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					                                                                                          Good Hope Hospital
                                                                                                                    NHS Trust




       ITU
       HDU                                                                     Advanced Perioperative
                                                                              Roles in the Management
                                      PACU                                    of Surgical emergencies
                            Theatres
       A&E


Radford, M.1, Jewkes, A3., Williamson, A.2, Johnston, P2, Abbassi.1
                                                                                                                     Presented by;

1.      Perioperative Emergency Care Team, Good Hope Hospital NHS Trust, UK                                             Mark Radford
2.      Department of Anaesthesia, Good Hope Hospital NHS Trust, UK                  Consultant Nurse (Perioperative Emergency Care)
3.      Department of Surgery, Good Hope Hospital NHS Trust, UK                                        Good Hope Hospital NHS Trust
                                      Good Hope Hospital
                                                   NHS Trust

Process Map for Emergency Surgery

        Queues waiting for assessment & review

                    Queues for beds

                                 waiting for procedure



     waiting for pain relief      waiting for Discharge
     & Hydration

                   = Hotspots!
                                       Good Hope Hospital
                                                    NHS Trust




Chaos Theory & Emergency Surgery


  • Predictability: Does the Flap
    of a Butterfly's Wings in Brazil
    set off a Tornado in Texas?"

  • Lorenz December 1972
                                                          Good Hope Hospital
                                                                         NHS Trust




The problems are caused by
                                           Poor co-ord &           Inability to
  Poor initial       Poor review             prep for
 assessment           systems                                       discharge
                                              theatre



  G.P’s           A&E              Wards               Theatre’s            Social S

   Bed capacity          Incompetent                 staffing         Bed capacity
    problems               managers                 problems           problems




Poor Documentation         Correlation of results           Poor communication
                                          Good Hope Hospital
                                                          NHS Trust




Delays Associated with Emergency Surgery
May 1998 - May 1999

               250

               200                             Surgeon
                                               Anaesthetist
               150
                                               Theatre staff
       Hours




                                               Patient
               100
                                               Admin
                                               Ward
                50
                                               Other

                 0
                          1999

      785.2 hours - 15.4% of Staffed Operating Time
    Missed opportunity for 392 Fractured Neck of Femurs?
                                      Good Hope Hospital
                                                     NHS Trust




Fundamental Questions ?

               •   Did we all agree we had a problem ?

               •   Did we all agree that it had to change ?

               •   How could we change ?

               •   What can be the nursing contribution?
                                                 Good Hope Hospital
                                                               NHS Trust




Ideal System

 • Full Psychological and Physical preparation for perioperative
   episode.

 • Ensuring preoperative assessment & optimisation is complete.
 • Need good quality clinical information to facilitate the above.

 • Maximise surgical resource use including Beds, Theatres &
    Manpower.
                                               Good Hope Hospital
                                                            NHS Trust




Potential Solutions

  • Ring Fence Emergency Beds/Theatre Sessions

  • Dedicated Anaesthetic & Surgical Team

  • Coordination with no clinical Assessment

  • Pre assessment, Optimisation and Coordination
                                                    Good Hope Hospital
                                                                          NHS Trust




Good Hope Hospital NHS Trust

               Good Hope
                Hospital
                           Population:450,000

                           No of acute beds:
                                              526 (6 ITU;6 HDU)
                                           92% Acute Bed Occupancy

                           No of surgical procedures:
                                       Elective 19,091; Emergency 3034

                           8 Operating Theatres (including 2 D/C)

                           Designated NCEPOD Theatre since 1996

                           Surgical specialities:
                           General / Colorectal / Vascular / Urology / T+O / Gynaecology
                                                           Good Hope Hospital
                                                                             NHS Trust




The Team

  •   Lead Consultant Anaesthetist & Surgeon.

  •   Nurse Consultant, Clinical Nurse Specialist & Specialist Nurse .

  •   Currently providing 8am till 6pm service Monday – Friday to all specialties


       –   Trauma & Orthopeadics (55%)

       –   General (Inc Vascular & Colorectal) (30%)

       –   Gynaecology (10%)

       –   Others (Inc Urology, Medicine etc.. ) (5%)
                                                   Good Hope Hospital
                                                                     NHS Trust
                       HO     Nurses    Domestic   Dog or Cat


        ON CALL                                                   ON CALL
        SURGEON                                                 ANAESTHETIST


                        CNS IN EMERGENCY
                             SURGERY

                               PATIENT                          Organise clinical
                             ASSESSMENT                             review



     ASA 1 or 2               ASA 1 or 2            ASA 3 or 4
                            MAJOR or above         Any procedure
   MINOR or INTER
      procedure               procedure


PREPARE FOR THEATRE                    ENSURE APPROPRIATE
                                            PREOP Ix
IDENTIFY APPROPRIATE
    THEATRE SLOT                       INSTITUTE OPTIMISATION
                                              if required
                                                              Good Hope Hospital
                                                                                 NHS Trust




Enhancing the Role of the Nurse
•   Case Manager for emergency surgical population.
•   ‘Organisational’ Awareness, work round the frailties of the system.
•   Referral access to senior clinicians, both diagnostically and for clinically
    specific treatment plans.
•   Need clinical skills to allow above to performed safely.


                  The Role involves


                  • Liasing with on call team to assess and optimise surgical patients.
                  • Provide information for improved clinical decision making.
                  • Maximising the use of surgical resources inc. beds and theatre space
                  • Release junior medical staff to gain operative surgical experience.
                  • Provide continuity for Surgical firms in the management of emergencies.
                                                              Good Hope Hospital
                                                                            NHS Trust




Core Clinical Skills



  •   History taking.
  •   Clinical examination with particular. reference to CVS, Airway and Respiratory
      systems.
  •   Empowered to order investigations.
  •   Data interpretation of lab results, CXR & ECG.
  •   Confidence to initiate optimisation & treatment plan.
  •   Sixth sense (Experience).
                                                    Good Hope Hospital
                                                                 NHS Trust




Challenging the Sacred Cows

  •   Nursing Autonomy in surgical &
      anaesthetic practice

  •   Change in culture to accept this
      information from a nurse!

  •   Coordinating Medical consultants activity.

  •   Developing a consultancy and
      collaboration network with Medical Staff


                                                   MOO
                                                                 Good Hope Hospital
                                                                              NHS Trust


Staffed Operating Theatre Time May 99 – May 01


                                                           99/00            00/01

      Number of Patient
      operated on 8am – 10pm                               1552             1692

      Utilisation 8am – 10pm                               64%              62%

      Time not utilised due to delay                       9%               7%
      From 8am – 10pm




                   11 % increase in cases operated on between 8 - 10 pm
                    10% Redistributed top Elective/Urgent Theatre Lists
                       21% reduction in delays to emergency theatre
                                                                                                                                           Good Hope Hospital
                                                                                                                                                                   NHS Trust




                                                                    Delay s Associated with Emergency Surgical Patients 1999 - 2001
+ve axis = Hours / -ve axis = % Difference



                                             200
                                                        165
                                                                                                                      145.75
                                             150
                                                                115

                                             100                                                                                                     74.5
                                                                                                                                 75.75

                                                                             43.5                48.5 46                                      50.5          50.0         1999/00
                                             50                                     30.75                                                                                2000/01
                                                                                                                                                                         % dif f

                                              0
                                                                                                            -5.2
                                                                                                                                            -48.0
                                                                   -30.3               -29.3
                                             -50
                                                   Surgeon Not available   Anaesthetist Not    Theatre Staff Not   Patient Not Prepared.            Other
                                                                              Available           Available.

                                                                                                  Delay s




                                                   48 % reduction in ‘patient not prepared’
                                                                  Good Hope Hospital
                                                                                      NHS Trust


‘Out of Hours’ Operating May 99 – May 01



                                                    99/00                     00/01

  No of patients operated on                         298                      209
  between 2200 and 0800 hrs

  Total amount of ‘callout’ hours                   550.5                     425.6
  utilised

  Cases completed out of hours as                    16.5                      11
  %




                Decrease in number of patients operated ‘out of hours’: 30%
                          Reduction of night time operating 23%
                                             Good Hope Hospital
                                                             NHS Trust




   ON CALL                                              ON CALL
   SURGEON                                            ANAESTHETIST


                       CNS IN EMERGENCY
                            SURGERY

                           PATIENT                   Organise clinical
                         ASSESSMENT                      review



     ASA 1 or 2            ASA 1 or 2         ASA 3 or 4
                        MAJOR or above       Any procedure
   MINOR or INTER
      procedure           procedure


PREPARE FOR THEATRE                ENSURE APPROPRIATE
                                        PREOP Ix
IDENTIFY APPROPRIATE
    THEATRE SLOT                  INSTITUTE OPTIMISATION
                                         if required
                                                                  Good Hope Hospital
                                                                                    NHS Trust




Management
            Of Emergencies with Specialist Nursing

 M. Radford,, P. Johnston, A. Williamson and A. Jewkes - 2001
 Management of the minor surgical emergency workload by specialist nurse pre-assessment and
      co-ordination
 British Journal of Surgery, Volume 88, Issues 1, Page 27,

 •   97% of Minors operated within 24 hours of admission
 •   52% reduction in cancellations of this group
 •   45% discharged in 24 hours
 •   15% on the same day
 •   21% redistributed to Elective Theater schedules



 • 600 bed days saved per annum
                                                   Good Hope Hospital
                                                                NHS Trust




Case
              Study Minor Pathway
•   24 years old – Engineer listed for I+D Pilonidal Abscess

•   Admitted at 3pm
•   Assessed by CNS at 3:45pm, Anaesthetic Assessment, Booked Day
    Case Bed, Theatre slot booked.
•   Discharged with Antibiotics/Analgesia and Advice at 4:30pm

•   Readmitted following day at 8 am
•   I+D performed at 10:30 am
•   Discharged at 12:30 pm
                                                    Good Hope Hospital
                                                                   NHS Trust




Case
              Study Minor Pathway
•   17 years old – Attends A&E with reducible RIH

•   Attends A&E at 9.30am, from GP
•   Referred by A&E staff to PECT at 11.00am
     – No pain, no lump – no problems – unsure on continuing management
     – Assessment complete
     – Surgeon Opinion obtained at 11.45


•   Surgical Date agreed for 2 weeks time
•   Pre Operatively Assessed at 12.30
•   Discharged at 1pm.
                                             Good Hope Hospital
                                                             NHS Trust




   ON CALL                                              ON CALL
   SURGEON                                            ANAESTHETIST


                       CNS IN EMERGENCY
                            SURGERY

                           PATIENT                   Organise clinical
                         ASSESSMENT                      review



     ASA 1 or 2            ASA 1 or 2         ASA 3 or 4
                        MAJOR or above       Any procedure
   MINOR or INTER
      procedure           procedure


PREPARE FOR THEATRE                ENSURE APPROPRIATE
                                        PREOP Ix
IDENTIFY APPROPRIATE
    THEATRE SLOT                  INSTITUTE OPTIMISATION
                                         if required
                                                                    Good Hope Hospital
                                                                                       NHS Trust




Management
              Of major abdominal pain


 Unpublished audit in 2004

 •   Arrival time to left A&E                            Week 1                Week2

 •   Mean                                                 3hrs.19mins           1hr.49mins
 •   Median                                    3hrs. 24mins          1hrs. 25mins

 •   Arrival time to investigations returned
 •   Mean                                                5hrs 42mins           1hrs. 25mins
 •   Median                                              4hrs 09mins           2hrs 48mins
                                                                               Good Hope Hospital
                                                                                                      NHS Trust




Management
              Of #NOF with Specialist Nursing

 A. Williamson and M. Radford, - 2002
 The Role of the Clinical Nurse Specialist in the pre-assessment and co-ordination of the care of the
     Fractured Neck of Femur - Good Hope Experience
 Anaesthesia (57), 11, pp 1148 )


 •     Reduction of Admission to Surgery time from 3.3 days to 1.6 Days (Median)
 •     Reduction in LOS from 29 days to 18 days (Median)
 •     Sustained Improvements in Times & LOS

     •Early Indicators of M&M from data shows a 5% mortality (in hospital) vs 14%
     not seen by team***

                       *** Patient Numbers @ 200 and have not been yet been applied to statistical analysis
                                           Good Hope Hospital
                                                        NHS Trust




    # Neck of Femur - Admission to Surgery Time


     3.5    3.34
       3
                                                1999
     2.5
                   1.9                          4 Months
       2
Days                     1.62 1.61              7 Months
     1.5                             1.2        12 Months
       1
                                                36 Months
     0.5
       0
                                               Good Hope Hospital
                                                                NHS Trust




Case
              #NOF Pathway
AS 93 yr old male
26/04/2002        Admission for falls at home under medics
         PMH:     COPD
                  CCF
                  IHD
                  Mild Parkinsonism
         Drugs: Ramipril 5mg bd; Bumetanide 2mg bd; Combivent
         Mild confusion
         Elevated Urea 23.5 Creatinine 184

28/04/2002      Fall  I/T  NOF
                                              Good Hope Hospital
                                                             NHS Trust




Case
              Study #NOF Pathway

29/04/2002    CNS Emergency surgery informed
              Consultant Anaesthetic review
              Rx       Intravenous fluids
                       Urinary catheterisation
                       Regular nebulisers /chest physiotherapy
 30/04/2002   Further review by CNS Em Surgery/Outreach
-02/05/2002   Improvement in fluid balance + chest
              Optimal pre-operative condition attained
02/05/2002    Hemiarthroplasty performed under spinal anaesthesia
              No intra-operative problems
15/05/2002    Discharge home
                                             Good Hope Hospital
                                                             NHS Trust




   ON CALL                                              ON CALL
   SURGEON                                            ANAESTHETIST


                       CNS IN EMERGENCY
                            SURGERY

                           PATIENT                   Organise clinical
                         ASSESSMENT                      review



     ASA 1 or 2            ASA 1 or 2         ASA 3 or 4
                        MAJOR or above       Any procedure
   MINOR or INTER
      procedure           procedure


PREPARE FOR THEATRE                ENSURE APPROPRIATE
                                        PREOP Ix
IDENTIFY APPROPRIATE
    THEATRE SLOT                  INSTITUTE OPTIMISATION
                                         if required
                                                   Good Hope Hospital
                                                                NHS Trust




Case
               Study - Operational Coordination

•   4 Cases booked in Emergency Theatre . Inc CMO (ASA 5E)

•   Child starved from 6am – pushed back
•   Co-ordinated
     – Got Theatre Team together (Vascular Th.)
     – Consultant Anaesthetist
     – Short of Surgeon – called Cons.

     – Procedure completed with no cancellations
                                                             Good Hope Hospital
                                                                          NHS Trust



Summary



•   The development of the Perioperative Emergency Care Team has seen;

     – Despite an increase in demand there has been marked improvements in the
       organisation of Emergency Surgery.

          •   Reduced Delays
          •   Reduced ‘Out of Hours’ Operating
          •   Improved Patient Assessment and Optimisation
          •   Improved Communication and User Experience

     –   Provided greater continuity in patient care for surgical teams.
     –   Maximised surgical resources including beds, theatre space & manpower.
     –   Improved opportunities for junior medical staff teaching.
     –   This has been achieved with significant clinical or operational cost.
                                                                                           Good Hope Hospital
                                                                                                                      NHS Trust




References
Radford M 2000
A Framework for Perioperative Advanced Practice
British Journal of Perioperative Nursing 10 (1) 50–54


M. Radford,, P. Johnston, A. Williamson, A. Jewkes
Management of the minor surgical emergency workload by specialist nurse pre-assessment and co-ordination
British Journal of Surgery, Volume 88, Issue s1, Page 27, May 2001

M. Radford,, P. Johnston, A. Williamson, A. Jewkes
Co-ordination of the emergency surgical workload by specialist nurse pre-assessment: the effect on emergency theatre operating
patterns
British Journal of Surgery, Volume 88, Issue s1, Page 27, May 2001



P. Johnston, A. Williamson, M. Radford
Emergency surgery in the NHS
Anaesthesia Vol. 56 Issue 12 Page 1203 December 2001

Williamson, A & Radford, M. (2002)
The Role of the Clinical Nurse Specialist in the pre-assessment and co-ordination of the care of the Fractured Neck of Femur - Good
Hope Experience
Anaesthesia (Accepted for publication May 2002)

Radford, M. Abbassi, A, Williamson, A, Johnston, P.
Redefining Perioperative Advanced Practice: The Nurse Specialist in Anaesthesia & Emergency Surgery
British Journal of Perioperative Nursing (Accepted for Publication April 2003)

				
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