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Rationale, aims and objectives A range of strategies have been proposed to identify and address operating theatre delays, including preoperative checklists, post-delay audits and staff education. These strategies provide a useful starting point in addressing delay, but their effectiveness can be increased through more detailed consideration of sources of surgical delay.
Method A qualitative, observational study was conducted at two Australian hospitals, one a metropolitan site and the other a regional hospital. Thirty surgeries were observed involving general, vascular and orthopaedic procedures which ranged in time from 20 minutes to almost 4 hours. Approximately 40 hours of observations were conducted in total.
Results The research findings suggest that there are two key challenges involved in addressing operating theatre delays: unanticipated problems in the clinical condition of patients, and the capacity of surgeons to regulate their own time. These challenges create unavoidable delays due to the contingencies of surgical work and competing demands on surgeons' time. The results also found that surgical staff play a critical role in averting and anticipating delays. Differences in professional authority are significant in influencing how operating theatre time is managed.
Conclusions Strategies aimed at addressing operating theatre delays are unlikely to achieve their desired aims without a more detailed understanding of medical decision making and work practices, and the intra- as well as inter-professional hierarchies underpinning them. While the nature of surgical work poses some challenges for measures designed to address delays, it is also necessary to focus on surgical practice in devising workable solutions.
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Operating theatre delays have a significant impact on the delivery of efficient and high-quality medical care in hospital settings. While not all delays affect patient health, they can increase anxiety for patients and their families and contribute to frustration and additional workload for theatre staff [1,2]. They also add to the total cost of surgical services [3,4] with potentially serious implications for already stretched hospital budgets.
The existing literature on surgical delays focuses predominantly on identifying sources of delay as well as what can be done to avoid them in the future [1–3,5–9]. Delays are frequently traced to a variety of system and human factors including equipment failure, problems with getting the patient into the operating theatre on time, lack of preparedness of patients, inappropriate preparation of patients, waiting for specialized equipment (e.g. radiography machine), alteration of lists to accommodate emergency or priority patients, unavailability of the surgeon and/or anaesthetist and by communication errors among theatre staff.
On the surface, while it may seem logical to address the causes of delay through measures designed to affect system and human inputs (such as more accurate scheduling of operations, and better team communication and organization) [2,5,8], we believe that the development, implementation and evaluation of effective strategies in the organization of services must be underpinned by more detailed scrutiny of (i) sources of delay that may be problematic to address; and (ii) how staff respond to, manage or seek to avoid delays altogether. Individual use of time in hospitals is organized within a broader temporal structure in which different professional groups coordinate their work and ascribe meaning to their activities . While cooperative work is built around the temporal organization of the world , time is also structured by, and negotiated through, everyday practice . Focusing on sources of delay that may be difficult to address through standardized strategies as well as the existing ways in which medical staff respond to or avert them contributes to an improved insight into those circumstances where external interventions to address delays are feasible and desirable.
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This paper draws upon observational data from a larger study which originally aimed to replicate research conducted by Lingard and colleagues [8,9] on team communication failure in operating theatres. As our observations were conducted, it became evident that many communication exchanges were concerned primarily with the use of time and timing in the theatre. As a consequence, we constructed and implemented a sub-study designed to address issues associated with timing and delay.
Our main method of data collection and analysis – observational research – is widely recognized as a rigorous method of qualitative inquiry, which is illustrated in the growing body of research that uses observational methods to examine team communication and reporting in clinical settings [13–17]. Observation ‘entails the systematic noting and recording of events, behaviors, [and] artifacts (objects) in the social setting chosen for study’. Researchers seek out patterns of behaviour, as well as being attentive to difference and discontinuity so as to avoid seeking a singular truth about what ‘really’ happened .
We observed 30 surgeries from two Australian hospitals, one a metropolitan site and the other a regional hospital. Approximately 40 hours of observations were carried out involving cases in general, vascular and orthopaedic surgeries. Observations varied in length, with the shortest lasting approximately 20 minutes and the longest almost 4 hours. The observations are summarized in Table 1. Not all observed procedures involved delays. Equally it is not possible to discuss all observed delays in this paper. Hence, examples of the types of delays observed are documented in the following sections.
Table 1. Characteristics of surgeries observed
|Observation||Research site||Procedure||Approximate duration (minute)||Delay observed?||Nature of delay|
| 1||Metropolitan||Left arm fistula||70||Y||US|
| 2||Metropolitan||Left arm fistula||40||Y||CE|
| 3||Metropolitan||Left lower leg amputation||65||Y||DP|
| 4||Metropolitan||Live kidney transplant (donor)||220||Y||CE, PA|
| 5||Metropolitan||Left arm fistula||70||Y||RU, DP|
| 6||Metropolitan||Live kidney transplant (recipient)||180||Y||DP|
| 8||Metropolitan||Laparoscopic colosectomy||60||N|| |
| 9||Metropolitan||Catheter insertion||65||Y||CE|
|10||Metropolitan||Live kidney transplant (recipient)||135||Y||US|
|12||Metropolitan||Cubital AVF||60||N|| |
|13||Metropolitan||Laparoscopic nephrectomy||140||N|| |
|16||Metropolitan||Live kidney transplant (recipient)||120||N|| |
|17||Regional||Partial mastectomy||70||N|| |
|19||Regional||Partial mastectomy||75||N|| |
|21||Regional||Open reduction and internal fixation for fibular fracture||30||N|| |
|22||Regional||Partial toe amputation||30||N|| |
|23||Regional||Total knee replacement||90||N|| |
|24||Regional||Partial mastectomy||45||N|| |
|25||Regional||Replacement of cast on patient's right arm||20||N|| |
|26||Regional||Total knee replacement||70||N|| |
|27||Regional||Hardware removal from tibia||70||N|| |
|28||Regional||Total mastectomy||135||N|| |
The research was approved by the Monash University Standing Committee on Ethics in Research Involving Humans and the Human Research Ethics Committees of the participating hospitals. All participants (patients, surgeons, nurses and theatre staff) gave their informed consent for the research to take place.
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Delay is an endemic feature of operating theatre work that contributes to inefficiencies in the use of surgical time. Yet, caution is required in prescribing standardized strategies. First, this paper shows that some types of delays are more problematic to address than others. The temporal flexibility of clinical work as well as variations in the condition of patients contributes to delays that may be unforeseeable or unavoidable. These types of delay create problems for efficient use of operating theatre time, but cannot easily be addressed through measures such as checklists or staff education. Significantly, as we found in observation 7, it may in fact be undesirable to address some delays because they have positive outcomes for the quality of medical care, such as ensuring that all risks are properly assessed before proceeding with an operation. Second, while certain aspects of surgical work might contribute to delays, medical staff play a central role in managing and avoiding delays. The existing literature assumes that the avoidance of delays requires measures to be developed and implemented that alter the behaviour of operating theatre staff so that they use their time more efficiently. This paper argues, in contrast, that strategies should focus in the first instance on building upon and working with existing work practices and the professional hierarchies underpinning them. There is no doubt that external interventions will continue to be important in addressing delays. Yet, these are unlikely to fully achieve their desired aims without closer scrutiny of why some types of delays are difficult – or indeed undesirable – to address, and the everyday practices used by staff to manage them.