Introduction Inefficient theatre utilisation is costly for patients, staff and healthcare organisations. Active management projects have proven effective at identifying and streamlining delays in the perioperative patient journey.
Aim The aim of this study is to assess whether a novel, wearable, autonomous, Wi-Fi-based real-time location services (RTLS) device could be used to accurately record and process theatre utilisation data.
Methods A novel RTLS device was employed in our theatre department between June and September 2017. Data were collected pertaining to time of arrival and departure from the surgical day ward, operating theatre and recovery using this device, and compared with our institution’s existing written record of theatre data.
Results 101 patients were enrolled, but manually recorded data were unavailable on 18 patients. Among the remaining 83 patients, mean difference in recorded start times was 0.43 min (p=0.64). Mean difference in theatre end times was 1.63 min (p=0.41). Mean difference recorded in overall time in theatre was 1.19 min (p=0.59).
Conclusion The RTLS device provided a reliable record of theatre utilisation, without requiring manual input, with potential as a tool to identify and improve inefficiencies in the theatre department.
- operating theatre utilitsation
- wearable devices
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Time in utilisation has been proposed in the literature as an important metric of operating theatre efficiency.1 Inefficient theatre utilisation can result in delay in timely access to surgical intervention for patients, and can have cost implications for the hospital.2 Effectively using operating theatre resources is, therefore, crucial to maximising health outcomes with limited resources within healthcare systems.3 Change-over time between operative cases constitutes a significant proportion of time expenditure through the course of a theatre list.4 Theatre utilisation can be streamlined by recording delays at each stage of the patient journey through the operating theatre department, and performing targeted interventions where appropriate.5
At present in our institution theatre utilisation data are recorded on paper by nursing staff and subsequently entered into an electronic management system by an administrator. More robust methods of data tracking have been suggested in the literature as beneficial in identifying causes of theatre inefficiency.6 Digital recording systems, such as patient tracking devices, have been shown to improve theatre utilisation when implemented.7 This study takes a novel approach to the use of a real-time location services (RTLS) device, in that it is worn by the patient rather than attached to medical devices or assets.
The aim of this project is to assess whether a novel, wearable, autonomous, Wi-Fi-based RTLS device could be used to accurately record and process theatre utilisation data.
Wi-Fi-based location monitoring
Wi-Fi access points (APs) emit signal across either the 2.4 or 5 GHz bandwidth. The signal strength that is emitted from these points is reduced by items such as walls, furniture and distance. In our institution, there are multiple different pre-existing Wi-Fi APs throughout the building. The signal strength from each of these APs overlaps each other giving each room a unique Wi-Fi signature. This is this fundamental principle on which Wi-Fi tracking is based. A once off mapping session was performed prior to commencing this pilot study which allowed the system to recognise each individual room within our theatre department, based on this unique Wi-Fi signature. The use of preinstalled Wi-Fi APs meant that no additional infrastructure was required in our theatre department.
Device design and data display
A novel RTLS Wi-Fi enabled device was developed by a local start up firm, Pinpoint Innovations. The RTLS was built using off-the-shelf components, with an all plastic exterior and a strap to allow it to be worn on the patient’s wrist. Using the Wi-Fi signature mapping described above, Wi-Fi telemetry was recorded by a microcontroller within the RTLS device, giving the patient’s location within the theatre department. This was relayed to a cloud server over a secure connection to the RTLS system to produce a time series data set of patient locations. This data set was then analysed using descriptive statistical techniques and displayed on a customised user interface accessible via desktop computers within the theatre department, eliminating the need for manual transcription. Should a reading be missed due to lack of a Wi-Fi connection the device could store the location information until a connection became available, ensuring a complete record of the patient’s journey through the theatre department.
The device was compatible with cleaning by hypochlorite. In line with guidance from our infection control team, the device was cleaned twice between patients (on removal from a patient and prior to subsequent re-application), and once cleaned between applications the device was suitable for use in those patients with potentially transmissible healthcare-associated infections.
Real-time location monitoring
Patients attending the Surgical Day Ward between June and September 2017 for same day elective surgery were opportunistically invited to participate in the pilot study. On providing written consent, the patients then affixed the RTLS device to their own wrist in the surgical day ward. The device recorded the patient’s location as they progressed through our theatre department from the day ward, to the preoperative waiting area, to the operating theatre and finally into the recovery area. The RTLS device was then removed as the patient left the recovery area following completion of their procedure.
Data were collected using the RTLS device in relation to time of arrival and departure from the surgical day ward, operating theatre and recovery. The existing manually entered theatre record was examined for each patient for arrival and departure times from the operating theatre. Time of arrival in the operating theatre was considered to be the theatre start time and time of departure from the operating theatre was taken as the theatre end time. Baseline demographic data, procedure type and surgical specialty were also recorded.
Statistical analysis was performed using Minitab 18.1 (Minitab, Pennsylvania, USA). Statistical significance was determined using the paired Student’s t-test, and p values<0.05 were considered statistically significant.
One hundred and one patients were enrolled in this pilot study. Manually recorded data were incomplete in 18 patients, leaving 83 patients with complete records available for comparison.
The mean patient age was 60.1 years (SD ±13.7 years; range 21–88 years), and 55 patients were female (66.3%). Fifty-one (61.4%) patients were discharged on the same day as their surgical procedure. Mean length of stay was 3.8 days (SD ±5.2 days; range 1–32 days). Twenty-nine (34.9%) patients underwent a general surgery operation and 23 underwent a breast surgery procedure (27.7%) (see table 1)
The mean difference in start times recorded by the RTLS device and recorded by the existing manual method was ±0.43 min (p=0.64; SD ±8 min; range −41 to +38 min) (see figure 1). The mean difference in recorded theatre end times was ±1.63 min (p=0.41; SD ±18 min; range −110 to 78 min) (see figure 2). The mean total time in theatre as recorded by the RTLS device was 150.69 min, compared with 149.5 min as recorded manually (difference 1.19 min; p=0.59; SD ±19.8 min; range −111 to 80 min) (see figure 3).
Our data show that this wearable RTLS device has similar accuracy to the manually recorded system that is currently used in our theatre department for recording theatre utilisation metrics. Indeed, our results show that the manual dataset was incomplete in 18 of 101 patients (17.8%) who were then excluded from further analysis—RTLS device data were available on all 18 of these patients, suggesting it may provide more comprehensive utilisation analysis. Additionally, while no statistically significant difference in overall operating time was noted between the RTLS device and manual recording of theatre times, a small number of outliers were seen. This likely reflects the impact of transcription errors in the manual data set, which may be seen as commonly as 18% of the time in a clinical setting.8
Coupled with a higher data capture rate and comparable accuracy, the RTLS device achieved this without relying on nursing staff to manually record time metrics, and without relying on an administrator to transcribe these data onto our institution’s pre-existing theatre utilisation analysis software programme. In the modern healthcare environment, excessive administrative burden may be detracting from patient-centred care.9 The RTLS device provides a simple technological solution to relieve some of this burden, while potentially providing improved data capture.
No complications were recorded with the use of the RTLS device, but a limitation of this study is that postoperative complications such as surgical site infections were not assessed.
RTLS devices have been used in healthcare settings previously, but their utility has previously been limited by substandard functionality in many existing devices.10 The novel approach taken in this study—allowing the device to be worn by the patient—could allow for a greatly enhanced role for RTLS both within the theatre environment, as demonstrated here, and throughout the hospital in general. A wearable RTLS device could, for example, be incorporated into patient identification labels, currently worn on the wrist in our facility and facilitate a revolution in the tracking of healthcare processes on an institution-wide level.
There are data published within the literature about pre-existing RTLS devices that support this optimistic view. Staff working with RTLS devices in an asset tracking have found them to be satisfactory and useful adjuncts.11 In an outpatient setting, RTLS devices have been shown to be effective at identifying inefficiencies and improving treatment times for patients.12 Additionally, RTLS devices may allow for optimising physician workflow in a patient orientated manner.13
There are limited published data to date about the role of RTLS devices in a theatre optimisation setting—one retrospective observational study suggested their use in theatre might improve efficiency of anaesthetists, although there were multiple other contributing factors.14 A Wi-Fi-based patient tracking tool was shown to result in a moderate improvement in theatre utilisation, as a component of a theatre management intervention.7 The data collected by this RTLS device is displayed in a real-time software dashboard, potentially allowing for identification of delays in patient flow and between cases. Whether identifying such issues could ultimately lead to increased efficiency in our theatre department will require further study.
There are numerous potential advantages to adopting an automated RTLS device to record theatre utilisation metrics as described above. While new technology in the healthcare environment is associated with a learning curve, electronic healthcare records have been shown to be as accurate as paper-based records, with advantages in terms of accessibility and reproducibility.15 16
There are some limitations in the use of this RTLS device—it must be manually applied and activated and subsequently deactivated at the start and end of the patient’s perioperative journey. It can only be used to track patients in zones with Wi-Fi APs and which have been mapped. It must be charged and cleaned between patient use. Additionally, this device depends on the existence of a Wi-Fi network within the theatre department, limiting its utility in other institutions if such a network is not already in situ. Despite these limitations, it has broad potential as a tracking and management tool in the theatre environment and in the healthcare setting in general.
Our results show that an automated, Wi-Fi-based RTLS device can be used to accurately record time-based theatre utilisation data, with potential applications in achieving improvements in perioperative patient flow and reducing administrative burden on healthcare staff.
We acknowledge the support of our colleagues in the Perioperative Directorate, University Hospital Limerick, in facilitating this work. The novel RTLS device described in this paper, and the associated data collection software system, is the work and intellectual property of Pinpoint Innovations.
Contributors All named authors made substantial contributions to this work, sufficient to meet the guidelines of the International Committee of Medical Journal Editors (ICMJE) of appropriate authorship. IB, CK, FB, EO and ST planned the study. CK, FB and EO designed and built the novel Real Time Location Services Device. RMO, IB, CK, FB, and EO collected data. RMO and ST wrote and submitted the manuscript. ST acts as guarantor for the overall content of the study.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests FB, CK and EO are cofounders of Pinpoint Innovations and have a beneficial ownership interest in the company.
Patient consent for publication Not required.
Ethics approval Ethical approval for this study was granted by the hospital ethics committee.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement All data relevant to the study are included in the article. All data relevant to the study are included in the article.