Establishing an Acute Surgical Unit

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Megan King, Perioperative Nurse Manager - Operating Theatres, Wagga Wagga Base Hospital delivered this presentation at the 2012 Operating Theatre Management conference. For more information about the annual event, please visit:
www.healthcareconferences.com.au

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Establishing an Acute Surgical Unit

  1. 1. Establishing an Acute Surgical Unit in a Rural Area Wagga Wagga Health Service September 12 Sherylle Sheehy ASU CNC, Megan King Perioperative NM
  2. 2. A little about Wagga Wagga Health Service Wagga Wagga Health Service
  3. 3.  Wagga Wagga is the largest inland city in NSW and one of Australia’s leading regional cities with a population over 61,000 (06/2008 census).  Wagga is the local Wiradjuri aboriginal word for crow and to create the plural, the Wiradjuri repeat the word. Thus Wagga Wagga translates as 'the place of many crows'.  Wagga Wagga Base Hospital is a rural referral hospital and the major acute care provider and referral hospital for the Murrumbidgee Local Health Network ... Wagga Wagga Base Hospital has 237 'beds' including 209 overnight inpatient beds and 28 ambulatory treatment places.(Wagga Wagga Hospital Clinical Services plan 08/2006) September 12Sherylle Sheehy ASU CNC, Megan King Perioperative NM
  4. 4.  5 Operating Theatres fully operational  Increase to 2012 average 795 operations per month September 12Sherylle Sheehy ASU CNC, Megan King Perioperative NM 600 650 700 750 800 850 0708 0809 0910 1011 1112 WWHS Operating Theatres Average Number of Operations per month 2007 - 2012 Mth Ave Expon. (Mth Ave)
  5. 5.  General – 8 General Surgeons  Orthopaedics – 6 Orthopaedic surgeons - 1 elective only  Urology – 3 Urologists  ENT – 2 ENT Surgeons  Vascular – 2 Vascular Surgeons  Ophthalmology – 3 Ophthalmologists  O&G – 1 O&G + locum service 2 Gynaecologists elective only  Paediatrics – 1 x Paediatric Surgeon  Endoscopy – 2 Physicians, 2 Respiratory Physicians  Dental  ECT  Vascular Access service September 12Sherylle Sheehy ASU CNC, Megan King Perioperative NM Types of Surgery
  6. 6.  Average 35 – 40% of all operations at WWBH are emergencies  Allocated Ortho Trauma and Emergency sessions  Ortho Trauma: Mon PM, Tuesday evening, Weds evening, Fri Am and Sunday all day + random extra sessions  Emergency: Every afternoon 1330 – 1730, then overnight and weekends September 12Sherylle Sheehy ASU CNC, Megan King Perioperative NM Emergency Surgery
  7. 7. Emergency Sessional Allocation September 12Sherylle Sheehy ASU CNC, Megan King Perioperative NM THEATRE TIME MON TUE WED THU FRI SAT SUN 1 AM Trauma PM Trauma Trauma 2 AM Emergency Emergency PM ASU ASU ASU ASU ASU Emergency Emergency 3 AM PM 4 AM PM 5 AM PM ENDO AM PM Evening / Overnight Emergency Emergency Emergency Emergency Emergency Emergency Emergency Trauma Trauma SESSIONS AM PM TOTAL
  8. 8. September 12 Sherylle Sheehy ASU CNC, Megan King Perioperative NM Historical Approach to General Surgery Presentations Surgeon: On call for 24hr period Normal public/private operating list Normal consulting in rooms Not always available during hours Theatre: Designated Emergency sessions often unable to be utilised or on occasions utilised for elective surgery Emergency Cases added to elective lists surgeon Emergency cases commenced after 1800
  9. 9. September 12Sherylle Sheehy ASU CNC, Megan King Perioperative NM  After hours operating , escalating overtime of staff – medical, nursing and ORA’s  Cancellation of elective patients to accommodate emergency cases  Increase in diagnostic tests  Delay in Surgical Review of ED presentation  Delay in consults on inpatients
  10. 10. Sherylle Sheehy ASU CNC, Megan King Perioperative NM % Emergency Surgery 2011 - pre ASU 0 20 40 60 80 100 Jan Feb Mar Apr May Jun Jul Aug Sep Oct 2200-0700 1800-2200 0700-1800
  11. 11. September 12Sherylle Sheehy ASU CNC, Megan King Perioperative NM
  12. 12.  The ASU model of care was driven by the surgeons  After consultation with WWBH Executive, funding for the model was sourced from MOH.  The surgeons as a group proposed how they would do their on call roster: decided 7 days on, full handover to next Surgeon, Friday to Friday.  A Registrar was to be allocated to ASU September 12Sherylle Sheehy ASU CNC, Megan King Perioperative NM Commencing an ASU
  13. 13. Getting Logistics Right September 12Sherylle Sheehy ASU CNC, Megan King Perioperative NM • Commence a Steering Committee with weekly meetings • Service Development Application • Business rules • Contracts for Doctors • How the Doctors will be paid • Identifying ASU patients in IPM to get reports • Position descriptions for CNC, Clerical, and Data Manager • Office space and Office fit outs • How will Private patients be managed. -
  14. 14.  Chaired by WWHS GM  Initially DM, DMS, DONM, Theatre Manager, Client  Services Manager, Business Manager  Meet weekly  Later included Director of Emergency  Separate meeting with WWHS Executive and Surgeons September 12Sherylle Sheehy ASU CNC, Megan King Perioperative NM Steering Committee
  15. 15.  Included cost modelling  Designed around cost benefits:  Reduced overtime  Reduced LOS  Reduced pathology and imaging costs  Staffed by:  CNC  Clerical Assistance  Data Manager September 12Sherylle Sheehy ASU CNC, Megan King Perioperative NM Service Development Application
  16. 16.  Developed by DMS in conjunction with Surgeons  WWHS expectations of how ASU will function  Includes rules on:  Roster provision including Registrar allocation to ASU  Consults and ward rounds  Handover  Allocated Emergency Operating time  Transfer from Emergency department  Supervision  Clinics  Protocols and pathways  Attending Rooms and Private hospital while on call  Timely Accounting Sherylle Sheehy ASU CNC, June 2012 Business Rules
  17. 17.  Special permission for a non standard contract for Surgeons  Surgeons submit separate claim to Normal VMO claim for ASU Sherylle Sheehy ASU CNC, June 2012 Surgeon contracts and payment
  18. 18.  Set up a different specialty for each surgeon in IPM  Eg “Dr Harrison” and “Dr Harrison ASU”  Allows printing a report for where patients are as no specific ward Sherylle Sheehy ASU CNC, June 2012 Identifying ASU patients in IPM
  19. 19.  Longer than we thought, had to go through Grading Committees  Easily recruited to CNC  Clerical and Data Manager took longer to recruit Sherylle Sheehy ASU CNC, June 2012 Position Descriptions
  20. 20.  Big problem as very limited space at WWBH  GM rearranged location of WWBH Staff to allow ASU to go into a newly built demountable office located in between A&E and Theatre  Begged, borrowed and stole office desks  Purchased new chairs, computers, Printer / fax / photocopier machine  4 desk spaces and computers (CNC, Clerical, Registrar and Intern) Sherylle Sheehy ASU CNC, June 2012 Office Space and Fit outs
  21. 21.  Worked with Surgeons and PLO’s to develop a patient brochure explaining the ASU including how it effects private patients  Surgeons historically have preferred to keep any emergency patients at Base Hospital for a variety of reasons  Decisions about which patients can be transferred to Private Hospital is determined on a case by case basis. September 12Sherylle Sheehy ASU CNC, Megan King Perioperative NM Private Patients
  22. 22. September 12Sherylle Sheehy ASU CNC, Megan King Perioperative NM
  23. 23. Sherylle Sheehy ASU CNC, Megan King Perioperative NM Results so far
  24. 24. 0 10 20 30 40 50 60 70 80 90 100 PercentageofProcedures 0800 - 1800 1800 - 2200 2200 - 0800 September 12Sherylle Sheehy ASU CNC, Megan King Perioperative NM
  25. 25. Sherylle Sheehy ASU CNC, Megan King Perioperative NM % Emergency Surgery 2011-pre ASU 0 10 20 30 40 50 60 70 80 90 100 Jan Feb Mar Apr May Jun Jul Aug Sep Oct 2200-0700 1800-2200 0700-1800
  26. 26. September 12Sherylle Sheehy ASU CNC, Megan King Perioperative NM 0 10 20 30 40 50 60 70 80 90 Dec Jan Feb Mar Apr May Jun Jul General Surgery Emergencies between 0700 - 1800 Comparison Pre and Post ASU Pre ASU 0700-1800 Post ASU
  27. 27. September 12Sherylle Sheehy ASU CNC, Megan King Perioperative NM 0 5 10 15 20 25 30 35 40 Dec Jan Feb Mar Apr May Jun Jul Emergency General Surgery Emergencies between 1800 - 2200 Pre and Post ASU Pre ASU 1800-2200 Post ASU
  28. 28. September 12Sherylle Sheehy ASU CNC, Megan King Perioperative NM 0 2 4 6 8 10 12 14 16 Dec Jan Feb Mar Apr May Jun Jul General Surgery Emergencies beween 2200 - 0700 Pre and Post ASU Pre ASU 2200-0700 Post ASU
  29. 29. September 12Sherylle Sheehy ASU CNC, Megan King Perioperative NM
  30. 30. 0 1 2 3 4 5 6 Jan- 11 Feb- 11 Mar- 11 Apr- 11 May- 11 Jun- 11 Jul- 11 Aug- 11 Sep- 11 Oct- 11 Nov- 11 Dec- 11 Jan- 12 Feb- 12 Mar- 12 Apr- 12 May- 12 Jun- 12 OvertimeFTE Months Nursing / ORA's Linear (Nursing / ORA's) ASU commenced Dec 2011 Nursing and ORA’s overtime
  31. 31.  Stake Holders Feedback - direct  Surveys Patients and staff - paper  Letter to GPs outlining function of ASU and contact numbers  Recruitment of Data Manager – commenced 20/8/2012 build data base and dashboard for reporting.  Concentration of protocol development.  Further refinement of CNC role now that Data Manager recruited. Where Are We Now
  32. 32. September 12Sherylle Sheehy ASU CNC, Megan King Perioperative NM Data Source Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Length of Stay (Pre and Post Project Implementation) Duration of Operations Surginet Length of Stay in Intensive Care Unit Pre Operative Length of Stay Nursing overtime Corvu surgical registrar overtime Use of Imaging eg CT scanning for positive appendix Deep Vein Thrombosis Prophylaxis – including timeliness Anti Biotic Prophylaxis - including timelines Unplanned Return to Theatres Registrar (Anaesthetic and Surgical) Supervision Duration of Operating Theatre Time (Supervised Vs Unsupervised - Registrar time) Impact on Elective Lap Chole vs Emergency LOS Appendix LOS and 30 Day Mortality-Laparoscopic Cholecystectomy Infection rates Readmission within 28 days % of Twilight Operating (1800-2200) Surginet % of Overnight Operating (2200-0700) Surginet Elective Cancellations due to Emergencies Surginet Delays Manual Time from Triage to Surgical Review Common ASU Surgical Procedures Utilisation of ASU Session Anaesthetic Start to Surgery Start Time ASU Utilisation per Specialty Emergency cancellation ASU Manual-Theatre ProcessrelatedCostrelatedQualityRelated Wagga Wagga Health Service Acute Surgical Unit Emergency Surgery Dashboard Dec 2011, Post ASU.
  33. 33. Sherylle Sheehy ASU CNC, Megan King Perioperative NM Questions?
  34. 34. September 12Sherylle Sheehy ASU CNC, Megan King Perioperative NM

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