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



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

Referral Management

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

a timely fashion

Waitlists

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

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

Queues

Treat in turn

Scheduling using Patient Flow Portals

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)

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

Electronic Patient Calling Systems

Wireless Patient Tracking

Electronic records & decision support

Traffic light filtering systems

Parallel Processing

PACU block

Theatre View

Dashboards

Discharge Strategies

Rigorous discharge planning

Patient Flow Management Tool

Criterion based, nurse initiated discharge

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

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

Health & Medicine