The following cases reported to PA-PSRS describe delays in operative procedures in which patients were kept under anesthesia for longer than their procedures required:
A patient was brought into the OR by anesthesia. Intubated under general anesthesia for start of surgery. Surgery was delayed because surgeon was in the OR with another case. Patient was maintained under light anesthesia until the surgeon was available. Patient asleep for an additional 45-60 minutes.
Sedation started. Doctor remained in the other [OR] room while this patient received anesthesia care for 75 minutes without surgical care. Actual surgical time [was] 11 minutes.
There are many reasons for delays in the operating room, some of which are unavoidable. A review of the PA-PSRS database for all operating room delays between June 2004 and September 2005 identified 48 reports of delays because of problems involving the surgeon. Those reports are categorized in Table 1.
|Pre-operative delay|| |
|Surgeon not available (including 1 report that delay was unavoidable)||16|
|Surgeon still doing another procedure||11|
|Surgeon involved in an emergency||4|
|Surgeon becoming familiar with new equipment||2|
|Surgeon doing a delivery||2|
|Assistant not available||1|
|Wrong surgeon listed – Correct surgeon doing another procedure||1|
|Intra-operative delay|| |
|Second surgeon (for two-part procedure) not available||3|
|Surgeon failed to make sure needed equipment was available||2|
|Surgeon became ill, requiring replacement||2|
|Second surgeon (for two-part procedure) doing another procedure||1|
|Surgeon left temporarily for a delivery||1|
|Surgeon left temporarily for another procedure||1|
|Surgeon failed to do the procedure properly, requiring a redo||1|
Of the total of 48 reports:
- Six (6) involved lack of planning regarding equipment, checking the schedule, or reviewing techniques.
- Nineteen (19) involved the surgeon being unavailable for unspecified reasons.
- Twenty (20) involved the surgeon being involved in another procedure.
Of the 20 reports in which the surgeon was reported to be involved in another procedure:
- Seven (7) implied a problem with coverage during the operative case.
- Thirteen (13) implied the conflict was due to tight scheduling.
Though not all reports mentioned the length of the delay, and it is likely that only the most egregious delays were reported, the average length of the delays, when reported, are shown in Table 2. More worrisome is that conscious sedation or general anesthesia was already being given to 11 of the 16 patients whose surgeons were not available (for an average of 30 minutes) and to 11 of the 18 patients whose surgeons were still doing other cases (averaging 43 minutes).
|Cause of Delay||Average Duration of Delay||Number of Cases |
|Lack of planning re: equipment and checking schedule||74 min||3|
|Surgeon doing another procedure without indication of coverage problem||47 min||12|
|Surgeon doing another procedure likely because of coverage problem||43 min||4|
|Surgeon not available, reason not specified||39 min||16|
|Surgeon became ill, requiring replacement||15 min||1|
It is possible that some of the unspecified delays were because of late notification of the surgeon for a “to follow” case, rather than a delayed response by the surgeon. Sometimes “double coverage” of operating and taking call is unavoidable.
Many busy surgeons “run two rooms” so that they can start one operation immediately upon completing another, without the delay necessitated by cleaning the room – and apparently, in some reported instances, without the delay of inducing anesthesia.
Although delay without the patient under anesthesia is usually an efficiency problem, delays under anesthesia can be a safety problem. The initial “time out” to verify the correct patient, procedure, site, and side are best done with the patient awake and, ideally, coherent. It is clear from most of these reports that the anesthesia team did not wait for the delayed surgeon.
PA-PSRS suggests the following strategies to reduce the risk of procedure delays:
- The surgeon can check the OR schedule prior to the start of the daily elective schedule and be fully prepared to do the case, including checking the equipment, prior to induction of anesthesia.
- The surgeon can transfer care of other patients to a backup colleague, if possible, while operating.
- The OR can notify the surgeon of a “to follow” case, in a timely fashion, typically when the orderly is being asked to bring the patient to the OR.
- If a surgeon is “running two rooms,” the switch can occur before the induction of anesthesia, rather than after, so that a proper “time out” can be done.