Kate Parker, Senior House Officer in Paediatric Dentistry Foundation Program Sharing Good Practice Event 11/6/14 Improving the efficiency of dental general anaesthetic theatre lists at Great Ormond Street Hospital

Background Great Ormond Street Hospital – tertiary centre, medically compromised children High need for dental treatment under general anaesthetic One full day theatre list on alternate weeks Therefore need GA lists to be as efficient as possible to accommodate high demand

Current practice Full day list: – hours operating time Four patients on list – comprehensive care Patients arrive at or On morning of GA patients seen by dental team, main medical team and anaesthetist Theatre team: dental consultant, dental SHO, dental nurse, anaesthetic consultant +/- registrar, theatre staff

Aims To investigate current efficiency of dental GA lists To establish where changes can be made to improve efficiency Increase capacity of dental GA lists Reduce waiting time for dental treatment under GA

Method Data collection: December 2013 – May 2014 All dental GA lists Data collection pro-forma designed and piloted The following data collected: Number of patients on list List start time List finish time For each patient: When arrived, seen by dental team, medical team, anaesthetist, time called to theatre, time in anaesthetic room, operating time, into recovery, any delays.

Data collection

Results December 2013 – May GA lists 16 full day lists, 1 half day list Scheduled to treat 62 patients: 54 patients treated 8 cancelled: unwell, lack of bed availability Average of 3.3 patients per list

Results 9 hours operating time per list Average of 3.3 patients per list 2.7 hours per patient Dental treatment: average 2.9 hours per list Non dental aspects: average 6.1 hours per list

Identifying areas for improvement Delay starting list – due to awaiting medical team assessing patient Average time first patient called for: 08.50am Average time treatment started: 09.30am Complex medical histories – long anaesthetic time, induction, recovery Often one anaesthetist – cannot induce one patient whilst one recovers, no overlap Changing anaesthetist in afternoon – delay due to re-briefing

Identifying areas for improvement Anaesthetic induction Range: 5 minutes – 55 minutes Average: 18 minutes Anaesthetic recovery Range: 5 minutes – 35 minutes Average: 13 minutes

Recommendations Medical teams to assess patient prior to day of the GA Always have one patient on list who has already been assessed by medical team – patient first in list Ensure all medical pre-op work up complete prior to day of GA Discuss complex cases with anaesthetist prior to day of GA Anaesthetic consultant and registrar allocated to list – to enable overlap of patients Same anaesthetists all day – to prevent having to re-brief

Identifying areas for improvement Patients scheduled for different pre-op and post-op wards spread all over hospital Staggered admission times Time wasted seeing patients pre-op and post-op Time wasted having to leave theatre and wards not close together or close to theatre

Recommendations Additional dentist scheduled to attend GA list to enable patients to be seen pre-op and post-op without disrupting operating time Same day admission ward – close to theatre Day stay recovery ward – close to theatre These wards are appropriate for majority of patients

Identifying areas for improvement Incorrect staring times Incorrect time of arrival Due to staggered admission and fasting times if any patients cancelled on day of GA, no other patient ready to go to theatre

Recommendations Patients called day before GA to confirm starving instructions and arrival times Try to have at least 2 patients arriving at 07.30am and starved for an 08.30am start - to prevent there being no patient ready to start at 08.30am Add a “quick case” to each list – simple dental treatment/ simple medical history. To attempt to reduce waiting list Extra GA lists added to overcome long waiting list

Discussion Complex patients to provide dental treatment under GA Require input from multiple medical teams – time consuming but essential for safe GA Comprehensive dental care required – fillings and extractions Majority of time used for medical aspects of patients care

Discussion Main improvements: Starting list earlier due to first patient seen by medical team prior to day of GA Less wasted time during GA due to having to leave theatre to see patients pre-op and post-op – another dentist in theatre, new wards Anaesthetic registrar – improved anaesthetic turn around

Conclusion Lots of small areas identified where improvements can be made to increase GA list efficiency Some aspects of patient care cannot be changed Measures put in placed to increase efficiency Changes implemented so far have been effective Plan to continue to monitor list efficiency and continually address areas for improvement

Thank you Any questions?