The operating room is often described as the surgical theater, and there's good reason for the comparison to actors on the stage. To start, there’s the carefully orchestrated performance that relies on both years and years of training to master the craft, as well as the skill and confidence needed to respond to unexpected changes on the fly and go by instinct when the situation calls for it.
And then there are the operational dependencies that determine how and when the show will go on. In a play, there’s an entire world of technical events taking place backstage and in parallel — lighting, sound, makeup, costume, direction — whose simultaneity ensures that the performance is uninterrupted and the magic on stage remains the focus. Similarly, the circulating nurse, surgical technician, physician’s assistant, and others make sure the surgeon and anesthesiologist are maneuvering unobstructed and with the technical support they need during each case.
Finally, there are the operational tasks that happen in plain sight: turnovers. In a play, turnovers take place between scenes and between acts, when the crew takes the stage to change scenery, update spike marks, make repairs, and prepare for the next setting. In surgery, turnovers last from when one patient is wheeled out until the next patient is wheeled in, and they consist of cleaning and disinfection, breakdown and setup of materials and equipment, and resetting the OR.
In both types of theater — stage and surgical — turnovers present a complicated dependency between operations and logistics, supported by tremendous coordination. Because the next scene or case cannot start until the breakdown and cleanup from the last one has been completed, the entire downstream schedule is affected by the efficiency of not only one turnover, but compounded by each subsequent turnover’s speed and timeliness. And, although goals can be set for turnovers, there’s little in the way of metrics and benchmarks to guide their improvement; not surprising when one considers all the other moving parts to focus on in stagecraft and surgery.
Three turnover teams and three coordination challenges
The nature of turnovers has not historically lent itself to much innovation. The cost of OR time was estimated at $46.04 per minute by the Journal of Orthopaedic Medicine in 2022. And, although the average cost of turnover time would definitely be lower than the cost of surgery time, the expense associated with slow turnovers is still a burden to health systems. While increasing the number of people assigned to any given task could improve the speed at which turnovers are executed, the cost of adding staff would badly hurt the hospital’s finances. And skipping steps to abridge turnovers would certainly lead to worse operational problems and risks to both the surgical team and the patient.
In short, turnovers are the confluence of many events that can go wrong in the operating room. First, there’s the obvious challenge created by certain necessary cost optimizations. Most hospitals today contract out cleaning to environmental services companies. And, although third parties generally offer quality at a good price, they also present communication problems that are not easily overcome, whether that’s a result of having different views of the schedule, too little direct correspondence between teams, inconsistent staffing, or minimal oversight. So, although an outside vendor helps with budget efficiency, it creates time inefficiency that can cost way more throughout the day.
Next, there’s the parallel processing conundrum. Where the first OR turnover challenge happens right on the surgical stage between scenes, this second coordination problem results from complexities between the mainstage and backstage. While environmental services and surgical techs are in the theater, post-op and pre-op are meant to be executing their tasks outside the OR to ensure patient readiness and a smooth turnover. But, in reality, so much of post-op and pre-op happens when members of the perioperative team, especially circulating nurses, are already busy, either providing patient care or attending to another turnover task. In most hospitals, the triggers for post-op and pre-op steps are tied to the EHR or fall on each department’s charge nurse to stage-manage problems they can’t see. And, unfortunately, even the most efficient teams tend to have latency in their documentation on an occasional basis, meaning transport of patients to and from the OR is sometimes set back, which draws out the turnover time.
Third, there’s the problem of logistical dependencies and coordination, especially as they relate to materials and equipment. After the tools used in the last case have been removed by surgical techs to go to sterile processing, case carts for the next case need to be brought in. Simultaneously, circulating nurses are outside of the OR, usually attending to pre- and post-op tasks. However, the chronology that determines the timely turnover of the OR between cases often breaks down because these three groups — circulating nurses, surgical techs, and environmental services — aren’t well connected. When cleaning is waylaid by unexpected issues or questions that environmental services can’t handle on their own, turnovers can be delayed until a circulating nurse returns to the OR. Not only does that delay cleaning, but it also prevents needed instruments — anesthesia equipment, C-arm devices, implants — from being brought in and prepared for the next case (and, often, for cases the rest of the day).
So much can go wrong during turnovers in the OR
There are countless other challenges related to turnovers that make it difficult to set goals for improvement. Sometimes case cards are incorrect, leading to sterile processing and inventory preparing the wrong tools or equipment — just imagine the chaos if the script provided to the stage crew of a play had cue and set errors. If the room is set up incorrectly during turnovers, the increased likelihood of staff exiting and entering during a surgery, repeatedly opening and closing the OR doors, is correlated with higher risk of infection. Environmental services might mistakenly leave a mop and bucket in the OR as the next patient wheels in. The charge nurse could be looking at two turnovers happening at the same time, both encountering a problem, and they simply have to choose one to prioritize. Or the turnover issue may happen early or late enough in the day that it doesn’t even register as a problem until it ultimately impacts the next case and the rest of the schedule.
There are so many ways turnovers can disrupt an OR’s case schedule. Like in a play where techs are constantly hustling to change settings between scenes, many of the issues happen right on stage in front of our faces. Yet, despite the miscoordination routinely contributing to delays, few have successfully been able to target improvements in the theater, whether surgical or dramaturgical. In our next post, we’ll explore how hospitals typically address the turnover problem and the factors exacerbating the issues for the surgical team.