Abstract
Background:
A new preoperative system (SANDPO) was incorporated into our electronic medical record to improve turnover time and patient safety. SANDPO requires the completion of specific tasks by Surgeons (S), Anaesthetists (A) and Nursing staff (N), completion of Documents (D), Patient consent and identification (P) and Operating Room (O, for OR) staff verifications before patients can be taken for surgery. The system was implemented at the same time in our main operating room and the Specialty Care Building, our new outpatient surgical area.
Aim:
Identify the impact of SANDPO on turnover time as a measure of operating room efficiency.
Methods:
Pre- and Post-SANDPO data from our Main (1 October 2021 to 26 August 2023) and Specialty Care Operating Rooms (26 September 2022 to 26 August 2023) were analysed to assess turnover time.
Results:
Compared to Pre-SANDPO, turnover time increased 24.1% in the main operating room and was significantly lower in the Specialty Care versus the main operating room. Adult cases experienced more delays versus paediatric. Simple setup cases showed the largest increases in turnover time.
Conclusion:
SANDPO, introduced by hospital administration to enhance safety, significantly and unexpectedly decreased operating room efficiency.
Keywords
Introduction and literature review
Turnover time (TOT), defined as the time between when a patient leaves the operating room (OR) (‘wheels out’) and the next patient enters (‘wheels in’), is a common metric of operating room efficiency (Athanasiadis et al 2021, Chua et al 2021, Tankard et al 2018). Delays in TOT are due to multiple factors and contribute to patient and staff dissatisfaction (Mansour et al 2021). Hospital operating rooms are major revenue generators for hospital systems; their inefficiency can significantly influence hospital revenue and viability. ORs are often burdened by built-in inefficiencies within the hospital (Athanasiadis et al 2024). To highlight factors causing delays, the ‘bottleneck’ model has been proposed. Factors can include inefficient equipment, supply chains and infrastructure, case complexity, late arrival of patients, insufficient personnel, lack of familiarity of personnel with procedures, miscommunication, slow information flow, disruptions in staff and patient management and perioperative surgical issues, to name a few (Mihalj et al 2022). The first case starts relative to expectations; TOT and operating room utilisation (scheduled time versus actual used time) are among the most typically analysed measures of OR efficiency (Athanasiadis et al 2021, Chua et al 2021, Tankard et al 2018). A variety of strategies related to improving first case on time start percentage, as well as decreasing TOTs have been utilised by OR managers (Beattie 1999, Overdyk et al 1998).
On 26 September 2022, our hospital instituted SANDPO, a new electronic medical record (EMR)-based lettering system in EPIC (EPIC Systems, Verona, WI, USA) in the main operating room (MOR) to improve efficiency. EPIC is also widely used in the United Kingdom (NHS Digital 2023). The SANDPO system was also implemented immediately upon the opening of the Specialty Care Building (SCB), our new ambulatory surgery facility. In the Surgery, Anaesthesia, Documents, Patient and Operating Room (SANDPO) system, surgeons, anaesthetists, preoperative and OR nurses are required to perform and document specific tasks in EPIC before the patient can be moved from the preoperative area to the operating room for surgery. These tasks include completion of the surgical and anaesthesia history, physical exam and consent; verification by the attending surgeon and anaesthetist; preoperative nursing evaluation and preparation; and operating room readiness for surgery.
Our objective was to compare TOT before and after SANDPO implementation in the MOR, and TOT in the MOR versus SCB after SANDPO implementation. We hypothesised that the SANDPO system would provide a standardised workflow to decrease TOTs in both our Main and SCB ORs.
Methods
The study was deemed exempt from full committee review and patient consent by our Institutional Review Board. We studied 16,632 operative cases performed in the operating room at the University of Illinois Hospital (Chicago, Illinois, USA) between 1 October 2021 and 26 August 2023. This allowed for 11 months of data collection before SANDPO (8739 cases), from 1 October 2021 to 26 September 2022, and 11 months of data collection post-SANDPO (7893 cases), from 26 September 2022 to 26 August 2023. Post-SANDPO cases performed in the SCB were collected from 26 September 2022 to 26 August 2023. The SCB Operating Rooms opened for the first time on 26 September 2022. We did not include procedures requiring anaesthesia outside of the OR such as interventional radiology, or obstetrics, because SANDPO was only instituted in the operating room. Measurements included procedure date, type of procedure, procedure complexity, procedure duration, in-room and out of room times and anaesthesia type (monitored anaesthesia care (MAC), Regional Anaesthesia or General Anaesthesia). Cases done on weekends and holidays were excluded to eliminate any impact of the greatly reduced staffing compared to weekdays. Since the last case of the day in a particular operating room had no TOT, that case was not included.
There was some training for personnel before the start of SANDPO consisting of an ‘in-service’, a brief training session for each of the different stakeholders, and a group of OR head nurses were assigned daily to monitor compliance and remind stakeholders to complete SANDPO.
TOT was calculated using Minitab Statistical Software, version 21, Minitab Limited, (Brandon Court, Progress Way, Coventry, UK) using the formula: Elapsed (If(Date(‘In Room Instant’) = Lag(Date(‘In Room Instant’)),’In Room Instant’ − Lag(‘Out of Room Instant’),‘*’)). We eliminated all cases with TOT > 90 minutes due to no-shows and scheduling issues. Data were stratified by patient age, case complexity and type of anaesthesia. The t-tests were performed to determine differences between groups, with p < 0.05 considered significant. Data are shown as median, mean and 25–75th percentiles.
Results
Figure 1 illustrates the time periods and numbers of OR cases included in the study. As shown in Figure 2, implementation of SANDPO in the MOR significantly increased TOT 24.1% from a mean of 42.4 (95% confidence interval (CI) = 42.0-42.7) to 52.6 (95% CI = 52.1-53.1) minutes after implementation of SANDPO (p < 0.0001). In the SCB, mean TOT was 35.4 (95% CI: 34.8-35.9) minutes, significantly lower than the TOT at the MOR both before and after SANDPO was implemented (p < 0.0001).
Timeline and number of cases for SANDPO
Comparison of TOT before and after SANDPO for all cases in MOR and SCB ORs
Differences in TOT were analysed before and after SANDPO for paediatric and adult cases in the MOR. The implementation of SANDPO significantly increased TOT by 26.0% for adult cases from the mean of 42.6 (95% CI = 42.3-43.0) to 53.7 minutes (95% CI = 53.2-54.3, p < 0.0001, Figure 3). SANDPO also increased TOT in paediatric cases by 6.6% from 37.7 (95% CI = 36.3-39.0) to 40.1 minutes (95% CI = 38.7-41.6, p = 0.014, Figure 3). TOT in SCB ORs for adults was 35.3 (95% CI = 34.9-35.9) and 33.3 minutes in paediatric (95% CI = 29.9-36.7) significantly lower than in the MOR post-SANDPO (p < 0.0001 and p < 0.001, respectively).
Comparison of TOT before and after SANDPO for paediatric and adult cases in MOR and SCB ORs
We also compared the TOT before and after SANDPO in the MOR for cases under Regional Anaesthesia, MAC and General Anaesthesia (Figure 4). In all instances, SANDPO significantly increased TOT. Cases performed under Regional Anaesthesia had a 13.1% increase in TOT, from 46.5 (95% CI = 45.1-47.9) to 52.6 minutes (95% CI = 50.2-55.0, p < 0.0001). For MAC, TOT increased by 50%, from 32.4 (95% CI = 31.8-32.9) to 48.6 minutes (95% CI = 47.1-50.0, p < 0.0001). For General Anaesthesia, TOT increased by 11.0%, from 47.9 (95% CI = 47.4-48.4) to 53.2 minutes (95% CI = 52.6-53.7, p < 0.0001).
Comparison of TOT before and after SANDPO under Regional, MAC and General Anaesthesia in MOR and SCB ORs
In SCB ORs, TOT for cases with General Anaesthesia was 37.5 (95% CI = 36.6-38.3), for MAC, it was 34.1 minutes (95% CI = 33.4-34.8), and for Regional Anaesthesia, it was 37.6 minutes (95% CI = 35.2-40.0), all of which were significantly lower than MOR post-SANDPO (p < 0.0001).
TOT was also compared based on the complexity of the case setup, as shown in Table 1. After SANDPO implementation, TOT increased by 15.7% for simple case setups (Type 1), 9.7% for moderate case setups (Type 2), and 9.1% for complex case setups, Type 3 (all p < 0.0001).
Comparison of TOT before and after SANDPO based on case setup complexity
Simple procedures had the greatest TOT increase by 15.6%, followed by intermediate cases at 9.7% and followed by the highest complexity cases at 9.1% (p < 0.0001).
Discussion
The SANDPO system in MOR at the University of Illinois Hospital unexpectedly led to a significant increase in overall TOTs (24.1%), despite its intended goal of improving efficiency. This increase was consistent across various categories of case complexities, anaesthetic types, types of cases and patient age, with the greatest impact on simple case setups and MAC procedures. These results demonstrate the potential for unintended consequences of implementing EMR-based OR efficiency systems. Interestingly, TOT in the SCB ORs remained significantly lower, possibly due to newer infrastructure and lower case complexity, suggesting that SCB’s structural efficiency and ambulatory nature buffered some of the adverse effects of SANDPO.
TOT increases were observed across all anaesthetic modalities, with MAC cases showing the most pronounced increase at 50%, followed by Regional Anaesthesia cases (13.1%) and General Anaesthesia (11.0%). The greater impact of SANDPO on MAC and Regional Anaesthesia cases, which require less preparation compared to General Anaesthesia, suggests that the additional documentation and tasks mandated by SANDPO disproportionately disrupted OR efficiency for procedures that should already have been more efficient. In MAC and Regional Anaesthesia cases, quick turnovers are common and expected. SANDPO requirements may have negated these efficiencies, showing that perhaps SANDPO was not effective for such anaesthesia types.
When comparing SCB ORs and MOR post-SANDPO, the SCB ORs had lower TOT for all types of anaesthesia. The TOT for SCB ORs for all cases was lower than in the MOR post-SANDPO. For cases under General Anaesthesia, the TOT was 29.5% lower (37.5 versus 53.2 minutes). For cases under Regional, the TOT was 28.5% lower (37.6 versus 52.6 minutes). For cases under MAC, the TOT was 29.8% lower (34.1 versus 48.6 minutes). These results suggest that structural efficiency of an outpatient surgery unit negated the effect of SANDPO on efficiency.
Paediatric cases, perceived as more complex due to the additional steps and care required, showed a smaller increase in TOT (6.6%) when compared to adult cases (26.0%) in the MOR. This suggests that the additional steps of SANDPO disproportionately impacted less complex cases, potentially due to unnecessary administrative burdens that disrupted previously streamlined processes. In addition, when comparing SCB ORs and MOR post-SANDPO, the SCB ORs showed a lower TOT for both paediatric and adult cases.
TOT increases for simple case setups (15.6%) were higher than those for moderate (9.7%) and complex setups (9.1%), a paradoxical result given the decreased demands of simpler cases. This could be due to additional documentation that was redundant or was not smoothly integrated into the existing EPIC framework, thus causing inefficiencies.
Overall, an apparent mechanism by which SANDPO potentially increased TOT time and decreased operating room efficiency, was that the different stakeholders in SANDPO (surgeons, anaesthetists, nurses) had specific tasks they needed to complete before the patient could be moved to the OR. Compared to before institution of SANDPO, there were extra checklists and items that needed to be completed before the respective letters could be ‘dropped’ or stated as being ready.
Comparison to existing literature
Previous studies have emphasised the importance of minimising delays and improving OR efficiency through targeted interventions, including optimising team communication and effectively using the EMR (Athanasiadis et al 2021, 2024, Chua et al 2021, Mansour et al 2021, Mihalj et al 2022). However, our study demonstrates that a one-size-fits-all application of EMR-based systems like SANDPO may unknowingly exacerbate inefficiencies when the specific needs of ORs and the institution are not taken into account. This agrees with other studies that demonstrate the potential for systems with similar intended efficiency to SANDPO, to disrupt flow if its design does not assimilate well with a hospital’s pre-existing practices (Attaallah et al 2016, Chishtie et al 2023, Hofer et al 2016, Pappada et al 2022).
Novel contributions
This study is among the first to evaluate the impact of an EMR-based lettering system on OR efficiency on a large scale and in the setting of an academic medical centre. Our data highlight the direct effect of such lettering systems on different case complexities, anaesthesia techniques and facilities, offering a detailed perspective on the unintended consequences of implementing EMR lettering systems such as SANDPO.
Limitations
This retrospective study relies on EMR data, which may not capture qualitative factors affecting TOT like differences in staffing or staff efficiency and compliance. In addition, results in this single-institution study might not be applicable to other institutions due to staffing numbers, case complexity, size of operating rooms and other systemic factors in the facilities. Differences between the MOR and SCB, such as OR staff per case and case complexity, likely influenced the results. Future prospective studies controlling for differences in case complexity are needed to better understand and address the effects of the SANDPO lettering system on OR inefficiencies. In addition, while SANDPO may have decreased operating room efficiency, it may have led to other benefits which were not measured such as decreased complications, increased patient safety and decreased length of stay in the hospital.
Conclusion
SANDPO increased overall TOT time by 24.1% in the MOR, resulting in unexpected decreases in operating room efficiency. The SCB consistently had lower TOT than the MOR both pre- and post-SANDPO. Adult cases were delayed more than paediatric cases. TOT increased 13% in Regional Anaesthesia cases and 50% for MAC Anaesthesia cases. Simple setup cases had the greatest increase in TOT post-SANDPO. In summary, SANDPO, introduced by OR leadership to enhance efficiency and patient safety, instead significantly slowed operating room efficiency. These results have important implications for hospital systems that use these lettering systems with their EMRs, as it shows that such lettering systems may alter operating room efficiency.
Footnotes
Acknowledgements
The authors are grateful to Natalie Setterberg for assistance with data collection.
Authors’ note
Source of the work: hospital operating room at University of Illinois Hospital, Chicago, Illinois, USA.
Author contributions
LK: conception, research, analysis, writing, review of the manuscript and approval of the manuscript. RJB: conception, research, analysis, writing, review of the manuscript and approval of the manuscript. SR: conception, research, analysis, writing, review of the manuscript and approval of the manuscript.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: The study was funded entirely by internal sources.
Ethical approval and informed consent statements
The study was deemed exempt by the Institutional Review Board of the University of Illinois at Chicago, STUDY2024-0432.
Data availability statement
Data will be made available upon request to the corresponding author.