The Model of a Safe Surgical Service

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The model of a safe surgical service

August 21, 2013

Catherine Reillyspeaks with the two joint leads of the NationalClinicalProgrammeinSurgery,ProfFrankKeaneandMrKenMealy, about how best to improve the safety and quality of care for surgical patients presenting in an emergency or acute setting.

The new Model of Care for Acute Surgery, prepared under the auspices of the National Clinical Programme in Surgery, noted that patients requiring acute surgical care constituted a major component of the workload in many surgical departments globally and that these patients were frequently the sickest, were often elderly and with considerable co-morbidities and poorer outcomes.

Many professional publications have noted that the standard of care in surgical emergencies internationally could be greatly improved, with emergencies comprising up to 90 per cent of general surgical deaths and complication rates exceeding similar elective operations by up to four times. Outcomes in Ireland were unlikely to be better, stated the Model of Care for Acute Surgery, although no data were available.

The model aims to provide a framework for the delivery of timelier, safer and more efficient care for the acute surgical patient and follows on from the Elective Surgery Model of Care that is being rolled-out across the country.

General SurgeonMr Ken Mealy, who is Joint Lead of the National Clinical Programme in Surgery alongside former RCSI PresidentProf Frank Keane, toldIrish Medical Timesthat there existed a “huge” body of international evidence indicating that acute surgical services were often poorly organised, poorly resourced and “evolved as being tacked-on to the end of elective surgical services”.

Attempts to improve care and outcomes on the international front have centrally involved a functional separation of acute and elective surgical streams. The new model has identified this as key to better care delivery, but Mr Mealy said achieving this division was “problematic”, particularly as the same group of surgeons generally dealt with both elective and emergency cases.

Joint leads: Mr Ken Mealy, General Surgeon, Wexford General Hospital; Dr Áine Carroll, National Director, Clinical Strategy and Programmes, HSE; and Prof Frank Keane

“Different countries have taken different approaches,” said Mr Mealy. “In the United States, they have appointed a whole series of emergency care surgeons, but they are working out of huge departments with maybe 20 to 30 surgeons, and 10 or 20 operating theatres, and hundreds of thousands of patient admissions every year — so the economics of that is very reasonable. That is more problematic in smaller countries. Ireland, in particular, has 32 acute surgical hospitals, or has had up to recently, and if you have got two or three surgeon teams it is very hard to separate those streams.”

Appointing an emergency surgeon in a small hospital would hardly be pragmatic, he said, but the separation would be achievable in bigger units.

“In the bigger hospitals we are saying that the way to get better outcomes is to separate the streams: have teams of surgeons, anaesthetists and other ancillary staff that you need to run a [acute] service that are available 24 hours a day, freed-up from all elective duties so that they can concentrate on emergency care patients and see them more promptly,” he said.

Asked if this could mean restricting acute surgery to a limited number of larger hospitals, Mr Mealy replied: “We are very much aware of the limitations of the programme, in the sense that we are delivering the model of care and are trying to get involved in performance enhancement in the hospitals that we go into. But it is not our role, as such, to dictate how that care should be provided, because we don’t have the ability to do that. But it may transpire, particularly with the announcement recently of the networks, that certain networks may well decide that some hospitals will be just elective care only and others would provide the acute care, in some or all of the surgical specialties.” This separation of elective and acute care had already been happening in the Mid-West and North-East, he noted.

Lancet mortality study

A paper published last year inThe Lancet, ‘Mortality After Surgery in Europe: a Seven-day Cohort Study’, reflected poorly on surgery in Ireland. The study of patients undergoing inpatient non-cardiac surgery found that patients in Ireland had the highest risk of dying in Western Europe and the fourth-worst mortality rate among 28 European countries. In the UK, the mortality rate was 3.6 per cent, well above the highest previous estimates of between 1 and 2 per cent. Ireland recorded a rate of 6.4 per cent.

Did the surgical community here accept the findings on Ireland? “The answer is we accept the report because it is actually published,” said Prof Keane. “Do we agree with the conclusions of the report or the methodology? There are some concerns about the conclusions and methodology, and the College of Surgeons is actually doing a study at the present time looking back over that data… Taken as read on face value, it would certainly be extremely concerning.” He said an “engagement” with the Editor ofThe Lancethad occurred, “and as I say, we are doing our own audit”.

Mr Mealy said the study had encouraged their resolve in ensuring that national audits under the National Office of Clinical Audit (NOCA) were the “way forward”. That this initiative had been agreed upon was one of the “fantastic spin-offs of the collaboration between the HSE and the clinical programmes”, said Mr Mealy, who is NOCA’s Clinical Director.

Confidential audits

The establishment of NOCA has not been without glitches and an important issue has remained unresolved. As was reported in IMT in March, the launch of the Irish Audit of Surgical Mortality (IASM) has been delayed due to fears that data could be vulnerable to court Orders of Discovery.

The IASM is one of four audit streams currently planned under NOCA and it is expected that the Health Information Bill will include provisions to resolve the confidentiality issue, said Mr Mealy.

The confidential nature of NOCA was not about hiding information from the general public, he underlined, but rather about “changing the culture within the clinical community” so as to encourage learning from adverse outcomes. Confidentiality was required so that doctors bought-in to the process, he said.

“Currently in an adversarial process, it is never shared because it is hidden within little silos around the country. Half of the adverse outcomes never reach any sort of inquiry, never reach the courts; if litigation is involved they are frequently settled out of court, so nobody learns,” he said.

One of the particularly interesting observations in the Model of Care for Acute Surgery was the high numbers of acute surgical inpatients who did not have a surgical procedure. In 2011, while acute inpatients accounted for 62 per cent of surgical admissions, some 44 per cent of those had no surgical procedure performed.

Prof Keane said there were various reasons for patients being admitted to hospital under surgical care, but not necessarily having a surgical procedure, including some cases of cellulitis and possible appendicitis, and patients with head trauma who needed further observation. He recognised that some surgical admissions would not, in the end, entail a surgical procedure, but that it was important insofar as possible to minimise hospital stay in order to free-up bed space.

Lengths of stay

Both of the surgeons agreed that it was imperative that shortening hospital stay did not compromise patient care. Mr Mealy commented: “If you look at across the water, some of the huge criticisms of the NHS in terms of quality outcomes, particularly with the Mid-Staffordshire report, is that you have your KPIs [Key Performance Indicators] and you tick all the boxes, but the level of care you could be providing could be awful for patients — but you are ticking the right boxes. So it is a case of getting the communication and the compassion and the empathy right, but also dealing with and processing patients efficiently.”

As to the successes of the National Clinical Programme in Surgery to date, Mr Mealy felt that these were largely associated with Prof Keane’s elective surgery programme.

The elective programme has worked to define ways of improving delivery of elective surgical care through a range of initiatives, such as standardised models of care guidelines for pre-admission assessment clinics, day surgery, day of surgery admissions and discharge planning; targets for average length of stay of surgical inpatients, as well as targets for day surgery across surgical specialties; monitored clinical outcomes through audit and clinical registries; and The Productive Operating Theatre (TPOT) to improve patient outcomes and experience, as well as theatre team performance and resource efficiency.

More patients, fewer beds

“I think it is very clear that our average length of stay is already decreasing and we have good evidence from 2010 to 2011 — we will have 2012 figures soon,” said Mr Mealy. “We are treating more patients in fewer beds, our day case rates are very rapidly increasing 10-to-15 per cent a year, and our day of admission surgery rates are very clearly increasing, so we are becoming much more efficient in how we process elective patients. I think there have been fairly impressive results so far.”

Asked if there were further programmes planned relating to different surgical specialties, Prof Keane suggested that national resources might not allow for this at the present time, although they would be welcomed. For the moment, much work remained under the generic programme, “in terms of trying to see how we can help hospitals implement the various components of the elective and the acute surgery models of care”, said Prof Keane.

Hospital visits

Over the past year, there have been the best part of 40 hospital visits, he said. “Seeing the changes and innovations that are going on in extremely difficult circumstances is really quite remarkable, but there is a huge amount to be done,” added Prof Keane. “We don’t think this is a programme that is going to be implemented in six months or a year; it is going to take a number of years… and obviously with the other changes that are happening in the health service at the moment, such as the hospital groups, ‘money follows the patient’, universal healthcare, all these other things are going on at the same time, it is going to be a slow process. We are absolutely convinced that the kind of message is the right message going out and we are also feeling very rewarded that people are picking up and understanding the message.”

Mr Mealy concurred, adding that, as they travelled around the country, they were encountering a “huge amount of good work being done” by many individuals and institutions under difficult circumstances, and “the public tend not to hear about it”.