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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
The Health Roundtable
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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The Health Roundtable
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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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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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
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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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The Health Roundtable
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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The Health Roundtable
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
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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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The Health Roundtable
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