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Effectiveness of a Countdown Timer in Reducing or Turnover Time

Article  in  Journal of Mobile Technology in Medicine · December 2017

DOI: 10.7309/jmtm.6.3.5

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 Original Article

Effectiveness of a Countdown Timer in

­Reducing or Turnover Time
1 2 1 3 4
Majbah Uddin, MS , Robert Allen, PhD , Nathan Huynh, PhD , Jose M. Vidal, PhD , Kevin M. Taaffe, PhD ,
5 4
Lawrence D. Fredendall, PhD , Joel S. Greenstein, PhD
1 2
Department of Civil and Environmental Engineering, University of South Carolina; School of Health Research,
3 4
Clemson ­University; Department of Computer Science and Engineering, University of South Carolina; Department of Industrial
5
­Engineering, Clemson University; Department of Management, Clemson University.
Corresponding Author: nathan.huynh@sc.edu

Background: In production environments, a countdown timer is used to report the status of the planned
1
start time and to provide both a communication mechanism and an accountability aid. It has been used
in the airline industry to remind all personnel of the remaining time until when the aircraft door should
be closed. This study explored the effectiveness of a countdown timer in the operating room (OR).
Aims: This study was designed to assess the effectiveness of a countdown timer in the OR setting and
to determine the factors that contribute to prolonged OR turnover time (TOT) (defined to be from
the “procedure finish” time of the preceding case to the “procedure start” time of the following case),
as well as the impact each of the significant factors has on TOT. In this study, the term case denotes
a surgical procedure.
Method: An Android app named ORTimer was developed for the study. The app was installed on
Android tablets that were placed at the Certified Registered Nurse Anesthetist (CRNA) workstations
in the OR at Greenville Memorial Hospital (GMH) in South Carolina. The CRNAs helped collect
the event milestones and record the delay reasons (if applicable). Additional OR case information was
extracted from GMH’s electronic medical record. Regression analysis was used to identify significant
factors that contribute to prolonged OR TOT and to estimate their impacts. A t-test was conducted
to test the hypothesis that the use of a countdown timer is effective in an OR environment.
Results: The data from a total of 232 cases where the ORTimer app was used were examined. Among the
factors (i.e., delay reasons and case information) considered, an outpatient from a following case had
the highest correlation with excessive room idle time, which is the difference between the actual TOT
and the allotted TOT. Delays due to patient-related issues added about 12.7 minutes to the turnover
time (90% CI: 7.2, 18.3) when other factors were fixed. Delays due to preoperative-related issues added
about 27.4 minutes to the turnover time (90% CI: 20.0, 34.7) when other factors were fixed.
1
Conclusions: As is the case with most production environments, the use of a visual management
tool such as the countdown timer in the OR is found to be effective. Additional research is needed to
determine whether this finding is applicable to other hospitals.
Keywords: Information Technology (IT) intervention, operating room efficiency, operating room
process improvement.
Journal MTM 6:3:25–33, 2017 doi:10.7309/jmtm.6.3.5 www.journalmtm.com

  JOURNAL OF MOBILE TECHNOLOGY IN MEDICINE VOL. 6  ISSUE 3  DECEMBER 2017 25

 Original Article

9 11
Introduction implemented by Collar et al. , Harders et al. , and
12
In this paper, we study the effectiveness of a count- Cendan and Good through the use of interdisci-
down timer, delivered via a mobile application, in plinary teams to reduce OR TOT. To do so, they
reducing turnover time in the operating room (OR), emphasized interdisciplinary cooperation between
as well as its ability to identify factors that most in- different members of the surgical team such as sur-
fluence prolonged turnover time. Before discussing geons and anesthesiologists. A significant conclu-
9
the technology of the timer, we first introduce the sion of Collar et al. is that turnover inefficiency is
relationship between cost and efficiency in the OR, due to systemic issues and not a lack of motivation.
and the effect that turnover time has on each.
Visual management is an important tool in lean
13
An OR is a very costly unit for a hospital to op- management. It is, for example, used in the airline
erate. For example, it is estimated that the cost of industry by visually displaying a timer to facilitate
operating an OR at Ohio State University Medical plane turnaround time. This study created a count-
2
Center is $1,200 to $1,300 per hour. Furthermore, down timer using a mobile app to measure OR
the opportunity cost of unused OR time is much TOT. The app was both a visual management tool
2
higher than the operating cost of the OR. In a re- as well as a data collection tool. This study evaluated
cent study, the variable OR labor (non-supply) cost the following: (i) the effectiveness of the use of the
was found to be $9.57 per minute at the partnering countdown timer in the OR setting, (ii) the factors
hospital, Greenville Memorial Hospital (GMH), that contributed to prolonged OR TOT, and (iii) the
3
for fiscal year 2015. These costs include salary and impact of each delay factor on OR TOT. To evaluate
benefits for all OR staff and CRNAs. This cost also the effectiveness of the countdown timer, we tested
includes temporary employee pay and all premium the null hypothesis that there is no difference in the
(overtime) pay. It is important to note that expenses mean TOT between the cases that used the timer
related to the anesthesiologists and surgeons are not and those that did not. The alternative hypothesis is
included in this figure. that the TOT in cases that used the timer is less than
those that did not use the timer.
Given that staffing the OR is a key operating cost, it
is critical to make the most efficient use of the time
Method
that an OR is in use. In other words, non-operative
time such as turnover time should be kept to a min- Mobile Application Development
imum. Turnover time (TOT) is generally defined as We designed a mobile application named ORTimer
the time from a patient leaving the OR to the follow- for this study. This mobile app was designed to be
4
ing patient arriving in the OR (e.g., ), but some facil- used on Android-based handheld tablets. We used
ities measure TOT from “procedure finish” time of the standard Android Software Development Toolkit
the preceding case to “procedure start” time of the and did not need any third-party libraries because of
following case. We adopted the latter approach as it the relative simplicity of the app. We developed the
is currently defined that way for other improvement app using the Android platform after having success-
initiatives within GMH. If TOT can be decreased, fully developed and tested other Android apps for
14
then one would expect an increase in throughput in health care applications. The app design was initi-
the OR, which will help to improve the hospital’s fi- ated by a request from GMH for a simple “egg timer”
5–7
nancial condition. The length of TOT is seen as application that would be used to time the duration
4
a measure of OR efficiency and a source of delays of the OR turnover. Our design process consisted of
8
in starting procedures. Reducing TOT length will multiple design-implement-review iterations: we de-
9
not only reduce overtime in the OR but also help sign and implement a version of the application, get
increase patient satisfaction by increasing timeliness feedback from various parties, and repeat. Starting
10
of procedure start times. with the “egg timer” request, we first designed a sim-
ple timer application with a start and stop button. We
Lean management principles are being used increas- presented this original prototype to the nursing staff
ingly in the surgical suite to improve performance who expressed the need for other buttons that would
9
(e.g., ); lean management is a systematic method modify the times after they had been entered. In our
designed to minimize waste without sacrificing pro- design meetings, we decided that the best way to im-
ductivity. One principle of lean management is in- plement that functionality was with the up/down ar-
volvement of all who are involved in a process in rows seen in the application. A second iteration of this
making process improvements. This principle was process led us to add the Notes button functionality.

  JOURNAL OF MOBILE TECHNOLOGY IN MEDICINE VOL. 6  ISSUE 3  DECEMBER 2017 26

 Original Article

The application was designed and implemented en- the remaining time and is green at first, turns to yellow
tirely by the authors with cooperation from GMH when less than 20% of the time remains, and finally to
staff; no outside consultants were involved in the de- red after the deadline has passed. Figure 1(c) shows
sign and implementation process. the Notes screen which asks the user to enter the rea-
son(s) for a delay. It contains a list of the most com-
Figure 1 shows screenshots of the different functions mon reasons so the user can check the ones that apply.
of the app. Figures 1(a) and 1(b) show the timer itself. The user also has the choice of entering a textual note
Figure 1(b) shows the timer after it has been started. explaining the reason for the delay in case none of the
The application will spend most of its time on this pre-defined reasons apply. The list of most common
screen as it displays the countdown timer. The “Pro- reasons was determined from both expert opinion and
cedure Finish” button at the top-left of the screen feedback from the textual notes entered by the CRNAs
starts the timer. The “Procedure Start” button stops during development testing. ­Figure  1(d) shows the
the timer. The up and down arrow buttons let the user “Settings” screen where turnover time can be defined
change the recorded start and stop times after the (presented as procedure finish to procedure start time)
timer has been stopped. There is a “Notes” button at and a room chosen. This screen is reached via a menu
the bottom which brings up the Notes screen, shown that appears when the user taps on the button at the
in Figure 1(c), a “Submit” button which saves the re- top-right (the three dots). This menu also contains an
sults of the timed event and restarts the timer, and a “Email data” option which lets the user send all the
“Reset” button which simply restarts the timer, throw- data that the app has gathered to our research staff as
ing away the current timer values. The remaining time a CSV file attachment. The email functionality, as well
and the total allotted time are shown in a large font in as the “Settings” page, requires a password to prevent
the middle of the timer. The timer bar counts down unauthorized users from viewing the data.

(a) (b)

(c) (d)

Figure 1: Screenshots of the ORTimer Mobile Application

  JOURNAL OF MOBILE TECHNOLOGY IN MEDICINE VOL. 6  ISSUE 3  DECEMBER 2017 27

 Original Article

Data Collection If desired, the CRNAs could also select s­ econdary

The ORTimer app was implemented in the D-core (an reasons to provide more information about the
­
operating ward) of GMH from May 1, 2016 to August delay cause. Also, more than one primary and sec-
15, 2016. This core has 8 rooms, and the types of cases ondary reason can be selected for one delay if multi-
varied from simple to complex. The D-core was known ple reasons contributed to the excess turnover time.
to have complicated setups, i.e., the TOT between cases Additionally, the app collected the elapsed TOT
was likely to be larger than for the other two cores due between the preceding and following cases. Periop-
to the nature of the cases scheduled in those rooms. erative management at GMH set a general goal for
The tablets with the ORTimer app installed were TOT to be no more than 75 minutes. Additional OR
placed above the computer at the anesthesia worksta- case information was extracted from GMH’s elec-
tion using off-the-shelf tablet mounting hardware. The tronic medical record (EMR). This case information
Certified Registered Nurse Anesthetist (CRNA) was includes whether the patient was outpatient or inpa-
responsible for the pressing of the event milestone but- tient, whether the case was add-on or scheduled, the
tons and recording of the delay reasons, if applicable. number of procedures in the case, etc. Using case
To minimize the CRNAs’ workload, the tablets and ID, case information was combined with the data
ORTimer apps were automatically turned on at the be- collected from the ORTimer app. Observations with
ginning of the day using a third-party software. This missing values were eliminated from the final dataset
approach made it easier for the CRNAs to remember used for model estimation.
to use the app and facilitated the data collection effort.
We did not include turnover times for cases that were
Perioperative services (POS) are performed in three not scheduled back-to-back. For these cases, there
phases: preoperative (Preop), intraoperative and is a “scheduled gap” between the two cases which
postoperative. The Preop process involves schedul- would extend the TOT. We removed these cases from
ing procedures in an OR and preparing the patient consideration since their delays are not caused by
before and on the day of the procedure. The intra- the OR staff, but rather the scheduling office. For
operative process involves the surgical procedure to the multiple regression analysis, the response vari-
be performed by a surgeon with support from POS able considered was turnover excess, which is de-
staff. The postoperative process involves scheduling fined as the difference between the actual TOT and
recovery rooms for the patients and providing the the allotted TOT. Turnover excess is used to mea-
appropriate level of nursing care and supplies until sure the amount of delay during the turnover time.
the patient is discharged or transferred from POS to Please note that turnover excess was set to zero if it
the appropriate nursing unit in the hospital. is negative. A total of 232 cases with delay reasons
was examined. Table  2 provides a summary of the
Table 1 lists all the delay reasons, related to OR turn- descriptive statistics of the variables considered for
over, collected by the app. To record the delay rea- model estimation. Turnover excess varies from 0 to
son(s), the CRNAs first had to record the primary 106.3 minutes with a mean of 11.8 minutes and stan-
reason (i.e., patient, OR equipment, anesthesia, dard deviation of 20.0 minutes. The number of pro-
surgeon, Preop, and scheduled gap) for the delay. cedures in preceding cases varies from 1 to 8 and the

Types Delay Reasons

Primary Patient OR equipment Anesthesia Surgeon Preop Scheduled
gap
Secondary Patient late to OR not ready Difficult Surgeon late to Labs not ready
hospital anesthesia OR
NPO issue Insufficient Difficult airway Surgeon late to Preop running
equipment Preop late
ICU patient Contaminated MDA delay Communication Waiting on 3rd
equipment issue party
Pediatric patient Communication CRNA delay
issue

Table 1: Delay reasons used in the ORTimer app

  JOURNAL OF MOBILE TECHNOLOGY IN MEDICINE VOL. 6  ISSUE 3  DECEMBER 2017 28

 Original Article

Variable Min Max Mean Std. dev.

Turnover excess (minutes) 0 106.317 11.818 20.015
Patient 0 1 0.116 0.321
OR equipment 0 1 0.151 0.359
Anesthesia 0 1 0.091 0.288
Surgeon 0 1 0.134 0.341
Preop 0 1 0.060 0.239
Outpatient (Preceding case) 0 1 0.534 0.500
Add-on case (Preceding case) 0 1 0.129 0.336
Number of procedures (Preceding case) 1 8 1.836 1.265
Outpatient (Following case) 0 1 0.496 0.501
Add-on case (Following case) 0 1 0.224 0.418
Number of procedures (Following case) 1 6 1.677 1.042

Table 2: Descriptive statistics of the variables

number of procedures in following cases varies from ranging from 0.07 to 0.38. The predictor having the
1 to 6. For the testing of the proposed hypothesis strongest correlation with turnover excess was outpa-
(H : there is no difference between “Timer” and “No tient from a following case (r = −0.38, p < 0.01). The
0
Timer”  TOTs), EMR reported unadjusted TOTs results also indicate that some of the predictors have
were used. This data source provided us the means strong correlations with each other. For instance,
to evaluate cases when the ORTimer app was used add-on case (following case) was strongly correlated
against cases when the ORTimer app was not used. with add-on case (preceding case) (r = 0.50, p < 0.01)
and with outpatient (following case) (r = −0.35, p <
Data Analysis 0.01). In contrast, the correlation between add-on
case (following case) and patient was found to be low
The statistical analysis first involved the estimation
(r = 0.16, p < 0.05). The correlations between OR
of the Pearson intercorrelation between variables.
equipment and patient (r = −0.12, p < 0.1), add-on
The analysis also involved the assessment of multi-
case (preceding case) and OR equipment (r = 0.12,
collinearity of the predictors. To accomplish this, the
p < 0.1), and add-on case (preceding case) and anes-
variance inflation factor (VIF) was examined. Typi-
thesia (r = −0.12, p < 0.1) were also found to be low.
cally, VIF measures how much the variance of a coef-
ficient is increased due to multicollinearity. VIF ≥ 10
15 The estimated multiple linear regression model is
indicates a serious multicollinearity problem. Next,
reported in Table 4. The table shows the unstan-
a multiple regression analysis was conducted. The
2 2 dardized regression coefficients (β), standardized
overall R and adjusted R of the regression model
regression coefficients (β’), t-statistics and corre-
were calculated to assess the percentage of the vari-
sponding p-values, 90% confidence intervals of the
ance in the turnover excess time that was explained by
coefficients, VIF values, coefficient of determination
the predictors. Lastly, the proposed hypothesis that the 2 2
(R and adjusted R ), and overall model significance
use of a countdown timer is effective in an OR envi-
(F-test). VIF values of predictors suggest that there
ronment was tested by employing a two-sample t-test.
is no serious problem with multicollinearity in the
data. The coefficients of all of the predictors except
Results and Discussion for the number of procedures (preceding case) are
Results of the Pearson intercorrelation analysis of the statistically significant at 0.1 significance level.
predictors are presented in Table 3. An outpatient is
a patient who is scheduled for a surgery and is not A delay due to patient-related issues contributed an
admitted overnight. A preceding case is the surgery estimated 12.7 minutes to OR turnover excess time,
occurring in the OR before the TOT under consid- with all other predictors held constant. That is, when
eration and a following case is the surgery after the OR TOT exceeds the allotted time threshold and
TOT under consideration. The correlation between there are patient-related issues, the following case is
turnover excess and the predictors was found to be low pushed back by estimated additional 12.7 minutes.
to medium, with the Pearson correlation values  (r) With a 90% confidence interval, this extra OR TOT

  JOURNAL OF MOBILE TECHNOLOGY IN MEDICINE VOL. 6  ISSUE 3  DECEMBER 2017 29

 Turnover Patient OR Anesthesia Surgeon Preop Outpatient Add-on case Number of Outpatient Add-on Number of
excess equipment (Preceding (Preceding procedures (Following case procedures
case) case) (Preceding case) (Following (Following
case) case) case)
Turnover excess 1.00
Patient 0.19*** 1.00
OR equipment 0.32*** −0.12* 1.00
Anesthesia 0.24*** −0.02 0.03 1.00
Surgeon 0.17** 0.02 0.05 0.05 1.00
Preop 0.25*** −0.09 −0.11 −0.08 −0.10 1.00

  JOURNAL OF MOBILE TECHNOLOGY IN MEDICINE

Outpatient −0.20*** −0.09 −0.16** −0.01 0.01 0.02 1.00
(Preceding case)
Add-on case 0.14** 0.14** 0.12* −0.12* 0.04 −0.04 −0.34*** 1.00
(Preceding case)
Number of 0.17*** 0.06 0.17*** 0.09 −0.08 −0.01 −0.39*** −0.09 1.00
procedures
(Preceding case)
Outpatient −0.38*** −0.23*** −0.25*** 0.02 −0.16** −0.11 0.27*** −0.23*** −0.08 1.00
(Following case)
Add-on case 0.07 0.16** 0.06 −0.10 0.01 0.04 −0.20*** 0.50*** −0.18*** −0.35*** 1.00
(Following case)
Number of 0.19*** 0.01 0.07 0.13* −0.02 0.08 −0.09 −0.08 0.24*** −0.29*** −0.17*** 1.00
procedures
(Following case)
* p < 0.1; ** p < 0.05; *** p < 0.01

Table 3: Correlations for turnover excess and predictor variables

VOL. 6  ISSUE 3  DECEMBER 2017 30

Original Article
 Original Article

Predictors β β’ t-statistic p-value 90% Confidence Interval VIF

Patient 12.723 0.204 3.79 <0.001 7.184, 18.261 1.21
OR equipment 16.352 0.293 5.30 <0.001 11.252, 21.451 1.33
Anesthesia 17.798 0.256 4.81 <0.001 11.682, 23.915 1.15
Surgeon 9.090 0.155 3.02 0.003 4.111, 14.070 1.13
Preop 27.366 0.326 6.16 <0.001 20.027, 34.704 1.10
Add-on case (Preceding case) 5.931 0.099 1.90 0.059 0.766, 11.095 1.17
Number of procedures 1.582 0.100 1.94 0.054 0.235, 2.928 3.06
(Preceding case)
Outpatient (Following case) −5.830 −0.146 −3.20 0.002 −8.841, −2.819 1.53
Number of procedures 1.427 0.074 1.61 0.108 −0.033, 2.888 2.82
(Following case)
R2 0.553
Adjusted R2 0.535
Overall model significance F (9, 223) = 30.70 (p < 0.001)

Table 4: Model estimation results

is between 7.2 and 18.3 minutes. In case of delay due

to OR equipment, holding all other predictors fixed,
an estimated 16.4 minutes is added to the turnover
excess time. With a 90% confidence interval, this ex-
cess time is between 11.3 and 21.5 minutes.

Holding all other predictors fixed, if there is a delay

in anesthesia, an estimated 17.8 minutes of additional
time is required beyond the allotted OR TOT. This
time is between 11.7 and 23.9 minutes, with a 90% con-
fidence interval. In case of delay due to surgeons, an
estimated 9.1 minutes is added to the following case
start time, holding all other predictors fixed. With 90%
confidence, this time is between 4.1 and 14.1 minutes.
Preop being the reason for delay in OR adds an esti- Figure 2: Box Plot of the TOT Groups
mated 27.4 minutes to turnover excess time, holding all
other predictors fixed. With 90% confidence, this time means Preop is the most significant variable in ex-
is between 20.0 and 34.7 minutes. plaining OR turnover excess time. Lastly, the overall
model is statistically significant, F (9, 223) = 30.70
A preceding case being an add-on case increases turn-
(p < 0.001), and the model explains 55.3% of total
over excess time by an estimated 5.9 minutes when all 2
variation in OR turnover excess time (R = 0.553).
other predictors are fixed. That is, an add-on case con-
tributes an extra 5.9 minutes to OR turnover excess
During the data collection period at GMH, data was
time compared to that of a regular case. In the case of
collected for 695 OR cases. Of these, 433 records
a preceding case, each procedure in the case adds an
had turnover times exceeding 75 minutes. Potential
estimated 1.6 minutes to the OR turnover excess time.
reasons for this longer TOT are: gaps in the sched-
When all other predictors are fixed, OR turnover excess ule, surgeons canceling/rescheduling their cases for
time is found to decrease by an estimated 5.8 minutes a later date, patient NPO (patient ate before sur-
for an outpatient relative to an inpatient in the follow- gery) issues, and surgeon unavailability (assisting
ing case. Each procedure in a following case adds an in another case, etc.). We divided these 433 records
estimated 1.4 minutes to OR turnover excess time. into two groups, based on the whether the ORTimer
app was used or not—referred to as “Timer” (125
The variable Preop has the highest absolute stan- records) and “No Timer” (308 records). It is evident
dardized regression coefficient (β’ = 0.326). That from Figure 2 that “No Timer” has more spread

  JOURNAL OF MOBILE TECHNOLOGY IN MEDICINE VOL. 6  ISSUE 3  DECEMBER 2017 31

 Original Article

Group Mean (minutes) Std. dev. (minutes) t-statistic p-value Test result
Timer 101.080 24.013 −1.932 0.027 Reject H0
No Timer 106.315 28.974

Table 5: Hypothesis test results

than “Timer”, i.e., the interquartile range of the first efforts. Additionally, decreased TOT will decrease
group is wider than that of second group. To ver- Preop waiting time for patients, which is highly cor-
ify whether there is a statistical difference between related with patient satisfaction scores.
OR turnover times in the “Timer” and “No Timer”
groups, a two-sample t-test was conducted. The null Due to the successful deployment of the ORTimer app
hypothesis (H ) is that there is no difference b
­ etween in the D-core at Greenville Memorial Hospital (GMH),
0
the “Timer” and “No Timer” turnover times. The it is being deployed in the Gastrointestinal (GI) labs at
alternative hypothesis (H ) is that the “Timer” turn- GMH as well. The GI labs are typically used for sim-
1
over time is less than that of the “No Timer” turn- pler cases where TOTs average approximately 16 min-
over time. Table 5 summarizes the results of the utes in duration. It will be interesting to see how the
t-test which yields a p-value of 0.027. Thus, the null results from the GI labs compare to that of D-core. In
hypothesis can be rejected at the 0.05 significance addition, talks between GMH and EMR IT staff are
level and we can conclude that the use of a count- underway regarding the integration of the ORTimer
down timer is effective in an OR environment. app and EMR. Specifically, discussions have focused
on allowing “Health Level 7” messages to be transmit-
Limitations ted to a server in which the ORTimer app would pick
up the data and decode it into usable information to
This study has three limitations that should be con-
run the timer. Such information would include pro-
sidered when interpreting its findings. First, this
cedure finish (to start the timer) and procedure start
study used data from only one hospital and only
(to finish the timing of the turnover). This approach
one core. Second, the ORTimer app was not used
would allow the app to be used without any human
by all CRNAs and not utilized in all OR cases in the
intervention (pressing of buttons). Once implemented,
D-core during the study period. Lastly, this study
this integration will open the way for automatic mile-
was observational in nature and not controlled. This
stone documentation through the electronic medical
is because the research was performed in a working
record which would eliminate unnecessary double doc-
hospital, and therefore, the study team had to allow
umentation. This integration will also allow us to cap-
the CRNAs the discretion to do what they viewed
ture more specific information about the patient and/
was best for the patient and the hospital.
or case in future versions of the app.

Conclusion Acknowledgements
1
As is the case with most production environments, This research was supported by the National Science
the use of a visual management tool such as the Foundation under grant IIS-1237080. In addition, we
countdown timer in the OR is found to be effective. would like to acknowledge staff at Greenville Memo-
The developed ORTimer mobile app enabled us rial Hospital for their continued participation and en-
and perioperative managers to obtain delay reasons thusiasm for process improvement research projects
for prolonged OR turnover time (TOT). This data and studies. In particular, we would like to acknowl-
set combined with the hospital’s electronic medical edge Brad Hoover, Adam McKee and the rest of the
record (EMR) provided a rich data set for identi- CRNAs for their support and feedback during design
fying the factors that contribute to prolonged OR and implementation of the ORTimer app.
TOT and quantifying their impacts.

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