Implementing a Preoperative Holding Area: Feasibility and Early Effects on First-Case Orthopaedic Theatre Starts in a Major Trauma Centre

TL;DR

A preoperative holding area improved readiness for first orthopedic surgeries but had limited impact on actual start times due to downstream delays.

Contribution

A repurposed preoperative holding area significantly improved patient readiness for first-case orthopedic surgeries in a trauma center.

Findings

Using a preoperative holding area reduced send-for time by 8.2 minutes, improving patient readiness.

On-time anaesthetic starts increased from 35% to 42.9% when the holding area was used.

Downstream operational factors limited the translation of earlier readiness into earlier anaesthetic starts.

Abstract

Background

Timely first-case starts underpin theatre productivity and reduce downstream delays. We evaluated whether introducing a proximal preoperative holding area improved first-case start performance across four orthopaedic theatres in a major trauma centre (MTC).

Methods

We conducted a prospective quality-improvement project (QIP) comparing a 2-week pre-intervention baseline with a 2-week post-intervention assessment period. The paediatric anaesthesia recovery bay was repurposed as a preoperative holding area for eligible adult first-case patients when available. Paediatric cases and cancelled lists were excluded. Operational timestamps were extracted from operating room management software and converted to minutes after 08:00. Primary outcomes were first-case send-for time and anaesthetic start time. Group comparisons used two-sided Welch’s t-tests with mean differences and 95% CIs. On-time performance was defined a priori as anaesthesia commencing ≤09:10 (≤70 minutes after 08:00) and compared using ORs with 95% CIs.

Results

We analysed 110 operating lists: 40 pre-intervention and 70 post-intervention, of which 35 used the holding bay. Relative to baseline, lists that used the holding bay demonstrated an earlier send-for by 8.2 minutes (mean 25.4 → 17.2 minutes after 08:00; mean difference -8.2; 95% CI -15.8 to -0.6; p=0.035), indicating significantly improved patient readiness. The mean anaesthetic start moved earlier by 2.3 minutes (79.2 → 76.9 minutes after 08:00; mean difference -2.29; 95% CI -10.1 to +5.6; p=0.56), a non-significant change. On-time starts increased from 35.0% (14/40) pre-intervention to 42.9% (15/35) with holding-bay use (OR 1.39; 95% CI 0.55-3.54). Analyses including all post-intervention lists, irrespective of holding-bay use, showed similar but attenuated effects.

Conclusions

Implementation of a preoperative holding area significantly advanced preoperative readiness and modestly shifted first-case anaesthetic starts earlier. The translation from earlier send-for to earlier induction was constrained by downstream operational factors. Characterisation of these constraints is essential to optimise upstream gains. Coupling dependable access to a dedicated holding space with a bundle, including pre-identification and pre-assessment of a “Golden Patient” and punctual multidisciplinary briefs with named handover, offers a credible route to consistently on-time first-case starts and improved theatre productivity.