Out-of-hours operating - failure to close the audit cycle

A prospective study of all out-of-hours operations performed in a district general hospital was undertaken over two periods. During the first period (1 month) facilities for emergency operating were reviewed and it was concluded that out-of-hours operating should be reduced and several tactics to improve the situation were agreed. A re-audit was undertaken, over 4 months (second period) and results of the two periods compared. Orthopaedic cases performed out-of-hours in both periods of study were 38% vs 40%. Mean theatre delay for general surgical cases in both periods was 5 h 30 min vs 5 h 21 min and theatre usage after midnight during weekdays showed no significant difference (23% vs 28%). 50% of operations performed after midnight in both periods could possibly have been avoided. The attempt to reduce out-of-hours operating failed because there was no protocol. In order to reduce inappropriate operating after midnight, a dedicated daytime emergency theatre is necessary in addition to an increase in the number of daytime orthopaedic trauma lists. Failure to close the audit cycle loop suggests that a more determined effort is required to reduce unsupervised emergency surgery and unnecessary sleep deprivation.