You’ve seen it at
your facilities: surgeons blame late OR starts and long cases on the anesthesiologists
taking too much time and anesthesiologists blame the surgeons for showing up
late for cases and taking too long to operate. And those perceptions actually
confound each other because the assumption that one or the other will be late
may actually cause surgeons and anesthesiologists to delay! And neither are
very good at predicting how long a case will actually take.
Yet another study
has demonstrated a disparity between the ability of surgeons and anesthesia
personnel to predict procedure duration and the actual duration of the
procedures (Travis 2014).
The researchers found that general surgeons in a New Zealand hospital underestimated
the time required for the procedure by 31 minutes. Plastic surgeons
underestimated by 5 minutes but orthopedic surgeons actually overestimated by 1
minute. Interestingly, anesthetists underestimated by 35 minutes. The authors
conclude that the inability of clinicians to predict the necessary time for a
procedure is a significant cause of delay in the operating room but there are potential
differences between specialties.
Yes, such misperceptions of procedure times do wreak havoc
with efficient operating room scheduling and throughput. They probably also
lead to problems in teamwork and communication and morale. But we are most
concerned about the potential impact for this time disparity from a patient
safety perspective.
We’ve already discussed the issue in several prior columns
(see our Patient Safety Tips of the
Week for August 26, 2014 “Surgeons’
Perception of Intraoperative Time” and March 10, 2009 “Prolonged
Surgical Duration and Time Awareness” and our January 2010 What’s
New in the Patient Safety World column “Operative
Duration and Infection”). There are a variety of adverse events that can potentially occur when
surgical cases go past their anticipated times.
One such potential adverse event is the occurrence of venous thrombembolism
(VTE). Most of us have assumed over the years that longer surgical
procedures were associated with increased risk of deep venous thrombosis (DVT)
and pulmonary embolism (PE). In fact, we have long recommended that the
operative team discuss either during the pre-op huddle/briefing or the surgical
“timeout” the expected duration of the procedure and what contingencies should
be considered if a certain duration is exceeded. But, much to our surprise,
there really had never been a high quality study looking quantitatively at the
relationship between surgery duration and VTE risk. Now a new study has done
just that (Kim 2014).
The researchers, using data from the American College of Surgeons National
Surgical Quality Improvement Program on over 1.4 million patients undergoing
surgery with general anesthesia, found an association between surgical duration
and VTE that increased in a stepwise fashion. Compared with a procedure of
average duration, patients undergoing the longest procedures experienced a
1.27-fold increase in the odds of developing a VTE event.
Another recent study looked at duration of surgery as a
possible risk factor for complications in neurosurgery (Golebiowski
2014). The authors did a review of 1,000 consecutive patients who
underwent planned surgery for intracranial tumors at a single institution. They
found that duration of surgery together with comorbidity and acquired
neurological deficits is an independent risk factor for extracranial
complications after brain tumor surgery. Duration of surgery was also associated
with surgical site infections. The odds ratio for extracranial
complications with duration of surgery per hour was 1.14. The authors note that
awareness of the harms of prolonged surgery may help neurosurgeons in planning
approaches and equipment and should be considered in regards to training
aspects. They also note that, in view of this association between case duration
and complications, any potential prolongation of cases for research purposes
should be discussed as part of informed consent.
Another study used American College of Surgeons National
Surgical Quality Improvement Program data to evaluate the impact or surgical
duration in patients who underwent lumbar fusion procedures (Kim,
BD et al 2014). They demonstrated that increasing operative time was
associated with step-wise increase in risk for overall complications, medical
complications, surgical complications, superficial surgical site infection, and
postoperative transfusions. Operative duration of 5 hours or more was also
associated with increased risk of reoperation, organ/space surgical site
infection, sepsis/septic shock, wound dehiscence, and deep vein thrombosis. The
editorial accompanying this study, however, urges caution in attributing too
much to surgical duration (Pearson
2014). It notes that the reasons for longer cases, including
patient-related factors and technical factors, may not have been adequately
accounted for in the analysis even though Kim et al. had used multivariate
risk-adjusted regression models.
A previous study on risk for postoperative pulmonary complications found that surgical duration
of at least 2 hours was one of seven independent risk factors for such
complications (Canet
2010). The authors developed a risk index based on these seven
objective, easily assessed factors and suggest the index can be used to assess
individual risk of postoperative pulmonary complications and focus further
research on measures to improve patient care.
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 our August 19, 2014 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 found 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.
In our September 29, 2009 Patient Safety Tip of the Week “Perioperative
Peripheral Nerve Injuries” and our May 2011 What’s New in the Patient
Safety World column “ASA
Updates Advisory for Prevention of Perioperative Peripheral Neuropathies”
we discussed duration of procedures and position in causing compressive nerve injuries. A recent
study (Delaney
2014) noted that total operative time was one of two predictors of postoperative
brachial plexus deficits after the Latarjet shoulder
procedure.
And remember – it is not just human factors that lead to
long surgical cases. There may be system issues as well. In our August 26, 2014 Patient Safety Tip of
the Week “Surgeons’
Perception of Intraoperative Time” we noted 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. Obviously patient-related issues are important.
For example, a recent study (Bradley
2014) showed that for total joint replacement each 5-point increase in patient
BMI increased operative time by 7 minutes. Unanticipated complications (bleeding,
anomalous anatomy, etc.) may occur as well. Even if you do a great job planning
in your pre-op huddle/briefing there are always potential contingencies that
arise. A key piece of equipment might break or get contaminated, necessitating
a delay to get a replacement.
Some have advocated for estimates of and discussions about anticipated
surgical duration during the surgical “timeout”. We think that is too late and
not the best opportunity for that discussion. Rather, we recommend that the OR
team, during the presurgical huddle/briefing, 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 might
be wise to avoid nerve compression, compartment syndrome, or rhabdomyolysis. 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!)
In our July 22, 2014
Patient Safety Tip of the Week “More
on Operating Room Briefings and Debriefings” (and other columns) we
noted some of the issues that might be discussed in a pre-op briefing/huddle
(plus we’ve added some questions that came from last week’s column “Iatrogenic
Burns in the News Again” on iatrogenic burns related to warming
devices):
But beware you don’t make the process too complicated. Your
pre-op briefing should probably take no more than about 2-3 minutes. Be sure to
customize them. A briefing for an orthopedic surgery case is likely to be
significantly different than one for a gynecological procedure.
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 and more often as the case
approaches the average duration for similar cases). 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).
In our August 26,
2014 Patient Safety Tip of the Week “Surgeons’
Perception of Intraoperative Time” we noted 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:
See our prior columns on huddles, briefings,
and debriefings:
References:
Travis E, Woodhouse S, Tan R, et al. Operating theatre time,
where does it all go? A prospective observational study. BMJ 2014; 349: g7182
http://www.bmj.com/content/349/bmj.g7182.full.pdf+html
Kim JYS, Khavanin N, Rambachan A, et al. Surgical Duration and Risk of Venous
Thromboembolism. JAMA Surg 2014; Published online December 03, 2014
http://archsurg.jamanetwork.com/article.aspx?articleid=1984239
Golebiowski A, Drewes
C, Gulati S, et al. Is duration of surgery a risk factor for extracranial complications and surgical site infections
after intracranial tumor operations?
Acta Neurochirurgica
2014; Date: 02 Dec 2014
http://link.springer.com/article/10.1007%2Fs00701-014-2286-3
Kim BD, Hsu WK, De Oliveira GS, et al. Operative Duration as
an Independent Risk Factor for Postoperative Complications in Single-Level
Lumbar Fusion: An Analysis of 4588 Surgical Cases. Spine 2014; 39(6): 510-520
Pearson A. Duration of Surgery: Independent Risk Factor for
Complications? The Spine Blog March 28, 2014
http://journals.lww.com/spinejournal/blog/SpineBlog/pages/post.aspx?PostID=324
Canet J, Gallart
L, Gomar C, et al. Prediction of Postoperative
Pulmonary Complications in a Population-based Surgical Cohort. Anesthesiology
2010; 113(6): 1338-1350
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 American College of Surgeons 2010; 210: 60-65
http://www.journalacs.org/article/S1072-7515%2809%2901411-2/abstract
Delaney RA, Freehill MT, Janfaza DR, et al. Neuromonitoring
the Latarjet Procedure. Journal of Shoulder and Elbow
Surgery 2014; 23(9): e229–e230 Published in issue: September, 2014
http://www.jshoulderelbow.org/article/S1058-2746%2814%2900287-0/abstract
Bradley BM, Griffiths SN, Stewart KJ, et al. The Effect of
Obesity and Increasing Age on Operative Time and Length of Stay in Primary Hip
and Knee Arthroplasty. J Arthroplasty
2014; 29(10) 1906–1910
http://www.arthroplastyjournal.org/article/S0883-5403%2814%2900399-4/abstract
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