TURNOVER

A frequent complaint by surgeons is that slow turnovers between cases cause significant delays in completing the surgery schedule.^[7] One of the issues that leads to confusion with room turnover is the perception of what

TABLE 86-6 -- Delays in start of first case of the day

Surgeon controlled	45%
Patient controlled	23%
Anesthesia controlled	17%
Nurse controlled	15%

TABLE 86-7 -- Reasons for surgeon-controlled delays

No history and physical examination in chart

No consent obtained

Ordered new laboratory test; results not available

Changed schedule order or procedure

Surgeon not available

constitutes turnover. A surgeon may believe that surgical "downtime," or the time when the incision is closed on the first patient until the beginning of the incision on the next patient, is turnover. Academic surgeons frequently assume that the time between when they leave the OR before the incision is closed (by a junior resident or medical student) until they are called back in for the beginning of the next case is turnover. The OR nurse may consider turnover as the time from removing the used equipment from the first case until the equipment is in place for the next patient. Unless everyone agrees on what turnover is, it is difficult to measure and create improvements in this area of OR function.^[28] The AACD glossary (see Appendix 2 ) defines turnover as the time from when one patient is moved out of the OR until the succeeding patient is moved in. This turnover time applies only when the second case is scheduled to immediately follow the first case.

The period when the OR is empty between patients is a very busy time. The nurses have used instruments to return to decontamination processing. A housekeeping service must clean the OR floors and wipe down all surfaces, including the OR table. Nurses must assemble and organize equipment for the next case. They may also be required to check on the next patient and verify that the paperwork is completed and the procedure is correctly listed. The anesthesiology team is likewise very busy. They must transport the first patient to the PACU, assess vital signs, give a report to the PACU nurse, and submit any required paperwork for the case. Drugs must be checked back in and new drugs obtained for the next case. The anesthesiology team must ensure that the anesthesia equipment is replaced and ready for the next patient. Then they must see the next patient and complete any preoperative paperwork, obtain consent forms, discuss anesthesia plans with the patient, and answer questions.

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A key factor that affects turnover time is the distances between the OR, PACU, and same-day surgery/holding room. The preoperative area must have patients ready on time and have all required paperwork and preoperative test results ready. The drug management system must be efficient to permit access to new medications, as well as manage controlled substances. An organized turnover team to clean up and get the OR ready for the next case is essential. Key factors to decrease turnover time are found in Table 86-9 . Turnover times are also dependent on the type of surgical procedure being performed. The complexity of room setup and the need for patient preparation greatly affect room turnover ( Table 86-10 ). ^[29] There is no nationally agreed-on time for acceptable turnover. When performing turnover between simple procedures, such as cataract extractions, the turnover time may reasonably be 10 minutes. However, when performing turnover between heart bypass procedures or complex orthopedic cases, 45 minutes or longer may be required. Setting a goal for 20- to 30-minute turnovers for most cases seems to be reasonable. I would note that in most facilities, turnover represents only 10% to 20% of the total case time. Although reductions in turnover times may save 5 to 10 minutes per case, these time savings do not usually translate into large reductions in time for completing a single OR's schedule. However, reducing turnover time does create a mindset of efficiency and focus on throughput, which may translate to improvement in surgical preparation and case completion times. Turnover may be most important as a symbol of team organization and focus on achieving maximal OR throughput.

Excessive focus on turnover time is like beating a dead horse. More time is lost complaining about issues and strategizing for solutions than can be realistically gained and used for other purposes.^{[30] [31]} There is no magic number. Turnover time is also a favorite topic of consultants because it tends to strike an emotional chord with

TABLE 86-10 -- Average turnover times

Total-hip replacement	44 min
Total-knee replacement	46 min
Knee arthroscopy	38 min
Coronary artery bypass	52 min
Laparoscopic cholecystectomy	30 min
Cataract extraction	21 min

surgeons and hospital administrators. In reality, most efforts to reduce turnover times result in very modest reductions in completion of the surgical schedule.^[31] If an OR performs four cases in a day and can reduce turnovers by 10 minutes, the total time that can be saved is 30 minutes (3 turnovers × 10 minutes = 30 minutes). This small time savings may result in reduced overtime expenses and improved satisfaction measures, but it is not likely to provide sufficient time to perform additional cases.^[32] Some benchmarking data have been published on turnover for specific procedures.^{[29] [31] [32] [33] [34]} A recent review at four academic institutions indicated that turnover times ranged from 34 to 66 minutes.^[31] This information should be considered when an institution looks at its own specific turnover data to determine realistic goals for OR improvement.