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POST OPERATIVE FORM PROJECT It is appropriate that today we speak about this major initiative undertaken by both the Victorian Surgical Consultative Council (VSCC) and the Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM) as it follows on in a very natural way from the World Health Organisation (WHO) checklist which I should add is endorsed by the VSCC and the Royal Australasian College of Surgeons (RACS). This form concerns the instructions pertaining to junior medical staff and nursing staff that have been given by the operating surgeon and anaesthetist to outline the appropriate care of the patient in the first 24 hours post-operation. Although on face value it would appear to be a simple task, I can say without fear of contradiction from any of those involved that it has been a long and arduous journey and there is still quite a way to go. It is a concept that, like the WHO checklist, will only succeed if it is fully supported by all surgeons. My argument is very simple. This format just has to be better than what has been present in the past! Look at four examples of existing forms – 2 from major public hospitals and 2 from private hospitals. If one is lucky there is a small space on the form for possible post-operative orders – of course you all know what is written in this small area on the majority of cases – RIB & RPAO (or routine post- operative observations). How embarrassing is that! Particularly when one has to appear in the Court and particularly the Coroners Court. If I could now spend just a minute or two outlining the journey that has been undertaken over the past 4 years or so. 1 CORONIAL RECOMMENDATIONS Following a number of coronial investigations (and in particular a case where the Coroner came to a VSCC meeting to discuss his recommendations) involving post-operative mortality, the Coroner recommended the development of a universal post-operative order form to be used by all Victorian hospitals. Initially there had been no response to these recommendations but then, after considering the cases, the VSCC thought it was appropriate to respond to the recommendations and the VCCAMM also agreed. PROJECT 1 – DEVELOPMENT OF NINE POST-OPERATIVE PRINCIPLES The initial work commissioned by the Department of Human Services (DHS) through the VSCC and the VCCAMM was undertaken by the Austin Health Department of Surgery and Anaesthesia and their Clinical Governance Unit. In February 2006, they developed a set of 9 principles that needed to be incorporated in any post-operative order form. Their work involved a survey of 150 Victorian health services and a world-wide literature search to identify best practice principles and guidelines. THE NINE PRINCIPLES In summary, these nine principles involve the following matters:- • standard post-operative orders are essential for all invasive procedures • there needs to be clear guidelines to support an implementation process in a given health service 2 • the orders are never just routine and should be completed by an appropriate member of the surgical/anaesthetic team • the orders should be both written and verbal allowing appropriate handover from theatre to recovery room and recovery room to ward • the orders should involve both post-anaesthetic and post-surgical instructions. PROJECT 2 – DEVELOPMENT OF A POST-OPERATIVE ORDER FORMAT Following the initial project, the VSCC and the VCCAMM commissioned further work to develop a post-operative order format. The project was supported by the DHS and the VMIA and after an appropriate tender process, a Project team from three health services (Austin Health, Barwon Health and Bayside Health) was appointed to carry out the work. The post-operative order format was designed to be applicable across the state in a wide range of hospital settings including public and private health services, stand-alone and integrated facilities as well as metropolitan, regional and rural settings. The project involved 6 main elements:- • incorporation of the nine post-operative order principles • further development and piloting of the generic tool from the first project • testing in at least 5 different types of surgery and at least one day procedure • testing in two major teaching, one rural one regional and the private sector • development of the implementation guide • report on the outcomes of the testing and recommendations for the State 3 The final report was presented to the VSCC on 28 January 2009. COMMUNICATION TO HEALTH SERVICES In January this year I wrote to all health services in Victoria that undertake surgical procedures outlining the project and enclosing the Executive Summary and recommendations of the Project team as well as including a document entitled “Implementation Guide for Organisational Introduction and use of the Post-Operative Order Checklist”. Included in the communication was a copy of the form. COMMUNICATION TO HEALTH SERVICES I think it is very important to state that there will always be concerns about the form. Show the form to a hundred different people and there will be 100 objections. However, because of necessity, there has to be some consensus. Don’t try and change the form – accept the form “warts and all” and if necessary, after time and appropriate validation within a particular health service, make some minor changes. FINAL STAGE – “THE ROLLOUT” There have been some logistic problems with this the final stage but thanks to major support from the VMIA this is now about to occur with the appointment of a project officer and presentation of the format at a number of workshops both in the city and in the country. 4 The main task of the project officer in this last stage will be to organise the workshop and be available to individual health services to consult about the implementation process. CONCLUSION Many adverse events occur because of poor communication and this form should have a major influence on the quality and safety of the care of patients in the immediate post-operative period. We already have some evidence that this is the case. One anticipates however that communication between surgeons, registrars, interns and nursing staff will improve a hundred fold. This “dream” however will not occur unless all surgeons embrace it and hopefully in a reasonably short period of time it will become part of the operating room culture. 5