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Eye hospital efficiencies below global benchmarks – SA study

A six-month study of ophthalmology-theatre efficiency in a large tertiary eye hospital in South Africa found that all parameters were below international benchmarks, notes MedicalBrief.

Researchers say 65% of surgeries at the hospital started late and there was a cancellation rate of 16%, which is significantly higher than the recommended benchmark of 2%.

With the country’s public health system having such hlimited resources and long surgical waiting lists, efficient running theatres is particularly crucial, given the limited budget: theatre inefficiency is a major cause of wasted resources.
The cross-sectional study of ophthalmological surgery by the Department of Ophthalmology, Charlotte Maxeke Johannesburg Academic Hospital, and the Faculty of Health Sciences at Wits University was performed over six months at St John Eye Hospital, a tertiary academic eye hospital in Diepkloof, Soweto.

It serves a large population of Soweto and surrounding areas, and receives referrals from six secondary hospitals, two of which are the main referral hospitals in North West Province. It has three operating theatres, but no dedicated emergency theatre, so emergencies are added on to the elective theatre list as they arise.

This potentially results in cancellations of elective cases or an overrun of the list beyond the allocated eight hours, said the authors, whose study was published in the South African Medical Journal.

Data for this study were collected from the theatre register for surgical procedures performed from December 2018 to May 2019. Records for January 2019 were missing and could not be found at the time of collecting data. Elective lists during December run from 1 to 14 December, when the elective lists for the hospital stop for the national festive holidays and resume on 15 January.

All records with incomplete data were excluded. Surgical procedures that were cancelled during this period were included in the study.

Reasons for cancellations were categorised as either patient related or hospital related. Reasons for the former included being medically unfit, not arriving for surgery, refusing surgery, incomplete surgical work-up, change in treatment plan, and others. Reasons for hospital-related cancellations were unavailability of theatre time, unavailability of the surgeon or nursing staff, equipment breakdown, power outage, theatre scheduling error, unavailability of beds, and others.

In total, 1 527 patient theatre records were collected: 29 had incomplete data and 16 operations were performed on public holidays and thus excluded. These included some first and last cases on the lists (an attrition rate of 3%). A total of 1 482 cases in 229 surgery lists were included in the study: 135 lists were under local anaesthesia and 94 were under general anaesthesia. The patients comprised 796 females (54%) and 686 males (46%), with a median (IQR) age of 52 (26 -67) years.

Of the operations, 550 (37%) were performed under general anaesthesia and 932 (63%) under local anaesthesia.

There were 128 640 minutes of theatre time available during the study period. Overall theatre utilisation was 82 330 minutes (64%).

The turnaround time (time between patients, when the operating theatre has no patient in it) was 31 935 minutes, accounting for 25% of available total theatre time.


A total of 241 theatre cases were cancelled, giving a cancellation rate of 16%: 128 (53%) of the cancellations were patient initiated and 113 (47%) hospital initiated. The most common reasons for patient-initiated cancellations were medical unfitness (n=60; 47%) and failure to arrive for surgery (n=43; 34%).

The most common reasons for hospital-initiated cancellations were unavailability of theatre time (n=63; 56%) and lack of theatre equipment (n=30; 27%).

Medical unfitness was the most common reason for patient-initiated cancellations in both local (n=41; 68%) and general (n=19; 32%) anaesthesia lists. The most common reasons for hospital-initiated cancellations in general anaesthesia and local anaesthesia lists were unavailability of theatre time (n=27; 79%) and lack of theatre equipment (n=30; 54%), respectively.

Theatre lists that end before their scheduled completion time also reduce theatre utilisation. In the study, underrunning by 60 minutes resulted in a total loss of 8 275 minutes during the study period, equating to a 6% reduction in theatre utilisation.

Ophthalmological procedures are generally short theatre cases, particularly if they are done under local anaesthesia. Theatre time equivalent to this “lost time” could accommodate many procedures such as cataract surgery, and have a considerable impact on reducing ophthalmology waiting lists.

The Royal College of Anaesthetists recommends that fewer than 10% of lists should end more than 15 minutes later than the scheduled finishing time. Although specific reasons for overruns were not investigated in the present study, possible contributing factors may include the over-booking of theatre lists and prolonged operating times for procedures done by trainee junior surgeons.

Case cancellations on the day of surgery may lead to underrunning of theatres, resulting in wasted time and adding to the long waiting lists, to which the cancelled patients have to be added. An international benchmark for cancellations is 2%, according to New South Wales guidelines. In the South African study the cancellation rate was 16%, significantly above the recommended rate.

The most common hospital-initiated reason for cancellation in the present study was lack of theatre time (56%).

SA has resource constraints, so it is not surprising that lack of theatre equipment was the second most common reason for hospital-initiated cancellations.

The authors said there were several limitations to the study. Its retrospective nature means that the data collected may have inaccuracies, and there may be missing data. The theatre registry did not have reasons recorded for the delayed starting times, which could have given more information on specific causes of theatre inefficiencies.


This study adds to the understanding of factors affecting theatre efficiency. Although the theatre efficiency parameters are suboptimal, with large room for improvement, theatre utilisation of 62% and only 45% late starts are better than those found in other local studies.

Scheduling of lists is very important and will improve most of the parameters that make for an efficient theatre. The overall cancellation rate of 16% is also suboptimal. To reduce cancellations and improve overall theatre efficiency, more attention should be paid to preoperative assessments, not only of the patients, but also of the equipment required on the day of surgery.

Study details

Operating theatre efficiency at a tertiary eye hospital in South Africa

M. Tsimanyane, K. Koetsie, A. Makgotloe.

Published in the South African Medical Journal in May 2023


South Africa is a resource-limited country that needs efficient operating theatres for surgical care to function cost-effectively. Regular assessment of theatre efficiency in our setting is therefore needed.

To describe ophthalmology theatre efficiency at a central hospital in SA and compare this with international benchmarks.

St John Eye Hospital is the ophthalmology section of Chris Hani Baragwanath Academic Hospital in Soweto, SA. It has three operating theatres. A cross-sectional study was done of the theatres’ registry of surgical procedures over a six-month period. Data analysed included the starting and finishing times of theatre lists, surgical cases that were cancelled on the day of surgery, and theatre utilisation rates. These data were compared with international benchmarks.

A total of 1 482 surgical procedures in 229 theatre lists were included in the study. Sixty-five percent of these theatre lists started late, accounting for 4 236 minutes of lost theatre time, significantly more than the maximum of 10% recommended by the Royal College of Anaesthetists. Of theatre lists, 23% and 30% finished after 16h15 (theatre overrun) and before 16h00 (theatre underrun), respectively. This is more than double the 10% recommended by the Royal College of Anaesthetists. The theatre utilisation rate was 62%, which is significantly lower than the ideal utilisation rate of 80%. The cancellation rate was 16%, which is significantly higher than the international benchmark of 2% recommended by the New South Wales guidelines. The most common reasons for cancellations were medical unfitness of the patient and lack of operating theatre time.

All theatre efficiency parameters at St John Eye Hospital were below international benchmarks.


SA Medical Journal article – Operating theatre efficiency at a tertiary eye hospital in South Africa (Creative Commons Licence)


See more from MedicalBrief archives:


Cataract surgery under pressure — SA Ophthalmological Society


Long queues for eye patients in Gauteng


Prioritise cataract surgeries, urge SA experts as backlogs build up


Cases of blindness set to triple in four decades









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