Discussion
The relay strategy positively impacted median TOT and IQR for overall OR system and individual ORs with a baseline TOT above the institutionally accepted threshold of 40 min. After the intervention, a significantly higher TOT was noticed in cases needing a regional block before surgery and in patients coming from the ICU. In this study, most stakeholders involved in OR processes were implicated in causes of delay. In addition, surgery-related issues were identified as the main reason for delay.
In our study, the reduction in TOT may not be sufficient to add another case to the daily schedule; however, it could positively impact revenue by reducing overtime staffing needs. Furthermore, decreasing the workload may positively affect workers’ satisfaction.9 10 In order for revenue to increase as a result of the relay strategy, the cost of a lead CRNA must be offset by other cost savings. In our study, the lead CRNA did not raise the expenses, given that the role was assigned to one of the floating CRNAs. These CRNAs in our institution are available for level one trauma cases, relief of anaesthesia residents for academic purposes and to give breaks to anaesthesia providers directly involved in patient care. The flexibility of these floating CRNAs allowed us to conduct the study without negative effects on OR coverage; however, future research should address cost-effectiveness of this strategy.
OR processes involve several stakeholders that contribute to OR inefficiencies. Hence, to decrease the delays in the OR, all of them must be involved to maximise the effect of interventions. Therefore, the sole involvement of anaesthesia providers in our relay strategy may have limited its impact.2 4 Although delays in the OR are multifactorial, poor communication is the root problem in several cases. Improvement of communication between different team members has been shown to decrease OR delays.3 Our findings are in agreement with previous studies, where surgeon availability accounted for a significant proportion of the delays. However, other causes of delay such as nursing and anaesthesia staff unavailability, unprepared patients, cleaning delays and congested holding areas were not as frequent in our study as compared with previous studies.11 15
In the healthcare industry, technology has helped deliver a better quality of care to patients by minimising the effect of human errors and assisting in improving process efficiency.3 16 17 Efficient and safe patient care delivery involves the coordination of several processes that happen simultaneously and in sequence. These multitude of activities are constantly generating data whose proper and timely analysis helps providers to develop and implement interventions aimed at improving the service offered and ultimately promote healthy patient-related outcomes. However, despite the availability of technology designed for this purpose, there is still a significant gap between data repositories and products of analysis that could lead to actionable insights.18–20 In this study, the use of Microsoft Teams software chat allowed to enhance communication in the OR, and it was a sustainable intervention. However, automated data collection possible and the format of the chat lent itself for communication of non-essential information that was sometimes redundant. Therefore, to enhance the impact of our intervention, we consider necessary the development of a software application to streamline efficient communication channels that improve team dynamics and generate data that can be transformed into knowledge through data analysis.
One major limitation of this study is the sample size. Even though we included 636 observations, the number of study cases was drastically reduced when we analysed each OR separately. Therefore, we consider that the drop in TOT was not significant for most of the individual ORs due to insufficient sample size per OR. The small sample size per OR is also related to the non-normal distribution of our response variable. We recognised that the normality assumption was not valid, even after a logarithmic transformation of the TOT. We used non-parametric tests for analysis. The scope of our study was not to determine the robustness of the non-parametric tests in our population; however, Monte Carlo simulations could have added value to our analysis as we might have been able to identify the validity under violation of underlying assumptions.21 Alternatives for analysis are generalised additive models for location, scale and shape and generalised linear models with extension to mixed models.22 23 In light of this limitation, we reported location and spread measures as median and IQRs. Additionally, the use of non-parametric tests is practical, and the results are still valid.
Furthermore, with the obtained data, we were not able to quantify the cost-effectiveness of our intervention. Another major limitation of our study is that the results cannot be extrapolated to other centres with different complexity levels and different types of surgeries or to non-academic centres.
This study focused on an intervention implemented for the general OR. However, each subspeciality has different turnover rates due to the length and complexity of the procedures. Consequently, further studies must be conducted to assess the effect of customised interventions directed to specific subspecialties. Likewise, future quality improvement projects need to focus on personalised interventions for patients requiring regional blocks before surgery and inpatients coming to the OR from the ICU, as we acknowledge that these circumstances may lead to prolonged TOT.