1. The Health Roundtable Emergency general surgery model of care Presenter: Mr Douglas Stupart Innovation Poster Session HRT1215 – Innovation Awards Sydney 11 th and 12 th Oct 2012 1 3-3a_HRT1215-Session_STUPART_BARWON_VIC

2. The Health Roundtable Key problem: Emergency Surgery  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 2

3. The Health Roundtable AIM OF THIS INNOVATION Implement a sustainable model of care to improve the service provided to emergency general surgery patients by January 2012 3

4. The Health Roundtable Arrival in Emergency Department Theatre booking time Operation start time Discharge from hospital 4

5. The Health Roundtable BASELINE DATA Overall OperationTime from ED to surgery (hours) Time from booking to surgery (hours) Hospital length of stay (days) Appendicectomy12 (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) Laparotomy26.5 (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) 5

6. The Health Roundtable KEY CHANGES IMPLEMENTED  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 6

7. The Health Roundtable OUTCOMES SO FAR 7

8. The Health Roundtable Arrival in Emergency Department Theatre booking time Operation start time Discharge from hospital ControlStudyP- 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.) 8

9. The Health Roundtable OperationControlStudy P- value Appendicectomy E.D. to surgery12.0 (11.0-13.0)13.0 (11.0-14.0)0.85 Booking to surgery3.6 (3.2-4.2)3.5 (2.9-4.2)0.56 Hospital stay2.0 (2.0-2.0)2.0 (2.0.2.0)0.25 Laparotomy E.D. to surgery26.5 (19.0-56.0)18.5 (13.0-27.2)0.0083 Booking to surgery3.1 (2.2-4.1)2.3 (1.8-2.9)0.016* Hospital stay13.0 (11.0-15.0)10.0 (9.0-12.0)0.0089* Abscess drainage E.D. to surgery11.0 (9.9-16.0)12.0 (9.8-15.2)0.47 Booking to surgery5.8 (4.6-6.5)4.2 (3.1-5.1)0.011 Hospital stay1.0 (1.0-2.0)2.0 (1.0-2.0)0.71 9

10. The Health Roundtable 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 Days Length of Stay (Days) cases 10

11. The Health Roundtable OUTCOMES – NIGHT TIME OPERATIONS AverageMedian *10/116.57 *11/1233 X2 appendix X3 laparotomy X1 bleeding ulcer X1 sigmoidoscopy X1 retroperitoneal abscess Funded Project Period 11

12. The Health Roundtable 10/11 & 11/12 Financial Years General Surgery cases done 0000 – 0800 hrs MeanMedian *10/116.57 *11/1233 X2 appendix X3 laparotomy X1 bleeding ulcer X1 sigmoidoscopy X1 retroperitoneal abscess Funded Project Period 12

13. The Health Roundtable Pre implementation Post implementation 1 2 3 4 5 6 P=0.0012 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 OUTCOME: SURGEON SATISFACTION 13

14. The Health Roundtable OUTCOMES SO FAR  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 14

15. The Health Roundtable LESSONS LEARNT  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 15

16. The Health Roundtable Barwon Health Emergency Surgery Team David Watters, Meryl Bui Viet, Glenn Guest, Douglas Stupart Dennis O’Leary and Shannon Ryan 16