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Influence of sequencing the shortest and least variable cases early in the workday on operating room performance when constrained by post-anesthesia care unit availability: a narrative review
Journal article   Peer reviewed

Influence of sequencing the shortest and least variable cases early in the workday on operating room performance when constrained by post-anesthesia care unit availability: a narrative review

Nafisa Mostofa, Franklin Dexter and Sarah S. Titler
Perioperative care and operating room management, Vol.43, 100654
06/2026
DOI: 10.1016/j.pcorm.2026.100654

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Abstract

Sequencing the cases with the smallest variability in case duration first usually means performing the shortest cases first. In the absence of downstream constraints such as full phase I post-anesthesia care unit beds (PACU), such sequencing reduces both patients’ average tardiness from scheduled start times and waiting times. However, PACU beds are often at capacity. We reviewed studies on case sequencing for operating room and non-operating anesthetizing locations. Searches were performed in Scopus, using keywords and citations, reflecting the structure of the operating room management field. To find articles relevant to surgical sequencing constrained by PACU bed availability, a multi-step search methodology was employed. Shortest or least variable cases first were ruled out (or in) by reading and consideration of each article’s mathematical model(s) and solution algorithms. :Twenty-six articles studied surgical case sequencing while incorporating downstream (e.g., PACU) constraints. No articles reported conditions in which the least variable or shortest cases sequenced to be performed first achieved best organizational performance. The three articles that made specific comparisons all found that the shortest cases first strategy performed relatively poorly. Managerial epidemiology studies from multiple hospitals showed that, in reality, current practice was the unsynchronized sequencing of multiple surgeons’ lists of cases. This behavior resulted in a random and thus uniform rate of admission into the PACU, achieving close to minimum peaks in bed and nursing demand, thus minimizing costs. : The results of this narrative review show that sequencing surgical cases for the least variable and shortest cases to be performed first in operating rooms each workday is counterproductive. Unless a facility uses one of the sophisticated mathematical methods, clinical directors are recommended to change nothing and benefit from the resulting random sequencing.
 Computer Simulation Operating Rooms/organization and administration Personnel Staffing and Scheduling Recovery Room/organization and administration

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