 2014
Surgeons’ Perception of
Intraoperative Time
We once overheard a conversation in which a surgeon was
attempting to schedule a colorectal case into a free 2-hour opening on the OR
schedule. The battle-tested OR manager responded “Dr. X, you’ve never done a
case in less than 3 hours!”. The surgeon begged to
differ. He was sure he only took about 2 hours, on average, for such cases. But
the OR manager had data to back her up. In fact, the surgeon had never done
such a case in less than 3 hours and most lasted considerably longer.
We’ve done a number of columns about the potential patient
safety consequences of prolonged procedures and addressed the issue of lack of
awareness of the duration of surgery. So one question to ask is “How aware are
surgeons of their intraoperative time utilization?”.
One group of researchers, in fact, addressed that very
question recently (Erestam 2014). That
group did a pilot study in a Swedish academic center using surgeons’
perceptions of time spent in various phases of colorectal procedures compared
to actually measured times. They found little difference at the group level
between perceived and actual times. But at the individual level they found
substantial variation. Time spent in the dissection/resection stage had the
most variation (varied from 43 to 308 minutes). They also found a correlation
between duration of some phases and duration of other phases. For example, a
longer duration of the dissection/resection phase correlated with a longer time
to close the abdomen. And a longer duration of the hand-sewn anastomosis also
correlated with the time needed to close the abdomen.
The study was just a pilot study. There were 18 surgeons in
a single center and actual time was only measured in 21 cases. The authors
anticipate a larger study. But we don’t doubt for a minute the basic premise: surgeons
typically have a poor awareness of their intraoperative time utilization. Note
that in the Erestam study the surgeons were asked
about their case time utilization at a time when they were not operating. Our
experience is that surgeon awareness of case duration during actual surgery is
even worse.
Our March 10, 2009
Patient Safety Tip of the Week “Prolonged
Surgical Duration and Time Awareness” discussed time unawareness during
many surgeries. In addition to the potential impact on infectious
complications, we noted that there are other potential patient safety issues
related to prolonged surgical duration such as DVT, decubiti, hypothermia,
fluid/electrolyte shifts, nerve compression, compartment syndromes, and rhabdomyolysis. Long-duration cases also increase
the likelihood of personnel changes that increase the chance of retained
foreign objects or retained surgical items (see last week’s Patient Safety Tip
of the Week “Some
More Lessons Learned on Retained Surgical Items”). And the fatigue
factor comes into play with longer cases, increasing the likelihood of a
variety of other errors.
Surgical case duration is also one of the few modifiable
risk factors for surgical infections. A number of studies in the past have
demonstrated an association between perioperative infection and the duration of
the surgical procedure. In our January 2010 What’s New
in the Patient Safety World column “Operative
Duration and Infection” we noted a study (Proctor
et al 2010) which looked at a large database of general
surgical procedures and demonstrated a linear relationship between duration of
surgery and infectious complications. The infectious complication rate
increased by 2.5% per half hour and hospital length of stay (LOS) also
increased geometrically by 6% per half hour.
There are many factors that may lead to increased surgical
durations, including case type and complexity, emergency vs. elective nature, patient-related
factors, proficiency of the surgeon, lack of team familiarity, interruptions, equipment
issues, presence of trainees and poor communication.
In our July 21, 2012
Patient Safety Tip of the Week “Surgical
Case Duration and Miscommunications” we discussed a study (Gillespie
2012) on the various factors involved in prolonging surgery. They looked at
most of the above factors plus intraoperative interruptions and whether or not
pre-op huddles/briefings were done. Mean duration of surgery for all cases was
85 minutes, compared to an expected mean duration of 60 minutes. Preoperative
briefings were done in only 12.5% of cases. Communication failures occurred in
57% of the cases, an average of 1.9 per case, and the only factor that independently
predicted deviation from expected duration of surgery was the number of
miscommunications. While interruptions were frequent (occurring in 66.9% of
cases, with a mean number of interruptions per case = 2.3) they did not
independently predict prolonged duration. Miscommunications were more frequent
when some members of the OR team had less experience. They also had examples
where insufficient or inaccurate information was conveyed but the recipient did
not seek clarification.
Gillespie et al. spend a good deal of time discussing the
value of preop briefings. We, of course, are big fans
of the preop huddle/briefing. See our prior columns on pre-op briefings and
post-op debriefings:
- April 9, 2007 “Make
Your Surgical Timeouts More Useful”
- May 22, 2007 “More
on TeamSTEPPS™”
- December 9, 2008 “Huddles
in Healthcare”
- March 10, 2009 “Prolonged
Surgical Duration and Time Awareness”
- January 11, 2011 “NPSA
(UK) ‘How to Guide’: Five Steps to Safer Surgery”
- March 2009 “Surgical
Team Training”
- April 2012 “Operating
Room Briefings and Debriefings”
- July 31, 2012 “Surgical
Case Duration and Miscommunications”
- January 2014 “A
Tool to Assess Pre-op Briefings”
- July 22, 2014 “More
on Operating Room Briefings and Debriefings”
During a preop huddle the team will often recognize that a piece of
important equipment is missing, avoiding the considerable delay that might have
occurred if that had been discovered well into the case. Checklists have
been utilized more often for the preoperative briefings or huddles. We
previously noted a study by Lingard et al (Lingard
2008) that used a checklist to structure short team briefings and
documented reduction in the number of communication failures. Our December 9,
2008 Patient Safety Tip of the Week “Huddles
in Healthcare” discussed an article by Nundy and
colleagues at Johns Hopkins (Nundy 2008).
They used a very simple format for pre-operative briefings that led to a 31%
reduction in unexpected delays in the OR and a 19% reduction in communication
breakdowns that lead to delays.
We recommend that the OR team, during the presurgical huddle, should discuss issues related to
prolonged cases. For example, they should discuss whether intraoperative DVT
prophylaxis should begin if the procedure lasts beyond a certain duration. Or
discuss at what duration a repositioning of the patient (to avoid nerve
compression, compartment syndrome, or rhabdomyolysis)
might be wise. And it would be very useful to have an estimate of time
remaining to again trigger some discussion on the above issues. In addition to
the DVT prophylaxis and repositioning issues, it might raise questions about
the need to temporarily ease up on traction. It might direct attention to
maintenance of the patient’s body temperature. In a very prolonged case it
might raise questions about the need for further doses of prophylactic
antibiotics.
So good communication begins before the patient has actually
entered the OR and is necessary throughout the case to ensure more efficient
and safe performance of surgery. (And don’t forget that the postop debriefing
may help you save time during your next case as well!)
We also recommend that someone in the OR, usually the anesthesiologist,
be tasked with calling out the running case duration at regular intervals (for
example, every 30 minutes). That makes everyone aware of the issues that may
need to be considered in cases that are taking longer than expected. The
announcement of the duration should be accompanied by announcement of pre-agreed-upon
actions (for example, a second dose of antibiotics or a change in patient
positioning).
No one is happy when surgical cases take too long. There are
safety issues, as noted above, for the patient. Staff dissatisfaction increases.
Other patients and surgeons become disappointed if their subsequent case has to
be cancelled (and that next patient’s employer becomes unhappy if he/she has to
take a second day off from work). Your surgical scheduling becomes chaotic. Your
hospital or facility may suffer financially due to unexpected overtime costs
and lost opportunity costs (for other cases that might have been done).
So make surgical case duration an issue of importance for
your organization. Make sure you keep good data on duration of all cases, major
and minor, and actually utilize that data during scheduling. Do your pre-op
huddles/briefings and post-op debriefings in all cases. And make intraoperative
time awareness part of your regular OR routines.
Our prior columns
focusing on surgical case duration:
- March 10, 2009 “Prolonged
Surgical Duration and Time Awareness”
- January 2010 “Operative
Duration and Infection”
- July 21, 2012 “Surgical
Case Duration and Miscommunications”
References:
Erestam S, Erichsen
A, Derwinger K and Kodeda K.
A survey of surgeons’ perception and awareness of intraoperative time
utilization. Patient Safety in Surgery
2014; 8: 30 (1 July
2014)
http://www.pssjournal.com/content/8/1/30
Procter LD, Davenport DL, Bernard AC, Zwischenberger JB. General
Surgical Operative Duration Is Associated with Increased Risk-Adjusted
Infectious Complication Rates and Length of Hospital Stay, Journal of the Amercican College of
Surgeons 2010; 210: 60-65
http://www.journalacs.org/article/S1072-7515%2809%2901411-2/abstract
Gillespie BM, Chaboyer W, Fairweather N. Factors that influence the expected length
of operation: results of a prospective study. BMJ Qual Saf 2012;
21(1): 3-12 Published Online First: 14 October 2011 doi:10.1136/bmjqs-2011-000169
http://qualitysafety.bmj.com/content/21/1/3.abstract?sid=a1703020-3342-4181-ae2f-34beffbcd699
Lingard L, Regehr
G, Orser B, et al. Evaluation of a Preoperative
Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to
Reduce Failures in Communication. Arch Surg, Jan
2008; 143: 12-17
Nundy S, Mukherjee A, Sexton JB,
et al. Impact of Preoperative Briefings on Operating Room Delays: A Preliminary
Report. Arch Surg 2008; 143(11): 1068-1072
http://archsurg.ama-assn.org/cgi/content/abstract/143/11/1068
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