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Rockford Health System, Rockford, IL
To the Editor:
I read with interest the article Abouleish et al. (1). As have most institutions, we have struggled with the measurement of "turnover time" and whether or not to include it in block time utilization. Our solution is quite different from that described in this article and, I believe, warrants inclusion of turnover time in the calculation of operating room utilization.
Our premise has been that it is entirely possible to measure turnover time and that the time required to set up for and clean up after a case should be attributed to the actual case. We, therefore, use our intraoperative nursing documentation software to measure the following events: Set-up start, Set-up complete, Patient in Room, Prep Start, Prep End, Procedure Start, Procedure End, Patient Out of Room, Room Clean. We have identified an additional interval that we call "Delay Time," which is the time from Set-up complete until the patient enters the room. Analysis of our data reveals that the vast majority of "Delay Time" is attributable to surgeon delay (surgeon not available for whatever reason). When the delay time exceeds 10 min, the nurse must enter a reason for the delay from a predefined list of reasons. We believe that delay time that is attributable to the surgeon should be included in the time for the procedure and should be part of the block time utilization calculation.
Measuring turnover time in the above manner allows us to determine the "turnover time," which we define as the sum of Set-up time and Room Clean time (+ Delay Time as appropriate) for the case in question. This method keeps the turnover time as part of a single case and, therefore, is not dependent on the scheduled following or preceding case. As important as this is to determine block time utilization, a greater benefit of this method is that it also allows more accurate prediction of how much OR time should be allotted to a given procedure so scheduling can be more realistic.
I believe that the authors have made a potentially problematic decision by taking one month’s turnover data and extrapolating it to the entire 13-mo period. Data should be available for all cases in the study period in order to draw any conclusions about including or excluding turnover time in determining block time utilization. Measuring turnover time as we do allows for a complete data set and does not require manual measurement methods that may actually influence turnover times (Hawthorne Effect).
In addition, arbitrarily excluding turnover times of >75 min may mask a problem with slow turnover times—a potential topic for quality improvement. Finally, attributing the turnover time following a case to the succeeding case may inadvertently allocate too much (or too little) time to the service not responsible for the long turnover time, as the authors correctly point out. This could be solved by measuring the actual times required for set up and clean up and attributing these times to the case in question. Doing so gives a better picture of actual operating room utilization.
Reference
Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX
In Response:
We appreciate Dr. Mowbray’s comments about our article (1). We agree that defining case duration to include "in-room" plus set-up and turnover times would permit better identification of delays and assignment of turnover times. In fact, the Association of Anesthesia Clinical Directors (AACD) uses this definition in their procedural times glossary (www.aacdhq.org) (2). Unfortunately, our operating room (OR) information system does not include set-up and clean-up times in it nor does it have the capacity to include these times. Therefore, because we had to calculate turnover time on a case-by-case basis, we limited our review to a 1-mo sample. We feel that this method provided reasonable estimates that were consistent with our clinical experience.
On the issue of delays, we agree with Dr. Mowbray that this should be the real focus of OR management, not turnover times. From the data available, we could not determine whether times between cases >75 min resulted from a delay between cases or from cases that were added to a room after all scheduled cases had been completed. Therefore, we excluded these outlier turnover times from our analysis. We consider it unlikely that more precise quantification of turnover times and characterization of delays would alter the conclusions of our study.
References
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