www.imt.ie
(http://www.imt.ie/features-opinion/2013/08/the-model-of-a-safe-surgical-service.html)
The model of a safe surgical service
August 21, 2013
Catherine Reilly speaks with the two joint leads of the
National Clinical Programme in Surgery, Prof Frank Keane andMr Ken Mealy, about how best to
improve the safety and quality of care for surgical patients presenting in an emergency or acute
setting.
The new Model of Care for Acute Surgery, prepared under the auspices of the National
Clinical Programme in Surgery, noted that patients requiring acute surgical care constituted
a major component of the workload in many surgical departments globally and that these
patients were frequently the sickest, were often elderly and with considerable co-morbidities
and poorer outcomes.
Many professional publications have noted that the standard of care in surgical emergencies
internationally could be greatly improved, with emergencies comprising up to 90 per cent of
general surgical deaths and complication rates exceeding similar elective operations by up
to four times. Outcomes in Ireland were unlikely to be better, stated the Model of Care for
Acute Surgery, although no data were available.
The model aims to provide a framework for the delivery of timelier, safer and more efficient
care for the acute surgical patient and follows on from the Elective Surgery Model of Care
that is being rolled-out across the country.
General Surgeon Mr Ken Mealy, who is Joint Lead of the National Clinical Programme in
Surgery alongside former RCSI President Prof Frank Keane, told Irish Medical Times that
there existed a “huge” body of international evidence indicating that acute surgical services
were often poorly organised, poorly resourced and “evolved as being tacked-on to the end of
elective surgical services”.
Attempts to improve care and outcomes on the international front have centrally involved a
functional separation of acute and elective surgical streams. The new model has identified
this as key to better care delivery, but Mr Mealy said achieving this division was
“problematic”, particularly as the same group of surgeons generally dealt with both elective
and emergency cases.
Joint leads: Mr Ken Mealy, General Surgeon, Wexford General Hospital; Dr Áine Carroll, National
Director, Clinical Strategy and Programmes, HSE; and Prof Frank Keane
“Different countries have taken different approaches,” said Mr Mealy. “In the United States,
they have appointed a whole series of emergency care surgeons, but they are working out of
huge departments with maybe 20 to 30 surgeons, and 10 or 20 operating theatres, and
hundreds of thousands of patient admissions every year — so the economics of that is very
reasonable. That is more problematic in smaller countries. Ireland, in particular, has 32 acute
surgical hospitals, or has had up to recently, and if you have got two or three surgeon teams
it is very hard to separate those streams.”
Appointing an emergency surgeon in a small hospital would hardly be pragmatic, he said,
but the separation would be achievable in bigger units.
“In the bigger hospitals we are saying that the way to get better outcomes is to separate the
streams: have teams of surgeons, anaesthetists and other ancillary staff that you need to run
a [acute] service that are available 24 hours a day, freed-up from all elective duties so that
they can concentrate on emergency care patients and see them more promptly,” he said.
Asked if this could mean restricting acute surgery to a limited number of larger hospitals, Mr
Mealy replied: “We are very much aware of the limitations of the programme, in the sense
that we are delivering the model of care and are trying to get involved in performance
enhancement in the hospitals that we go into. But it is not our role, as such, to dictate how
that care should be provided, because we don’t have the ability to do that. But it may
transpire, particularly with the announcement recently of the networks, that certain networks
may well decide that some hospitals will be just elective care only and others would provide
the acute care, in some or all of the surgical specialties.” This separation of elective and
acute care had already been happening in the Mid-West and North-East, he noted.
Lancet mortality study
A paper published last year in The Lancet, ‘Mortality After Surgery in Europe: a Seven-day
Cohort Study’, reflected poorly on surgery in Ireland. The study of patients undergoing
inpatient non-cardiac surgery found that patients in Ireland had the highest risk of dying in
Western Europe and the fourth-worst mortality rate among 28 European countries. In the
UK, the mortality rate was 3.6 per cent, well above the highest previous estimates of
between 1 and 2 per cent. Ireland recorded a rate of 6.4 per cent.
Did the surgical community here accept the findings on Ireland? “The answer is we accept
the report because it is actually published,” said Prof Keane. “Do we agree with the
conclusions of the report or the methodology? There are some concerns about the
conclusions and methodology, and the College of Surgeons is actually doing a study at the
present time looking back over that data… Taken as read on face value, it would certainly be
extremely concerning.” He said an “engagement” with the Editor of The Lancet had
occurred, “and as I say, we are doing our own audit”.
Mr Mealy said the study had encouraged their resolve in ensuring that national audits under
the National Office of Clinical Audit (NOCA) were the “way forward”. That this initiative had
been agreed upon was one of the “fantastic spin-offs of the collaboration between the HSE
and the clinical programmes”, said Mr Mealy, who is NOCA’s Clinical Director.
Confidential audits
The establishment of NOCA has not been without glitches and an important issue has
remained unresolved. As was reported in IMT in March, the launch of the Irish Audit of
Surgical Mortality (IASM) has been delayed due to fears that data could be vulnerable to
court Orders of Discovery.
The IASM is one of four audit streams currently planned under NOCA and it is expected that
the Health Information Bill will include provisions to resolve the confidentiality issue, said Mr
Mealy.
The confidential nature of NOCA was not about hiding information from the general public,
he underlined, but rather about “changing the culture within the clinical community” so as to
encourage learning from adverse outcomes. Confidentiality was required so that doctors
bought-in to the process, he said.
“Currently in an adversarial process, it is never shared because it is hidden within little silos
around the country. Half of the adverse outcomes never reach any sort of inquiry, never
reach the courts; if litigation is involved they are frequently settled out of court, so nobody
learns,” he said.
One of the particularly interesting observations in the Model of Care for Acute Surgery was
the high numbers of acute surgical inpatients who did not have a surgical procedure. In
2011, while acute inpatients accounted for 62 per cent of surgical admissions, some 44 per
cent of those had no surgical procedure performed.
Prof Keane said there were various reasons for patients being admitted to hospital under
surgical care, but not necessarily having a surgical procedure, including some cases of
cellulitis and possible appendicitis, and patients with head trauma who needed further
observation. He recognised that some surgical admissions would not, in the end, entail a
surgical procedure, but that it was important insofar as possible to minimise hospital stay in
order to free-up bed space.
Lengths of stay
Both of the surgeons agreed that it was imperative that shortening hospital stay did not
compromise patient care. Mr Mealy commented: “If you look at across the water, some of
the huge criticisms of the NHS in terms of quality outcomes, particularly with the MidStaffordshire report, is that you have your KPIs [Key Performance Indicators] and you tick all
the boxes, but the level of care you could be providing could be awful for patients — but you
are ticking the right boxes. So it is a case of getting the communication and the compassion
and the empathy right, but also dealing with and processing patients efficiently.”
As to the successes of the National Clinical Programme in Surgery to date, Mr Mealy felt that
these were largely associated with Prof Keane’s elective surgery programme.
The elective programme has worked to define ways of improving delivery of elective surgical
care through a range of initiatives, such as standardised models of care guidelines for preadmission assessment clinics, day surgery, day of surgery admissions and discharge
planning; targets for average length of stay of surgical inpatients, as well as targets for day
surgery across surgical specialties; monitored clinical outcomes through audit and clinical
registries; and The Productive Operating Theatre (TPOT) to improve patient outcomes and
experience, as well as theatre team performance and resource efficiency.
More patients, fewer beds
“I think it is very clear that our average length of stay is already decreasing and we have
good evidence from 2010 to 2011 — we will have 2012 figures soon,” said Mr Mealy. “We
are treating more patients in fewer beds, our day case rates are very rapidly increasing 10to-15 per cent a year, and our day of admission surgery rates are very clearly increasing, so
we are becoming much more efficient in how we process elective patients. I think there have
been fairly impressive results so far.”
Asked if there were further programmes planned relating to different surgical specialties,
Prof Keane suggested that national resources might not allow for this at the present time,
although they would be welcomed. For the moment, much work remained under the generic
programme, “in terms of trying to see how we can help hospitals implement the various
components of the elective and the acute surgery models of care”, said Prof Keane.
Hospital visits
Over the past year, there have been the best part of 40 hospital visits, he said. “Seeing the
changes and innovations that are going on in extremely difficult circumstances is really quite
remarkable, but there is a huge amount to be done,” added Prof Keane. “We don’t think this
is a programme that is going to be implemented in six months or a year; it is going to take a
number of years… and obviously with the other changes that are happening in the health
service at the moment, such as the hospital groups, ‘money follows the patient’, universal
healthcare, all these other things are going on at the same time, it is going to be a slow
process. We are absolutely convinced that the kind of message is the right message going
out and we are also feeling very rewarded that people are picking up and understanding the
message.”
Mr Mealy concurred, adding that, as they travelled around the country, they were
encountering a “huge amount of good work being done” by many individuals and institutions
under difficult circumstances, and “the public tend not to hear about it”.