Megan King, Wagga Health Service: Establishing A Consultant Led 7 Day Acute Surgical Unit: Improving Outcomes

Establishing an Acute Surgical Unit in a Rural

Area

Wagga Wagga Health Service

November 13 Sherylle Sheehy ASU CNC, Megan King Perioperative NM

Wagga Wagga is the largest inland city in NSW and one of Australia’s leading regional cities with a population over 61,000 (06/2008 census).

Wagga is the local Wiradjuri aboriginal word for crow and to create the plural, the Wiradjuri repeat the word. Thus Wagga Wagga translates as 'the place of many crows'.

Wagga Wagga Base Hospital is a rural referral hospital and the major acute care provider and referral hospital for the Murrumbidgee Local Health Network ... Wagga Wagga Base Hospital has 237 'beds' including 209 overnight inpatient beds and 28 ambulatory treatment places. (Wagga Wagga Hospital Clinical Services plan 08/2006)


Sherylle Sheehy ASU CNC, Megan King Perioperative NM


New Wagga Wagga Health Service



General – 8 General Surgeons Orthopaedics – 6 Orthopaedic surgeons - 1 elective

only Urology – 3 Urologists ENT – 2 ENT Surgeons Vascular – 2 Vascular Surgeons Ophthalmology – 3 Ophthalmologists O&G – 1 O&G + locum service 2 Gynaecologists

elective only Paediatrics – 1 x Paediatric Surgeon Endoscopy – 2 Physicians, 2 Respiratory Physicians Dental ECT Vascular Access service


Types of Surgery


Historical Approach to General Surgery Presentations

Surgeon: On call for 24hr period Normal public/private operating list Normal consulting in rooms Not always available during hours

Theatre: Designated Emergency sessions often unable to be utilised or on occasions utilised for elective surgery Emergency Cases added to elective lists surgeon Emergency cases commenced after 1800


Issues

• After hours operating , escalating overtime of staff –

medical, nursing and ORA’s

• Cancellation of elective patients to accommodate

emergency cases

• Increase in diagnostic tests

• Delay in Surgical Review of ED presentation

• Delay in consults on inpatients


Commencing an ASU

The ASU model of care was driven by the surgeons

After consultation with WWBH Executive, funding for the

model was sourced from MOH.

The surgeons as a group proposed how they would do their on

call roster: decided 7 days on, full handover to next Surgeon,

Friday to Friday.

A Registrar was to be allocated to ASU

Average 35 – 40% of all operations at WWBH are emergencies

Allocated Ortho Trauma and Emergency sessions

Ortho Trauma: almost every day of month

Emergency: Every afternoon 1330 – 1730 (ASU), then overnight and weekends


Emergency Surgery

Emergency Sessional Allocation


THEATRE TIME MON TUE WED THU FRI SAT SUN

1 AM Trauma Trauma

Trauma

PM Trauma Trauma Trauma Trauma Trauma Trauma

2 AM Emergency Emergency

PM ASU ASU ASU ASU ASU Emergency Emergency

3 AM

PM

4 AM

PM

5 AM

PM

ENDO AM

PM Evening /

Overnight Emergency Emergency Emergency Emergency Emergency Emergency Emergency

Getting Logistics Right


• Commence a Steering Committee with weekly meetings

• Service Development Application

• Business rules

• Contracts for Doctors

• How the Doctors will be paid

• Identifying ASU patients in IPM to get reports

• Position descriptions for CNC, Clerical, and Data Manager

• Office space and Office fit outs

• How will Private patients be managed. -

Steering Committee


• Chaired by WWHS GM

• Initially DM, DMS, DONM, Theatre Manager, Client Services

Manager, Business Manager

• Meet weekly

• Later included Director of Emergency

• Separate meeting with WWHS Executive and Surgeons

Service Development Application


• Included cost modelling

• Designed around cost benefits: • Reduced overtime • Reduced LOS • Reduced pathology and imaging costs

• Staffed by:

• CNC • Clerical Assistance • Data Manager

Business Rules


• Developed by DMS in conjunction with Surgeons • WWHS expectations of how ASU will function • Includes rules on: Roster provision including Registrar allocation to ASU Consults and ward rounds Handover Allocated Emergency Operating time Transfer from Emergency department Supervision Clinics Protocols and pathways Attending Rooms and Private hospital while on call Timely Accounting

Surgeon Contracts & Payment


• Special permission for a non standard contract for Surgeons

• Surgeons submit separate claim to Normal VMO claim for ASU

Identifying ASU Patients in iPM


• Set up a new sub specialty for each surgeon in IPM

• Eg ‘Dr Harrison’ specialties of ‘General Surgery’ or ‘Acute Surgical’

• Allows printing a report for where patients are as there is no specific ward for ASU patients

Position Descriptions


• Longer than we thought, had to go through Grading

Committees

• Easily recruited to CNC

• Clerical and Data Manager took longer to recruit

Office Space and Fit Out


• Big problem as very limited space at WWBH

• GM rearranged location of WWBH Staff to allow ASU

to go into a newly built demountable office located in

between A&E and Theatre

• Begged, borrowed and stole office desks

• Purchased new chairs, computers, Printer/fax/

photocopier machine

• 4 desk spaces and computers (CNC, Clerical, Registrar and Intern)

• Worked with Surgeons and PLO’s to develop a patient brochure explaining the ASU including how it affects private patients

• Surgeons historically have preferred to keep any emergency patients at Base Hospital for a variety of reasons

• Decisions about which patients can be transferred to Private Hospital is determined on a case by case basis.


Private Patients




Results so far


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% 08:00 - 18:00 % 18:00 - 22:00 % 22:00 - 08:00

WWBH % General Surgery emergency cases - grouped by Case Start Time.

WWBH % General Surgery emergency cases - grouped by Case Start Time.

Data Source:- SurgiNet custom report - (all Fields, All Records) extraction of data by Time of Day ranges (EXCEL)



Data Source:- SurgiNet report SN027A


Data Source:- SurgiNet report SN027A

Sherylle Sheehy ASU CNC, Megan King Perioperative NM Data Source:- SurgiNet SN011

Sherylle Sheehy ASU CNC, Megan King Perioperative NM Data Source:- SurgiNet custom report - (all Fields, All Records) EXCEL sum / count of selected times / records by month


Data Sources:- SurgiNet custom report - (all Fields, All Records) CORVU staff payroll report EXCEL sum / counts of selected times / records by month

Sherylle Sheehy ASU CNC, Megan King Perioperative NM Data Source:- SurgiNet SN027B EXCEL sum of times for selected records by month


Data Source:- SurgiNet SN027B EXCEL % of cases by specialty and month

Sherylle Sheehy ASU CNC, Megan King Perioperative NM Data Sources:- SurgiNet custom report - (all Fields, All Records) EXCEL counts of selected times / records by month


Sherylle Sheehy ASU CNC, Megan King Perioperative NM Data Source:- Pathology service provider invoice records from LHD Finance office.


Data Source:- SurgiNet custom report - (all Fields, All Records) then manual selection of category for each procedure

Ward Round Checklist

DVT program

Cholecystectomy Case Delay Audit.


Quality improvement projects


Ward Round Checklist

WARD ROUND CHECK LIST

EXAMINATION MANAGEMENT

Hands washed (before & after) Results (checked)

Wounds /Patient examined) Mobility (maximised)

Lines & Tubes (site & need reviewed) Diet (maximised)

Bowels (treated if BNO > 24 hr) Allied health (consulted)

CHART REVIEW COMMUNICATION

Vitals (checked) Nurse on round (present)

DVT prophylaxis / TEDS (charted + given) EDD :

Analgesia (adequate)

Medications (new/routine)

Fluids (U/O & Balance checked) Date: ___________ Signed: ________________

One potential solution - trial


Ward Round Sticker

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

May Jun Jul Aug Sept Oct

%ASU Patients with Discharge Plan (Ward Round Checklist Sticker introduced late May/early

June)

Ward round sticker introduced

Data Source:- ASU Internal Audit

Sherylle Sheehy ASU CNC, Megan King Perioperative NM Data Source:- ASU Internal Audit

Sherylle Sheehy ASU CNC, Megan King Perioperative NM Data Source:- ASU Internal Audit

Road Blocks

Sherylle Sheehy ASU CNC, September 2012


Roadblocks Limited consultation with all key stakeholders in planning phase Admission process in PAS System couldn’t identify the patients in

ASU Recruitment of Clerical Support Clerical Support commenced 25th June, 2012

• Inability to recruit Data Manager Commenced 20th August, 2012

• Delays in Database Construction via LHN IT • Development of Protocols for Standardise Patient Care • Workload of ASU Medical Team – JMO’s – 25 – 30 patients each day • Appropriate Outpatient Clinic Time • Accredited Registrars access to Surgical Procedures – not meeting

requirements • Some KPIs unable to be easily measured eg Pathology and Imaging

costs

Sherylle Sheehy ASU CNC

Margaret Fifield Relieving ASU CNC

Greg Atkinson ASU Data Manager

Michelle Sleep (Previous WWHS GM)


Acknowledgements


Questions?

Megan King, Wagga Health Service: Establishing A Consultant Led 7 Day Acute Surgical Unit: Improving Outcomes

Health & Medicine