'Golden Patient': A quality improvement project aiming to improve trauma theatre efficiency in the Royal Gwent Hospital

Reducing trauma theatre list delays through improved communication between orthopaedic teams and radiographers: A quality improvement project

AIMS

This quality improvement project was performed to improve delays in starting our trauma theatre lists by implementing measures to improve effective communication between the surgical team and the theatre radiographers.

MATERIALS AND METHODS

This was a quality improvement project performed prospectively for 30 orthopaedic trauma lists over two cycles. Only lists requiring fluoroscopy guidance (image intensifier) for the first case were included. Interventions included improvements in use of theatre booking forms with fluoroscopy request checkboxes, dedication of an allocated radiographer for the trauma lists, timely communication of the finalised theatre list order and radiographers participating in the team briefing.

RESULTS

Improvements in the timing of fluoroscopy requests and prompt arrival of the radiographer to the theatre were achieved. Furthermore, there was elimination of radiographer-related surgical start time delays following implementation of the interventions. Nevertheless, only minimal improvements were achieved in the participation of the radiographers for the trauma theatre team briefings.

CONCLUSION

Although reasons for trauma theatre delays are multifactorial, this quality improvement project has demonstrated that these delays can be reduced through improved communication between radiographers and the orthopaedic team. This is especially important for theatre cases requiring the use of an image intensifier.

Time is a terrible thing to waste: optimising use of intraoperative monitoring practitioner time towards maximising in-house IOM service provision and reducing spend on external provision

Intraoperative monitoring (IOM) during orthopaedic and neurosurgical operations informs surgeons about the integrity of patients' central and peripheral nervous systems. It is provided by IOM practitioners (IOMPs), who are usually neurophysiology healthcare scientists. Increasing awareness of the benefits for patient safety and surgical outcomes, along with post-COVID-19 service recovery, has resulted in a material increase in demand for IOM provision nationally, and particularly at Salford Royal Hospital (SRH), which is a regional specialist neurosciences centre.There is a shortage of IOMPs in the UK National Health Service (NHS). At SRH, this is exacerbated by staff capacity shortage, requiring £202 800 of supplementary private provision in 2022.At SRH, IOMPs work in pairs. Our productive time is wasted by delays to surgical starts beyond our control and by paired working for much of a surgery session. This quality improvement (QI) project set out to release productive time by: calling the second IOMP to theatre only shortly before start time, the other IOMP returning to the office during significant delays, releasing an IOMP from theatre when appropriate and providing a laptop in theatre for other work.We tested and refined these change ideas over two plan-do-study-act improvement cycles. Compared with complete paired working, we increased the time available for additional productive work and breaks from an average of 102 to 314 min per operating day, not quite achieving our project target of 360 min.The new ways of working we developed are a step towards ability (when staff capacity increases) to test supporting two (simultaneous) operations with three IOMPs (rather than two pairs of IOMPs). Having significantly improved the use of staff time, we then also used our QI project data to make a successful business case for investment in two further IOMP posts with a predicted net saving of £20 000 per year along with other associated benefits.

The Golden Patient Initiative: A Systematic Review

Operating theatres and surgical resource consumption comprise a significant proportion of healthcare costs. Inefficiencies in theatre lists remain an important focus for cost management, along with reducing patient morbidity and mortality. With the emergence of the coronavirus disease 2019 (COVID-19) pandemic, the number of patients on theatre waiting lists has surged. Hence, there is a pressing need to utilise the already limited theatre time and fraught resources with innovative methods. In this systematic review, we discuss the Golden Patient Initiative (GPI), in which the first patient on the operating list is pre-assessed the day prior to surgery, and we aim to assess its impact and overall efficacy. A literature search using the following four databases was conducted to identify and select all clinical research concerning the GPI: Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (EMBASE), and the Cochrane library. Two independent authors screened articles against the eligibility criteria, using a process adapted from the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Data extracted included outcomes measured, follow-up period, and study design. The results showed significant heterogeneity, and hence a narrative review was conducted; 13 of the 73 eligible articles were included for analysis. Outcomes included delay in theatre start time, number of surgical case cancellations, and changes to total case numbers. Across the studies, a 19-30-minute improvement in theatre start time was reported (p<0.05), as well as a statistically significant decrease in case cancellations. Our analysis provides encouraging conclusions with regard to greater theatre efficiency following the application of GPI, a low-cost solution that can easily be implemented to help improve patient safety and lead to cost savings. However, at present, it is largely implemented among local trusts, and hence larger multi-centre studies are required to gather conclusive evidence about the efficacy of the initiative.

EP.TU.216Golden Patient Protocol: A Closed Loop Audit

Introduction

Identifying a ‘Golden Patient’ the proceeding day improves emergency theatre efficiency and overall operating capacity.

Aim

Use this strategy to improve theatre efficiency in our Regional Plastic Surgery Department.

Methods

Cycle one:

Interventions:

Cycle two:

Cycle three:

Results

Cycle one:

Cycle two:

Cycle three:

Conclusions

Use of the ‘Golden Patient’ protocol improves emergency theatre efficiency with subsequent effect on overall operating capacity.

Impact of COVID-19 Pandemic on Trauma Theatre Efficiency

Introduction

A large transformation in the management of trauma has ensued following the COVID-19 (coronavirus disease 2019) pandemic. There has been an increase in reliance on guidance for decision-making and alterations in the working of the trauma theatre. This has largely been due to the safety measures implemented. Theatre efficiency has gained increasing importance over the years, and with the added pressure of the pandemic, it is essential that trauma theatres operate efficiently. There has been no data analysing the efficiency of trauma theatre during this pandemic.

Methods and Results

We retrospectively analyzed the data at our hospital and looked into the parameters to assess trauma theatre efficiency. It was noted that the operative time and anaesthetic time went up significantly in 2020 in comparison to 2019. Also, the change over time and the late start time was significantly high in 2020. A large proportion of cases did not start on time in 2020. This resulted in a decrease in the efficiency of theatre usage.

Discussion

Reduced productivity of the trauma theatre has been due to several reasons, many of which include implementation of safety measures, such as personal protective equipment (PPE), theatre cleaning, recovery of patients, using designated routes for transfer, and many others. The challenge lies in applying these new measures into our daily practice at the same time while providing efficient care.

Conclusion

Our study highlights the key areas of concern and improvement which need to be addressed in order to render effective trauma care.

Reducing neurosurgical theatre start time delays by seventy minutes through application of the 'Golden Patient' initiative

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.

A Novel Interdisciplinary Iterative Approach for Optimizing the Electronic Health Record to Improve Perioperative Efficiency

OBJECTIVE

We present a holistic perioperative optimization approach led by a CI team with the goal to optimize the workflow within our EHR, improve operative room metrics and user satisfaction.

SUMMARY OF BACKGROUND DATA

The EHR has become integral to perioperative care. Many approaches are utilized to improve performance including systems-based approaches, process redesign, lean methodology, checklists, root cause analysis, and parallel processing. Although most reports describe strategies improving day or surgery productivity, few include perioperative interventions to improve efficiencies.

METHODS

An interdisciplinary CI team consisting of clinicians, informatics specialists, and analysts spent 6 weeks assessing users and optimizing all perioperative areas (scheduling, day of surgery, postop discharge/admission). Elbow-to-elbow retraining and simultaneous content development was performed utilizing an Agile workflow process optimization with the Scrum framework. This iterative approach averaged 1 week from build to change implementation. Pre/post optimization surveys were sent.

RESULTS

Two hundred forty-two perioperative enhancements were completed. While most impacted documentation, all areas were enhanced including billing, reporting, registration, device integration, scheduling, central supply, and so on. FCOTS improved from <70% to >85% and total delay was halved. These parameters were consistently sustained for over 1 year after the 6-week optimization. While only 5% of pre-optimization users agreed to proficiency in the EHR system, this improved to 70% post-optimization. Furthermore, EHR confidence and acceptance improved from 40% to 90%.

CONCLUSIONS

To improve workflow efficiency, all who contribute to the perioperative process must be assessed. This IT driven initiative resulted in improved FCOTS, perioperative workflows, and user satisfaction.