Reasons for delays in start of first elective case of the day at Charlotte Maxeke Academic Hospital: a prospective study.

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Rixongile Style Manganyi, Amanda Nkuna, Nana Yaa Fening This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5153250/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background First case start time measures operating theatre and patient readiness, and it may contribute to perioperative delays. Improving the first case start time is associated with higher theatre productivity. The aim of this study was to determine the first elective case start time and identify reasons for delays at Charlotte Maxeke Johannesburg Academic Hospital, a multidisciplinary tertiary theatre complex. Method A prospective observational study was conducted on all first elective cases of the day from June to August 2023. Times and reasons for delays in patient flow were documented, starting from theatre arrival until the beginning of the procedure. The times were analysed in relation to the departmental protocol for first case start times. p < 0.05 was considered statistically significant. All the statistical analyses were performed via Stata 15 (StataCorp, USA). Results A delay prevalence of 97.5% was reported, with only 10 cases having started on time. The mean delay time was 47.5 minutes (IQR 33–85), and the standard deviation was 53.2. The most frequent reasons for delays were surgeon-related factors accounting for 23.7%, followed by logistics-related factors accounting for 17.7%. Most of these causative factors are preventable. Conclusion A majority of the first cases at CMJAH are delayed and the reasons for delays are multifactorial, but preventable. Multiple strategies can be employed to mitigate the causes of delays, thus improving theatre utilisation and saving costs. delays scheduled start time elective first case Figures Figure 1 Figure 2 Figure 3 Background Operation theatres form part of the costly components of a hospital budget, and maximising operation theatre utilisation is crucial to ensure optimum cost benefits. 1 , 2 , 3 The primary goal of improving operating theatre management is to improve the theatre throughput or efficiency, patient care, and good outcomes without increasing costs. 4 – 7 Studies have argued that even the smallest improvement in operating theatre efficiency can increase productivity. 7 – 9 Theatre productivity is defined as the quantity of output produced per unit input. 8 It can be calculated by taking total costs or resources utilised and dividing it by the average output for that specific period. Theatre productivity can be measured for a specific single theatre, theatre unit, specific surgical discipline, or multiple institutions. 8 International studies have shown that 16–24% of operating theatres' productivity and expenditure may be wasted due to the inefficient functioning of theatre complexes, contributing to limited healthcare resources. 1 , 4 Hospital systems are now paying increased attention to workflow efficiency and waste reduction. 4 In South Africa, public hospital theatre utilisation averages between 30–40% compared with the private sector, which averages 48%. 1 One of the most current discussions in both public and private hospitals' theatre utilisation is improving operating theatre efficiency to ensure optimum cost benefits. 1 – 4 Although studies have identified potential elements that can contribute to the success of operating theatre workflow efficiency and prevent unnecessary wasteful expenditures, challenges still exist in terms of implementing such elements. One of the challenges includes the difficulties in pinpointing when and where most failures to improve workflow efficiency occur. 4 , 5 According to Bauer et al., 2 this makes it difficult to develop an action plan to improve efficiency and limits the success of operating theatre workflow efficiency. The success of operating theatre workflow is dependent on multiple factors, including adherence to the scheduled start time of the first surgical cases. 6 – 10 Adherence to the scheduled first-case start time and efficient room turnover optimises theatre utilisation. 6 , 7 This also reduces time wastage, overruns, and unnecessary cancellations, resulting in patients’ longer hospital stays, and increased care costs such as food, medication, and hospital expenditures. 8 , 9 Inefficient theatre utilization prolongs the elective waiting list period, resulting in patient dissatisfaction and to some extent compromising patients’ safety. 11 , 12 Studies have shown a remarkable improvement in the reduction in delays of first case start times after implementing strategies and policies to mitigate such delays. 13 – 39 Over 9 months there was an improvement of 6–60% in the first case start time according to Wrist et al. 40 For example, strategies such as preparation of equipment in advance, regular equipment servicing, improving interdepartmental communication and compliance, proper planning and ensuring preanaesthetic instructions are followed, were reported to improve theatre efficiency and meaningfully reduce hospital costs. 35 , 37 Given this context, the overarching goal of this study was to determine the reasons for delays in the start of the first elective case of the day at a teaching hospital, and ultimately develop strategies to mitigate the causes of such delays to improve theatre workflow and productivity and ensure optimum cost benefits. The specific objectives included determining the actual first case start times, identifying preventable and nonpreventable causes (modifiable and nonmodifiable factors responsible for such delays), and classifying causes of delay. Five categories can be used to classify causes of delay. These factors include patient-related factors (e.g. violating fasting guidelines), surgeon-related factors (e.g. late or unavailable surgeon), anaesthesia-related factors (e.g. late, difficult intubation), nursing-related factors (late, drugs counting), and logistics-related factors ( porters being late, equipment failure). Methods This was a prospective and observational study conducted over three months from 3 June 2023 to 8 August 2023 at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). CMJAH is a 1088-bed teaching hospital affiliated with the faculty of health sciences of the University of Witwatersrand in Parktown, Johannesburg, Gauteng Province, South Africa. All qualifying adults and paediatric patients who were scheduled for weekday elective surgery as first cases, booked at least one day before the operation were included. Cases not requiring an anaesthetist and done after hours (before 07:00 and after 16:00), during public holidays, or on weekends were excluded. The study protocol was reviewed by the human research ethics committee of the Witwatersrand University and deemed nonhuman subjects’ research. Approval to conduct the study at the hospital and access patients’ medical files and theatre record books was granted by the theatre management. A convenience method of sampling was used. The inclusion criteria were all age groups, elective cases, first cases of the day and cancelled first elective cases. Cases that were excluded were emergency cases, cases that were performed after the scheduled elective time and cases that did not require an anaesthetist. A total of 406 cases met the inclusion criteria and were analysed. Data were collected using the data collection tool (Appendix 1) and the following times were recorded: date, theatre name, surgical specialty, procedure, scheduled first case time, porter send-off time, and theatre arrival time. Upon arrival in theatre, patient’s in-room time, anaesthesia time, and procedure times were recorded. The cases that did not have documented times or reasons for delay, data were obtained from medical records. The scheduled first case was defined as the first elective case scheduled in the operating room for the day. Scheduled first case time was defined as the time when the case was posted to start in the operating theatre, which differed across different specialties. On-time start was the patient’s in-room time that occurs at or before the scheduled first case time. Start time delay was defined as the patient in-room time that occurs after the scheduled first case time. A grace period of 5 minutes was considered when analysing the data. Delay times were calculated using frequencies and means with 95% confidence intervals at various stages per specialty. Similarly, the reasons for delays were categorised and calculated accordingly. A p-value < 0.05 was considered statistically significant. All the statistical analyses were performed using Stata 15 (StataCorp, USA). Results A total of 427 cases met the inclusion criteria, of which 21 cases were cancelled. The reasons for cancellation included low theatre temperatures (8 cases), poor patient optimisation (3 cases), unavailability of postoperative ICU beds (3 cases), patient unfit for theatre (2 cases), equipment failure (1 case), invalid consent (1 case), patient’s pathology resolved (1 case), incorrect booking (1 case), and 1 case due to no available anaesthetist. The remaining 406 scheduled first cases from 14 different surgical specialties were analysed. Figure 1 shows a flow diagram of the study data. The following were scheduled first case start time per specialty: 07:00 for cardiac surgery, 07:30 for urology, ENT, general surgery, trauma surgery, orthopedics surgery, vascular surgery, ophthalmology, and maxillo-facial surgery; and 08:00 for gynecology, plastic surgery, breast surgery, and pediatric surgery. The distribution of cases per specialty is shown in Table 1 . Table 1 DISTRIBUTION OF CASES BY SPECIALTY SPECIALTY N (%) Gynecology 28 (6.6) Urology 28 (6.6) ENT 19 (4.4) Maxillo-facial surgery 25 (5.9) Ophthalmology 24 (5.6) Plastic and breast surgery 24 (5.6) Orthopedic surgery 86 (20.1) Trauma surgery 11 (2.8) General surgery 38 (8.9) Cardiothoracic surgery 46 (10.8) Neurosurgery 21 (4.9) Pediatric surgery 60 (14.0) Vascular surgery 16 (3.7) Audiology 1 (0.2) Among all 406 cases studied, 97.5% ( n = 396) of those cases experienced a significant delay in starting the first case, which was statistically significant ( p < 0.001). Only 2.5% ( n = 10) of the cases were deemed to be on time. The mean delay time for all the cases was 47.3 minutes, the mean delay time for porter send-off was 7.2 minutes (SD 23.8), the in-room delay time was 42.7 minutes (SD 40.1), the anaesthesia delay time was 50,7 minutes (SD 40.7), and the procedure delay time was 90 minutes (SD 69.0). There was a 19% delay during porter send-off, 40% at theatre arrival, 93% in-room delay time, 96% at anaesthesia delay time, and 97.5% at procedure delay time. The mean delay time per specialty at different time delays is shown in Table 2 . Table 2 Frequency of delays in first elective cases, Mean delay time, Standard deviation, and total delay time. Specialty Total number of cases analyzed Delayed cases n (%) Mean delay time (minutes) Standard deviation Total delay time minutes (%) Audiology 1 1(100) 43.5 22.6 59 (0.3) Cardiothoracic surgery 44 44 (100) 70.3 63.4 5554 (11.1) ENT 16 16 (100) 36 40 1364 (4.0) General surgery 34 34 (100) 46.2 40 2843 (8.6) Neurosurgery 19 19 (100) 64.0 66.4 2444 (4.8) Ophthalmology 23 23 (100) 53.3 39.7 1971 (5.8) Plastic & breast surgery 22 22 (100) 42.5 40.9 1852 (5.6) Urology 26 26 (100) 44 45 2185 (6.6) Vascular surgery 16 16 (100) 48.6 52.3 1454 (4.0) Orthopedic surgery 83 81 (96.7) 51.3 52 8434 (20.5) Paediatric surgery 60 58 (96.1) 30.2 31.7 3526 (14.6) Maxillo-facial surgery 25 23 (92) 50.3 38.4 2311 (5.8) Trauma surgery 10 9 (90) 46.2 40.8 1108 (2.3) Gynaecology 27 24 (88.9) 23.7 34.7 1567 (6.0) P = 0.001 There were only five departments that did not have 100% delayed cases. These included gynaecology with a delayed percentage of 88.9%, trauma surgery (90%), maxillo-facial surgery (92%), paediatric surgery (96.1), and orthopedic surgery (96.7%). The rest of the specialties had 100% delayed cases. Delays at porter send-off and theatre arrival time were low whereas almost 100% of delays occurred at in-room, anaesthesia, and procedure times. The three most delayed specialties were cardiothoracic surgery, neurosurgery and ophthalmology. The delay percentages at different stages of the three most delayed specialties are shown in the table below (Table 3 ). Table 3 Delay percentages at different stages of the three most delayed specialties. Specialty Cardiothoracic surgery Ophthalmology Neurosurgery Overall delayed cases n (% of the total number of cases) 44 (100) 23 (100) 17 (100) Delayed Porter send-off time n (% of the total number of cases) 12 (27) 1 (4) 8 (47) Delayed theatre arrival time n (% of the total number of cases) 29 (66) 9 (39) 5 (29) Delayed in-room time n (% of the total number of cases) 43 (98) 23 (100) 16 (94) Delayed Anaesthesia time n (% of the total number of cases) 44 (100) 23 (100) 17 (100) Delayed procedure time n (% of the total number of cases) 44 (100) 23 (100) 17 (100) A total of 1072 reasons for delay were identified during the study. The reasons for the delay were classified into six categories, namely: patient-related factors, surgeon-related factors, anaesthesia-related factors, nursing-related factors, logistics-related factors, and others, which were further classified into no reason documented and delayed cascade (meaning that further delay was due to prior delays). Surgeon-related factors accounted for the most delays at 353 (23.7%), followed by other reasons i.e., cascading delays at 339 (22.8%), logistics-related factors at 264 (17.7%), nursing-related factors at 241 (16.1%) and anaesthesia-related factors at 192 (12.9%). Patient-related factors accounted for the lowest percentage of delays, at 35 (2.3%) as shown in Fig. 2 . The surgeon being late accounted for 58.9% of all surgeon-related causes, followed by incorrect booking of the surgical list at 14.1%. The most common reasons among other categories included outpatients being late under patient-related factors accounting for 52% and late anaesthetists accounting for 40.2%. The ward nurses preparing patients late or presenting incomplete handover documents accounted for 30%. Late porters accounted for 30% of all logistics-related causes. Common reasons for delays are shown below in Fig. 3 . The causes for delays in the start of the first elective case of the day are further classified into preventable and nonpreventable factors. Preventable causes constitute 86% of all causes, whereas 13.4% are nonpreventable. Discussion The study has shown the prevalence of delays in the first elective case of the day start time to be within the global standard as depicted in publications. 17 Delays in start time are a widespread problem faced by both developing and developed countries. It has a negative impact on the quality of health and negatively affects theatre utilisation. 21 The goal of operating theatre is to maximise its use and mitigate any form of delay. A delayed start time invariably led to slates finishing late and unplanned cancellations. This has led to increased costs through overtime payments. 21 For this reason, first case start times have been used as a performance indicator and to implement improvement strategies to optimise theatre utilisation. 19 This study has revealed a considerable number of delayed cases, accounting for 97.5% of all cases. This is similar to the findings of a study by Cox Beaur et al., 2 where they studied 5598 patients across three high-volume urban hospitals between July 2012 and November 2013. They reported that 98% of the cases were delayed. Similarly, a higher delay prevalence of 99% was reported in a study conducted in a Nigerian hospital comprising 1170 patients by Okeke et al. 17 These studies were conducted in both developed and developing countries, respectively. However, these findings contrast with those of a Canadian nine-year prospective study of 1531 elective cases in which just over 50% (51.4%) of cases were delayed. 36 This large gap in delay prevalence may be attributed to the premise that the study setting was in a specialised neurosurgical unit as compared to a multi-specialty system at CMJAH. Another contributing factor may be resources and the capacity to cater to operating theatre needs. This study revealed a 0.23% ( 21 cases) cancellation rate. This is lower than the findings in a study by Fayed et al. 42 where they studied 1813 cases over 3.5 years. They had an 11.1% cancellation rate. 42 These numbers are similar to those reported in the Nigerian study by Okeke et al. 41 , which reported a 9.1% cancelation rate among the 1296 cases studied. This difference might be explained by the nature of their studies, where they studied all booked elective cases in contrast to our study, where only the first elective cases were studied. The most common reasons for cancellation were low theatre temperatures (38%), poor patient preparation (14.2%), and the unavailability of ICU beds (14.2%). Patient-related factors were the most common causes of cancellations reported by Fayed et al. 42 and Okeke et al. 41 Majority of patients did not show up for the procedure while in Nigeria, patients were cancelled due to a lack of funds. 41 , 42 This study took place in the winter season which could have contributed to low theatre temperatures. Theatre thermostat devices in our hospital do not function well, contributing to failure to detect or adjust low temperatures. Another contributing factor is that all theatre temperature controls are centralised, making it difficult to single out a specific theatre and adjust its temperature. The department with the highest cancellation rate is Orthopaedics surgery with 28%. Jayed et al. 42 in a four-year retrospective study of 1813 cases in Saudi Arabia reported that ophthalmology had the highest cancellation rate accounting for 37% of all cancelled cases, whereas Okeke et al. 41 reported that general surgery was at the top of the list accounting for 36%. This highlights that there are multifactorial contributing factors across various institutions. The causes of delays in our study were multifactorial, with the most common being surgeon-related factors (23.7%). This was followed by logistics-related factors at 17.7% and nursing-related factors at 16.1%. These findings are similar to those of a study by Overdyk et al. 34 , which reported that surgeons’ unavailability was the most common reason for delays accounting for more than half of the reasons. This contrasts with a Nigerian study by Okeke et al., wherein patient-related factors were the leading cause of delays, accounting for 31.1% of all delays. 17 This may be attributed to affordability as patients are required to fund their medical bills. Our study revealed that more than half (58.9%) of the delays were due to surgeons being late. This was followed by incorrect booking of surgical lists; either the list was submitted late, it changed on the morning of the procedure, or there was a change in the order of the patients. Issues including invalid, missing, or unsigned consent forms were also among the common causes of delays. Other causes of delays were miscommunication between team members; poor patient preparation; and poor preprocedure preparations, such as positioning, prewashing, or insertion of a transurethral catheter. Logistics-related causes were the second highest reasons for delays. Porters being late accounted for 30% of all logistics-related causes. A similar finding was revealed by Jonnalagadda et al. 38 in a six-week prospective study of 594 cases, where the most common reason for the delay was patient transportation to theatre (17%). In our study, other reasons for delays included equipment failure (25%), delayed cleaning, and waiting for ICU beds or investigations. The common nursing-related issues included the late arrival of nurses, drug counting which delays the anaesthesia start time, and ward nurses’ late preparations. The reason for these delays accounted for 4.4% of all delays. This percentage was lower than the 60% reported in a study conducted by Cox Beaur et al. 2 The overall mean delay time in this study was 47.3 (IQR 33–52) minutes. This value is almost twice the mean delay times of 28.2 minutes and 21.6 minutes reported by Cox Beaur et al. and Shuster et al. 2 , 39 The difference in the setting of the studies by Cox Beaur et al. and our study might be the reason for these findings. Their study took place in a dedicated neurosurgical facility whereas our study took place in a center catering to multiple disciplines. Factors such as equipment malfunction, theatre temperature instability, and water shortages were not among the reasons for the delay in their study. The specialties with the lowest prevalence of delays were audiology, paediatric surgery, and gynaecology. Similarly, Shuster et al. 39 studied 21357 cases across twenty-two German hospitals over 9-months period and reported that gynaecology and ENT specialties had the least delays. The most delayed specialty in our study was cardiothoracic surgery, with a mean delay time of 70.3 minutes (IQR 50–125), followed by neurosurgery, with 64.0 minutes (IQR 32.5–120), and ophthalmology with 53.3 minutes (IQR 50–90). In a study conducted by Cox Beaur et al., 2 neurosurgery was the most delayed specialty. However, a study by Okeke et al. 17 reported that general surgery, orthopedic surgery, and urology had the greatest delays. On the other hand, Hicks et al. 19 studied 3604 cases in a level one trauma center in 2018 and reported that paediatric surgery and trauma surgery had the most delays. These findings show that there is no universal start time applicable across surgical specialties, and that different institutions have different challenges affecting first-case start times across various specialties. The main goal in trying to identify the areas of delays in the start time of the first elective cases was to mitigate these delays for better outcomes. We found that 86% of all the reasons for delays were preventable factors and that 13.4% were nonpreventable. This highlights room for improvement. 7 The most common preventable cause of delay is staff being late. Numerous strategies have been shown to improve outcomes. The financial incentives method involves financially rewarding healthcare providers who perform better. 23 Han et al 25 implemented a mandate to pay neurosurgical registrars if they managed to ensure that the patient was brought to the theatre on time or earlier. They managed to reduce the first-case start delays by 7.17%, and patients were brought to the theatre 30 minutes early. Improved interdepartmental communication and frequent meetings to discuss the roles and expectations of each team member have been shown to reinforce the first case on-time start. 26 Overdyk et al 34 implemented theatre efficiency educational strategies for staff over 2 weeks, and they improved the first case start time by 22 minutes. l The logistics-related factors included cleaning theatre rooms late, nonconducive theatre temperatures, waiting for the availability of ICU beds, and equipment failure. The theatre temperatures must be checked before and at the end of each theatre list to ensure that the temperatures are within the recommended values. Regular equipment servicing and appointing of a designated team to ensure up-to-date equipment functioning will reduce late first-case starts. Cleaning theatres at the end of a theatre list reduces the need for morning cleaning. Strengths and limitations The overarching strength of the study is that it contributes to the body of knowledge in the subdiscipline of anaesthesiology, given that reasons for delays in first elective case start times have been identified. Strategies can be implemented accordingly to reduce such delays. The study was conducted in a single academic hospital setting. Thus, the generalisation of its findings is limited. Conclusion The study reported an alarmingly high rate (97.5%) of delayed cases, with surgeon-related factors being the most common cause. Majority of these causative factors are preventable and can be improved. Strategies can be put in place to mitigate these delays. In doing so, costs may be reduced, and the quality of health care may be improved. Abbreviations CMJAH Charlotte Maxeke Johannesburg Academic Hospital ENT Eyes, Nose and Throat HOD Head of Department CEO Clinical executive officer IQR Interquartile range SD Standard deviation ICU Intensive care unit DMAIC Define, measure, analysis, improvement, and control UK United Kingdom HIV Human immunodeficiency virus Declarations Ethics approval This study was approved by the Human Resource Ethics Committee, Witwatersrand University, with approval number M221067. This study was a nonhuman study; hence, it did not require patient consent. Consent for publication Not applicable Availability of data and materials The data are available upon request with permission from Witwatersrand University. Competing interests The authors declare that they have no competing interests. Funding This study did not receive any funding from other parties. Authors’ contributions This study has no contributions from the other authors. Acknowledgements Department of Anaesthesiology, Charlotte Maxeke Johannesburg Academic Hospital. Author information Rixongile Style Manganyi, MBChB, DA(SA) (2610358) 1 Nana Yaa Fening, MBChB, DA(SA), FCA(SA) MMed (Wits) 1 Amanda Nkuna, MBChB, DA(SA), FCA(SA) MMed (Wits) 1 1Department of Anaesthesiology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa References Lee DJ, Ding J, Guzzo TJ. Improving operating room efficiency. Curr Urol Rep. 2019;20(6):28. Cox Bauer CM, Greer DM, Vander Wyst KB, Kamelle SA. First-case operating room delays: patterns across urban hospitals within a single health care system. J Patient Cent Res Rev. 2016;3:125–35. 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Fayed A, Elkouny A, Zoughaibi N, Wahabi HA. Elective surgery cancelation on day of surgery: An endless dilemma. Saudi J Anaesth. 2016 Jan-Mar;10(1):68–73. Additional Declarations No competing interests reported. Supplementary Files DATACOLLECTIONSHEET.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5153250","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":360657269,"identity":"7ea3b090-86b7-4d65-9dee-c582ef4eb688","order_by":0,"name":"Rixongile Style Manganyi","email":"data:image/png;base64,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","orcid":"","institution":"University of the Witwatersrand","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Rixongile","middleName":"Style","lastName":"Manganyi","suffix":""},{"id":360657270,"identity":"1dcb8c8e-615d-41f8-a795-e2ff5b4f993e","order_by":1,"name":"Amanda Nkuna","email":"","orcid":"","institution":"University of the Witwatersrand","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Amanda","middleName":"","lastName":"Nkuna","suffix":""},{"id":360657271,"identity":"5b843f83-7533-4c8f-b9e9-4634a486a8eb","order_by":2,"name":"Nana Yaa Fening","email":"","orcid":"","institution":"University of the Witwatersrand","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nana","middleName":"Yaa","lastName":"Fening","suffix":""}],"badges":[],"createdAt":"2024-09-25 15:38:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5153250/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5153250/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":66067933,"identity":"0e9eecdd-4a00-42e1-9995-74451b6ca886","added_by":"auto","created_at":"2024-10-07 11:36:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":43921,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlow diagram of the study data.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5153250/v1/74548301bfdb3d0d63492295.png"},{"id":66066999,"identity":"7d4dec92-12c4-4b30-8810-d1480174bd5f","added_by":"auto","created_at":"2024-10-07 11:28:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":30642,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eReasons for delays\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5153250/v1/9efb98edc2b86e8c5b21e7a8.png"},{"id":66066997,"identity":"1241c546-8029-4fe3-87cf-36f30a1bba6b","added_by":"auto","created_at":"2024-10-07 11:28:41","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":42909,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCommon reasons for delays\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5153250/v1/f35d8e1e8066b76acbde79db.png"},{"id":66069322,"identity":"1d59b5dd-5ea5-477a-a620-8045b9983544","added_by":"auto","created_at":"2024-10-07 11:44:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":586182,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5153250/v1/9b6acb79-e1f0-49a0-9b54-2d55b32d205a.pdf"},{"id":66067000,"identity":"23c71a49-1b55-404e-b8c4-942544626d98","added_by":"auto","created_at":"2024-10-07 11:28:41","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":18094,"visible":true,"origin":"","legend":"","description":"","filename":"DATACOLLECTIONSHEET.docx","url":"https://assets-eu.researchsquare.com/files/rs-5153250/v1/9497b934e164e6433ca881c9.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Reasons for delays in start of first elective case of the day at Charlotte Maxeke Academic Hospital: a prospective study.","fulltext":[{"header":"Background","content":"\u003cp\u003eOperation theatres form part of the costly components of a hospital budget, and maximising operation theatre utilisation is crucial to ensure optimum cost benefits.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e The primary goal of improving operating theatre management is to improve the theatre throughput or efficiency, patient care, and good outcomes without increasing costs.\u003csup\u003e\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Studies have argued that even the smallest improvement in operating theatre efficiency can increase productivity.\u003csup\u003e\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Theatre productivity is defined as the quantity of output produced per unit input.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e It can be calculated by taking total costs or resources utilised and dividing it by the average output for that specific period. Theatre productivity can be measured for a specific single theatre, theatre unit, specific surgical discipline, or multiple institutions.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eInternational studies have shown that 16\u0026ndash;24% of operating theatres' productivity and expenditure may be wasted due to the inefficient functioning of theatre complexes, contributing to limited healthcare resources.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Hospital systems are now paying increased attention to workflow efficiency and waste reduction.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e In South Africa, public hospital theatre utilisation averages between 30\u0026ndash;40% compared with the private sector, which averages 48%.\u003csup\u003e1\u003c/sup\u003e One of the most current discussions in both public and private hospitals' theatre utilisation is improving operating theatre efficiency to ensure optimum cost benefits.\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAlthough studies have identified potential elements that can contribute to the success of operating theatre workflow efficiency and prevent unnecessary wasteful expenditures, challenges still exist in terms of implementing such elements. One of the challenges includes the difficulties in pinpointing when and where most failures to improve workflow efficiency occur.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e According to Bauer et al.,\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e this makes it difficult to develop an action plan to improve efficiency and limits the success of operating theatre workflow efficiency.\u003c/p\u003e \u003cp\u003eThe success of operating theatre workflow is dependent on multiple factors, including adherence to the scheduled start time of the first surgical cases.\u003csup\u003e\u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Adherence to the scheduled first-case start time and efficient room turnover optimises theatre utilisation.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e This also reduces time wastage, overruns, and unnecessary cancellations, resulting in patients\u0026rsquo; longer hospital stays, and increased care costs such as food, medication, and hospital expenditures.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Inefficient theatre utilization prolongs the elective waiting list period, resulting in patient dissatisfaction and to some extent compromising patients\u0026rsquo; safety.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eStudies have shown a remarkable improvement in the reduction in delays of first case start times after implementing strategies and policies to mitigate such delays.\u003csup\u003e\u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37 CR38\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e Over 9 months there was an improvement of 6\u0026ndash;60% in the first case start time according to Wrist et al.\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e For example, strategies such as preparation of equipment in advance, regular equipment servicing, improving interdepartmental communication and compliance, proper planning and ensuring preanaesthetic instructions are followed, were reported to improve theatre efficiency and meaningfully reduce hospital costs.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eGiven this context, the overarching goal of this study was to determine the reasons for delays in the start of the first elective case of the day at a teaching hospital, and ultimately develop strategies to mitigate the causes of such delays to improve theatre workflow and productivity and ensure optimum cost benefits. The specific objectives included determining the actual first case start times, identifying preventable and nonpreventable causes (modifiable and nonmodifiable factors responsible for such delays), and classifying causes of delay. Five categories can be used to classify causes of delay. These factors include patient-related factors (e.g. violating fasting guidelines), surgeon-related factors (e.g. late or unavailable surgeon), anaesthesia-related factors (e.g. late, difficult intubation), nursing-related factors (late, drugs counting), and logistics-related factors ( porters being late, equipment failure).\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis was a prospective and observational study conducted over three months from 3 June 2023 to 8 August 2023 at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). CMJAH is a 1088-bed teaching hospital affiliated with the faculty of health sciences of the University of Witwatersrand in Parktown, Johannesburg, Gauteng Province, South Africa. All qualifying adults and paediatric patients who were scheduled for weekday elective surgery as first cases, booked at least one day before the operation were included. Cases not requiring an anaesthetist and done after hours (before 07:00 and after 16:00), during public holidays, or on weekends were excluded. The study protocol was reviewed by the human research ethics committee of the Witwatersrand University and deemed nonhuman subjects\u0026rsquo; research. Approval to conduct the study at the hospital and access patients\u0026rsquo; medical files and theatre record books was granted by the theatre management.\u003c/p\u003e \u003cp\u003eA convenience method of sampling was used. The inclusion criteria were all age groups, elective cases, first cases of the day and cancelled first elective cases. Cases that were excluded were emergency cases, cases that were performed after the scheduled elective time and cases that did not require an anaesthetist. A total of 406 cases met the inclusion criteria and were analysed.\u003c/p\u003e \u003cp\u003eData were collected using the data collection tool (Appendix 1) and the following times were recorded: date, theatre name, surgical specialty, procedure, scheduled first case time, porter send-off time, and theatre arrival time. Upon arrival in theatre, patient\u0026rsquo;s in-room time, anaesthesia time, and procedure times were recorded. The cases that did not have documented times or reasons for delay, data were obtained from medical records. The scheduled first case was defined as the first elective case scheduled in the operating room for the day. Scheduled first case time was defined as the time when the case was posted to start in the operating theatre, which differed across different specialties. On-time start was the patient\u0026rsquo;s in-room time that occurs at or before the scheduled first case time. Start time delay was defined as the patient in-room time that occurs after the scheduled first case time. A grace period of 5 minutes was considered when analysing the data.\u003c/p\u003e \u003cp\u003eDelay times were calculated using frequencies and means with 95% confidence intervals at various stages per specialty. Similarly, the reasons for delays were categorised and calculated accordingly. A \u003cem\u003ep-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/em\u003e was considered statistically significant. All the statistical analyses were performed using Stata 15 (StataCorp, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 427 cases met the inclusion criteria, of which 21 cases were cancelled. The reasons for cancellation included low theatre temperatures (8 cases), poor patient optimisation (3 cases), unavailability of postoperative ICU beds (3 cases), patient unfit for theatre (2 cases), equipment failure (1 case), invalid consent (1 case), patient\u0026rsquo;s pathology resolved (1 case), incorrect booking (1 case), and 1 case due to no available anaesthetist. The remaining 406 scheduled first cases from 14 different surgical specialties were analysed. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows a flow diagram of the study data.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe following were scheduled first case start time per specialty: 07:00 for cardiac surgery, 07:30 for urology, ENT, general surgery, trauma surgery, orthopedics surgery, vascular surgery, ophthalmology, and maxillo-facial surgery; and 08:00 for gynecology, plastic surgery, breast surgery, and pediatric surgery. The distribution of cases per specialty is shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDISTRIBUTION OF CASES BY SPECIALTY\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSPECIALTY\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGynecology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28 (6.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28 (6.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eENT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19 (4.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaxillo-facial surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25 (5.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOphthalmology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24 (5.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlastic and breast surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24 (5.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthopedic surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e86 (20.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrauma surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (2.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38 (8.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiothoracic surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46 (10.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurosurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21 (4.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePediatric surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60 (14.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVascular surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (3.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAudiology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (0.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eAmong all 406 cases studied, 97.5% (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;396) of those cases experienced a significant delay in starting the first case, which was statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Only 2.5% (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;10) of the cases were deemed to be on time. The mean delay time for all the cases was 47.3 minutes, the mean delay time for porter send-off was 7.2 minutes (SD 23.8), the in-room delay time was 42.7 minutes (SD 40.1), the anaesthesia delay time was 50,7 minutes (SD 40.7), and the procedure delay time was 90 minutes (SD 69.0). There was a 19% delay during porter send-off, 40% at theatre arrival, 93% in-room delay time, 96% at anaesthesia delay time, and 97.5% at procedure delay time. The mean delay time per specialty at different time delays is shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency of delays in first elective cases, Mean delay time, Standard deviation, and total delay time.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialty\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal number of cases analyzed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDelayed cases \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003cp\u003edelay time (minutes)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStandard deviation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTotal delay time minutes\u003c/p\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAudiology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e59 (0.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiothoracic surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5554 (11.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eENT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1364 (4.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2843 (8.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurosurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e66.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2444 (4.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOphthalmology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e39.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1971 (5.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlastic \u0026amp; breast surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1852 (5.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2185 (6.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVascular surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1454 (4.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthopedic surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81 (96.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8434 (20.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaediatric surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (96.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3526 (14.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaxillo-facial surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2311 (5.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrauma surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1108 (2.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGynaecology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (88.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1567 (6.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eP = 0.001\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThere were only five departments that did not have 100% delayed cases. These included gynaecology with a delayed percentage of 88.9%, trauma surgery (90%), maxillo-facial surgery (92%), paediatric surgery (96.1), and orthopedic surgery (96.7%). The rest of the specialties had 100% delayed cases. Delays at porter send-off and theatre arrival time were low whereas almost 100% of delays occurred at in-room, anaesthesia, and procedure times. The three most delayed specialties were cardiothoracic surgery, neurosurgery and ophthalmology. The delay percentages at different stages of the three most delayed specialties are shown in the table below (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDelay percentages at different stages of the three most delayed specialties.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialty\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCardiothoracic surgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOphthalmology\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNeurosurgery\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall delayed cases \u003cb\u003en\u003c/b\u003e (% of the total number of cases)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelayed Porter send-off time \u003cb\u003en\u003c/b\u003e (% of the total number of cases)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (47)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelayed theatre arrival time \u003cb\u003en\u003c/b\u003e (% of the total number of cases)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelayed in-room time \u003cb\u003en\u003c/b\u003e (% of the total number of cases)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43 (98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (94)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelayed Anaesthesia time \u003cb\u003en\u003c/b\u003e (% of the total number of cases)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelayed procedure time \u003cb\u003en\u003c/b\u003e (% of the total number of cases)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eA total of 1072 reasons for delay were identified during the study. The reasons for the delay were classified into six categories, namely: patient-related factors, surgeon-related factors, anaesthesia-related factors, nursing-related factors, logistics-related factors, and others, which were further classified into no reason documented and delayed cascade (meaning that further delay was due to prior delays). Surgeon-related factors accounted for the most delays at 353 (23.7%), followed by other reasons i.e., cascading delays at 339 (22.8%), logistics-related factors at 264 (17.7%), nursing-related factors at 241 (16.1%) and anaesthesia-related factors at 192 (12.9%). Patient-related factors accounted for the lowest percentage of delays, at 35 (2.3%) as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe surgeon being late accounted for 58.9% of all surgeon-related causes, followed by incorrect booking of the surgical list at 14.1%. The most common reasons among other categories included outpatients being late under patient-related factors accounting for 52% and late anaesthetists accounting for 40.2%. The ward nurses preparing patients late or presenting incomplete handover documents accounted for 30%. Late porters accounted for 30% of all logistics-related causes. Common reasons for delays are shown below in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The causes for delays in the start of the first elective case of the day are further classified into preventable and nonpreventable factors. Preventable causes constitute 86% of all causes, whereas 13.4% are nonpreventable.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study has shown the prevalence of delays in the first elective case of the day start time to be within the global standard as depicted in publications.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Delays in start time are a widespread problem faced by both developing and developed countries. It has a negative impact on the quality of health and negatively affects theatre utilisation.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e The goal of operating theatre is to maximise its use and mitigate any form of delay. A delayed start time invariably led to slates finishing late and unplanned cancellations. This has led to increased costs through overtime payments.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e For this reason, first case start times have been used as a performance indicator and to implement improvement strategies to optimise theatre utilisation.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis study has revealed a considerable number of delayed cases, accounting for 97.5% of all cases. This is similar to the findings of a study by Cox Beaur et al.,\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e where they studied 5598 patients across three high-volume urban hospitals between July 2012 and November 2013. They reported that 98% of the cases were delayed. Similarly, a higher delay prevalence of 99% was reported in a study conducted in a Nigerian hospital comprising 1170 patients by Okeke et al.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e These studies were conducted in both developed and developing countries, respectively. However, these findings contrast with those of a Canadian nine-year prospective study of 1531 elective cases in which just over 50% (51.4%) of cases were delayed.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e This large gap in delay prevalence may be attributed to the premise that the study setting was in a specialised neurosurgical unit as compared to a multi-specialty system at CMJAH. Another contributing factor may be resources and the capacity to cater to operating theatre needs.\u003c/p\u003e \u003cp\u003eThis study revealed a 0.23% ( 21 cases) cancellation rate. This is lower than the findings in a study by Fayed et al. \u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e where they studied 1813 cases over 3.5 years. They had an 11.1% cancellation rate. \u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e These numbers are similar to those reported in the Nigerian study by Okeke et al. \u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e, which reported a 9.1% cancelation rate among the 1296 cases studied. This difference might be explained by the nature of their studies, where they studied all booked elective cases in contrast to our study, where only the first elective cases were studied. The most common reasons for cancellation were low theatre temperatures (38%), poor patient preparation (14.2%), and the unavailability of ICU beds (14.2%). Patient-related factors were the most common causes of cancellations reported by Fayed et al. \u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e and Okeke et al. \u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e Majority of patients did not show up for the procedure while in Nigeria, patients were cancelled due to a lack of funds. \u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e,\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e This study took place in the winter season which could have contributed to low theatre temperatures. Theatre thermostat devices in our hospital do not function well, contributing to failure to detect or adjust low temperatures. Another contributing factor is that all theatre temperature controls are centralised, making it difficult to single out a specific theatre and adjust its temperature. The department with the highest cancellation rate is Orthopaedics surgery with 28%. Jayed et al. \u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e in a four-year retrospective study of 1813 cases in Saudi Arabia reported that ophthalmology had the highest cancellation rate accounting for 37% of all cancelled cases, whereas Okeke et al. \u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e reported that general surgery was at the top of the list accounting for 36%. This highlights that there are multifactorial contributing factors across various institutions.\u003c/p\u003e \u003cp\u003eThe causes of delays in our study were multifactorial, with the most common being surgeon-related factors (23.7%). This was followed by logistics-related factors at 17.7% and nursing-related factors at 16.1%. These findings are similar to those of a study by Overdyk et al.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e, which reported that surgeons\u0026rsquo; unavailability was the most common reason for delays accounting for more than half of the reasons. This contrasts with a Nigerian study by Okeke et al., wherein patient-related factors were the leading cause of delays, accounting for 31.1% of all delays.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e This may be attributed to affordability as patients are required to fund their medical bills. Our study revealed that more than half (58.9%) of the delays were due to surgeons being late. This was followed by incorrect booking of surgical lists; either the list was submitted late, it changed on the morning of the procedure, or there was a change in the order of the patients. Issues including invalid, missing, or unsigned consent forms were also among the common causes of delays. Other causes of delays were miscommunication between team members; poor patient preparation; and poor preprocedure preparations, such as positioning, prewashing, or insertion of a transurethral catheter.\u003c/p\u003e \u003cp\u003eLogistics-related causes were the second highest reasons for delays. Porters being late accounted for 30% of all logistics-related causes. A similar finding was revealed by Jonnalagadda et al.\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e in a six-week prospective study of 594 cases, where the most common reason for the delay was patient transportation to theatre (17%). In our study, other reasons for delays included equipment failure (25%), delayed cleaning, and waiting for ICU beds or investigations. The common nursing-related issues included the late arrival of nurses, drug counting which delays the anaesthesia start time, and ward nurses\u0026rsquo; late preparations. The reason for these delays accounted for 4.4% of all delays. This percentage was lower than the 60% reported in a study conducted by Cox Beaur et al.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e The overall mean delay time in this study was 47.3 (IQR 33\u0026ndash;52) minutes. This value is almost twice the mean delay times of 28.2 minutes and 21.6 minutes reported by Cox Beaur et al. and Shuster et al.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e The difference in the setting of the studies by Cox Beaur et al. and our study might be the reason for these findings. Their study took place in a dedicated neurosurgical facility whereas our study took place in a center catering to multiple disciplines. Factors such as equipment malfunction, theatre temperature instability, and water shortages were not among the reasons for the delay in their study.\u003c/p\u003e \u003cp\u003eThe specialties with the lowest prevalence of delays were audiology, paediatric surgery, and gynaecology. Similarly, Shuster et al.\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e studied 21357 cases across twenty-two German hospitals over 9-months period and reported that gynaecology and ENT specialties had the least delays. The most delayed specialty in our study was cardiothoracic surgery, with a mean delay time of 70.3 minutes (IQR 50\u0026ndash;125), followed by neurosurgery, with 64.0 minutes (IQR 32.5\u0026ndash;120), and ophthalmology with 53.3 minutes (IQR 50\u0026ndash;90). In a study conducted by Cox Beaur et al.,\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e neurosurgery was the most delayed specialty. However, a study by Okeke et al.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e reported that general surgery, orthopedic surgery, and urology had the greatest delays. On the other hand, Hicks et al.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e studied 3604 cases in a level one trauma center in 2018 and reported that paediatric surgery and trauma surgery had the most delays. These findings show that there is no universal start time applicable across surgical specialties, and that different institutions have different challenges affecting first-case start times across various specialties.\u003c/p\u003e \u003cp\u003eThe main goal in trying to identify the areas of delays in the start time of the first elective cases was to mitigate these delays for better outcomes. We found that 86% of all the reasons for delays were preventable factors and that 13.4% were nonpreventable. This highlights room for improvement. \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e The most common preventable cause of delay is staff being late. Numerous strategies have been shown to improve outcomes. The financial incentives method involves financially rewarding healthcare providers who perform better. \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Han et al \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e implemented a mandate to pay neurosurgical registrars if they managed to ensure that the patient was brought to the theatre on time or earlier. They managed to reduce the first-case start delays by 7.17%, and patients were brought to the theatre 30 minutes early. Improved interdepartmental communication and frequent meetings to discuss the roles and expectations of each team member have been shown to reinforce the first case on-time start. \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Overdyk et al \u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e implemented theatre efficiency educational strategies for staff over 2 weeks, and they improved the first case start time by 22 minutes. \u003csup\u003el\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe logistics-related factors included cleaning theatre rooms late, nonconducive theatre temperatures, waiting for the availability of ICU beds, and equipment failure. The theatre temperatures must be checked before and at the end of each theatre list to ensure that the temperatures are within the recommended values. Regular equipment servicing and appointing of a designated team to ensure up-to-date equipment functioning will reduce late first-case starts. Cleaning theatres at the end of a theatre list reduces the need for morning cleaning.\u003c/p\u003e\n\u003ch3\u003eStrengths and limitations\u003c/h3\u003e\n\u003cp\u003eThe overarching strength of the study is that it contributes to the body of knowledge in the subdiscipline of anaesthesiology, given that reasons for delays in first elective case start times have been identified. Strategies can be implemented accordingly to reduce such delays. The study was conducted in a single academic hospital setting. Thus, the generalisation of its findings is limited.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study reported an alarmingly high rate (97.5%) of delayed cases, with surgeon-related factors being the most common cause. Majority of these causative factors are preventable and can be improved. Strategies can be put in place to mitigate these delays. In doing so, costs may be reduced, and the quality of health care may be improved.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCMJAH Charlotte Maxeke Johannesburg Academic Hospital ENT Eyes, Nose and Throat\u003c/p\u003e \u003cp\u003eHOD Head of Department CEO Clinical executive officer IQR Interquartile range\u003c/p\u003e \u003cp\u003eSD Standard deviation\u003c/p\u003e \u003cp\u003eICU Intensive care unit\u003c/p\u003e \u003cp\u003eDMAIC Define, measure, analysis, improvement, and control\u003c/p\u003e \u003cp\u003eUK United Kingdom\u003c/p\u003e \u003cp\u003eHIV Human immunodeficiency virus\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Human Resource Ethics Committee, Witwatersrand University, with approval number M221067. This study was a nonhuman study; hence, it did not require patient consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data are available upon request with permission from Witwatersrand University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any funding from other parties.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has no contributions from the other authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDepartment of Anaesthesiology, Charlotte Maxeke Johannesburg Academic Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRixongile Style Manganyi, MBChB, DA(SA) (2610358)\u003csup\u003e1\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eNana Yaa Fening, MBChB, DA(SA), FCA(SA) MMed (Wits)\u003csup\u003e1\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmanda Nkuna, MBChB, DA(SA), FCA(SA) MMed (Wits)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e1Department of Anaesthesiology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLee DJ, Ding J, Guzzo TJ. Improving operating room efficiency. Curr Urol Rep. 2019;20(6):28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCox Bauer CM, Greer DM, Vander Wyst KB, Kamelle SA. First-case operating room delays: patterns across urban hospitals within a single health care system. J Patient Cent Res Rev. 2016;3:125\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWallace L, Muir M, Romano L, Wyllie T, Gyomber D, Hodgson R. Assessing operating theatre efficiency: a prospective cohort study to identify intervention targets to improve efficiency. ANZ J Surg. 2021;91(11):2382\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFoglia RP, Ruiz JE, Burkhalter L. An Evolutionary Change in First Case on Time Starts Using Perioperative Process Improvement, Communication and Enhanced Data Integrity. Global J Perioper Med. 2017;1(1):013\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiller RD, Pardo MC Jr. Basics of Anesthesia. 7th ed. Philadelphia, PA, USA: Elsevier; 2018. pp. 803\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDell AJ, Kahn D. Surgical resources in South Africa: a review of the number of functional operating theatres. S Afr J Surg. 2018;56(3):2\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInnovations NAFC. Operating theatre efficiency guidelines: a guide to the efficient management of operating theatres in New. South Wales Hosp. 2014;1(1):9\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoutlana HJ. Theatre efficiency. S Afr J Anesth Analg. 2021;27(6):182\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan As AB, Brey Z, Numanoglu A. Issues in medicine: improving operating theatre efficiency in South Africa. S Afr Med J. 2011;101(7):444.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHartmann D, Sunjka B. Private theatre utilisation in South Africa: a case study. S Afr Med J. 2013;103(5):285\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePashankar DS, Zhao AM, Bathrick R, Taylor C, Boules H, et al. A Quality improvement project to improve first case on-time starts in the pediatric operating room. Pediatr Qual Saf. 2020;5(4):e305.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsai MH, Hudson MD, Emerick ME, McFadden TD. The true relevance of first case start delays. Am J Surg. 2015;209(2):427\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsmal II, Cronj\u0026eacute; L, Keerath K. An audit of operating theatre utilisation and day-of-surgery cancellations at a regional hospital in the Durban metropole. S Afr Med J. 2019;109(10):765\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorel SD, Gonzanga Gomez NA. Improving on-time first case starts: an integrative review and quality improvement project plan. Perianesth Nurs. 2021;36(6):717\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoffman CR, Horrow J, Ranganna S, Green MS. Operating room first case start times: a metric to assess systems-based practice milestones. BMC Med Educ. 2019;19(1):446\u0026ndash;446.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoos C, Bertheau S, Hauptvogel T, Auhuber T, Taube C, et al. Case delay in the OR morning start in hospitals of different size and academic status: results from a German multicenter study to identify incidence and causes of delayed anesthesia ready time. Anaesthetist. 2020;70(1):23\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkeke C, Okorie C, Ojewola R, Omoke N, Obi A. Delay of surgery start time: experience in a Nigerian teaching hospital. Niger J Surg. 2020;26(2):110\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeak NJ, Lazo MCJ, Yee-Wen S, Ciccone D, Kresky S, et al. First Case On-Time Starts Barriers and Strategies to Success and Sustainability. J Perianesth Nurs. 2021;36(4):e14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHicks KB, Glaser K, Scott C, Sparks D, McHenry CR. Enumerating the causes and burden of first case operating room delays. Am J Surg. 2020;219(3):486\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen Y, Gabriel RA, Kodali BS, Urman RD. Effect of Anesthesia Staffing Ratio on First-Case Surgical Start Time. J Med Syst. 2016;40(5):115\u0026ndash;115.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePandit JJ, Abbott T, Pandit M, Kapila A, Abraham R. Is \u0026lsquo;starting on time\u0026rsquo; useful (or useless) as a surrogate measure for \u0026lsquo;surgical theatre efficiency\u0026rsquo;? Anaesthesia. 2012;67(8):823\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLizaur-Utrilla A, Martinez-Mendez D, Miralles-Mu\u0026ntilde;oz FA, Marco-Gomez L, Lopez-Prats FA. The negative impact of waiting time for primary total knee arthroplasty on satisfaction and patient-reported outcome. Int Orthop. 2016;40(11):2303\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHalim UA, Khan MA, Ali AM. Strategies to improve start time in the operating theatre: a systematic review. J Med Syst. 2018;42(9):160\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Veen-Berkx E, Elkhuizen SG, Kalkman Cor J, Buhre WF, Kazemier G. Successful interventions to reduce first-case tardiness in Dutch university medical centers: Results of a nationwide operating room benchmark study. Am J Surg. 2014;207(6):949\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcNamara R, Baker C, Mullen J, Lenehan B, Grimes S, et al. Use of lean principles to improve flow of patients with fractured neck of femur-The HOPE Study. Ir Med J. 2014;107:70\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGee E, Saunder T, Fletcher S, Quarmby C, Peterson G. Improving first case start times: a rural perspective. ANZ J Surg. 2017;87(11):955\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMathews L, Kla KM, Marolen KN, Sandberg WS, Ehrenfeld JM. Measuring and improving first case on-time starts and analysis of factors predicting delay in neurosurgical operating rooms. J Neurosurg Anaesthesiol. 2015;27(3):203\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGupta R, Tat Q, O'Brien J, Shaw M, Cumbler E, et al. Utilization of lean project management principles and health informatics to reduce operating room delays in a vascular surgery practice. Am J Surg. 2022;223(1):176\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNaik SV, Dhulkhed VK, Shinde RH. A prospective study on operation theater utilization time and most common causes of delays and cancellations of scheduled surgeries in a 1000-bedded tertiary care rural hospital with a view to optimize the utilization of operation theatre. Anest: Essays Res. 2018;12(4):797\u0026ndash;802.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalzer C, Raackow D, Hahnenkamp K, Flessa S, Meissner K. Timeliness of operating room case planning and time utilization: influence of first and to-follow cases. Front Med. 2017;4:49\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrink H, Van der Walt C, Van Rensburg GH. Fundamentals of research methodology for health care professionals. 4th ed. Cape Town, South Africa: Juta and Company (Pty)Ltd; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBotma Y, Greeff M, Mulaudzi FM, Wright SCD. Research in health sciences. Cape Town: Pearson Holdings Southern Africa; 2010.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRees C. The Practice of nursing research-appraisal, synthesis, and generation of evidence. 6th ed. London: Royal College of Nursing Publishing Company (RCN); 2009.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOverdyk FJ, Harvey SC, Fishman RL, Shippey F. Successful strategies for improving operating room efficiency at academic institutions. Anesth Amp; Analg. 1998;86(4):896\u0026ndash;906.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh D, Cai L, Watt D, Scoggins E, Wald S. Improving operating room efficiency through reducing first delays in an academic centre. J Healthc Qual. 2023;45(5):308\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWong J, Khu KJ, Kaderali Z, Beinstein M. Delays in the operating room: signs of an imperfect system. Can J Surg. 2010;53(3):189\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGupta B, Agrawal P, D\u0026rsquo;souza N, Soni KD. Start time delays in the operating room: Different perspectives. Saudi J Anaesth. 2011;5(3):286\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJonnalagadda R, Walround ER, Hariharan S. Evaluation of reasons for cancellations and delays in a developing country. Int J Clin Pract. 2005;59:716\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchuster M, Pezella M, Taube C, Bialas E, Pierrer M, Bauer M. Delays in starting morning operating lists: an analysis of more than 20,000 cases in 22 German Hospitals. Dtsch Arztebl Int. 2013;110(14):237\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWright JG, Roche A, Khoury AE. Improving on-time surgical starts in an operating room. Can J Surg. 2010;53(3):167\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkeke CJ, Obi AO, Tijani KH, Eni UE, Okorie CO. Cancellation of elective surgical cases in a Nigerian teaching hospital: Frequency and reasons. Niger J Clin Pract. 2020;23(7):965\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFayed A, Elkouny A, Zoughaibi N, Wahabi HA. Elective surgery cancelation on day of surgery: An endless dilemma. Saudi J Anaesth. 2016 Jan-Mar;10(1):68\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"delays, scheduled, start time, elective, first case","lastPublishedDoi":"10.21203/rs.3.rs-5153250/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5153250/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eFirst case start time measures operating theatre and patient readiness, and it may contribute to perioperative delays. Improving the first case start time is associated with higher theatre productivity. The aim of this study was to determine the first elective case start time and identify reasons for delays at Charlotte Maxeke Johannesburg Academic Hospital, a multidisciplinary tertiary theatre complex.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eA prospective observational study was conducted on all first elective cases of the day from June to August 2023. Times and reasons for delays in patient flow were documented, starting from theatre arrival until the beginning of the procedure. The times were analysed in relation to the departmental protocol for first case start times. \u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/em\u003e was considered statistically significant. All the statistical analyses were performed via Stata 15 (StataCorp, USA).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA delay prevalence of 97.5% was reported, with only 10 cases having started on time. The mean delay time was 47.5 minutes (IQR 33\u0026ndash;85), and the standard deviation was 53.2. The most frequent reasons for delays were surgeon-related factors accounting for 23.7%, followed by logistics-related factors accounting for 17.7%. Most of these causative factors are preventable.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eA majority of the first cases at CMJAH are delayed and the reasons for delays are multifactorial, but preventable. Multiple strategies can be employed to mitigate the causes of delays, thus improving theatre utilisation and saving costs.\u003c/p\u003e","manuscriptTitle":"Reasons for delays in start of first elective case of the day at Charlotte Maxeke Academic Hospital: a prospective study.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-07 11:28:36","doi":"10.21203/rs.3.rs-5153250/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f8651cc5-ab68-424a-bed3-24630defdfc4","owner":[],"postedDate":"October 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-07T11:28:36+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-07 11:28:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5153250","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5153250","identity":"rs-5153250","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}