Innovation Poster Session
HRT1215 – Innovation Awards
Sydney
11th and 12th Oct 2012
Emergency general surgery model
of care
Presenter: Mr Douglas Stupart
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3-3a_HRT1215-Session_STUPART_BARWON_VIC
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Key problem: Emergency Surgery
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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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Arrival in
Emergency
Department
Operation
start time
Theatre
booking
time
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Discharge
from
hospital
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BASELINE DATA
Overall
Operation
Time from ED to Time from
surgery (hours) 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
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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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Arrival in
Emergency
Department
Operation
start time
Theatre
booking
time
Discharge
from
hospital
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.)
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Operation
Control
Study
Pvalue
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
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*
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
Laparotomy
Abscess drainage
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OUTCOMES: CHOLECYSTECTOMY
Higher 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
Length of Stay (Days)
cases
Days
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OUTCOMES – NIGHT TIME OPERATIONS
X2 appendix
X3 laparotomy
X1 bleeding ulcer
X1 sigmoidoscopy
X1 retroperitoneal abscess
Funded Project Period
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*10/11
*11/12
Average
6.5
3
Median
7
3
11
10/11 & 11/12 Financial Years
General Surgery cases done 0000 – 0800 hrs
X2 appendix
X3 laparotomy
X1 bleeding ulcer
X1 sigmoidoscopy
X1 retroperitoneal abscess
*10/11
*11/12
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Mean
6.5
3
Median
7
3
Funded Project Period
12
OUTCOME: SURGEON SATISFACTION
Pre implementation
Post implementation
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5
6
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
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P=0.0012
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OUTCOMES SO FAR
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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
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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
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Barwon Health Emergency Surgery Team
David Watters, Meryl Bui Viet, Glenn Guest, Douglas Stupart
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The Health Roundtable Dennis O’Leary and Shannon Ryan