The Health Roundtable Emergency general surgery model of care Presenter: Mr Douglas Stupart Innovation Poster Session HRT1215 – Innovation Awards Sydney.

The Health Roundtable

Emergency general surgery model

of carePresenter: Mr Douglas Stupart

Innovation Poster SessionHRT1215 – Innovation AwardsSydney 11th and 12th Oct 2012

13-3a_HRT1215-Session_STUPART_BARWON_VIC


Key problem: Emergency Surgery

Under- resourced Poorly planned Compete with elective patients Often performed after hours Uncertainty and stress for patients awaiting surgery Impact on service delivery Impact on surgeons’ job satisfaction

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AIM OF THIS INNOVATION

Implement a sustainable model of care to improve the service provided to

emergency general surgery patients by January 2012

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The Health Roundtable 4


BASELINE DATA

OverallOperation Time from ED to surgery (hours)

Time from booking to surgery (hours)

Hospital length of stay (days)

Appendicectomy 12 (11.0-13.0) 3.6 (3.2-4.2) 2.0 (2.0-2.0)

Laparoscopic cholecystectomy

38.0 (30-45.9) 7.4 (5.3-13.7) 4.0 (3.0-4.9)

Laparotomy 26.5 (19.0-56.0) 3.1 (2.2-4.1) 13.0 (11.0-15.0)

Drainage of abscess

11.0 (9.9-16.0) 5.8 (4.6-6.5) 1.0 (1.0-2.0)

All emergency operations

19.0 (18.0-21.0) 4.8 (4.3-5.4) 3.0 (3.0-4.0)

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KEY CHANGES IMPLEMENTED

Consultant leadership of emergency and urgent surgery Consultants on site to make decisions and perform

operations during the day Half day operating list every day for emergency general

surgery or life threatening emergencies Director of Surgery or delegate to manage bookings for

urgent and emergency surgery Project officer to monitor performance Weekly and monthly feedback to general surgeons

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OUTCOMES SO FAR

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Control Study P- value

E.D. to surgery (hours)

19 (18-21) 18 (17-19) 0.033

Booking to surgery (hours)

4.8 (4.3-5.4) 3.9 (3.5-4.3) <0.0001

All values are stated as median (95% C.I.)8


Operation Control Study P-

value

Appendicectomy

E.D. to surgery 12.0 (11.0-13.0) 13.0 (11.0-14.0) 0.85

Booking to surgery 3.6 (3.2-4.2) 3.5 (2.9-4.2) 0.56

Hospital stay 2.0 (2.0-2.0) 2.0 (2.0.2.0) 0.25

Laparotomy

E.D. to surgery 26.5 (19.0-56.0) 18.5 (13.0-27.2) 0.0083

Booking to surgery 3.1 (2.2-4.1) 2.3 (1.8-2.9) 0.016*

Hospital stay 13.0 (11.0-15.0) 10.0 (9.0-12.0) 0.0089*

Abscess drainage

E.D. to surgery 11.0 (9.9-16.0) 12.0 (9.8-15.2) 0.47

Booking to surgery 5.8 (4.6-6.5) 4.2 (3.1-5.1) 0.011

Hospital stay 1.0 (1.0-2.0) 2.0 (1.0-2.0) 0.71

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OUTCOMES: CHOLECYSTECTOMYHigher percentage of cholecystectomies done within 48 hours (57.78 to 78.72%)Reduced median waiting time from 41.77 to 26.4 hours (P<0.001)Reduced median length of stay

Days

Length of Stay (Days)

cases

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OUTCOMES – NIGHT TIME OPERATIONS

Average Median*10/11 6.5 7*11/12 3 3

X2 appendixX3 laparotomyX1 bleeding ulcerX1 sigmoidoscopyX1 retroperitoneal abscess

Funded Project Period

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10/11 & 11/12 Financial YearsGeneral Surgery cases done 0000 – 0800 hrs

Mean Median*10/11 6.5 7*11/12 3 3

X2 appendixX3 laparotomyX1 bleeding ulcerX1 sigmoidoscopyX1 retroperitoneal abscess

Funded Project Period12


Pre implementation Post implementation

123456

P=0.0012

1)I am satisfied with the current model of care

2)I am satisfied with my overall level of job satisfaction

3)I am satisfied with the level of supervision provided during surgery

4)I am satisfied with the flexibility of the current roster

5)I am satisfied with my current hours of work

6)I have the support I need from other staff

OUTCOME: SURGEON SATISFACTION

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OUTCOMES SO FAR

Less after hours (18.00-8.00) operations Better access to emergency and urgent list during the

day Reduced waiting times for surgery Improved outcomes for laparotomies and

cholecystectomies Elective surgery performance has improved Happier general surgical staff No increase in surgical staff costs

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LESSONS LEARNT

Instituting regular consultant-led emergency operating sessions improves service delivery and the job satisfaction of surgeons (and anaesthetists)

Surgical leadership of emergency theatre allocation improved access to theatre

Allocation of a general surgical emergency list resulted in more surgery done in hours and less night time operating

No impact on hospital initiated postponements No impact on concurrent elective surgical

performance improvement initiatives No change in complications and postoperative

mortality We can still improve performance in ED 15


Barwon Health Emergency Surgery Team

David Watters, Meryl Bui Viet, Glenn Guest, Douglas StupartDennis O’Leary and Shannon Ryan 16

The Health Roundtable Emergency general surgery model of care Presenter: Mr Douglas Stupart Innovation Poster Session HRT1215 – Innovation Awards Sydney.

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