Previous Next

ON-TIME STARTS

Starting the first procedure of the day on time is crucial to setting the tone for how an OR functions. If there is a delay in getting the first case started, it often affects the overall mood and support for performing all the cases in the room efficiently. It is important for everyone to agree what start time means. Surgeons have historically believed that start time is when they make the first incision. Anesthesiologists believe that they have started on time if they have completed induction at the prescribed time. Nurses believe that if the room is prepared and ready, they have done all they can for the start. Obviously, when no one agrees on what constitutes start time, misunderstandings and dissatisfaction with room starts will occur.

In 1996, a group in the AACD published a procedure times glossary that for the first time sought to create a standard for all OR events and time periods. [25] This glossary has now been accepted by the American Society of Anesthesiologists, AORN, and the American College of Surgeons and serves as the standard for descriptive terms in the OR. An excerpt of the glossary may be found in Appendix 2 . The glossary describes start time as the time that the patient enters the OR. Surgeons may complain that if the patient enters the room at the posted start time, they have no idea when the patient will actually be ready for the incision. At our institution we reviewed times from the patient entering the OR to completion of preparation. In uncomplicated cases (patient supine with no invasive monitoring lines), preparation could be completed in 15 minutes in 78% of cases. If the case was complicated (position other than supine, invasive monitors), the duration from start time to completion of preparation averaged 30 minutes. These data were shared with surgeons so that they could anticipate the time from room start (patient in room) until preparation completed.

On-time starts depend on many factors. Patients must arrive at the facility early enough to complete preoperative preparations and to have complied with all preoperative instructions (NPO, medications, laboratory tests). The preoperative/admitting process must be organized and allow sufficient personnel and space to process patients and make them available to surgeons and anesthesiologists. Operating room nurses must have the operating room and equipment ready. Anesthesia personnel must have the equipment in the room checked, drugs


3124

TABLE 86-4 -- Room block guarantees

Operating Room No.

2 3 4 5 6 7 8 9 10 11 12 14 15 16 17 18 19 20 21 22 23
Monday Uro
Ort Uro CTS Ort Neu Ort Gen Gen Gen Ped
Pla Ort Gyn Ent Ent
CTS CTS
Tuesday Uro
Ort Uro CTS Ort Neu Ort Neu Gen Gen
Opt Pla Gyn Gyn Ent Ent Gen CTS CTS
Wednesday Uro
Ort Uro CTS Ort Neu Ort Neu Gen Gen Ort
Pla Ent Gyn Ent Ent Gen CTS CTS
Thursday Uro
Ort Uro CTS Ort Neu Ort Neu Gen Gen Ped Ent Pla Pla Gyn Ent Ent Gen CTS CTS
Friday Uro
Ort Uro CTS Ort Neu Ort Neu Gen Gen
Opt Pla Gen Gyn Ent Ent Gen CTS CTS
CTS, cardiothoracic surgery; Ent, otolaryngology; Gen, general surgery; Gyn, gynecology; Neu, neurosurgery; Opt, ophthalmology; Ort, orthopedics; Pla, plastic surgery; Ped, pediatric surgery; Uro, urology.


3125

TABLE 86-5 -- Suggested block release times
Service Release Time
Cardiothoracic 1 day
Vascular surgery 2 days
Orthopedics 3 days
Neurosurgery 4 days
Pediatric surgery 1 wk
General surgery 1 wk
Gynecology 1 wk
Ophthalmology 1 wk
Otolaryngology 1 wk
Plastic surgery 2 wk

prepared, paperwork completed, and intravenous lines or special needs addressed. Surgeons must be available and have consent, history, and physical examination and any patient questions or needs addressed. All these factors must be completed before the room start can occur. A common misconception by many surgeons is that if a room start is delayed, it is due to anesthesia factors. Many anecdotal reports by OR clinical directors do not support this concept. We recently studied reasons for all delayed room starts and grouped delays into factors controlled by patients, surgeons, anesthesiologists, and nurses. The results ( Table 86-6 ) demonstrate that surgeons controlled the largest number of delays in first starts. Some of the most common reasons for surgeon-controlled delays are listed in Table 86-7 .

Reports of success in starting first cases on time demonstrate that this complex process is a challenge. If the definition of an on-time start is that the patient is in the room by the start time, delays occur in 40% to 90% of first starts.[26] [27] If an on-time start is categorized as the patient in the room within 10 minutes of the scheduled start time, delays still occur in 5% to 50% of cases. Identifying causes of delays, focusing efforts to removing barriers to smooth patient flow, improving communications between preoperative personnel, patients, surgeons, nurses, and anesthesiologists, and creating an atmosphere (culture) of shared ownership in starting on time will improve on-time starts. Other keys for increasing on-time starts are listed in Table 86-8 .

Previous Next