Problem
Regular late finishes of long operating theatre sessions lead to staff fatigue and can reduce work satisfaction; ultimately staff may refuse to continue with that extra commitment. Reducing late starts would be expected to have some impact on this as well as making work schedules more predictable for theatre staff and patients.
The Walton Centre NHS Foundation Trust is a large specialist hospital on the outskirts of Liverpool providing comprehensive neurological, neurosurgical and pain management services to patients from across northwest England and north Wales, and also receives some referrals from all other parts of the UK. It is a designated major trauma centre, receiving emergency neurological trauma transfers from across the region. The Neurosurgery Division is one of the largest in the UK, conducting approximately 3000 elective and 2000 emergency surgical cases per year, together with 1000 day-case procedures.
Following a regional merger of adult spinal deformity services, over the last 5 years we have experienced a significant increase in the number of surgical cases finishing after 17:00. Many complex operations last from 7 to 10 hours (so occupy a full day in theatre: three-session cases), placing additional pressure on staff to work late. Surgical cases are scheduled based on their complexity. Most spinal elective procedures that require neurophysiology monitoring are planned as three-session cases (all-day cases). They are classified as Short, Medium or Long, with anticipated (planned) finish times of 19:00, 20:00 or 20:30, respectively. Elective cases that finish after their planned finish time are classed as finishing late.
Due to ongoing shortages of theatre staff, and staff unwillingness to work beyond their shift finishing time there has been an increase in the use of on-call theatre staff to cover those cases that finish after 19:00. In addition, X-ray and two-dimensional and three-dimensional CT scan imaging elective service provision is reduced after 17:00, with limited cover until 20:00 and thereafter an on-call service (primarily to cover emergency cases). In the neurophysiology department we have a limited number of staff able to work beyond 17:00 and we do not operate an on-call service. Furthermore, neurophysiology monitoring is at its most intensive at the very end of the procedure when staff fatigue is at its highest. There are thus many negative consequences of later-than-planned surgery finishes.
The ultimate issue is late finishes (over-runs) of surgical sessions. This is a very difficult area to do quality improvement (QI) in, as there are many contributing factors and a lot of unpredictable variation. We focused on what is in our span of influence in neurophysiology. This led us to concentrate on the duration of in-theatre pre-surgery preparation (ie, prior to knife-to-skin)—the period during which the patient is anaesthetised and we (neurophysiology scientists) conduct a range of baseline measurements to set up for patient monitoring during the surgery. Excessive durations here will delay the start of surgery and so, it would be logical to assume, would tend to impact on the overall finish time.
We used the Model for Improvement and its Plan-Do-Study-Act (PDSA) cycles.1 Our (stretch) aim was to reduce pre-surgery duration to 45 min, and so, contribute to on-time starts and consequently, we hoped, to on-time session finishes, within the 3 months of our QI project. We capture the cause-effect logic of the project in an action effect diagram2 in online supplemental figure S1.