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Department of Human Services

ToolkitOperating Theatres

A toolkit of the Patient Flow Collaborative

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Toolkit Operating theatres


Introduction

Goals of the toolkit

Overview and strategy

Health service team

Processes

Data

Resources

Diagnostics and tools

Introduction

What is the operating theatre toolkit for?

The operating theatre toolkit has been designed to develop organisation wide strategic management of current operating theatre services and promote best practice.

Who should use the toolkit?

The toolkit will promote discussion and innovate solutions around possible present constraints. Anyone with responsibility for effective theatre utilisation will benefit from this tool.

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What are the aims of the toolkit?

The patient flow collaborative aims to remove unnecessary constraints or delays in the patient process. It is recognised that operating theatre utilisation will deliver effective and efficient service to aid patient flow.

How should the concepts be implemented from this toolkit?

Local theatre innovation teams should discuss tools and concepts adapting these to their local context.




Introduction

The operating theatre toolkit is based on whole system thinking and includes a whole of hospital perspective on effective and efficient theatre utilisation.

Goals

Key elements to efficient use of operating theatres are:

• Effective management

• Good communication

• Well trained staff

• Appropriate facilities and equipment

• Operational layout that allows flow of patients.

Support services play a large part in maximising efficiency by providing:

• Pre-operative preparation and assessment

• Available beds

• Sterile theatre equipment

• Portering, cleaning and maintenance staff.

Effective planning and scheduling systems will enable smooth patient flow thus increasing capacity, improving patient and carer experience, improved employee satisfaction and morale.

Your feedback

Feedback on this first version of the operating theatre toolkit is welcome and will be used to update subsequent versions.

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Introduction



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Processes

Data

Resources


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Theatre Management structure

Planning patient pathways

Staffing

Operating list management

Effective use of theatre time

Theatre design

Trauma and emergencies

Postponements

Key elements

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Introduction



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Processes

Data

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Staffing



Theatre design


Postponements


Day to day management should be provided by an experienced trained and skilled theatre manager, who is responsible for clear communication, ensuring competent staffing and suitable equipping of all theatres. Suitable systems for planning activity should be available to allow allocation of staff, and to respond safely and flexibly when changes take place to routines. Policies should be developed to deal effectively with changes to operating lists. Operating lists should be clearly posted well in advance and in suitable locations. Theatre management team should regularly review utilisation, cancellations, list overruns, late starts and waiting lists.

Theatre management structure

Theatre management structure should be clearly defined with accountability for:

• Full budgetary authority

• Adequate sessional allowance

• Information systems

• Utilisation

• Administrative, medical and nursing staff.


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Staffing



Theatre design


Postponements

Planning patients pathways

Patients pathways should take into account ways to maximise use of theatres and bed availability. Patients admitted to pre-operative units can be transferred to wards following surgery allowing time for discharge of previous patients.

Integration of pre-operative assessment and day case recovery area located adjacent to theatres provides an efficient use of space, skilled staff and may aid patient transport to and from theatres. This scheme also reduces time on ward rounds for surgeons and anaesthetist as patients are in one place.



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Staffing



Theatre design


Postponements

Staffing

Staffing

• Anaesthetic departments should provide a system of staffing that works locally and is acceptable to staff

• Department staffing should match clinical activity, with sufficient cover for elective and emergencies

• Robust systems for booking leave must be in place and owned by all, with an advertised leave policy

• A lead anaesthetic consultant should be identified to support the theatre management team and trainees

• Adequate orientation of new or locum staff should be made a priority

• Adequate staffing should be available to cover governance tasks of note recording and data entry.


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Staffing



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Postponements



• Close communication and coordination between pre-op area and theatre using agreed procedures is essential

• A nominated person should liaise with wards and transport staff from theatres

• A suitable holding area staffed and equipped will assist with smooth flow

• Agreement should be made for preparation and transport of patients to and from theatres

• Policies on fasting, anticoagulation, shaving, dentures, jewellery, appropriate underwear and removal of make-up should be developed

• Units should agree the level of training needed to escort patients to and from theatres

• A documented system of handover and identification of patient should be in place

• A system to book critical care beds for elective admissions should be in place and booking confirmed before anaesthesia for surgery.


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Staffing



Theatre design


Postponements



It is important that all theatre lists start and finish at the agreed time. Agreement should be made to make this possible.

• Realistic scheduling of theatres will prevent cancellations

• All day theatre lists have proven efficient, within the synchronising of surgical and anaesthetic

time and staffing

• Good time keeping principles should be adopted and monitored by the theatre management

team

• Pro-active re-allocation of cancelled theatre lists.


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Staffing



Theatre design


Postponements

Theatre design

Theatre design and operational layout

Design of operating theatres is essential for maximising patient flow, consideration needs to be made for:

• Large multi-purpose accommodation to enable increase in complexity and equipment

• Transport routes that flow through stages of theatre care

• Internal communication IT systems that facilitate appropriate communication and supervision.


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Postponements


Good communication enables clinical decisions to be made rapidly, increasing the number of surgical procedures carried out in a safe time and environment. Time should be allowed for the Anaesthetist to assess emergency patients to their satisfaction. Experienced surgical staff should prepare patients who have multiple and complex medical problems, this can prevent cancellation at anaesthetic assessment. Pre-operative assessment for patients who are elderly, have multiple and complex medical problems can benefit from a team approach between anaesthetist, surgeon and physician.

Trauma and emergency surgery

Effective planning for emergency and trauma surgery is needed to prevent cancellation of elective surgery.

Provision of exclusive emergency list will assist in preventing cancelled elective surgery.


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Staffing



Theatre design


Postponements

Postponements

Cancellations of surgery

It is extremely distressing and stressful to patients who are postponed surgery, many cancellations can be prevented by assisting patient flow with good planning in:

• Bed management• Pre-operative assessment• Increased communication

Regular review of cancellation can assist with target areas for redesign and innovation.

Cancellation data should be collected and reviewed weekly with agreed action plans.

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Staffing



Theatre design


Postponements

Health service team

It is essential for operating theatre innovation to have a skilled, trained and committed innovation team. The team should consist of representatives of all theatre staff groups.

Management – clinical/non clinical

Nursing – Pre op and theatres, including operating department practitioners

Clinical – Anaesthetist/Surgeons

Administration – Admin and Portering

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Processes

AdmissionReceive patient to ward following operation

Administration Processes will also need to map demonstrating process from:

Initial recording of overall patient processes should be made covering:

Allocation totheatre list

Theatre reception on day of operation


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Processes

Theatre

Recovery

Home

Theatre

Recovery

Bed

Home

Bed

Theatre

HDU/ITU

Bed

Home

ICU

Theatre

ICU

Bed

Home

Theatre

ICU

Bed

Home

Process map groups

Mapping tipMap high level group first


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Processes

Scheduling

The realistic building of theatre lists start in processes outside of theatre environment, essential validation of how ‘lists’ are made needs to be undertaken to maintain effective and efficient operating theatres. Agreement can be made on average time per procedure to enable effective booking of theatre lists. Average time per operation can be agreed and used to assist building theatre templates.

Case 1

Case 2

Case 3

9.00 am 12.30pm


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Process steps examples

Processes

Step Time per step

Patient transported from ward 5

Patient checked in to theatre 5

Patient taken to anaesthetic room 2

Anaesthetic given 10Patient positioned onto theatre table 5

Surgery completed 40

Patient taken to recovery area 5

Patient in post op 20

Patient taken to ward 5

Theatre hands over patient to ward 5


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Process steps examples

Processes

Step Time per step

Colour code

Patient transported from ward 5

Patient checked in to theatre 5

Patient taken to anaesthetic room 2

Anaesthetic given 10Patient positioned onto theatre table 5

Surgery completed 40

Patient taken to recovery area 5

Patient in post op 20

Patient taken to ward 5

Theatre hands over patient to ward 5


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Build your schedule

Processes

Use graph paper with one square per minute to sequence time scales per procedure.

1 MINUTE102 MINUTES


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Build your schedule

Processes

Transfer graph sequence timescales to chart clinic time.

9.00 am start1.30 pm end

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Data

Core data set

Suggested Measures

• Late Starts (e.g. >15mins) / Early Finishes (e.g. >60mins) / Overruns (e.g. >30mins)

• Example – For ten Orthopaedic sessions with a scheduled start time of 8:30am the sample showed four (or 40%) started >15mins late.

• Number of Major Procedures (>1hr) v Minor Procedures (<1hr) by Specialty

• Average time in theatre by specialty / procedure

• Lost time due by Cancellation reasons e.g. no beds, patient unfit

• Number of patients arriving in theatre with consents not completed by week

• Delays

• Monitor theatre delays for one week to agree on the top 10 reasons for delays. When this is agreed, 4 weeks data will be collected against the top 10 delays. Once 4 weeks of 10 delays have been gathered SPC charts will need to be produced. Time needs to be collected against each reason(s) per day, as the top ten offenders may not amount to the longest waste in time.

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Resources

Aim: To increase the utilisation and quality of care within operating theatres.

Change Concepts • Review operating theatre utilisation (see tool kit)

• Scheduling

• Identify system to report delays daily via agreed criteria

• Remove delays, complexity and hand offs within administration process

• Smooth process from Emergency Department / Inpatient wards to Operating Room and back to ward

• Review stages of Transfer from ward /Emergency Department, recovery to ward

• Review capacity and demand for emergency and elective theatre

• Review role of theatre coordinator and joint work with Pre-Operative and bed management

• Review equipment turn around times via Central Sterilising Services Department and booking of equipment

• Review recovery and transfer procedures – develop appropriate ‘pull’ process to theatre/wardsEnd of section

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1. Operating theatre checklist

2. Delay proforma

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Documents

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