Measure to quantify the influence of time from end of surgery to tracheal extubation on operating room workflow

The impact of delays in extubation on operating room (OR) workflow are challenging to assess because such delays may or may not be a bottleneck to the patient leaving the OR. We developed an observational measure that quantifies the influence of extubation times on OR workflow.

The time from dressing on the patient (or its functional equivalent) to tracheal extubation was observed in ORs, among a cohort of adult patients undergoing elective (scheduled) general anesthesia. During the first 36 extubations, the measure was developed using qualitative methods. During the subsequent 64 extubations, qualitative observation was supplemented with quantitative measurement. Interrater reliability was assessed during the final 30 of the 64 extubations. Video 1 (see Supplemental Digital Content 1, http://links.lww.com/AA/A396) shows animation of a typical observation period.

The developed measure was a single value for each case: whether at least 1 person was doing no visible physical activity potentially related to patient care for at least 1 minute between dressing on the patient and tracheal extubation. Assessing reliability, 2 raters' listings of cases with no versus 1 or more people idle were identical for 30 of 30 cases (95% lower confidence limit >90%). Spearman r = 0.99 (95% lower confidence limit 0.99) for time from dressing on patient to extubation. Predictive validity was shown by positive correlation between the percentage of cases with at least 1 person idle and extubation time (P < 0.0001): 21% for <5 minutes, 42% for 5 to 10 minutes, 87% for 10 to 15 minutes, and 100% for >15 minutes.

Longer times to extubation are associated with an increased chance of at least 1 person waiting in the OR. This measure can be used in observational studies and for lean engineering projects to assess conditions when time to extubation affects workflow. Observers can combine use of this measure for extubation times with the previously developed measure for studying the influence of induction times on OR workflow.