Introduction
Clinical governance is a recognized concept that is strongly emphasized and championed
by the British National Health Service. It should be promoted in a healthcare system
(especially when public) as it provides a framework for accountability and quality
improvement.[1 ] One aspect of clinical governance that can aid in quality improvement is clinical
audit, which allows recognizing areas where service improvement is needed.[1 ]
Pakistan is a lower-middle-income country (LMIC) with a population of over 220 million.
On a national scale, Pakistan suffers from a deficit of 18 million surgeries per year,
many lifesaving and straightforward.[2 ] It is recognized that the reasons contributing to this tragedy include a virtually
absent clinical governance system, poor hospital administration, absenteeism, lack
of accountability, and a culture that does not promote quality improvement.[3 ]
[4 ]
[5 ] This has led to a somewhat ironic situation, where Pakistan as a LMIC does not meet
the demand of the surgical burden in its population, not from a lack of qualified
doctors or absence of centers equipped with the latest technology to perform even
the most technically advanced contemporary surgeries, but rather a managerial and
infrastructural culture which lacks a clinical governance system and hence quality
improvement.[2 ]
[3 ]
[4 ]
[5 ]
Neurosurgery in Pakistan, for the masses, is provided by government-funded public
hospitals and is free at the point of delivery. There is a wide disparity in neurosurgical
centers throughout the country regarding their capacity and resources. Out of the
approximately estimated 42 centers nationally, only the quaternary centers at the
major teaching hospitals are equipped to provide state-of-the art neurosurgical care
and subspecialty niches.[6 ] Even these centers have an uphill struggle with the resource constraints of a LMIC.
Pakistan's overall national healthcare budget from the federal government is a modest
0.6 to 1.19% of the gross domestic product and 5.1 to 11.6% of the development budget.[7 ] There is now, however, increasing demand for service improvement at public hospitals
by the government.[3 ]
Operating theaters (OT) make up a substantial proportion of a hospitals annual spending,
and OT delays have a massive impact on resource utilization.[4 ] Efficient OT time utilization acts as a surrogate for those successfully admitted
and operated upon, reflecting the surgical volume on elective lists.[8 ] There is sparsity in audits evaluating neurosurgical OT time utilization relative
to other surgical specialties from the international literature.[9 ]
[10 ] The limited neurosurgical OT publications are from the developed Western countries[10 ]
[11 ]
[12 ] with only one well-conducted study from India,[9 ] our neighbor LMIC country that is most comparable to us concerning the issues facing
neurosurgery in public sector hospitals. A comprehensive literature search shows that
there are no audits inspecting neurosurgical OT utilization in Pakistan. Deficiencies
in OT time can lead to loss of revenue and the waste of human resources. Recognizing
such perioperative delays is fundamental to developing solutions for improving OT
efficiency in any surgical specialty.[8 ]
[9 ]
[10 ]
[11 ]
[13 ] It is therefore essential for neurosurgery departments in each country to audit
their own OT utilization as the issues faced and areas required for quality improvement
are likely to be uniquely different from region to region.
This study aimed to analyze neurosurgery OT time utilization at our neurosurgical
center and identify and present our areas for quality improvement. This is the first
study from Pakistan to assess OT time utilization for neurosurgery. We postulated
that the significant delays were administrative from both our department and the anesthesia
department. Thus, our anesthesia colleagues were consulted and closely involved in
forming suggestions and recommendations.
Materials and Methods
Setting
Institutional review board deemed this to be a service delivery audit project and
thus formal review was not required. After approval, in this observational study,
we prospectively analyzed all elective neurosurgical cases at the Department of Neurosurgery,
Allama Iqbal Medical College, Jinnah Hospital Lahore, Punjab, Pakistan. A staff nurse
performed data collection in each OT on a predesigned proforma and was blinded to
the project to minimize bias. The study involved all elective neurosurgical cases
from January to April 2021.
We are a national referral center in a 1,600-bed government-funded major teaching
hospital. There is a dedicated three OT suite scheduled for elective neurosurgery,
operating from 8 AM to 2 PM. The neurosurgery department, its wards, and OT are on the same floor, but OTs are
housed in a separate enclosure. Ward staff are responsible for transferring elective
surgery patients from the prepared list to preoperative bay. From preoperative bay,
OT paramedic staff transports patients to the OT table. Here the anesthesia team arrives,
and once the patient is anesthetized, surgery begins. Any surgical case proceeding
past 2 PM is continued by operating staff, including resident/registrars and consultants.
Neurosurgical nurses, however, change following 2 PM , as does the anesthesia team. When surgery continues past 2 PM , anesthesia cover is only provided by the senior registrar/chief resident. The department
of anesthesia at our hospital provides individual cover for each OT in neurosurgery.
Operational Definitions
Delay in arrival to preoperative area: The patient should be present in preoperative area officially by 8 AM. Delay in arrival past 8 AM was documented in minutes.
Transfer time to OT: This was the delay from preoperative bay to the designated theater. Delay was documented
when the patient transfer was impeded by logistical issues such as late arrival or
absence of theater staff and lack of patient marking. The transfer should be seamless
from preoperative bay to OT table and within minutes. Staff from the ward take patients
to preoperative bay, from where sterile theater staff transport the patient to OT.
Delay in arrival of anesthesia team: This was the delay in the arrival of the anesthesia team to patients present in OT
ready to be anaesthetized. Officially, the anesthesia team should arrive at 8 AM.
Anesthesia preparation, induction, and intubation time: The time taken for anesthesia induction and handover to the surgeon.
Pure operative/surgical time: Time between patient positioning/initial skin incision and wound closure.
Extubation and anesthesia handover time: Time taken by the anesthesia team to extubate the patient and hand them over for
either ward or high dependency unit transfer as indicated.
Total time taken by scheduled case: The sum of the parameters above.
Data Analysis
Data were analyzed using Statistical Package for Social Sciences Version 27 (SPSS).
Mean times were calculated for each of the mentioned parameters for the same neurosurgical
case during the study duration. OT utilization was assessed to identify delays by
both the neurosurgical and anesthetics departments.
Results
A total of 148 elective surgeries were performed during the study duration. These
are divided into cranial (94 surgeries) and spinal cases (54 surgeries) in [Tables 1 ] and [2 ]. The tables summarize the theater time utilization, including the mean values for
the time consumed for each parameter/delay and how much this contributed to a particular
case as a percentage of the total OT consumption for the average of all cases of a
particular type. All times were recorded in minutes. The total time consumed purely
operating was 59%. However, this was as low as 52% across all spinal cases and 62%
across all cranial cases. [Fig. 1 ] pie chart shows theater time utilization over the entire study duration for all
neurosurgical procedures. [Figs. 2 ] and [3 ] pie charts show the same stratified by cranial and spinal cases, respectively.
Table 1
Operation theater utilization for all elective cranial surgery cases across study
duration
All parameters in minutes
MCA aneurysm clipping
VP shunt
Brain tumor excision-iCT NN guided
MVD
Craniopharyngioma-subfrontal translamina terminalis
Pituitary adenoma excision-iCT assisted
3D cranioplasty
CSF leak repair-fluorescein guided endonasal
ICP and brain tissue oxygen monitoring
Wound re-exploration
Posterior fossa-hemangioblastoma
CP angle schwannoma
Posterior fossa decompression-Chiari 1 malformation
Endoscopic third ventriculostomy
Number of cases
8
28
4
8
1
8
4
8
1
8
4
4
4
4
Delay in arrival to preoperative bay
18 (3.3%)
37
(12.9%)
16 (3.5%)
20 (4.3%)
10 (1.7%)
22 (4.4%)
26 (8.8%)
20 (4.5%)
5 (4%)
20 (7.6%)
14 (2.1%)
12 (2.9%)
8 (2.4%)
5 (1.4%)
Transfer time to operating theater
7 (1.3%)
15 (5.2%)
22 (4.8%)
12 (2.6%)
105 (18.1%)
16 (3.2%)
16 (5.4%)
15 (3.4%)
5 (4%)
15 (5.7)
10 (1.5%)
7 (1.7%)
3 (0.01%)
18 (5%)
Anesthesia arrival delay
12 (2%)
18 (6.3%)
7 (1.5%)
14 (3%)
15 (2.6%)
10 (2%)
22 (7.5%)
15 (3.4%)
7 (5.5%)
18 (6.8%)
20 (3%)
32 (7.8%)
13.00 (3.9%)
20 (5.5%)
Anesthesia preparation, induction, and intubation time
125 (23%)
75 (26.1%)
70 (15.4%)
98 (21%)
75 (13%)
108 (21.4%)
70 (23.8%)
83 (19%)
20. (15.7%)
50 (19%)
90 (13.3%)
95 (23.2%)
110 (32.6%)
250 (69.2%)
Pure operative surgical time
350 (64%)
120 (41.8%)
320 (70.3%)
295 (63%)
375 (64.6%)
315 (62.5%)
135 (46%)
280 (63.7%)
90 (70.8%)
142 (53.6%)
510 (75.7%)
225 (55%)
175 (52%)
50 (13.9%)
Anesthesia extubation time
35 (6.4%)
22 (7.7%)
20 (4.4%)
28 (6%)
Patient not extubated and was shifted to ICU on ventilation
33 (6.5%)
25 (8.5%)
26 (6%)
Patient not extubated and was shifted to ICU on ventilation
19 (7.2%)
30 (4.4%)
38 (9.3%)
28 (8.3%)
18 (5%)
Total time taken by scheduled case
547
287
455
467.00
580
504
294
439.00
127
264
674
409
337
361
Abbreviations: 3D, three-dimensional; CP, cerebellopontine; CSF, cerebrospinal fluid;
ICP, intracranial pressure; ICU, intensive care unit; MCA, middle cerebral artery;
MVD, microvascular decompression; VP, ventriculoperitoneal.
Note: All parameters are in minutes and represent mean time consumed by each parameter
across all cases of a particular type of case.
Table 2
Operation theater utilization for all elective spinal surgery cases across study duration
All parameters in minutes
Endoscopic lumbar discectomy
Spinal fixation-percutaneous transpedicular screw fixation
Spinal fixation-open extramedullary transpedicular screw fixation
Spinal tumor- intramedullary
Open lumbar discectomy
Anterior cervical discectomy with interbody fusion
Number of cases
8
20
8
4
6
8
Delay in arrival to preoperative bay
96 (18.3%)
13 (5.3%)
24 (7.3%)
18 (6.3%)
23 (6.3%)
18 (5.5%)
Transfer time to operating theater
8 (1.5%)
18 (7.3%)
3 (0.001%)
11 (3.9%)
13 (3.5%)
13 (4%)
Anesthesia team arrival delay
100 (19%)
9 (3.7%)
8 (2.45%)
10 (3.5%)
9 (2.5%)
13 (4%)
Anesthesia preparation, induction, and intubation time
142 (27%)
57 (23.3%)
42 (12.8%)
75 (26.4%)
81 (22%)
75 (22.8%)
Pure operative surgical time
160 (30.5%)
130 (53%)
230 (70.3%)
150 (52.8%)
220 (60%)
190 (57.6%)
Anesthesia extubation and handover time
19 (3.6%)
18 (7.3%)
20 (6.1%)
20 (7%)
21 (5.7%)
20 (6.1%)
Total time taken by scheduled case
525
245
327
284
367
329
Note: All parameters are in minutes and represent mean time consumed by each parameter
across all cases of a particular type of case.
Fig. 1 The operation theater utilization across the study duration as time consumed (minutes)
by each parameter for all procedures.
Fig. 2 The operation theater utilization across the study duration as time consumed (minutes)
by each parameter for all elective cranial surgeries.
Fig. 3 The operation theater utilization across the study duration as time consumed (minutes)
by each parameter for all elective spine surgeries.
Following pure operating time, 23% of OT utilization was consumed by anesthesia intubation
(as a percentage of total time consumed across all cases). This was 19% for all cranial
cases. [Tables 1 ] and [2 ] show the variation in anesthetic intubation time. Anesthesia extubation and handover
of patients following surgery were consistent among all cases, accounting for nearly
5.5% of the entire OT utilization, and they were the same in cranial and spinal cases
too. Other sources of delays included the late arrival of the anesthesia team to OT.
These late arrivals totaled 382 minutes (6.4 hours) over the 4-month study duration
accounting for 5% of the total OT utilization. Again, in spinal surgery, however,
the proportion of time lost due to the late arrival of the anesthesia team was higher
than cranial cases, accounting for approximately 7% of OT utilization in scheduled
spinal and 4% in all cranial cases.
Sources of delays from the neurosurgical department ancillary staff included delays
in patient transfer from ward to preoperative bay in the morning at the designated
time. This accounted for 5.5% (443 minutes) of all OT time utilization over the study
duration for all scheduled cases. Again, when examining all spinal surgery cases alone,
there was a significant proportion of delays due to late shifting from ward to the
preoperative room, accounting for approximately 9% of OT utilization in all spinal
surgery cases. For cranial cases, this was only 4%. Finally, the last identified source
of delay resulted from the delay in transferring the patient from preoperative bay
to the designated OT. This delay accounted for approximately 4% (343 minutes) of OT
time and is the only delay parameter, slightly lower across all spinal cases (∼3.3%),
and in all cranial cases accounted for and 4.6% of the OT utilization.
Statistical Analysis
A two-proportion Z-Test was used to assess if delay parameters differed across all
cranial and all spinal surgeries. Differences between proportions were regarded as
significant if p -values were less than 0.05. Spinal surgery suffered significantly more delays where
OT utilization for the pure surgical operating time was 10% less than cranial surgeries
(52 vs. 62%; p < 0.00001). In addition, delay in transfer from ward to preoperative bay, delay in
anesthesia team arrival, and anesthesia preparation induction and intubation time
were significantly more in spinal surgery (8.9, 6.7, 23.2%, respectively) compared
with cranial surgery (4.9, 3.9, 19.5% respectively; p -values < 0.05).
Discussion
In an ideal world, optimal use of the OT should be without cancellations, delays,
and should start and close on time. While this theoretical utopia may not be wholly
achievable, it is certain that neurosurgeons need to lead efforts to recognize and
address unnecessary and avoidable delays in service delivery, streamlining the process
on operating days with department staff and colleagues of other specialties. At a
department level, we strived to recognize and improve our delays; therefore, we performed
this audit to recognize our problems and address them. Clinical audits are shown to
be essential in improving service provision, and documentation of perioperative delays
is shown to be crucial in developing solutions to improve OT efficiency in surgical
specialities.[11 ]
[14 ]
Overall, OT utilization has been streamlined worldwide, with efficiency improving
from 40 to 77% and 81%, while in some instances, recently, 91% from the late 20th
century to early 2000.[9 ] This demonstrates that auditing has identified areas for improvement and led to
subsequent improvements in OT utilization. We have identified several gross time delays
and poor management structure that significantly impedes workflow efficiency. Our
problems, however, are typical for public sector hospitals in Pakistan. Our department's
significant sources of delay include late arrival to preoperative area and the transfer
from here to the OT. These delays account for approximately 10% of all OT utilization
in the study duration. The ward staff is responsible for transferring the patients
to the preoperative room outside the theater, both of which are in separate enclosures
to the wards. One of the major reasons for this delay was patients being admitted
without investigations from other departments, such as an echocardiogram or an endocrine/allied
specialty workup. This led to several cases where patients had incomplete investigations
the morning of surgery which had to be chased. To address this, we will implement
changes to the way patients are admitted as an inpatient. Those requiring elective
surgery will need to have most, if not all, investigations completed before admission.
This will improve bed space/utilization, and we believe it will also be better for
the patient to avoid being admitted for long periods without need while awaiting routine
investigations.
Additionally, patients must be immediately transferred to OT once in their preoperative
bay by the sterile theater staff, including theater nurses and paramedical staff.
Delays have been principally due to lack of case marking and poor communication regarding
which OT individual patients are allocated to the night before surgery. We plan to
address this by disseminating transparent instruction on which procedure should be
designated to which theater, and which registrar/resident and consultant will be operating.
As shown in [Table 3 ], when comparing our anesthesia preparation and intubation time and our surgical/operating
times to the other two studies for common neurosurgical procedures, ours are significantly
longer. It may not be appropriate to compare operating times as this will vary enormously
for numerous reasons from surgeon to surgeon and center to center, let alone between
continents. It is, however, useful to propose reasons for our discrepancy and provide
a comparison in the literature. While it is generally acknowledged that longer surgery
is associated with more morbidity, our setup is such that while our staff is diverse
with subspecialist interests from neurovascular niches to complex spine, we are in
the position where we predominantly are training residents and young consultants for
a broad general neurosurgical practice. Although this is changing and the need for
subspecialists is increasing, general neurosurgery is mostly what trainees will be
exposed to in most centers. In the study by our Indian colleagues Saikia et al,[9 ] the authors mentioned that their pure operative/surgical time was shorter for complex
neurovascular procedures than the British study by Iyer et al[12 ] due to being exclusively operated by neurovascular consultants. In contrast, the
latter may have had teaching given to residents/registrars. In our case, for such
subspecialty procedures, senior residents and junior consultants are often being supervised
by the senior faculty to build proficiency in this area.
Table 3
Comparison of surgical and anesthetic times for common neurosurgical procedures between
our study and relevant previous studies
Title
Iyer et al, 2004[12 ]
Saikia et al, 2015[9 ]
Our study
Surgery
Mean anesthesia time (minutes)
Mean surgery time (minutes)
Mean anesthesia time (minutes)
Mean surgery time (minutes)
Mean anesthesia time (minutes)
Mean surgery time (minutes)
Brain tumor surgery
37
131
25
222
70
320
Aneurysm
51
213
24
157
125
350
Ventricular-peritoneal shunt
28
60
24
100
75
120
Spinal tumor surgery
31
165
23
189
75
150
Posterior fossa surgery
55
160
29
280
90
510
Open lumbar discectomy
24
115
Not provided
Not provided
81
220
Anterior cervical discectomy
31
57
Not provided
Not provided
75
190
Microvascular decompression for Trigeminal nerve
47
169
Not provided
Not provided
98
295
Foramen magnum decompression
41
118
Not provided
Not provided
110
175
Vestibular schwannoma (retrosigmoid approach)
45
376
Not provided
Not provided
95
225
For us, when senior faculty alone were operating on certain cases such as vestibular
schwannomas, where residents were not taught, pure surgical time was significantly
shorter than that of our British colleagues (225 vs. 376 minutes). Some comparisons
for surgical times, however, may not be appropriate. For example, our brain tumor
surgeries had a mean pure operative time of 320 minutes, while this was 222 minutes
for Saikia et al[9 ] and 131 minutes for Iyer et al[12 ] in our case. As the studies do not provide further details about the type and locations
of the tumor, a fair comparison cannot be made. We had used an intraoperative computed
tomography scanner for most brain tumor cases that may, in part, have a modest contribution
to the increased time.
Similarly, what cases constituted as posterior fossa surgery were not specified by
Iyer et al[12 ] or Saikia et al,[9 ] but for us, all cases were of hemangioblastomas that are considerably longer than
other posterior fossa surgeries. Iyer et al[12 ] state nothing can be done to reduce pure operative surgical and anesthesia preparation
and intubation time. Saikia et al[9 ] recommend proper coordination between ancillary equipment technicians of spinal
fluoroscopy and intraoperative computed tomography scanner. We regularly use both
and aim to streamline the teamwork between surgeons and theater staff to reduce operating/surgical
time. Furthermore, to reduce the surgical time for resident-led cases, we have acquired
an advanced neurosurgery simulator to give more exposure to trainees.
Sources of delays from the anesthesia team included late arrivals to the OT, accounting
for approximately 4% of OT utilization (223 minutes) over the study duration. This
delay occurred on all OT days and was as low as 7 minutes but usually between 15 and
30 minutes.
Interestingly, our anesthesia preparation and intubation time are two to three times
longer than those reported by our British and Indian colleagues.[9 ]
[12 ] While Iyer et al[12 ] mention that little can be done to reduce anesthesia time, it was felt our anesthesia
preparation time was excessive. Unnecessary monitoring without proper patient stratification
was discussed with our anesthesia colleagues. Anesthesia was longer for simple spinal
surgery cases, even compared with more complicated cranial surgeries. For example,
the team inserted central venous pressure and A-lines even in simple spinal surgery
cases and generally believed that neurosurgery patients should get aggressive neuromonitoring
for all cases. Anesthesia preparation and intubation times were observed to vary with
no particular reason and unrelated to the case's complexity. Extubation time, however,
was consistent and raised no concern. Both departments are now in the process of reforming
the use of intraoperative neuromonitoring in an evidence-based manner. Saikia et al[9 ] state that their shorter anesthesia preparation time was due to less aggressive
invasive neuromonitoring, which is a notion we support and have proposed to our anesthesia
colleagues. Finally, to reduce anesthetic preparation time further, it was decided
to manage and anesthetized patients in parallel rather than serially. We also believe
that this is the reason why spinal surgery cases were longer, as they received anesthesia
after cranial surgeries were dealt with.
Perspectives and Suggestions Made in Conjunction with Our Anesthesia Colleagues
Our results were presented to our anesthesia colleagues and jointly discussed by department
chairs to address concerns. Our anesthesia colleagues highlighted that the main factors
contributing to delays included:
Lack of exposure to neurosurgery in the vast majority of anesthesia residency training
programs under the two FCPS and MD training program schemes in Pakistan.
Lack of ancillary staff support for anesthetist in our neurosurgical theaters.
The discussion on anesthesia raises a much broader and important issue for neurosurgery
in Pakistan, which is the virtually absent concept of neuroanesthesia as a (sub)specialty.
Despite being the sixth most populous country with a high burden of neurosurgical
disease, the World Federation of Societies of Anaesthesiology lists Pakistan with
only 1.64 per 100,000 general anesthetists. There is no formal training or post-training
fellowship in neuroanesthesia.[15 ] Our anesthesia colleagues feel there are two issues regarding training; first as
a percentage of every hospital in the country that is accredited to provide anesthesia
training, the overwhelming majority of hospitals do not have a neurosurgery department
as neurosurgery departments themselves are severely lacking in our country and unfortunately
many are centralized to major cities,[6 ]
[16 ] thus making the many remaining hospitals have doctors training and qualifying in
anesthesia without any exposure to neurosurgery.[6 ]
[16 ] This had led to service by several junior consultant staff in our hospital (senior
registrars) who make up the bulk of our anesthesia department, and many of these are
not permanent so there are rotating anesthetists whom many of are providing neurosurgery
cover for the first time and so face a steeper learning curve. In large teaching hospitals,
a single anesthesia department provides cover to all surgical specialties with already
limited staff.
The second issue our anesthesia colleagues expressed, and one that is perhaps not
as relevant to our immediate delays is the lack of subspecialization in neuroanesthesia.
This is specifically the need to have neuroanesthetic consultants in a dedicated neuroscience
institute as this may benefit the increasing demand for subspeciality neuroanesthesia
in more complex neurosurgical procedures and logistical advantages as a result of
having a dedicated neuro anesthesia team.[15 ]
[17 ] The former issue, of general anesthetists lacking neurosurgery exposure in their
training impacting even general neurosurgical cases, is more pressing. Our anesthesia
colleagues and ourselves are lobbying to move to a dedicated Institute of Neuroscience
model. Anesthetists in Pakistan are reforming training to include a longer rotation
(>6 months) to neurosurgery/neuroanesthesia during residency by collaborating with
hospitals in their localities with neurosurgical departments or those in other cities
in proximity. In addition, it is also recognized the need to create postresidency
fellowship training in neuroanaesthesia.[15 ] These two are the long-term goals that are desirable for the developments of both
neurosurgery and anesthesia as a specialty in Pakistan.
Examples of lack of staff cited by anesthesia colleague include absence of paramedical
supporting staff to assist anesthetists during preparation and intubation. Unlike
other surgical departments, at the time of writing it is the neurosurgical OT assistants
who assist anesthetists during intubation after which they return to assist the operating
neurosurgeons. This issue principally concerns inadequate staffing and is one we as
a team are working to address.
At the heart of this article, we hope our recommendations lead to what Naik et al[18 ] achieved after auditing, streamlining, and improving their OT utilization of their
surgical specialties (excluding neurosurgery) at a 1,000-bed tertiary care rural hospital.
Most delays are avoidable and can be addressed by proper planning, optimization of
patient transfer and resources, and, fundamentally, excellent communication between
surgeons, anesthetists, and management staff.[18 ] This ensures optimal use of time and benefits all specialties (neurosurgery and
anesthesia), ancillary staff, hospital managers, and, most importantly, the patient.
The goal of our article was to attempt to quantify the poor efficiency of neurosurgical
theater utilization in public sector hospitals in Pakistan and contextualize and discuss
the broader factors that contribute. While we discuss the interventions and changes,
we are attempting to improve OT utilization, these can only be assessed when we reaudit
after gross structural changes are appropriately made and have been in place for an
appropriate duration. If we do demonstrate improvement, our strategies may not be
completely applicable to every department. Regardless, our setting means that our
proposed solutions can provide the foundation for developing personalized strategies
for those within a similar setting with similar issues concerning OT utilization and
managerial delays in developing countries like Pakistan.
