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POST OPERATIVE FORM PROJECT

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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.




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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




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   •   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



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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.




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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.




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