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 “ ” we noted a study ( ) 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:
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:
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)
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
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
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
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