Only 25.5% of participants were physically present in the OR before the hospital’s incision time of 2.30 a.m., with staff, equipment, and medication ready, despite the majority of participants (60.6%) arriving at the OR waiting area at or before 2.00 a.m. This implies that even with prompt arrivals from the surgical ward, there appears to be a delay in the operating room’s preparation. Furthermore, this signifies that there may be room for improvement in terms of streamlining procedures and making sure that the required personnel levels and resources are ready and available for incoming patients.

The study also revealed that 74.5% of first-case patients entered the operating theater at or after the incision time, indicating a delayed first-case start time. This finding is comparable to a nine-month retrospective analysis of a related study from 22 German hospitals, where 70% of first-case start times were seen to be delayed [2]. In contrast, our findings indicated a higher frequency of late first-case start times when compared to related studies by Mathews et al. and Kayla B. Hicks et al. where the incidence of first-case delay was reported to be 67% and 55%, respectively [28, 29]. Our findings also revealed a lower incidence of first-case delays compared to a study from Addis Ababa, Ethiopia, where the start time was delayed in 93.4% of cases [12]. Similarly, a 15-month prospective study conducted in Nigeria reported first-case delays in almost all patients at the study center, with a rate of 99.3% [30]. Varying definitions of first case delay, study setting, study population, and causes for delay could be the cause of this large variation in prevalence. There are consequences for OR efficiency, patient care, and expenditure of resources from this occurrence of late first case start times, which represents a serious challenge to perioperative management.

Additionally, incomplete preoperative anesthetic evaluation was observed in 24 (4.5%) of the cases. In order to identify any patient-related problems or concerns that might affect the surgical procedure’s schedule or operation, the anesthetist must perform a thorough review. If these concerns are not addressed during the preoperative evaluation, there may be last-minute modifications or interventions, which could cause the first case to start later than expected [31]. Additionally, insufficient assessment may result in the need for extra time to retrieve or prepare patient-specific materials or drugs, which would further delay the start of the surgical procedure [32].

Coordinating and communicating amongst members of the surgical team can also be hindered by the anesthetist’s missing orders. In 32 cases (6%), anesthetists forgot to make a preoperative order for one or more pieces of equipment or drugs. Partially prepared preoperative care might occur when an anesthetist neglects to order supplies or drugs required before the day of surgery for a surgical procedure. Thus, the beginning of the first case may be delayed since the surgical team has to spend more time obtaining or getting ready for these supplies [33].

Furthermore, a problem with anesthesia-related equipment was discovered prior to 54 (10.2%) of first-case elective surgeries. It is commonly understood that anesthesia professionals rely on a variety of equipment, including anesthetic machines, monitors, and airway management devices, to ensure patient safety and optimal anesthesia delivery. When anesthesia-related equipment is unavailable or malfunctioning, this may require efforts to repair or replace equipment, obtaining alternate equipment from other departments or facilities, or adjusting the surgery schedule to accommodate the delay. These resource-intensive steps can waste significant time and manpower, compounding delays in initiating the initial case on time [34].

Patients scheduled for surgery often have overnight pre-operative preparations that must be completed before the procedure. A lack of proper overnight preparation was discovered in 33 (6.2%) of patients scheduled for the first day of elective surgery.

This finding is supported by an audit to assess different perspectives of the OR staff regarding the various causative factors of first-case operative delay in the OR, which revealed that more than 60% of respondents cited a lack of adequate preoperative patient preparation as the reason for the surgery start-time delay [1]. Inappropriate or inadequate overnight preparation has also been determined to result in delays in locating and retrieving necessary items and needed medication, further contributing to the delay in starting surgery [35].

Furthermore, before the first case of the operation day, the surgeon was preoccupied in 33 (6.2%) of the cases with other activities such as the patient consultation administrative work, and other clinical responsibilities. Efficient time management and prioritization are necessary to strike a balance between these tasks and make sure that the first case of the day gets to the operating room on time. On the other hand, if morning rounds or other activities extend beyond the first case’s scheduled start time, the surgeon’s entrance into the operating room may be delayed, which may result in later first case start times [7, 33].

First-case surgical procedures cannot start on schedule without the presence of the entire surgical team, which includes surgeons, surgical assistants, anesthesiologists, nurses, and other support staff [36]. In the majority of cases, surgical teams (surgeons or assistants) and anesthetists were physically present in the OR at or after 2.30 a.m., which is after the hospital’s first-case incision time. Anesthetists require sufficient time before surgery in order to prepare the anesthetic workstation, go over patient data, and review preoperative evaluations. If they are late, it could interfere with workflow and teamwork, delaying the initial case [7, 34, 37]. Similarly, surgeons and support staff need sufficient time to review patient charts, gather necessary equipment, and conduct final assessments before the start of surgery. Delays in these preparations due to late team arrival can prolong the overall surgical timeline and contribute to late first case start times [2, 38].

The first case start time delay was approximately 2.5 times more likely to occur for patients who enter the OR waiting area from the ward at or after 2:30 a.m. than for those who arrive before or at 2:00 a.m. An observational study of 889 cases by Chinonye et al. found that the main cause of the delay in the first case was the porters’ tardiness. A related study indicates that the primary reason for the theater’s inefficiency in starting surgery late was the patient’s delayed arrival in the operating room [39, 40]. Chekol et al. from Debre Tabor, Ethiopia, also discovered that the common cause of scheduled case cancellations was inadequate patient preparation before the morning of surgery [41]. This could be explained by arriving early allows sufficient time for preoperative preparation, including patient assessment, consent procedures, preparing the operating table and anesthesia induction. Early arrival also allows for thorough communication between the surgical team, anesthesia providers, and other healthcare professionals involved in the procedure [22, 42].

This study discovered a significant association between the first case’s delayed start time and the surgeon’s actual arrival time in the operating room. Thus, there was a 10.5-fold increase in the chance of a delayed first-case start time if the surgeon entered the operating room at or after 2:30 a.m. Comparably, a study conducted in South Africa and India demonstrated that surgeon-related factors, including late surgeon arrival time, were the first reasons for the first-case start time delay [4, 43]. Anesthetists and surgeons’ tardiness was found to be the primary cause of late surgery start times in a baseline assessment of an interventional study from Rwanda that aimed to increase the percentage of first surgeries starting on time from 3–25% [7]. This could be explained by the fact that surgeons are essential to the preoperative stages of the procedure; they organize surgical sites, update patient assessments, and collaborate with anesthesia providers, nurses, and support staff to ensure that everyone is ready for the scheduled surgery. When a surgeon is late, these crucial steps get started later, which results in later first-case start times.

Furthermore, patients who arrived with abnormal investigation results were 2.4 times more likely to have a delayed first case start time. Our result is supported by several suggestions, despite the fact that it does not align with those of other relevant studies. In order to assess the clinical relevance of abnormal laboratory data and their possible influence on the surgical process, more investigation may be necessary [44, 45]. Extra consultations or permissions from other healthcare practitioners, such as specialists or medical consultants, may also be necessary in situations where abnormal investigation results raise concerns about a patient’s health or fitness for surgery. Furthermore, considering the patient’s underlying medical issues, the surgical team may evaluate the advantages and disadvantages of moving forward with surgery in response to abnormal investigation results. The extra evaluation, conversation, and coordination of consultations can all interfere with the scheduled procedure and cause delays in the commencement of surgery [15, 45].

The study’s strengths include the fact that it is multicenter and prospective in nature, with the aim of identifying root causes of first-case delay by taking into account more factors, including patient characteristics such as age and comorbidities, which improves the findings’ applicability to larger populations or healthcare settings. Despite this, the study may have various limitations. First, due to the fact that patient preparation, induction, airway management, and regional or peripheral nerve blocks may take some time after the patient enters the operating room, our definition of late first-case start time may not accurately reflect the actual incidence of late first-case start time. Likewise, we also only focus on pre-operative time waste before the patient enters the OR, and we do not assess time waste in the OR before starting the incision. Second, we only examined the late start time of first-case surgery and did not include wasted time during other phases of surgery, such as turnover time. The fourth limitation is that data on first-case delays was collected only by anesthetists, which may reflect a reporting bias and alter the study’s outcome. As a result, future studies that take into consideration the limitations of this study are recommended.