Title : Improving time to theatre: Reducing avoidable cancellations and delays to surgery in trauma - A quality improvement project
Abstract:
Background: Timely surgery is among the strongest determinants of outcome in trauma and orthopaedics. Hip fracture fixation within 36 hours is mandated under the NHS Best Practice Tariff; for many other injuries, early intervention reduces pain, complications, and length of stay. When cases are cancelled or delayed, patients fast repeatedly, occupy acute beds, and experience avoidable distress. Repeated observation by the on-call team at Queen’s Hospital, BHRUT, indicated that many delays arose from fixable ward-level causes - missing pre-operative bloods, outstanding echocardiograms, or unresolved anticoagulation - yet no systematic prospective data existed to quantify or categorise these events.
Aim: To measure the scale and modifiable causes of cancellations and delays to trauma surgery at Queen’s Hospital, and to implement simple, ward-owned changes that the trauma team could sustain.
Methods: A retrospective service evaluation was conducted from November 2025 to March 2026 across Theatre 5 and Theatre 6 (main trauma theatres) at Queen’s Hospital. After records proved unreliable, a bespoke data-capture tool was developed. Every cancellation and delay event across 683 consecutive trauma theatre cases was recorded. Of 166 total events, 57 were identified as same-day re-booking artefacts (wrong procedure or side, rescheduled the same day, with surgery proceeding) and excluded. The remaining 109 genuine cancellation events were categorised by cause and modifiability. A further 100 cases were recorded as delayed beyond their clinical target time.
Results: Three modifiable priority causes accounted for most genuine cancellations and delays:
•Administrative and process errors (n?=?34) genuine booking and listing mistakes.
•Theatre time and list-access failures (n?=?21) overbooking, displacement of urgent cases by emergencies, and absence of a protected slot for time-critical Expedited trauma.
•Patient not ready for theatre (n?=?19) pre-operative bloods, echocardiogram, or anticoagulation management not completed at admission.
Communication and handover failures were a cross-cutting theme across all categories. Together these three causes accounted for approximately 80% of avoidable events.
Interventions: Three low-cost, team-owned changes were designed and are being tested through a single PDSA cycle over eight weeks: (1) a pre-operative readiness routine completed by the admitting registrar/SHO on arrival (bloods, ECG, early echo flag for ASA 3–4, documented anticoagulation plan); (2) an overnight pre-operative check by the night on-call team confirming all results are back and valid by midnight; and (3) a reliable pre-list handover including a daily theatre brief, ward notification the evening before, and a ‘ready for theatre’ check before any patient is listed.
Targets: Genuine avoidable cancellations: ↓?30% from baseline (∼109 cases) · Cases delayed beyond target time: ≤?55% (from 85%) · Avoidable pre-operative causes: ≤?1 in 10 events (from ∼1 in 4).
Conclusion: The majority of genuine theatre cancellations and delays in this cohort were avoidable and attributable to three modifiable causes. Simple, ward-owned interventions targeting pre-operative readiness, overnight verification, and list discipline are now under active PDSA testing. This QIP offers a replicable model for trauma theatre efficiency improvement across NHS Trauma & Orthopaedic departments, with a planned second cycle across King George Hospital.
