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Lepercq D, Gauss T, Godier A, Bellet J, Bouhours G, Bouzat P, Cailliau E, Cook F, David JS, Drame F, Gauthier M, Lamblin A, Pottecher J, Tavernier B, Garrigue-Huet D. Association of Organizational Pathways With the Delay of Emergency Surgery. JAMA Netw Open 2023; 6:e238145. [PMID: 37052916 PMCID: PMC10102875 DOI: 10.1001/jamanetworkopen.2023.8145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 02/24/2023] [Indexed: 04/14/2023] Open
Abstract
Importance Delayed admission of patients with surgical emergencies to the operating room occurs frequently and is associated with poor outcomes. In France, where 3 distinct organizational pathways in hospitals exist (a dedicated emergency operating room and team [DET], a dedicated operating room in a central operating theater [DOR], and no dedicated structure or team [NOR]), neither the incidence nor the influence of delayed urgent surgery is known, and no guidelines are available to date. Objective To examine the overall frequency of delayed admission of patients with surgical emergencies to the operating room across the 3 organizational pathways in hospitals in France. Design, Setting, and Participants This prospective multicenter cohort study was conducted in 10 French tertiary hospitals. All consecutive adult patients admitted for emergency surgery from October 5 to 16, 2020, were included and prospectively monitored. Patients requiring pediatric surgery, obstetrics, interventional radiology, or endoscopic procedures were excluded. Exposures Emergency surgery. Main Outcomes and Measures The main outcome was the global incidence of delayed emergency surgery across 3 predefined organizational pathways: DET, DOR, and NOR. The ratio between the actual time to surgery (observed duration between surgical indication and incision) and the ideal time to surgery (predefined optimal duration between surgical indication and incision according to the Non-Elective Surgery Triage classification) was calculated for each patient. Surgery was considered delayed when this ratio was greater than 1. Results A total of 1149 patients were included (mean [SD] age, 55 [21] years; 685 [59.9%] males): 649 in the DET group, 320 in the DOR group, and 171 in the NOR group (missing data: n = 5). The global frequency of surgical delay was 32.5% (95% CI, 29.8%-35.3%) and varied across the 3 organizational pathways: DET, 28.4% (95% CI, 24.8%-31.9%); DOR, 32.2% (95% CI, 27.0%-37.4%); and NOR, 49.1% (95% CI, 41.6%-56.7%) (P < .001). The adjusted odds ratio for delay was 1.80 (95% CI, 1.17-2.78) when comparing NOR with DET. Conclusions and Relevance In this cohort study, the frequency of delayed emergency surgery in France was 32.5%. Reduced delays were found in organizational pathways that included dedicated theaters and teams. These preliminary results may pave the way for comprehensive large-scale studies, from which results may potentially inform new guidelines for quicker and safer access to emergency surgery.
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Affiliation(s)
| | - Tobias Gauss
- Division of Anesthesia–Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Anne Godier
- Department of Anaesthesiology and Critical Care, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
- Université de Paris, Inserm, Innovations Thérapeutiques en Hémostase, Paris, France
| | - Julie Bellet
- Pôle d’anesthésie-réanimation, CHU de Lille, Lille, France
| | - Guillaume Bouhours
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire d’Angers, Angers, France
| | - Pierre Bouzat
- University of Grenoble Alpes, Inserm, U1216, Grenoble Institut Neurosciences, Grenoble, France
| | | | - Fabrice Cook
- Department of Anesthesia and Surgical Intensive Care, Henri Mondor University Hospital of Paris, Paris XII School of Medicine, Creteil, France
| | - Jean-Stéphane David
- Service d’Anesthésie Réanimation, Groupe Hospitalier Sud, Hospices Civils de Lyon, Lyon, France
| | - Fatou Drame
- AP-HP, Beaujon University Hospital, DMU PARBOL, Department of Anaesthesiology and Critical Care, Clichy, France
| | - Marvin Gauthier
- Division of Anesthesia–Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Antoine Lamblin
- Anesthesiology and Critical Care Medicine Department, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- Espace Ethique Méditerranéen, Efaculté de Médecine de Marseille, Timone University Hospital, Marseille, France
| | - Julien Pottecher
- Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre, Department of Anaesthesiology, Critical Care and Perioperative Medicine, Université de Strasbourg, Faculté de Médecine, Fédération de Médecine Translationnelle de Strasbourg, ER 3072, Strasbourg, France
| | - Benoit Tavernier
- Pôle d’anesthésie-réanimation, CHU de Lille, Lille, France
- Université Lille, CHU Lille, ULR 2694–METRICS, Lille, France
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Hong GS, Lee CW, Lee JH, Kim B, Lee JB. Clinical Impact of a Quality Improvement Program Including Dedicated Emergency Radiology Personnel on Emergency Surgical Management: A Propensity Score-Matching Study. Korean J Radiol 2022; 23:878-888. [PMID: 35926842 PMCID: PMC9434742 DOI: 10.3348/kjr.2022.0278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 06/12/2022] [Accepted: 06/13/2022] [Indexed: 11/15/2022] Open
Abstract
Objective To investigate the clinical impact of a quality improvement program including dedicated emergency radiology personnel (QIP-DERP) on the management of emergency surgical patients in the emergency department (ED). Materials and Methods This retrospective study identified all adult patients (n = 3667) who underwent preoperative body CT, for which written radiology reports were generated, and who subsequently underwent non-elective surgery between 2007 and 2018 in the ED of a single urban academic tertiary medical institution. The study cohort was divided into periods before and after the initiation of QIP-DERP. We matched the control group patients (i.e., before QIP-DERP) to the QIP-DERP group patients using propensity score (PS), with a 1:2 matching ratio for the main analysis and a 1:1 ratio for sub-analyses separately for daytime (8:00 AM to 5:00 PM on weekdays) and after-hours. The primary outcome was timing of emergency surgery (TES), which was defined as the time from ED arrival to surgical intervention. The secondary outcomes included ED length of stay (LOS) and intensive care unit (ICU) admission rate. Results According to the PS-matched analysis, compared with the control group, QIP-DERP significantly decreased the median TES from 16.7 hours (interquartile range, 9.4–27.5 hours) to 11.6 hours (6.6–21.9 hours) (p < 0.001) and the ICU admission rate from 33.3% (205/616) to 23.9% (295/1232) (p < 0.001). During after-hours, the QIP-DERP significantly reduced median TES from 19.9 hours (12.5–30.1 hours) to 9.6 hours (5.7–19.1 hours) (p < 0.001), median ED LOS from 9.1 hours (5.6–16.5 hours) to 6.7 hours (4.9–11.3 hours) (p < 0.001), and ICU admission rate from 35.5% (108/304) to 22.0% (67/304) (p < 0.001). Conclusion QIP-DERP implementation improved the quality of emergency surgical management in the ED by reducing TES, ED LOS, and ICU admission rate, particularly during after-hours.
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Affiliation(s)
- Gil-Sun Hong
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Choong Wook Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - Ju Hee Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Bona Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jung Bok Lee
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Mohamed F, Grinlinton M, Henshall K, Cox M, MacCormick AD. The Red Blanket Protocol in a tertiary centre in Aotearoa New Zealand: does this trauma protocol improve time to surgery and clinical outcomes? ANZ J Surg 2022; 92:1714-1723. [PMID: 35792666 DOI: 10.1111/ans.17878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 06/05/2022] [Accepted: 06/10/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients who are haemodynamically unstable from surgical emergencies require prompt surgical intervention, and delay to surgery may lead to poorer clinical outcomes. The Red Blanket Protocol (RBP) is a communication algorithm intended to facilitate surgery as expediently and safely as possible. By developing a protocol for these channels of communication, RBP may reduce the time to surgical intervention and improve patient outcomes. Our aim was to identify whether patient outcomes, including time to surgery, blood product use and survival were improved by the Red Blanket protocol. METHODS Haemodynamically unstable adults in Middlemore Hospital, Aotearoa New Zealand from 1/1/2014 to 31/12/2015 were compared with RBP patients from 1/4/2017 to 1/4/2020. Time from emergency department (ED) to knife-to-skin (KTS) was compared between the groups. The number of blood products used, LOS and 30- and 90-day survival were also compared between the pre-protocol and RBP groups. RESULTS Thirty-two patients were identified in the pre-protocol group, and 25 in the RBP group. The median time from ED to KTS reduced from 84 to 70.5 min after the implementation of RBP (P = 0.044). The median number of blood products was 21 pre-protocol and 11.5 in the RBP group (P = 0.102). The median LOS was 8 versus 4 days in the RBP group (P = 0.204). 30-day survival rate was comparable in the two groups (65% versus 60% (P 0.71)). CONCLUSION RBP was associated with a shorter time to knife-to-skin for haemodynamically unstable patients. There was no significant difference in clinical outcomes between the two groups. Larger studies are required to assess clinical outcomes of the RBP.
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Affiliation(s)
- Fardowsa Mohamed
- Department of General Surgery Southland District Health Board Invercargill New Zealand
| | - Megan Grinlinton
- Department of General Surgery Northland District Health Board Whangarei New Zealand
| | - Kevin Henshall
- Department of General Surgery Counties Manukau Health Auckland New Zealand
| | - Murray Cox
- Department of General and Vascular Surgery Taranaki District Health Board New Plymouth New Zealand
| | - Andrew D. MacCormick
- Department of General Surgery Counties Manukau Health Auckland New Zealand
- Department of Surgery University of Auckland Auckland New Zealand
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Hansen JB, Humble CAS, Møller AM, Vester-Andersen M. The prognostic value of surgical delay in patients undergoing major emergency abdominal surgery: a systematic review and meta-analysis. Scand J Gastroenterol 2022; 57:534-544. [PMID: 35019790 DOI: 10.1080/00365521.2021.2024250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Mortality following major emergency abdominal surgery is high. Surgical delay is regarded as an important modifiable prognostic factor. Current care-bundles aim at reducing surgical delay, most often using a six-hour cut-off. We aimed to investigate the evidence supporting the in-hospital delay cutoffs currently used. METHODS MEDLINE, EMBASE and the Cochrane Library were searched. We included studies assessing in-hospital surgical delay in major emergency abdominal surgery patients. Studies were only included if they performed adjusted analysis. Surgical delay beyond six hours was the primary cutfrom interest. The primary outcome was mortality at longest follow-up. Meta-analyses were conducted if possible. RESULTS Eleven observational studies were included with 16,772 participants. Two studies evaluated delay in unselected major emergency abdominal surgery patients. Three studies applied a six-hour cutoff, but only a study on acute mesenteric ischemia showed an association between delay and mortality. Meta-analysis showed no association with mortality at this cutoff. An association was seen between hourly delay and mortality risk estimate, 1.02 (95% confidence interval [CI], 1.00 - 1.03), and on subgroup analysis of hourly delay in perforated peptic ulcer patients, risk estimate, 1.02 (95% CI, 1.0 - 1.03). All risk estimates had a very low Grading of Recommendations Assessment, Development, and Evaluation score. CONCLUSION Little evidence supports a six-hour cutoff in unselected major emergency abdominal surgical patients. We found an association between hourly delay and increased mortality; however, evidence supporting this was primarily in patients undergoing surgery for perforated peptic ulcer. This review is limited by the quality of the individual studies.
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Affiliation(s)
- Jannick Brander Hansen
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES), Department of Anaesthesiology, Copenhagen University Hospital Herlev-Gentofte, Copenhagen, Denmark
| | - Caroline Anna Sofia Humble
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES), Department of Anaesthesiology, Copenhagen University Hospital Herlev-Gentofte, Copenhagen, Denmark.,Centre of Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Ann Merete Møller
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES), Department of Anaesthesiology, Copenhagen University Hospital Herlev-Gentofte, Copenhagen, Denmark
| | - Morten Vester-Andersen
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES), Department of Anaesthesiology, Copenhagen University Hospital Herlev-Gentofte, Copenhagen, Denmark
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Patel MS, Thomas JJ, Aguayo X, Gutmann D, Sarwary SH, Wain M. The Effect of Weekend Surgery on Outcomes of Emergency Laparotomy: Experience at a High Volume District General Hospital. Cureus 2022; 14:e23537. [PMID: 35494929 PMCID: PMC9041642 DOI: 10.7759/cureus.23537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2022] [Indexed: 11/05/2022] Open
Abstract
Aims Emergency laparotomies (ELs) are associated with significant morbidity and mortality. Delays to the theater are inevitably associated with worse outcomes. Higher mortality has been reported with admissions over the weekend. The aim of this study is to compare the delays and outcomes of emergency laparotomies performed on weekdays (WD) and weekends (WE) at a high-volume, large district general hospital. Methods A retrospective review of a prospectively maintained database was performed for all patients who underwent general surgical emergency laparotomy between June and October 2021. Patient outcomes were compared between delayed and non-delayed surgeries as per the NCEPOD (National Confidential Enquiry into Patient Outcomes and Death) classification. The primary outcome compared was the 30-day post-operative mortality and morbidity determined by the Clavein-Dindo class ≥2. Secondary outcomes included the time from booking to anaesthesia start time, i.e., time to theatre (TTT), delay in surgery, out-of-hours (OOH) surgery, and unplanned return to theatres. Results Of the 103 laparotomies included, 33% were performed over the weekend. The most common indication for emergency laparotomy was bowel obstruction (53.4 %), followed by perforation (28.2%). There was no significant difference in mortality, the TTT (p = 0.218), delay in surgery with respect to the NCEPOD category of intervention (p = 0.401), postoperative length of stay (p = 0.555), number of cases operated OOH as well as unplanned return to theatres. There was a significant difference in the morbidity of patients between the two groups (Clavein-Dindo class ≥2, p = 0.021). Conclusion With consistent consultant involvement, an equivalent standard of weekend emergency surgical service can be delivered.
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Parmar D, Woodman M, Pandit JJ. A graphical assessment of emergency surgical list efficiency to determine operating theatre capacity needs. Br J Anaesth 2021; 128:574-583. [PMID: 34865827 DOI: 10.1016/j.bja.2021.10.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/24/2021] [Accepted: 10/16/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Unlike elective lists, full utilisation of an emergency list is undesirable, as it could prevent patient access. Conversely, a perpetually empty emergency theatre is resource wasteful. Separately, measuring delayed access to emergency surgery from time of booking the urgent case is relevant, and could reflect either deficiencies in patient preparation or be because of an occupied (over-utilised) emergency theatre. METHODS We developed a graphical method recognising these two separate but linked elements of performance: (i) delayed access to surgery and (ii) operating theatre utilisation. In a plot of one against the other, data fell into one of four quadrants, with delays associated with high utilisation signifying the need for more emergency capacity. However, delays associated with low utilisation reflect process deficiencies in the emergency patient pathway. We applied this analysis to 73 consecutive lists (>300 cases) from two UK hospitals. RESULTS Although both hospitals experienced similar rates of delayed surgery (21.8% vs 21.0%; P=0.872), in one hospital 83% of these were associated with low emergency theatre utilisation (suggesting predominant process deficiencies), whereas in the other 73% were associated with high utilisation (suggesting capacity deficiency; P<0.0001). Increasing emergency capacity in the latter resulted in shorter delays (just 6.7% cases excessively delayed; P<0.0001 for effect of intervention). CONCLUSIONS This simple graphical analysis indicates whether more emergency capacity is necessary. We discuss potential applications in managing emergency surgery theatres.
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Affiliation(s)
- Deovrat Parmar
- Department of Surgery, Royal London Hospital, London, UK
| | - Myles Woodman
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jaideep J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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Tulloch I, Forrester J, Gosavi S, Grahovac G. Reducing neurosurgical theatre start time delays by seventy minutes through application of the 'Golden Patient' initiative. Br J Neurosurg 2020; 36:3-10. [PMID: 33030051 DOI: 10.1080/02688697.2020.1822513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND This project's focus was on improving neurosurgical theatre efficiency through the application of Javed et al's Golden Patient initiative to the emergency theatre setting. This initiative has not previously been used in neurosurgery, so we have had to consider how to adapt it. Phase I's primary objective was to quantify theatre start time delays. Phase II assessed whether introducing the initiative reduced the delays. METHODOLOGY We performed an observational retrospective service evaluation project. Data was collected on weekday theatre start times over 12-week periods pre- and post-initiative. We quantified the delay in theatre start times and recorded the reasons for delays. Following the initiative's introduction, we repeated the evaluation process. Mean and median theatre start times were compared. An ANOVA test was used to confirm statistical significance. RESULTS Data was collected on 49 days and on 48 days over 12-week periods in both Phase I and II respectively. Phase I of this project identified that there was on average an 86.7 minute delay in starting the theatre each day. The theatre start time was delayed in 91.7% of cases. A 72.3 minute reduction in the theatre start time delay was noted following the initiative's introduction (p < .0005), with an improvement in the average emergency theatre start time from 09:56 to 08:44 (08:30 is the recognised theatre start time). We have identified hospital-wide and doctor-related contributing factors which require further attention, most notably, relating to issues around transferring patients from the ward to theatre. CONCLUSIONS We have identified a statistically significant improvement in reducing theatre start time delays following the introduction of the initiative. This relatively simple intervention improved communication amongst the multidisciplinary team and led to a notable improvement in the service provided to patients by reducing start time delays. Through tackling identified areas, we hope to further reduce theatre start time delays leading not only to financial savings but also to further improvements in the quality of care provided to our neurosurgical patients.
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Maine RG, Kajombo C, Purcell L, Gallaher JR, Reid TD, Charles AG. Effect of in-hospital delays on surgical mortality for emergency general surgery conditions at a tertiary hospital in Malawi. BJS Open 2019; 3:367-375. [PMID: 31183453 PMCID: PMC6551403 DOI: 10.1002/bjs5.50152] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 01/22/2019] [Indexed: 12/14/2022] Open
Abstract
Background In sub‐Saharan Africa, surgical access is limited by an inadequate surgical workforce, lack of infrastructure and decreased care‐seeking by patients. Delays in treatment can result from delayed presentation (pre‐hospital), delays in transfer (intrafacility) or after arrival at the treating centre (in‐hospital delay; IHD). This study evaluated the effect of IHD on mortality among patients undergoing emergency general surgery and identified factors associated with IHD. Methods Utilizing Malawi's Kamuzu Central Hospital Emergency General Surgery database, data were collected prospectively from September 2013 to November 2017. Included patients had a diagnosis considered to warrant urgent or emergency intervention for surgery. Bivariable analysis and Poisson regression modelling was done to determine the effect of IHD (more than 24 h) on mortality, and identify factors associated with IHD. Results Of 764 included patients, 281 (36·8 per cent) had IHDs. After adjustment, IHD (relative risk (RR) 1·68, 95 per cent c.i. 1·01 to 2·78; P = 0·045), generalized peritonitis (RR 4·49, 1·69 to 11·95; P = 0·005) and gastrointestinal perforation (RR 3·73, 1·25 to 11·08; P = 0·018) were associated with a higher risk of mortality. Female sex (RR 1·33, 1·08 to 1·64; P = 0·007), obtaining any laboratory results (RR 1·58, 1·29 to 1·94; P < 0·001) and night‐time admission (RR 1·59, 1·32 to 1·90; P < 0·001) were associated with an increased risk of IHD after adjustment. Conclusion IHDs were associated with increased mortality. Increased staffing levels and operating room availability at tertiary hospitals, especially at night, are needed.
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Affiliation(s)
- R. G. Maine
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - C. Kajombo
- Department of SurgeryKamuzu Central HospitalLilongweMalawi
| | - L. Purcell
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - J. R. Gallaher
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - T. D. Reid
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - A. G. Charles
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
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Turnbull GS, Hakimi M, McLauchlan GJ. Trauma theatre productivity - Does the individual surgeon, anaesthetist or consultant presence matter? Injury 2018; 49:969-974. [PMID: 29455911 DOI: 10.1016/j.injury.2018.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 01/27/2018] [Accepted: 02/09/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION With rising NHS clinical and financial demands, improving theatre efficiency is essential to maintain quality of patient care. Consistent teams and consultant presence have been shown to improve outcomes and productivity in elective orthopaedic surgery. The aim of this study was to investigate the impact on trauma theatre productivity of different surgeons and anaesthetists working together in a Major Trauma Centre. The influence of consultant presence and weekend operating on productivity was also considered. METHODS Data relating to a single orthopaedic trauma theatre was gathered retrospectively for a two-year period. Variables including orthopaedic and anaesthetic consultant presence, number and complexity of operations performed and procedure start times were collected for daily trauma lists. Individual anaesthetic and orthopaedic consultants were compared by productivity outcomes. The impact of surgeons operating more frequently with one anaesthetist was also examined. RESULTS Data relating to 2384 patients undergoing a total of 2787 procedures was collected. Orthopaedic consultant presence at the first surgical case (p < 0.05) and for 50% or greater of cases (p < 0.05) lead to higher mean number of cases performed per list and reduced turnaround time. Despite working with a significantly higher number of different consultant anaesthetists (p < 0.001) in year two, the productivity of surgeons as judged by list start time, total cases per list and total operating time was not significantly affected. Significantly earlier start times (p < 0.001) and shorter turnaround times (p < 0.001) at weekends led to maintained productivity despite shorter theatre time. No significant difference in productivity was found when comparing individual anaesthetic and orthopaedic consultants. Productivity was not significantly increased by surgeons operating more frequently with one individual anaesthetist. CONCLUSION In the setting of an acute trauma theatre, orthopaedic consultant presence led to increased productivity. Furthermore, individual surgeon and anaesthetist pairings had no effect on overall productivity. Future efforts to improve productivity should focus on achieving earlier start times, consultant supervision of lists and reduced turnaround times between cases.
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Affiliation(s)
- Gareth S Turnbull
- Clinical Research Fellow, Department of Orthopaedic Surgery, Golden Jubilee National Hospital, Agamemnon St, Clydebank, G81 4DY, United Kingdom.
| | - Mounir Hakimi
- Speciality Trainee Registrar, Department of Trauma and Orthopaedic Surgery, Lancashire Teaching Hospitals, Sharoe Green Lane, Preston, PR2 9HT, United Kingdom
| | - George J McLauchlan
- Consultant Trauma and Orthopaedic Surgeon, Department of Trauma and Orthopaedic Surgery, Lancashire Teaching Hospitals, Sharoe Green Lane, Preston, PR2 9HT, United Kingdom
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Ho YM, Cappello J, Kousary R, McGowan B, Wysocki AP. Benchmarking against the National Emergency Laparotomy Audit recommendations. ANZ J Surg 2017; 88:428-433. [DOI: 10.1111/ans.14164] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 06/17/2017] [Accepted: 06/25/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Yiu Ming Ho
- Department of Surgery; Logan Hospital; Logan City Queensland Australia
- Department of Medicine; Griffith University School of Medicine; Gold Coast Queensland Australia
| | - Julie Cappello
- Department of Surgery; Logan Hospital; Logan City Queensland Australia
| | - Ramin Kousary
- Department of Surgery; Logan Hospital; Logan City Queensland Australia
| | - Brian McGowan
- Department of Surgery; Logan Hospital; Logan City Queensland Australia
| | - Arkadiusz P. Wysocki
- Department of Surgery; Logan Hospital; Logan City Queensland Australia
- Department of Medicine; Griffith University School of Medicine; Gold Coast Queensland Australia
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McIsaac DI, Abdulla K, Yang H, Sundaresan S, Doering P, Vaswani SG, Thavorn K, Forster AJ. Association of delay of urgent or emergency surgery with mortality and use of health care resources: a propensity score-matched observational cohort study. CMAJ 2017; 189:E905-E912. [PMID: 28694308 DOI: 10.1503/cmaj.160576] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Delay of surgery for hip fracture is associated with increased risk of morbidity and mortality, but the effects of surgical delays on mortality and resource use in the context of other emergency surgeries is poorly described. Our objective was to measure the independent association between delay of emergency surgery and in-hospital mortality, length of stay and costs. METHODS We identified all adult patients who underwent emergency noncardiac surgery between January 2012 and October 2014 at a single tertiary care centre. Delay of surgery was defined as the time from surgical booking to operating room entry exceeding institutionally defined acceptable wait times, based on a standardized 5-level priority system that accounted for surgery type and indication. Patients with delayed surgery were matched to those without delay using propensity scores derived from variables that accounted for details of admission and the hospital stay, patient characteristics, physiologic instability, and surgical urgency and risk. RESULTS Of 15 160 patients, 2820 (18.6%) experienced a delay. The mortality rates were 4.9% (138/2820) for those with delay and 3.2% (391/12 340) for those without delay (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.30-1.93). Within the propensity-matched cohort, delay was significantly associated with mortality (OR 1.56, 95% CI 1.18-2.06), increased length of stay (incident rate ratio 1.07, 95% CI 1.01-1.11) and higher total costs (incident rate ratio 1.06, 95% CI 1.01-1.11). INTERPRETATION Delayed operating room access for emergency surgery was associated with increased risk of inhospital mortality, longer length of stay and higher costs. System issues appeared to underlie most delays and must be addressed to improve the outcomes of emergency surgery.
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Affiliation(s)
- Daniel I McIsaac
- Departments of Anesthesiology (McIsaac, Abdulla, Yang), Surgery (Sundaresan) and Medicine (Forster), University of Ottawa; The Ottawa Hospital (McIsaac, Yang, Sundare-san, Doering, Forster), Civic Campus; Ottawa Hospital Research Institute (McIsaac, Thavorn, Forster), Ottawa, Ont.; Institute for Healthcare Optimization (Green Vaswani), Newton, MA
| | - Karim Abdulla
- Departments of Anesthesiology (McIsaac, Abdulla, Yang), Surgery (Sundaresan) and Medicine (Forster), University of Ottawa; The Ottawa Hospital (McIsaac, Yang, Sundare-san, Doering, Forster), Civic Campus; Ottawa Hospital Research Institute (McIsaac, Thavorn, Forster), Ottawa, Ont.; Institute for Healthcare Optimization (Green Vaswani), Newton, MA
| | - Homer Yang
- Departments of Anesthesiology (McIsaac, Abdulla, Yang), Surgery (Sundaresan) and Medicine (Forster), University of Ottawa; The Ottawa Hospital (McIsaac, Yang, Sundare-san, Doering, Forster), Civic Campus; Ottawa Hospital Research Institute (McIsaac, Thavorn, Forster), Ottawa, Ont.; Institute for Healthcare Optimization (Green Vaswani), Newton, MA
| | - Sudhir Sundaresan
- Departments of Anesthesiology (McIsaac, Abdulla, Yang), Surgery (Sundaresan) and Medicine (Forster), University of Ottawa; The Ottawa Hospital (McIsaac, Yang, Sundare-san, Doering, Forster), Civic Campus; Ottawa Hospital Research Institute (McIsaac, Thavorn, Forster), Ottawa, Ont.; Institute for Healthcare Optimization (Green Vaswani), Newton, MA
| | - Paula Doering
- Departments of Anesthesiology (McIsaac, Abdulla, Yang), Surgery (Sundaresan) and Medicine (Forster), University of Ottawa; The Ottawa Hospital (McIsaac, Yang, Sundare-san, Doering, Forster), Civic Campus; Ottawa Hospital Research Institute (McIsaac, Thavorn, Forster), Ottawa, Ont.; Institute for Healthcare Optimization (Green Vaswani), Newton, MA
| | - Sandeep Green Vaswani
- Departments of Anesthesiology (McIsaac, Abdulla, Yang), Surgery (Sundaresan) and Medicine (Forster), University of Ottawa; The Ottawa Hospital (McIsaac, Yang, Sundare-san, Doering, Forster), Civic Campus; Ottawa Hospital Research Institute (McIsaac, Thavorn, Forster), Ottawa, Ont.; Institute for Healthcare Optimization (Green Vaswani), Newton, MA
| | - Kednapa Thavorn
- Departments of Anesthesiology (McIsaac, Abdulla, Yang), Surgery (Sundaresan) and Medicine (Forster), University of Ottawa; The Ottawa Hospital (McIsaac, Yang, Sundare-san, Doering, Forster), Civic Campus; Ottawa Hospital Research Institute (McIsaac, Thavorn, Forster), Ottawa, Ont.; Institute for Healthcare Optimization (Green Vaswani), Newton, MA
| | - Alan J Forster
- Departments of Anesthesiology (McIsaac, Abdulla, Yang), Surgery (Sundaresan) and Medicine (Forster), University of Ottawa; The Ottawa Hospital (McIsaac, Yang, Sundare-san, Doering, Forster), Civic Campus; Ottawa Hospital Research Institute (McIsaac, Thavorn, Forster), Ottawa, Ont.; Institute for Healthcare Optimization (Green Vaswani), Newton, MA
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Richards SK, Cook TM, Dalton SJ, Peden CJ, Howes TE. The ‘Bath Boarding Card’: a novel tool for improving pre-operative care for emergency laparotomy patients. Anaesthesia 2016; 71:974-6. [DOI: 10.1111/anae.13574] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Ang WW, Sabharwal S, Johannsson H, Bhattacharya R, Gupte CM. The cost of trauma operating theatre inefficiency. Ann Med Surg (Lond) 2016; 7:24-9. [PMID: 27047660 PMCID: PMC4796663 DOI: 10.1016/j.amsu.2016.03.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 03/03/2016] [Accepted: 03/03/2016] [Indexed: 11/08/2022] Open
Abstract
The National Health Service (NHS) is currently facing a financial crisis with a projected deficit of £2billion by the end of financial year 2015/16. As operating rooms (OR) are one of the costliest components in secondary care, improving theatre efficiency should be at the forefront of efforts to improve health service efficiency. The objectives of this study were to characterize the causes of trauma OR delays and to estimate the cost of this inefficiency. A 1-month prospective single-centre study in St. Mary's Hospital. Turnaround time (TT) was used as the surrogate parameter to measure theatre efficiency. Factors including patient age, ASA score and presence of surgical and anaesthetic consultant were evaluated to identify positive or negative associations with theatre delays. Inefficiency cost was calculated by multiplying the time wasted with staff capacity costs and opportunity costs, found to be £24.77/minute. The commonest causes for increased TT were delays in sending for patients (50%) and problems with patient transport to the OR (31%). 461 min of delay was observed in 12 days, equivalent to loss of £951.58/theatre/day. Non-statistically significant trends were seen between length of delays and advancing patient age, ASA score and absence of either a senior clinician or an anaesthetic consultant. Interestingly, the trend was not as strong for absence of an anaesthetic consultant. This study found delays in operating TT to represent a sizable cost, with potential efficiency savings based on TT of £347,327/theatre/year. Further study of a larger sample is warranted to better evaluate the identified trends. Delays in operating turnaround time result in substantial financial waste. Causes of delays are reported in this study. Trends between age, ASA score and senior clinician presence with delays were found. Resolving this issue could potentially save an estimated £350,000/theatre/year.
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Affiliation(s)
- W W Ang
- Imperial College London, South Kensington Campus, London, SW7 2AZ, UK
| | - S Sabharwal
- Imperial College Healthcare NHS Trust, Department of Orthopaedics, The Bays, South Wharf Road, St Mary's Hospital, London, W2 1NY, UK
| | - H Johannsson
- Imperial College Healthcare NHS Trust, St. Mary's Hospital, Praed Street, London, Greater London, W2 1NY, UK
| | - R Bhattacharya
- Imperial College Healthcare NHS Trust, Department of Orthopaedics, The Bays, South Wharf Road, St Mary's Hospital, London, W2 1NY, UK
| | - C M Gupte
- Imperial College Healthcare NHS Trust, Department of Orthopaedics, The Bays, South Wharf Road, St Mary's Hospital, London, W2 1NY, UK
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