Matthew Woodward, University of Oxford
Introduction. Surgical Emergency wards and theatres have to manage an unpredictable and variable work flow in a complex system with multiple roles and competing priorities. This paper reports on a human factors study in a tertiary care hospital which runs a large Surgical Emergency Unit (SEU) working with a busy emergency surgery theatre. The overarching study aim was to improve patient safety for a cohort of patients requiring appendectomies by getting cases to theatre in timescales required for the severity of condition. At any time patients admitted in urgent need of surgery will necessarily disrupt the previously agreed theatre operating list orders. Given the changeable list and a physically distributed unit (four wards over two floors), effective communication between theatres and wards was observed and identified as a challenge and as an area to improve.
Methods. The study applied process analysis to document patient flow and key decision points. Subsequently a link analysis was conducted to analyse the complexity of communications between theatres and the SEU wards. The analyses were run in participatory workshops with healthcare staff and subsequently distributed for comment and validation.
Having identified communications/awareness of list order as an area for improvement a range of potential changes were generated and prioritised with staff. Two main projects were conducted. Firstly the staffing rota was changed to ensure that a given Consultant would continue care of a patient throughout the patients stay with a view to improving continuity of care. Secondly a new role, a Transfer Nurse Assistant was trialled for 3 months which included responsibility for tracking and communicating emergency theatre list order. A related initiative implemented a computer application to make the list order more widely available.
Data was collected at two levels to assess the impact of the changes: Firstly baseline (pre-intervention) data was collected to categorise the appendectomy patient cohort by urgency (using severity of sepsis as a marker). Times were then collected and calculated between triage, the surgeon’s decision to operate and the start of operation. These times were compared against the Royal College of Surgeons (RCS) recommended guidelines for the different categories of sepsis.
Secondly data on day-to-day communications and patient transfers were collected to evaluate the frequency and timeliness of ward-theatre communications. An assessment of the readiness of ward patients to be sent to theatre and waiting times was also collected. This data was gathered by adapting the porters’ job cards.
Baseline data shows that a number of patients across all levels of sepsis do not reach surgery within the recommended timescales (13%), thus there is scope for improvement. The baseline data also indicated that communication could be more reliable. For those patients that were not ready/prepared for theatre on 62% occasions an indication/call regarding list order had not been received by the nurse. This paper will report the post intervention data (currently under analysis, soon to be completed) which will allow the impact of the change projects in this complex system to be discussed.