daryl williams, melbourne health: achieving national elective surgery target in victoria

Achieving national elective surgery targets

(NEST) in Victoria

Professor Daryl Williams

Divisional director surgery, perioperative, trauma & surgical oncology,

Royal Melbourne Hospital

Talk overview •  NEST targets and categorisation •  Referral, waitlists •  Optimisation of patients •  Streaming and elective/emergency mix •  Models of care •  Scheduling and queuing theory •  Optimal theatre efficiency •  Discharge planning •  Future trends

Talk overview

•  NEST targets and categorisation •  Referral, waitlists •  Optimisation of patients •  Streaming and elective/emergency mix •  Models of care •  Scheduling and queuing theory •  Optimal theatre efficiency •  Discharge planning •  Future trends

National Elective Surgery Target

NEST is divided into two complementary strategies:

  Part 1: Stepped improvement in the number of patients treated within the clinically recommended time.

  Part 2: A progressive reduction in the number of patients who are overdue for surgery beyond the clinically recommended time.

*Na$onal  Partnership  Agreement  (NPA)  on  Improving  Public  Hospital  Services,  pg  14  -­‐  26  hCp://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/Content/npa-­‐improvingpublichospitals-­‐agreement  

NEST Part 1

Time   Cat  1  Target   Cat  2  Target   Cat  3  Target  

Baseline   92.3%   86.6%   89.4%  

By  Dec  2012   96%   90%   92%  

By  Dec  2013   100%   93%   95%  

By  Dec  2014   100%   97%   97%  

By  Dec  2015   100%   100%   100%  

  By 2015 100% of patients waiting for elective surgery will be treated within their clinical recommended time.

NEST Part 2

Cat   31  Dec  10  (Baseline)  

31  Dec  12  (Target)  

31  Dec  13  (Target)  

31  Dec  14  (Target)  

31  Dec  15  (Target)  

1   0  days   0  days   0  days   0  days   0  days  

2   39  days   29  days   20  days   10  days   0  days  

3   130  days   98  days   65  days   33  days   0  days  

  By 2015 the average overdue wait time will be zero days

Total numbers of additions & removals from ES waitlist

Median wait time to surgery in public hospitals 2010-11

Variation in clinical urgency categorisation 2010/11

Australian data for hip replacement

Australian admission data

Current categories for elective surgery

Source:  The  Australian  Ins$tute  of  Health  and  Welfare  (AIHW)  (2008)  Na$onal  Health  Data  Dic$onary  no.  14,  

Na#onal  Benchmarks.  Urgency  with  which  the  pa$ent  requires  elec$ve  hospital  care/surgery  

Surgical  Category   DescripBon  of  recommended  Bmeframes  Category  1   admission  within  30  days  desirable  for  a  condi$on  that   has  the  poten$al   to  deteriorate  

quickly  to  the  point  that  it  may  become  an  emergency  Category  2   admission  within  90  days   desirable  for  a  condi$on  causing  some  pain,  dysfunc$on   or  

disability  but  which  is  not   likely  to  deteriorate  quickly  or  become  an  emergency  

Category  3   admission  at  some  $me  in  the  future  acceptable  for  a  condi$on  causing  minimal   or  no  

pain,  dysfunc$on  or  disability,  which  is  unlikely  to  deteriorate  quickly  and  which   does  not  have  the  poten$al  to  become  an  emergency.  

National definitions for categorisation

National Categorisation Overarching principle

  Patients who require an elective procedure are assigned an urgency category by the treating clinician   Appropriate to patient and their clinical condition   Not influenced by availability of hospital/doctors

Multifaceted approach to meet targets

Talk overview •  NEST targets and categorisation •  Referral, waitlists •  Optimisation of patients •  Streaming and elective/emergency mix •  Models of care •  Scheduling and queuing theory •  Optimal theatre efficiency •  Discharge planning •  Future trends

Referral Management

  Electronic   Standardised   Appropriate for public hospitals   Acceptance based on the capacity to treat in

a timely fashion

Waitlists

Talk overview •  NEST targets and categorisation •  Referral, waitlists •  Optimisation of patients •  Streaming and elective/emergency mix •  Models of care •  Scheduling and queuing theory •  Optimal theatre efficiency •  Discharge planning •  Future trends

Optimising Health

  General preventative strategies

  Targeted initiatives

  Improved cardiorespiratory capacity

TKR and Pre-habilitation

•  Pre-operative muscle exercise program may improve outcome –  resistance training, flexibility, step

training –  3x week, 8 weeks –  improved strength, functional

outcomes at 1 and 3 months »  Swank A. J Strength Cond Res 2011;

25: 318

Talk overview •  NEST targets and categorisation •  Referral, waitlists •  Optimisation of patients •  Streaming and elective/emergency mix •  Models of care •  Scheduling and queuing theory •  Optimal theatre efficiency •  Discharge planning •  Future trends

Emergency Surgery trends Victoria

Surgical caseload 2008-2011

Who does emergency surgery?

Elective – emergency mix

Outcomes of EGS model   Direct clinical effects

  Decreased night time operating   Reduced length of stay   Decreased complication rates   Lower return to theatre rates

  Staff   Improved satisfaction of surgeons   Improved training of registrars

  Electives   Lower elective surgery cancellation rates   Maintenance of elective surgery numbers

  Cost neutral

RMH demand profile

70% can wait longer than 8 hours

Emergency surgery demand & supply

Timeliness of Emergency Surgery

Talk overview •  NEST targets and categorisation •  Referral, waitlists •  Optimisation of patients •  Streaming and elective/emergency mix •  Models of care •  Scheduling and queuing theory •  Optimal theatre efficiency •  Discharge planning •  Future trends

Queues

Treat in turn

Scheduling using Patient Flow Portals

Variation

Variation

Variation

Variation

Care Bundles and Enhanced Recovery After Surgery (ERAS)

  Care bundles are groupings of practice processes that individually improve care, but when applied together result in a substantially greater improvement.

Colorectal ERAS

Orthopaedic Joint ERAS

Malviya  A.  Acta  Orthopedica  2011;  82:  577  

ERAS outcomes   Lowered LOS   Less complications   ?Decreased Mortality

  4500 consecutive joint replacements

  reduced 90 day mortality: 0.8% to 0.2%

  reduced LOS: mean 6 to 3 days   less transfusion: 23% to 10%   less complications

  Malviya A. Acta Orthopedica 2011; 82: 577

Checklists

  A simple memory aid to ensure processes of care are completed

  Example safe surgery saves lives

Safe Surgery Checklist •  3 principles: "

  Simplicity "  Wide applicability "  Measurability "

  Process "  literature review"  consensus among experts"  wide consultation"  piloting and evaluation"

Results: Death & Complications

Change in Complications

Change in Death

High Income 10.3% -> 7.1%* 0.9% -> 0.6%

Low and Middle Income

11.7% -> 6.8%* 2.1% -> 1.0%*

* p<0.05 Haynes et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine

360:491-9. (2009)

Talk overview •  NEST targets and categorisation •  Referral, waitlists •  Optimisation of patients •  Streaming and elective/emergency mix •  Models of care •  Scheduling and queuing theory •  Optimal theatre efficiency •  Discharge planning •  Future trends

Perioperative patient flows •  Patient Streams

–  Day case versus multiday –  Hubs of specialisation –  Flexible environments

•  Stratification systems –  Suitability for pathways –  Perioperative Risk Stratification

•  Efficiency Benchmarking –  Real time tracking

On the day

  Start Time Matrix

  3 key constraints – theatres, PACU, beds

  Transparency of processes and flow  Real time tracking of patients with automated alerts  ERAS, standardised pathways and bundles

Start time matrix

Start time matrix

Electronic Patient Calling Systems

Wireless Patient Tracking

Electronic records & decision support

  Traffic light filtering systems

Parallel Processing

PACU block

Theatre View

Dashboards

Talk overview •  NEST targets and categorisation •  Referral, waitlists •  Optimisation of patients •  Streaming and elective/emergency mix •  Models of care •  Scheduling and queuing theory •  Optimal theatre efficiency •  Discharge planning •  Future trends

Discharge Strategies

  Rigorous discharge planning

  Patient Flow Management Tool

  Criterion based, nurse initiated discharge

Talk overview •  NEST targets and categorisation •  Referral, waitlists •  Optimisation of patients •  Streaming and elective/emergency mix •  Models of care •  Scheduling and queuing theory •  Optimal theatre efficiency •  Discharge planning •  Future trends

Balancing public and private

Public

Swingers

Private

  Private insurance hospital cover percentages   June 1999: 30.6%

  Introduction of 30% private health insurance rebate   June 2011: 45.3%

Australian elective & emergency surgeries in public and private

4.1% per annum increase in private elective surgery

A decreasing queue discourages private insurance

  If waiting times are diminished in public then private rates may decrease Private

Swingers

Public

Victorian patients waiting >365 days for surgery

Thank you