1) A day case emergency hand surgery system was introduced in 2003 at a hospital in Birmingham to treat hand trauma patients as outpatients rather than inpatients. This led to a 37% increase in the number of patients treated between 2003-2004 and 2004-2005. 2) Prior to the new system, only 4% of patients were treated without being admitted, whereas in 2004-2005 60% of patients were treated as day cases, saving over 1,600 bed days. 3) Patient satisfaction increased significantly with complaints reduced by 99% after implementing the coordinated day case system versus before when most patients were admitted as inpatients for hand injuries.

1. Two Years Experience of Day Case Emergency
Hand Surgery in Birmingham
A. Mahon, M. McCarthy, M.A.C. Craigen, V. Rajaratnam, O.G. Titley, F. Peart, M.A. Waldram
The Birmingham Hand Centre, Selly Oak Hospital, Birmingham, UK.
Introduction Comparison of Hand Cases Perormed
In November 2003, a day case emergency hand surgery system was
introduced to deal with hand trauma at University Hospital, Birmingham.
The patients are assessed in the Accident Department by a Senior House
Officer or Specialist Registrar on the day of referral, and strict criteria are
used to assess eligibility for day case treatment. A Hand Coordinator
liases with patients, surgeons and the ambulatory theatre department to
organise treatment on consultant led dedicated daytime hand lists.
Twelve lists per week serve the current referral load.
An escalation policy exists in order to deal with excessive waiting times
or large numbers of patients awaiting surgery. This is triggered when
more than 8 patients are awaiting surgery or patients wait more than 3
days for surgery. Available lists and staff are sought and, when necessary,
an additional theatre list will be organised on a weekend or an evening.
Objectives Survey of Patients’ Expections Versus
Perceptionof Service Using SERVQUAL Tool
The aim of this study was to assess the effect this reorganisation in terms
of numbers of patients treated, theatre utilisation and patient
satisfaction.
Patients and Methods
Data on patients treated has been collected on a prospective basis.
Theatre records were used to assess theatre utilisation. Numbers of
complaints were recorded with the assistance of the Patient Advice and
Liaison Service (PALS).
Year 1 Year 2
Results 01/04/03-31/03/04 01/04/03-31/03/05
The number of patients treated in 2003/2004 was 1261 compared
with1725 in 2004/2005, an increase of 37%. Prior to November 2003,
only 4% of patients were treated without inpatient stay, 33% of
patients were treated in the day surgery unit in 2003/2004, compared
with 60% in 2004/2005. This amounts to an estimated saving of 1656
bed days in 2004/2005. PALS received an average of 4 complaints per
week prior to implementation of the day case protocol and only 3 in
the 2-year period since – a reduction of 99%.
Discussion
Prior to the implementation of the Day Case Hand Surgery protocol, we
found that the majority of patients referred to our unit were admitted
to await surgical treatment. As the majority of such injuries are neither
life nor limb threatening, they are not seen as a priority for surgery.
This frequently results in delayed treatment, beds being occupied by
patients who are receiving nothing more than oral medication, patient
dissatisfaction and ultimately, complaints about treatment.
The introduction of dedicated day theatre lists for hand trauma and a
senior nurse to coordinate the hand trauma lists and liase with patients
has improved the situation considerably. Although patients may still
wait several days for surgery, they now do so at home. They are
informed at an early stage, when they are likely to undergo surgery and
cancellations are rare. This has resulted in greater patient satisfaction as
indicated by a 99% reduction in complaints. A prior study carried out in
our unit has shown further objective evidence of patient satisfaction by
using the SERVQUAL tool.
Treating hand trauma patients as day cases has not led to an increase in
complications and this may be related to the use of a strict protocol.
The use of an escalation policy at times when the number of patients
requiring treatment exceeds normal capacity has been successful.
Conclusions
The introduction of a hand coordinator led, day case emergency hand
surgery protocol has resulted in a marked increase in the number of
patients treated, and reduced the burden on main theatre. In addition The Birmingham Hand Centre
there is better patient satisfaction. We feel that this is a good model
for the organisation of a hand trauma service.