Establishing an Acute Surgical Unit

Establishing an Acute Surgical Unit in a Rural

Area

Wagga Wagga Health Service

September 12Sherylle Sheehy ASU CNC, Megan King Perioperative NM

A little about Wagga Wagga Health Service

Wagga Wagga Health Service

Wagga Wagga is the largest inland city in NSW and one of Australia’s leading regional cities with a population over 61,000 (06/2008 census).

Wagga is the local Wiradjuri aboriginal word for crow and to create the plural, the Wiradjuri repeat the word. Thus Wagga Wagga translates as 'the place of many crows'.

Wagga Wagga Base Hospital is a rural referral hospital and the major acute care provider and referral hospital for the Murrumbidgee Local Health Network ... Wagga Wagga Base Hospital has 237 'beds' including 209 overnight inpatient beds and 28 ambulatory treatment places. (Wagga

Wagga Hospital Clinical Services plan 08/2006)


5 Operating Theatres fully operational

Increase to 2012 average 795 operations per month


600

650

700

750

800

850

0708 0809 0910 1011 1112

WWHS Operating Theatres Average Number of Operations per month 2007 - 2012

Mth Ave

Expon. (Mth Ave)

General – 8 General Surgeons Orthopaedics – 6 Orthopaedic surgeons - 1 elective only Urology – 3 Urologists ENT – 2 ENT Surgeons Vascular – 2 Vascular Surgeons Ophthalmology – 3 Ophthalmologists O&G – 1 O&G + locum service 2 Gynaecologists elective only Paediatrics – 1 x Paediatric Surgeon Endoscopy – 2 Physicians, 2 Respiratory Physicians Dental ECT Vascular Access service


Types of Surgery

Average 35 – 40% of all operations at WWBH are emergencies

Allocated Ortho Trauma and Emergency sessions Ortho Trauma: Mon PM, Tuesday evening, Weds evening, Fri

Am and Sunday all day + random extra sessions

Emergency: Every afternoon 1330 – 1730, then overnight and weekends


Emergency Surgery

Emergency Sessional Allocation


THEATRE TIME MON TUE WED THU FRI SAT SUN

1 AMTrauma

PM Trauma Trauma

2 AM Emergency Emergency

PM ASU ASU ASU ASU ASU Emergency Emergency

3 AM

PM

4 AM

PM

5 AM

PM

ENDO AM

PM

Evening / Overnight Emergency Emergency Emergency Emergency Emergency

Emergency Emergency

Trauma Trauma

SESSIONS AM

PM

TOTAL


Historical Approach to General Surgery Presentations

Surgeon:On call for 24hr periodNormal public/private operating listNormal consulting in roomsNot always available during hours

Theatre:Designated Emergency sessions often unable to be utilised or on occasions utilised for elective surgery Emergency Cases added to elective lists surgeonEmergency cases commenced after 1800


After hours operating , escalating overtime of staff – medical, nursing and ORA’s

Cancellation of elective patients to accommodate emergency cases

Increase in diagnostic tests

Delay in Surgical Review of ED presentation

Delay in consults on inpatients

Sherylle Sheehy ASU CNC, Megan King Perioperative NM

% Emergency Surgery 2011 - pre ASU

0

20

40

60

80

100

Jan Feb Mar Apr May Jun Jul Aug Sep Oct

2200-0700

1800-2200

0700-1800


The ASU model of care was driven by the surgeons

After consultation with WWBH Executive, funding for the model was sourced from MOH.

The surgeons as a group proposed how they would do their on call roster: decided 7 days on, full handover to next Surgeon, Friday to Friday.

A Registrar was to be allocated to ASU


Commencing an ASU

Getting Logistics Right


• Commence a Steering Committee with weekly meetings• Service Development Application • Business rules• Contracts for Doctors • How the Doctors will be paid• Identifying ASU patients in IPM to get reports• Position descriptions for CNC, Clerical, and Data Manager• Office space and Office fit outs• How will Private patients be managed.

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Chaired by WWHS GM

Initially DM, DMS, DONM, Theatre Manager, Client

Services Manager, Business Manager

Meet weekly

Later included Director of Emergency

Separate meeting with WWHS Executive and Surgeons


Steering Committee

Included cost modelling

Designed around cost benefits: Reduced overtime Reduced LOS Reduced pathology and imaging costs

Staffed by: CNC Clerical Assistance Data Manager


Service Development Application

Developed by DMS in conjunction with Surgeons WWHS expectations of how ASU will function Includes rules on:

Roster provision including Registrar allocation to ASU Consults and ward rounds Handover Allocated Emergency Operating time Transfer from Emergency department Supervision Clinics Protocols and pathways Attending Rooms and Private hospital while on call Timely Accounting

Sherylle Sheehy ASU CNC, June 2012

Business Rules

Special permission for a non standard contract for Surgeons

Surgeons submit separate claim to Normal VMO claim for ASU


Surgeon contracts and payment

Set up a different specialty for each surgeon in IPM

Eg “Dr Harrison” and “Dr Harrison ASU”

Allows printing a report for where patients are as no specific ward


Identifying ASU patients in IPM

Longer than we thought, had to go through Grading Committees

Easily recruited to CNC

Clerical and Data Manager took longer to recruit


Position Descriptions

Big problem as very limited space at WWBH

GM rearranged location of WWBH Staff to allow ASU to go into a newly built demountable office located in between A&E and Theatre

Begged, borrowed and stole office desks

Purchased new chairs, computers, Printer / fax / photocopier machine

4 desk spaces and computers (CNC, Clerical, Registrar and Intern)


Office Space and Fit outs

Worked with Surgeons and PLO’s to develop a patient brochure explaining the ASU including how it effects private patients

Surgeons historically have preferred to keep any emergency patients at Base Hospital for a variety of reasons

Decisions about which patients can be transferred to Private Hospital is determined on a case by case basis.


Private Patients



Results so far

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100

Pe

rce

nta

ge

of

Pro

ced

ure

s

0800 - 1800 1800 - 2200 2200 - 0800



% Emergency Surgery 2011-pre ASU

0

10

20

30

40

50

60

70

80

90

100

Jan Feb Mar Apr May Jun Jul Aug Sep Oct

2200-0700

1800-2200

0700-1800


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10

20

30

40

50

60

70

80

90

Dec Jan Feb Mar Apr May Jun Jul

General Surgery Emergencies between 0700 - 1800 Comparison Pre and Post ASU

Pre ASU 0700-1800

Post ASU


0

5

10

15

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25

30

35

40


Emergency General Surgery Emergencies between 1800 - 2200 Pre and Post ASU

Pre ASU 1800-2200

Post ASU


0

2

4

6

8

10

12

14

16


General Surgery Emergencies beween 2200 - 0700 Pre and Post ASU

Pre ASU 2200-0700

Post ASU


0

1

2

3

4

5

6

Jan-11

Feb-11

Mar-11

Apr-11

May-11

Jun-11

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

Ove

rtim

e F

TE

Months

Nursing / ORA's

Linear (Nursing / ORA's)

ASU commenced Dec 2011

Nursing and ORA’s overtime

Stake Holders Feedback - direct

Surveys Patients and staff - paper

Letter to GPs outlining function of ASU and contact numbers

Recruitment of Data Manager – commenced 20/8/2012 build data base and dashboard for reporting.

Concentration of protocol development.

Further refinement of CNC role now that Data Manager recruited.

Where Are We Now


Data Source Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12

Length of Stay (Pre and Post Project Implementation)

Duration of Operations Surginet

Length of Stay in Intensive Care Unit

Pre Operative Length of Stay

Nursing overtime Corvu

surgical registrar overtimeUse of Imaging eg CT scanning for positive appendix

Deep Vein Thrombosis Prophylaxis – including timeliness

Anti Biotic Prophylaxis - including timelines

Unplanned Return to Theatres

Registrar (Anaesthetic and Surgical) Supervision

Duration of Operating Theatre Time (Supervised Vs Unsupervised -

Registrar time)

Impact on Elective Lap Chole vs Emergency

LOS Appendix

LOS and 30 Day Mortality-Laparoscopic Cholecystectomy

Infection rates

Readmission within 28 days

% of Twilight Operating (1800-2200) Surginet

% of Overnight Operating (2200-0700) Surginet

Elective Cancellations due to Emergencies Surginet

Delays Manual

Time from Triage to Surgical Review

Common ASU Surgical Procedures

Utilisation of ASU Session

Anaesthetic Start to Surgery Start Time

ASU Utilisation per SpecialtyEmergency cancellation ASU Manual-Theatre

Pro

cess

re

late

dC

ost

re

late

dQ

ual

ity

Re

late

dWagga Wagga Health Service Acute Surgical Unit

Emergency Surgery Dashboard Dec 2011, Post ASU.


Questions?


Health & Medicine

Establishing an Acute Surgical Unit