Disruption to the anaesthetic work during the preoperative phase (POP) of surgery delays surgery or unnecessarily prolongs the time the patient spends in the operating room.1 Although some of the evidence is descriptive,2 we know that disruption can affect patient safety and is a problem in the operating room.3–5 Many incidents are because of controllable factors such as poor care co-ordination. Such preventable disruptions may be minor, such as a telephone call, but if allowed to accumulate they increase workload,4,6 create stress and fatigue and pre-dispose to error.7–9
Previous studies have described disruptions in operating rooms and have developed tools to assess them.10,11 Other studies have attempted to reduce the ergonomic deficiencies that cause disruption.12–15 Some have measured the impact of disruption during operating room turnover time,16 non-operative time,17 operative time for minimally invasive surgery18 and intra-operative processes.1,10,11,19–21 Recent studies have identified disruptions during anaesthesia induction, and also during the perioperative pathway from anaesthesia room to recovery,22–25 whereas others have investigated the impact of disruptions on time efficiency in the operating room. Al-Hakim and Gong26 provided a prospective assessment of the impact of disruption on operative time, whereas Gillespie et al.27 assessed actual vs. expected operative time (as judged by operating surgeons), and linked these to intra-operative disruptions. Healey et al.21 found that interruptions added an average of 6 min to each case.
This study aimed to, first, systematically investigate the time added to anaesthetic work through disruptions during pre-anaesthesia, anaesthesia induction and patient positioning, and second to identify specific care co-ordination problems causing disruption.
Study design and setting
This was a prospective observational study of disruption occurring during pre-anaesthesia, anaesthesia induction and patient positioning stages, in the preoperative phase of care (POP).
Observations were conducted in two Australian hospitals; one a community hospital (eight operating rooms) and the other a large metropolitan teaching hospital (22 operating rooms); two hospitals in Thailand (community hospitals, 18 operating rooms); and one hospital in China (teaching hospital, 16 operating rooms). These hospitals were selected based on availability. Owing to the descriptive nature of the study and the small number of hospitals overall, we did not have, nor did we test, specific hypotheses about cultural, organisational or other differences between hospitals and countries.
Definition of disruption and care co-ordination
We defined disruption as any undesirable event that is either not part of the planned process, or a failure to implement the process as planned. The perioperative pathway comprises a chain of inter-related activities, which should be performed in a timely sequence; they should be co-ordinated. A disruption in one part of the pathway may disturb the work in other parts, for example, the transfer of a patient from the ward to the anaesthetic room for induction without case notes disrupts the process. We use the term ‘care co-ordination’ to refer to instances of synchronisation and integration of work across the perioperative pathway – including between different hospital departments, teams and individuals. In this study, we took a bottom-up approach and elicited the views of clinical experts to inform our thinking about care co-ordination problems and lapses that were associated with subsequent disruption to anaesthetic work (see study procedure).
Ethical approval for this study was provided by the Human Research Ethical Committee of the Toowoomba and Darling Downs Health Service District, Queensland, Australia (Human Research Ethical Committee No. TDDHSD HREC 2007/027) on 3 July 2008. Participating hospitals approved the study internally.
The research procedure comprised three stages; observer training, process mapping and observation.
Two observers carried out the observations. The first observer (L.A.H.) has an industrial engineering background with more 40 years of experience in human factors and system analysis in industry and academia. In the Australian hospitals, the second observer was a postgraduate student with human factors training. In the Thai and Chinese hospitals, the second observer was an experienced operating room nurse. All observers underwent training to ensure uniformity and assure the quality of the observations. The observers first reviewed the available literature on type and magnitude of disruptions in operating rooms. For training purposes, all observers conducted preliminary training observations in operating rooms under the supervision of a consultant anaesthetist. The anaesthetist explained the surgical care pathway to the observers and explained to them what they were observing (from pre to postoperative phases). The anaesthetist also arranged for the observers to meet and discuss disruptions in the operating room with a team of senior surgeons and scrub nurses to further improve the observers’ understanding of disruptions and their causes. The training lasted 6 weeks – during which the observers were trained 3 days per week and observed a total of 12 full procedures. The last five of these were analysed and showed high consistency between observers in identifying disruptive events, their effect on surgical flow and in identifying the problems causing the disruptions.
Expert derivation of care co-ordination problems
The research team met with a liaison officer, two to three operating room nurses and at least one consultant surgeon and one consultant anaesthetist in each hospital. The liaison officers were staff members (usually operating room administrators) allocated by the hospital to liaise with the study team in terms of study approvals and access to operating rooms. They accompanied observers, introduced them to teams and arranged meetings. The first meeting was conducted to discuss how the perioperative flow process breaks down into activities. Subsequent meetings followed an iterative pattern: the first part of the meeting was used to review and revise the process chart completed as a result of information collected from the previous meeting; sub-processes and activities for POP were highlighted for further analysis.
To gain insights into potential care co-ordination problems linked to disruption we interviewed senior anaesthetists, surgeons and nurses as well as surgical service managers at each hospital. The interviews were semi-structured, lasted approximately 20 min each, and were carried out at a place and time convenient to the participant. The interviews were intended to identify causes of preventable disruption during POP. Experts were asked to consider their practice of operating room working and to identify where bottlenecks appear preoperatively; what disrupts patient flow, what causes delays or safety concerns, and what they consider to be the origins of these problems and concerns. The interviewer (L.A.H. in all cases) took notes in real time, which were subsequently submitted to simple content analysis,28 alongside the process charts that we obtained in this phase, to provide the categories of care co-ordination problems that the observers linked to disruption during POP.
The liaison officer obtained the operating list, introduced the observers to patients and staff and explained the purpose of the observation and the anonymity of staff and patients. The observations covered the time taken for POP, starting from the patient being ready for pre-anaesthesia and ending when the patient was ready for incision. The observed events were recorded on a structured proforma divided into fields showing the type, the start time and the end time for each recorded event, which were manually recorded by the observer. Table 1 reports the categories of disruption that were assessed and their definitions. For practical purposes the time taken as a result of a disruptive event was measured manually in 15 s intervals.
Upon completion of each procedure, the observers reviewed the disruption and their causes with the study liaison officers and with a member of the operating team if clarification was needed. Data were subsequently entered into a spreadsheet for analysis.
Care co-ordination problems leading to disruption: expert views
Sixteen consultant anaesthetists and surgeons and 13 senior operating room nurses (Table 1) were interviewed. Similar preoperative care co-ordination problems were found across all three countries. Participants highlighted the importance of having timely co-ordination between the operating room team and preoperative staff as well as with the operating room management team. Accurate and available communication and information flow, written and verbal, between different departments was mentioned as a key contributor. They further emphasised the importance of team briefings immediately before surgery to minimise disruption later within their own teams and also in postoperative care, but were doubtful about the effectiveness of the current briefing practices across all study hospitals.
Through our content analysis, the following care co-ordination problems were derived:
- Co-ordination between surgical department and other departments prior to POP;
- Co-ordination between operating room administration and management services other than the surgical department prior to and during POP;
- Co-ordination within the preoperative team that receives and prepares the patient immediately prior to surgery, and between preoperative and operating room teams prior to and during POP;
- Co-ordination within the operating room team during POP.
These were based on the ‘bottlenecks’ and problems identified by the subject matter experts. Their views on the origins of these were reviewed and further defined into the four care co-ordination problems based on our extensive experience in perioperative pathways. The disruption that may occur during POP and the associated care co-ordination problems identified from these interviews together with our analysis are described in the Appendix, http://links.lww.com/EJA/A97.
Descriptive information and demographics of observed procedures
Data during POP for 64 observed procedures were analysed, of which 55 had complete datasets. Some cases were excluded because of unexpected termination of anaesthesia induction, patient complexities and incomplete data collection. Thirty-three cases were observed in Australian hospitals (21 in urban/teaching and 12 in regional/community hospitals), 10 in Chinese hospitals, and 12 in Thai hospitals (Table 1). Procedures were elective including general, oncological and urological surgery, and carried out under general anaesthesia with a senior consultant or attending-level physician for both surgery and anaesthesia. At least one senior scrub nurse with anaesthesia and surgical assistant were present during POP. At the time of the data collection, all study hospitals had a local version of the WHO Surgical Safety Checklist implemented alongside their normal perioperative protocols. Anaesthesia was carried out in rooms adjacent to the operating room in the Australian hospitals and within the operating room in the Chinese and Thai hospitals. Patient positioning for the majority of observed procedures was standard or modified supine position (n = 32). Other positioning included seven cases with lateral positioning, six with prone position, six with lithotomy and four with the Fowler position. In terms of clinical procedures, average POP duration ranged from approximately 15 min for supine positioning to 26 min for Fowler positioning. Owing to the ethical approval requirement, no further patient or procedure-level data, or team-level data were collected from these cases.
Percentage (%) agreement was used to measure the consistency within pairs of observers (inter-observer reliability) in the number of incidents they recorded and their type. A high level of agreement was obtained in the number and type of disruptive events ranging from 84 to 92% across hospitals. Good agreement was also obtained for the care co-ordination problems that led to disruption as attributed by the observers (range 74 to 87% across hospitals).
Per case observed, we recorded a median of three disruptions during POP (minimum = 2, maximum = 9). Disruptive events resulting from staff activities (the third type of disruption defined in Table 2) prolonged the POP period more than others (Table 3); on many occasions such activities involved corrections that needed to be made. Examples include having received the wrong or faulty attachment necessary for patient positioning on the table, discovering a fault in the anaesthesia equipment during POP, and reconfiguring lines. Although in most cases these activities took approximately 1 min, staff-related disruption added in some cases extra 3 to 5 min per patient. Disruption because of team activities, mainly what we defined as ‘team participation’, had the second largest impact on time taken, adding just under 1 min per patient and on some occasions up to 2.5 min; these were largely because of staff such as the surgeon or assistants, being absent and delaying proceedings. We also observed some variation in the time taken by disruptive events depending on the care co-ordination problem that triggered them (Table 4). Approximately 1 min per patient on average was added to the POP time because of disruption within the operating room team themselves or in their interaction with the preoperative team. Examples of such disruptions include wrong instrumentation available (a disruption within the operating room team), or delay in moving a patient to operating room as a result of miscommunication between the operating room team and the preoperative team. These two types of co-ordination lapses also had the maximum impact on POP duration, as they were found to add between 3 and 5 min to the POP duration.
The study extends our overall understanding of the impact of disruptive events on perioperative care – specifically the preoperative stage of care, from pre-anaesthesia to anaesthesia induction and subsequently patient positioning for surgery. Across operating rooms in three countries, we found an average of three disruptive events per case. Disruptive staff activities were associated with most time-wasting (on average 1 min, but up to almost 5 min per case). We were also able to elicit specific lapses in care co-ordination (from experienced operating room personnel), to which we subsequently linked these disruptions. Co-ordination lapses within the operating room team, and also between the operating room team and the preoperative team who receive and prepare the patient for surgery, were associated with most timewasting (on average 1 min each, but up to 5 min per case).
These findings are perhaps not surprising – disruption and interruption to care delivery have been described as being ever present not only during POP but also during surgery and the postoperative period.1,3–5,10,11,19–25 What this study offers is a time-based, objective analysis (within the limits of the human observers’ capabilities) of the added inefficiencies of such events: they simply add time to the procedures. This has implications for overall perioperative efficiency. The study illustrates that co-ordination lapses within the operating room team as well as between the operating room team and the preoperative team are the biggest contributors to timewasting. These disruptive events were preventable, adding evidence that better teamwork is required not only to enhance patient safety, as most of the literature shows,29 but also to improve efficiency in perioperative care. The staff-related disruption and associated timewasting that we found was often related to equipment – lack of availability, wrong equipment or malfunctioning equipment. Equipment-related problems in operating room are well established;30 they cause significant levels of disruption, which we show here is linked to inefficiency. Such problems can be reduced via better planning and checking, as shown in a recent systematic review.30 The operating room team often find themselves addressing problems which they should not be faced with at that time, typically when the patient is being readied and put to sleep. There is, therefore, an organisational element to operating room team working; for the operating room team to function efficiently problems upstream from the operating room need to be addressed.
It could be argued that there is another aspect to our dataset – namely the teams we observed may be showing signs of resilience by addressing problems as they arise, thus reinforcing the reliability of the perioperative pathway.31 This is certainly an interesting argument, but somewhat problematic when applied to the extent that we found. We found numerous incidents, which could have been avoided. The perspective we took was based on ergonomics and process optimisation, which addresses inefficiency.32,33 The teams did think ‘on their feet’ – they did not have any alternative. Our argument is that the potential level of inefficiency and disruption in the operating room may not be ideal. We would further propose that if avoidable disruption becomes minimised then operating room teams would have more ‘mindspace’ (cognitive capacity) to respond to complexities and pressures requiring true team resilience. Further research should test this proposition.
The study has limitations. It can be argued that the number of observations is relatively small and selective, and the results may not be generally applicable because we may have gravitated toward a more uniform caseload, where time efficiency may be less critical than in emergencies. We also relied on human observers mechanically allocating time measurements. In addition we included an element of qualitative, thematically analysed data, which inevitably carry a possibility of bias through participants’ own and our research team's subjective perspectives. The study also has strengths that include the combination of qualitative and quantitative measures across three countries, the multidisciplinary, clinical and ergonomic, perspective on the research question and the trained observers.
The study quantifies time inefficiencies affecting anaesthetic work during POP. We found an average three disruptive events affecting POP per case. Disruption involving personnel caused most timewasting, adding an average 1 min per disruption per case to the work. Such disruption has an impact on operating room efficiency, and can subsequently affect safety; it can be reduced.
Acknowledgements relating to this article
Assistance with the study: the research was part of a project titled ‘Adapted lean thinking for healthcare services’ (LAH). The authors gratefully acknowledge the thoughtful time of Queensland Health Project Liaison Officers and the staff and surgical teams working in the operating rooms of the study hospitals for their willingness to participate in the study and discuss its outcomes.
Financial support and sponsorship: the project has been partially sponsored by the University of Southern Queensland, Australia.
Conflict of interest: NS is the director of London Safety and Training Solutions Ltd, which provides safety and team training and advisory services on a consultancy basis.
SA is affiliated with the Imperial Patient Safety Translational Research Centre (www.cpssq.org), which is funded by the National Institute for Health Research (NIHR), UK. N.S.’ research was supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South London at King's College Hospital NHS Foundation Trust. N.S. is a members of King's Improvement Science, which is part of the NIHR CLAHRC South London and comprises a specialist team of improvement scientists and senior researchers based at King's College London. Its work is funded by King's Health Partners (Guy's and St Thomas’ NHS Foundation Trust, King's College Hospital NHS Foundation Trust, King's College London and South London and Maudsley NHS Foundation Trust), Guy's and St Thomas’ Charity, the Maudsley Charity and the Health Foundation. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.
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