S. N. Wythe1, K. T. Anderson1,2, M. A. Bartz-Kurycki1,2, D. N. Supak1, R. F. Martin1, G. M. Garwood1, R. Gutierrez1, A. L. Kawaguchi1,2, M. T. Austin1,2, K. P. Lally1,2, K. Tsao1,2 1McGovern Medical School, University Of Texas Health Sciences Center At Houston,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Houston, TX, USA
Introduction: Delays in surgery impact patient care and resource utilization. Operating room (OR) delay metrics are often defined when the patient enters the OR, but may not reflect in-room inefficiencies prior to incision. We hypothesized that low adherence to the pre-induction surgical safety checklist (SSC) may be associated with pre-OR delays or longer pre-incision times.
Methods: An observational study of a convenience sample of scheduled, elective pediatric surgical cases in a tertiary care children’s hospital was performed over a 12-week period by trained observers. Specialties included general and thoracic, urology, neurosurgery, ophthalmology, orthopedics, otorhinolaryngology (ENT), and plastic & reconstructive surgery. Performance of the pre-induction checklist in the pre-operative area between nursing staff, anesthesia staff and patient/parents was observed. Degree of adherence to the pre-induction SSC was the proportion of checklist items completed. Pre-OR delays are institutionally defined as cases in which the patient enters the OR more than 5 minutes after scheduled case start. Pre-incision time was calculated as the difference between scheduled case start or room entry, whichever occurred first, and incision time. Cases were classified by scheduled order in the day (first start vs. later case). Descriptive statistics, chi2, t-tests, ANOVA and linear regression were performed. Inter-rater reliability was determined before the start of study using Cohen’s kappa.
Results:Interrater reliability for SSC performance was 0.70 (95%CI 0.68 – 0.72) for 5 observers. Of the 197 observed cases, 33% had pre-OR delay. Median total pre-incision time was 38 minutes (IQR 23-52). Median pre-induction adherence was 85% (IQR 69-100%) and did not vary by specialty (p=0.73). Pre-induction adherence to the SSC (p=0.91) and specialty (p=0.17) were not associated with pre-OR delays. First cases of the day were more likely to be on time (p<0.01). Longer total pre-incision times were associated with specialty (p<0.01) and worse pre-induction checklist adherence (p<0.01). After adjustment for specialty, case order, and adherence to SSC, first cases (p<0.01), ENT specialty (p<0.01), and higher pre-induction checklist adherence (p<0.01) remained associated with shorter pre-incision times (figure).
Conclusion:While pre-OR delays are tracked and audited, total pre-operative time, including time in the OR prior to surgery is not usually captured. Trying to achieve one metric of timeliness and efficiency may drive the necessary preparations to the OR, where costs may be higher. Pre-operative readiness may be reflected by meaningful pre-induction SSC performance and better measured by total pre-operative time.
