In July 2014, after a comprehensive process of planning and consultation, we in St. Luke’s implemented a profound and comprehensive change programme in the operation of the Department of Surgery, writes Mr. Paul Balfe, Consultant Surgeon, St. Luke’s Hospital, Kilkenny. This project was one of the finalists in the 2015 HMI Leaders Award.
In the vast majority of acute hospitals throughout the state, the status quo is as follows:
- The Surgical Consultant and team on call on any particular day also have a full day’s elective duties simultaneously.
- Most if not all acute surgical presentations are first seen and managed by ‘middle men’ i.e. Emergency Department personnel who often are not very experienced from a surgical perspective and have other commitments.
- This almost inevitably lead to an unacceptable volume of out-of-hours surgery which by implication also means an unacceptable level of out-of-hours radiology, laboratory activity etc. with all the attendant safety and cost implications.
- Asymmetric workloads within a Department – one consultant may receive a disproportionate number of referrals on the basis of being a well known entity to the GP community while another equally competent colleague, who may simply be newer to the job, may receive a disproportionately low level of referrals even though he/she is perfectly capable of carrying out the work.
The National Clinical Programmes in Surgery which advocate the separation of Acute and Elective Surgical Pathways and the European Working Time Directive (EWTD) are two further major drivers of change.
Against this background that we decided to embark on a major change programme covering both the elective and emergency surgical pathways. The fundamental principles of the reform programme can be summarised as follows:
- Complete separation of the elective and emergency surgical pathways.
- The establishment of an Acute Surgical Assessment Unit (ASAU) where acute surgical presentations would be seen directly by the on-call surgical team.
- Designation of one of the operating theatres as an emergency theatre for both surgical and obstetric/gynaecology emergencies.
- The equal distribution of elective referrals among the four consultants thereby ensuring the shortest elapsed time between patient referral and patient review.
- Development of a roll-over four week consultant rota.
- Development of an SHO rota that is EWTD compliant but that also ensures that our trainees get exposure to the spectrum of surgical practice (emergency and elective surgery, endoscopy, ASAU, SOPD and the Procedure Clinic).
- Development of :
- Evidence-based protocols so as to reduce unnecessary inter-consultant variability regarding such matters as surveillance protocols in colorectal cancer, removal of sutures, management post varicose vein surgery etc.
- Patient information leaflets.
- A comprehensive NCHD handbook.
- Establishment of an on-site Skills Lab (shared with our Obstetric/Gynaecology colleagues) containing a comprehensive set of surgical instruments, practice rigs, laparoscopic simulators, endoscopy simulators etc. The lab is used for formal teaching but also facilitates 24 hour access by our trainees who can practice and hone their skills at a time that suits them.
- Appointment of a full-time academic surgeon to roll out comprehensive undergraduate teaching/training programmes for the large number of RCSI and University of Limerick students that rotate through St. Luke’s each academic year.
Apart from your surgical colleagues, it cannot be over-emphasised the importance of comprehensive and open consultation with ALL stakeholders in advance of launching such a major programme of change.
Emergency Surgical Pathway – Establishment of an Acute Surgical Assessment Unit (ASAU)
The ASAU is a Unit where patients with an acute surgical condition are seen and managed directly by the Surgical Service at presentation.
Since July 2014, the on-call team is available and free from competing elective duties and is thus available 24/7 to attend all acute surgical presentations. It was agreed in advance what would constitute an acute surgical presentation and an acute ED presentation.
The net effect is that senior decisions are made early in the patient service pathway and patients requiring surgical intervention have timely access to theatre. It also ensures that inappropriate admissions and discharges are reduced to an absolute minimum.
The Consultant Rota
The new consultant roll-over 4 week rota operates on the basis of three surgeons (S1 – S3) covering ALL the elective commitments at any one time with the fourth (S4) covering ALL the emergency commitments.
Elective Surgical Pathway
Where the consultant staff are of equal competence, it makes absolutely no sense that the length of time a patient is waiting for an outpatient’s appointment, an endoscopy procedure, or an operation should be determined by the inherent asymmetry in the referrals pattern within a particular department. It was agreed that referrals would no longer be directed to an named consultant but would instead be addressed to ‘Dear Department of Surgery’. The elective referrals would, on a daily basis, be divided equally into four and forwarded to each consultant for triaging. Once triaged, the referrals would then be distributed equally over the available SOPD and Procedure clinic slots in the weeks and months thereafter.
Simarly with endoscopy and surgery, the Consultant decides regarding the need for either and once again the patients are distributed equally over the available endoscopy and theatre lists in the weeks and months thereafter.
We conducted a six monthly audit of the operations of the ASAU covering the period November 2014 to April 2015.
Referral pathways
Not surprisingly, about half the acute surgical presentations presented on foot of a GP letter, with 37% self-referring.
Patients are triaged according to the well established colour-coding system of Red, Orange, Yellow and Green. ‘Red’ patients must be attended to before ‘Orange’ and so on. Nearly 70% of patients were seen within one hour of triaging with only 2% (mostly ‘green’ patients) waiting four hours or more.
Presentations – volume and outcomes
A little less than half the patients who presented were deemed to require admission. 43% were discharged either with no follow-up having been fully assessed including radiology, bloods etc.) or with follow up arrangements e.g. endoscopy, urgent USS
After-hours Surgery
With the combination of a dedicated acute surgical team available at all times, a designated emergency theatre and a policy of ‘life or limb’ governing the performance of emergency out-of-hours surgery, there has been a dramatic decrease in the volume of out-of-hours surgery with 90% of emergency surgery from Mon – Fri being carried out between the hours of 09.00 and 18.00.
Resource implications
Apart from the necessity to recruit more NCHD staff which was more due to compliance with the EWTD than the new work practices, there should be minimal resource implications. It’s more a question of using what we have to greater effect.
Conclusions
The implementation of such radical and profound changes to replace what have been long-established work practices is no small task and its success so far in St. Luke’s is a tribute to the teamwork exhibited by ALL the stakeholders. However, not having such wholehearted buy-in should not act as a disincentive to other institutions in beginning the engagement process, starting of course with the consultant surgeons themselves. While the fundamental principles and objectives will be the same, the model and speed of implementation needs to be tailored to the particular institution.
