Why does it take so long to start the first case in theatre???

In the UK, time wasted between seeing the first patient and knife to skin is brutal. There are more than 6 million patients waiting for surgery - more than 300 000 are waiting more than a year. Even when returning to pre-COVID conditions, clearing the elective surgery bottleneck will be challenging.

There has been some great work by @dr_imranahmad and @elboghdadly at Guy's and St Thomas using High Intensity Theatre (HIT) lists to reduce this backlog. Three teams in two theatres managed to get through ~20 cases per day (11 HIT lists and 240 cases). This included 6 specialities and cases lasting 30-45min. The use of video cameras in theatres allowing staff to monitor surgical progress is a bit disconcerting - but that is just me coming from an IT background and knowing how easy it is to compromise systems.

@GSTTnhs @ProximieAR Delighted that our innovative approach to dealing with the surgical backlog made it on the news today! Thank you to our surgical, nursing & anaesthetic colleagues..11 HIT lists, 240 cases done across 6 surgical specialities so farpic.twitter.com/94Kur1vG2V

— Imran Ahmad (@dr_imranahmad) April 23, 2022

Having completed my training in the UK, I currently work in Germany and have experienced two completely different health care systems. I thought it might be interesting to share how theatres run over here.

A normal working day

In Germany, work starts at 7:30. We have a quick morning brief where all patients in each theatre are being discussed. During this time, ODPs already get patients ready, take them to the anaesthetic room, connect monitoring, place IV access, draw up drugs and set up TIVA pumps. When we arrive in the anaesthetic room by ~7:45, everything is already done. For straight forward cases, we are often in theatre by 8:00. The day is much shorter than in the UK, with theatres finishing at 3pm. We often manage to get through 3 gastric bypasses, 5 sections, 8 gynae day case procedures, or 3 total thyroidectomies in one theatre.

Patients get seen the day before

The process of consenting patients on the day of surgery is not only problematic from a legal point of view, it's also terribly inefficient. Fighting over rooms to see patients, waiting for the surgeon to finish consenting, trying to find the notes, ... all reasons for a late arrival to the team brief.

In Germany, all patients are seen and consented the day before and problems sorted out well in advance. This means no surprises on the day of surgery. A handover is being done with the theatre co-ordinator at the end of the clinic. Difficulties are noted and it's also a great learning opportunity.

Pre-op clinic is not a popular job, it's busy and chaotic. Patients all tend to arrive at the same time and waiting times are long - a bit like A&E in the UK. We recently managed to optimise this process by booking time slots for patients.

An appointment will last a minimum of 25 minutes because all risks and options are discussed. For example, with knee surgery, the anaesthetist has to discuss a spinal and a general anaesthetic. Who gets what can be a bit tricky for new starters, but there is a document with common operations and anaesthetic techniques. When a patient wasn't consented for a regional technique, it cannot be done. In Germany, consent on the day of (elective) surgery is not allowed.

You do need manpower, loads of coffee and frequent breaks. There are 2-3 anaesthetists seeing patients for 9 theatres. When theatres finish early, people tend to help in pre-op clinic. As peri-operative medicine is now part of the new curriculum in the UK, it would be a great time to introduce trainee-led pre-op clinics.

No team brief / WHO meeting in the morning

In the UK, a team brief is done before the theatre list starts. All members have to be present - therefore, time is often spent waiting for the surgeons or anaesthetists who are still seeing their patients and/or getting changed. It's often not allowed to send for the patient until after the team brief.

Unfortunately, staff in a theatre are constantly changing in the NHS. Trainees frequently rotate, locum staff are common - it's often the first time the team is working together. For those reasons, a team brief is essential.

In Germany, trainees stay (mostly) at the same hospital throughout their training. Problems are sorted out well in advance. Surgical and anaesthetic plans are documented on the theatre computer system. Equipment problems are the exception rather than the norm. There is simply no need for a team brief. Delays such as waiting for the surgeon, anaesthetist or patient do no exist.

I've seen it

5-10min for patient to arrive, check in, faff with monitoring
5min GA
5-10min positioning, general faff with table
5-10min waiting for surgeon
5min surgeon scrubs
5min WHO and drapes
5-10min procedure
5min wakeup
5min scrub theatre for next case

— James Shuttleworth (@JAShuttleworth) March 22, 2022

Patient turnover

There is good communication with the surgeon and the anaesthetist. Surgeons usually let us know when to send for the next patient. The next patient arrives in the anaesthetic room before the current case is finished. No need for cameras in theatre.

ODPs prepare all drugs and cannulate the patient. In some places in the UK, there seems to be an anxiety to allow ODPs to draw up and administer drugs. However, sharing workload reduces cognitive load and prevents drug errors. ODPs are well trained and, unlike trainees, are not rotating. They not only develop a routine, but also gain a lot of experience working in the same theatre block all the time. They are less likely to make a drug error compared to new, frequently rotating or rushed anaesthetists. We have all heard of drug errors, like the wrong concentration of heparin being given - because a trainee just rotated to a new environment. As a new trainee, I accidentally put a remifentanil syringe into the propofol pump - because I was inexperienced using TIVA and hadn't developed a routine.

ODPs are currently allowed to administer drugs under a Patient Specific Direction. However, NHS England recognise the value of ODPs in other environments and there are currently talks to add ODPs to a Patient Group Direction as well.

Patients are induced on the theatre table and then moved into theatre. It always seemed rather strange to me to anaesthetise on the patient trolley, then move the patient onto the theatre table.

For spinal anaesthetics, we just wear sterile gloves and don't gown up. Saves time and the planet.

Rubbish from one spinal anaesthetic.

Is there a more sustainable way? pic.twitter.com/NnbAuo4U3F

— Tanya Selak (@GongGasGirl) April 7, 2022

When surgical drapes come off, the patient is expected to be awake - something I was struggling with a lot when I first came to Germany. In the UK, patients seem to be dropped off in recovery anaesthetised. I now use predominantly TIVA and turn off the anaesthetic when the surgeon is closing the skin. In less predictable operations, I ask the surgeons to give me a 5 min warning. Using a high opioid and low sedative technique allows a very good and predictable control of anaesthesia and the patient is wide awake when we leave theatre. Note that the EEG is useless here - it only tells you that the patient is currently asleep, but not what will happen with a painful stimulus. I found monitoring HR, BP and the patient's face more useful here.

Having an awake patient at the end of surgery makes life a lot easier. They can move into their bed by themselves - protecting our backs. There is also no need for oxygen or a patient monitor for the trip to recovery.

Theatre Co-ordinator

For every hospital (we have three), there is a senior consultant anaesthetist who is co-ordinating theatres. They

They can also help when there are problems in the anaesthetic room - an unpredictable difficult airway, a challenging spinal, help is always available. This is reassuring for anaesthetic trainees who always work solo. Trainees are only directly supervised in the first 6 months, after that, they are running their own lists. This is in direct contrast with the UK, where even senior trainees are often paired with a consultant anaesthetist. Ideally, there should be a middle ground for supervision - having someone in theatre to teach you every now and then but also having the opportunity to do an own list without someone looking over your shoulder all the time.

The high number of trainees currently doubled up with consultants is a golden opportunity. Allowing trainees to do their own list frees up consultant anaesthetists who can supervise several theatres. This raises the question - is there a need for Anaesthesia Associates or should we just trust and allow trainee anaesthetists to work more independently? How come junior trainees in Germany can run their own list, but in the UK this is not acceptable? I remember as a junior trainee when a consultant called in sick, there was a discussion whether a trainee was competent enough to do a gynae list (apparently I was not). This was somewhat surprising as back then, I was still expected to do a laparotomy on my own when I was on call (now unheard of).

Surgery

Can't really comment too much on this as it's not my area of expertise. But what is notable is that surgery is much quicker in Germany. Having founded the @AnaestheticsApp Logbook (if you haven't heard of it - the most advanced and best logbook for anaesthesia and critical care 🙂), I can slightly cheat and compare surgical time to the UK. Obviously, this is in no means accurate as my logbook was never set up for research or analysing cases. But this is the mean surgical duration for cases entered over the past 12 months in the UK.

Just a few examples:

I hope this was vaguely interesting or useful. If you have any questions, come and have a chat on Twitter @AnaestheticsApp. I will update this post as I get any other ideas or questions.