Quantification of emergency operating theatre process performance: a systematic review of clinical studies

BACKGROUND Operating theatre performance is an essential component of healthcare resource optimisation. Because of its time-critical nature, emergency operating theatre performance is a problem distinct to that of elective surgery. Process performance can be quantified through the related terms: productivity, efficiency, and effectiveness. This systematic review examined the metrics used to quantify emergency operating theatre performance and the methodological quality of the associated literature. METHODS PubMed, ISI Web of Knowledge, and Embase were searched from inception to December 2024 using Medical Subject Headings terms relating to metric, performance, and operating theatre. Studies were reviewed independently for inclusion and quality (ROBINS-I and GRADE). Only clinical studies are presented here. RESULTS In total, 32 clinical studies were included, and 19 performance metrics were identified (six efficiency; 10 effectiveness; three productivity). The median (range) performance metrics per study was 4 (1-7). Frequently reported metrics were out-of-hours operating (19 studies; 59%), delay (17 studies; 53%), and utilisation (13 studies; 41%). Eleven (34%) studies were low quality and 21 (66%) were very low quality. Twenty-six (81%) studies used insufficient metrics, 30 (94%) studies used non-generalisable metrics, 29 (91%) studies did not quantify trade-off between metrics, and 16 (50%) studies had insufficient scope of investigation. Interventions evaluated included reallocating theatre time (eight studies; 25%), increasing emergency theatre capacity (eight studies; 25%), and instituting acute care surgery services (six studies; 19%). CONCLUSIONS Currently, there is no widely recognised framework to assess the quality of emergency theatre performance study designs. There is a tendency within clinical studies to focus on effectiveness rather than efficiency, potentially reflecting clinicians' focus on patient outcome. Systematic biases that reduce evidence quality are common, creating uncertainty in the validity and generalisability of results. To mitigate the risk of future false economies, consensus on what constitutes best practice of theatre performance study design is required. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42021295480).