Christina Bannister, Steve Livesey
Wessex Cardiothoracic Centre
Southampton General Hospital
Non-elective patient burden
1400
Elective
1200
NonElective
1000
NonElective
800
Preop
Postop
600
400
Elective
200
0
2009 - 10
0
10
20
30
Rexius Scoring System
 To determine whether it was possible to reduce the length of stay for
these non-elective patients, the Rexius Scoring System was
implemented as a risk stratification tool for a period of four months.
 The model was created by Dr Helena Rexius et al in the Department of
Cardiothoracic Surgery at Sahlgrenska University Hospital in Sweden.
 It was constructed to identify patients with increased risk of death
while waiting for coronary artery bypass grafting.
 The score was used to facilitate and improve the prioritisation process.
 At Southampton General the Rexius Scoring System was used to
identify the appropriateness of our practice, in prioritising all patients
waiting for non-elective cardiac surgery.
 This was to ensure that the most urgent were operated on quickly, with
low risk patients potentially being sent home to wait.
 Within the Rexius Scoring System, each patient receives a score for a
set criteria:
Rexius Scoring System
ACS
Troponin +ve
3
Troponin –ve
2
Angiogram
LMS>50%
2
Valve
Concomitant AV Disease
2
Gender
Male
1
Operative Score
EuroSCORE
Reduced EF
0-3
0
4-6
1
>7
2
>50%
0
35-50%
1
<35%
2
Risk Groups
 All patients in our pilot period were assessed using this criteria and
depending on which factors they showed a score was created.
 The total score then determined which risk group the patient was
allocated to.
 The risk groups are:
Risk of Waiting
High Risk
>6 points
Medium Risk
3-5 points
Low Risk
0-2 points
 Based on this risk stratification model, decisions were made regarding
the timing of the patient’s operation.
 These are based on the guidelines created by Rexius and implemented
by Healthcare for London.
High Risk
Patient to be transferred to a cardiac surgery unit and
operated on as an in-patient within 1 week of admission
Medium Risk
Patient to be operated on within 2 weeks of admission
Low Risk
Patient to be sent home and date for operation must be
within 4 weeks of admission
The Role of the Nurse Case
Manager
 At Southampton General Hospital there is a team of Nurse Case
Managers (NCM) who manage individual Consultant caseloads.
 From outpatient appointments and pre-assessment clinics, through to
admission for surgery and post-operatively on the cardiac wards.
 The NCM’s also manage the non-elective patient pathway, ensuring
they are prepared for surgery, and are operated on in a timely fashion
dependent on their disease process and symptoms.
 The Rexius Scoring System was therefore a potentially useful tool for
the NCM’s to implement.
 This would ensure the non-elective patients who needed surgery the
most were given priority over those who could have been sent home
with a date for their operation.
 This had the possibility of freeing up beds, reducing patients’ length of
stay in hospital and saving costs for the unit.
Methods
 During a 4 month period 151 patients were referred to Southampton
General Hospital for non-elective cardiac surgery.
n=151
ACS Troponin +ve
74 patients
LMS Stenosis >50% on Coronary Angiography
49 patients
Aortic Valve Disease
65 patients
Male
115 patients
Median age
72 yrs (40-89)
Mean additive EuroSCORE
5.52
EuroSCORE 4-6
58 patients
EuroSCORE >7
54 patients
LVEF 35-50%
41 patients
LVEF <35%
10 patients
Results
 The Rexius Scoring System was applied to each patient as they were
referred.
Patients
High Risk
61
Medium Risk
85
Low Risk
5
Patients
Accepted for cardiac surgery
140
Not suitable for surgery
9
Transfers revoked by DGH
4
Patient did not want operation
1
Patients died whilst waiting for surgery
4
Patients died post-operatively
5
Low Risk Patients
 The 5 low risk patients referred as non-elective patients were those that
could have potentially been sent home with a date to come back for
cardiac surgery.
 On closer clinical examination of these patients, it was identified that
actually this was not to be possible.
 In all the cases, the patients had a disease process that fell outside the
scope of the Rexius Scoring System therefore scoring them lower than
was clinically needed.
 Of the 5 low risk patients:
Patients
Mitral Valve Disease
3
Pericardial Effusion
1
Left Atrial Myxoma
1
 All these patients were clinically identified as needing urgent non-
elective cardiac surgery and it was not possible to send any of them
home to wait for their operations.
Conclusions
 The Rexius Scoring System is a useful tool for prioritising non-elective
patients.
 Referrals made were appropriate for all patients.
 The system is a guide, it cannot replace sound clinical judgement, and
needs to be expanded clinically to include symptoms to be effective.
 The system was set up to assess patients waiting for Coronary Artery
Bypass Graft Surgery only.
 The Rexius Scoring System only identified 5 low-risk patients
 None of the patients referred for non-elective surgery could be
discharged home to wait for an early date
 This reflects the high risk profiles of this population of patients
Discussion
 If non-elective patients referred to a tertiary centre for urgent cardiac
surgery are sent home to wait, they are at potentially greater risk of an
adverse event occurring.
 In today’s medical-legal society, is it better to keep all this group in
hospital whilst waiting for surgery, thereby negating that risk, rather
than trying to save costs?