Professor Ray McLaughlin

University Hospital Galway.

TTT Overall General Urology Plastics Vascular

Number 3,600 1,600 490 892 130

All age groups 26 25 47 20 40

< 16 years 10 11 1:17 25 N/a

Total No.

of

Operations

No. of

Operations

working

hours

No. of

Operations

out of

Hours

Appendicectomy 1090 528(48%) 562(52%)

Endoscopy 538 323(60%) 215(40%)

Laparotomy 380 177(47%) 203(53%)

I & D 184 97(53%) 87(47%)

Hernia Repair 86 42(49%) 44(51%)

EUA 78 48(62%) 30(38%)

General Electric/HSE Patient Flow Project

Preparation work (Including Training)

VSM Kaizen

Sustainability

Project Timeline

Project

Scoping

& Planning

VSM Kaizen

Prep

for Kaizen

Basic

Training (For Project

Team)

Process

Obs & Data

Collection

30 Day

report

60 Day

report

90 Day

report

Sustainability Check Points

October 2016 November 2017

July 2017

Emergency surgery - Why change?

Before Kaizen:

Multiple points of delay along the patient pathway:

• Long waits in ED to be diagnosed & admitted

• No dedicated Acute Surgical Assessment area

• Long waits for access to emergency surgery -

frequently 30+ patients on the list

• Emergency Theatre pausing due to downstream

flow issues in recovery

• Delays in accessing surgical beds on wards

Emergency

Department

Access

Assesment

Unit and

Emergency

surgery

Ward

Emergency

operating

Theatre

4 Sub-teams

ASAU Access & ED

Emergency Theatres &

Governance

Recovery

❶

❷

❸

Ward-level

Fiona Gleeson-Keane

Síle Kelly / Mairead

McCormick

Ray McLaughlin

Michelle McNamara

Ciara Breen

TEAM LEAD: SUB-TEAM:

❹

Team Summary

KEY CHANGES:

1. Access criteria

2. Priority diagnostics

3. Bloods at first triage

4. Flag for surgical pathway from RAN

PROBLEM: ASAU opened and now requiring criteria to identify suitable patients.

CHANGE: Criteria developed agreed upon and signed off by surgical consultants and ED

consultants

• Total patients 455

• PET Times – 73.63% under

6hr

Reduce inappropriate

admissions

• 37% Not deemed for

admission

Better patient care.

Better patient satisfaction

48%

15%

37%

0%

ASAU Patient Outcomes

Admitted to ESU

Admitted to Other

Discharged Home

Left Department

PROBLEM: Delays in acquiring blood samples and review of their diagnostic results may

increase Patient Experience Times and obscure patient experience.

CHANGE: Nurses obtaining and requesting routine bloods from laboratory as per consultant

led protocols.

Impact: • No issues or time delays with

routine blood tests to date.

• 26% of cannulae sited and blood

tests taken in the Emergency

Department.

• Remaining 74% of done in the

Acute Surgical Assessment Unit.

Next steps:

• Continue to monitor developments and manage any

delays to initiating treatment.

• Monitor demand for extra blood tests to be added

to protocols if need arises.

26%

74%

% Bloods completed in

ED / ASAU

17/07/2017

to

25/08/2017

% completed in ED

% completed in MAUASAU

30 Day Report Out

Team Summary

KEY CHANGES:

1. Prioritisation & Governance of Emergency

Theatres

2. Re-instate theatres 15 & 16 (on 3rd Floor)

3. Create 2nd Emergency Theatre (Now 6 & 7)

4. Dedicated specialty pathways for Emergency

(Em.) Theatres (Urology/ENT/MaxFax)

5. Alternate areas to expedite central lines

6. Anaesthetic nurse reviews on wards

7. Extended recovery hours and changed practices

Code Category Description Target time to theatre Expected location Example Scenarios Typical procedures

1 Immediate Immediate (A) lifesaving or (B) limb or organ-saving intervention. Resuscitation simultaneous with surgical treatment.Minutes Next available Ruptured aortic aneurysm Repair of ruptured aortic aneurysm

Score 5 Surgeon and team must be available May displace electivesMajor trauma to abdomen or thorax Laparotomy/ thoracotomy for control of haemorrhage

to perform case immediately Fracture with major neurovascular deficitFasciotomy

Compartment syndrome

Testicular torsion

2 Urgent Acute onset or deterioration of conditions that threaten life, limb or organ survival; fixation of fractures; relief of distressing symptoms.Hours Emergency list Appendicectomy

Score 4 Surgeon and team must be available Perforated bowel with peritonitis Laparotomy for perforation

to perform case at 20 minutes notice Critical organ or limb ischaemia Embolectomy

Bowel obstruction Strangulated hernia repair

Abscess drainage

Incarcerated hernia

Perforating eye injuries

3 Expedited Stable patient requiring early intervention for a condition that is not an immediate threat to life, limb or organ survival24 Hours emergency list Tendon and nerve injuries Repair of tendon and nerve injuries

Score 3 Surgeon and team must be available Stable & non-septic patients for wide range of surgical proceduresExcision of tumour with potential to bleed or obstruct

to perform case at 1 hour notice 9am-5pm Flexible cysto

Renal stone

Retinal detachment

CABG

Carotid procedures

4 Pending Surgical procedure planned or booked in advance of routine admission to hospitalPlanned Theatre re-instatementEncompasses all conditions not classified as immediate, urgent or expedited.Elective AAA repair

Score 2 surgeon and team to discuss timing or spare emergency capacityCentral line insertion Laparoscopic cholecystectomy

Change of dressings

Second look laparotomy

Note Additional weighting to be given for ;

Clinically Unwell Patients Score +5

Children Score +1.5

Diabetics Score +1

Early warning score abnormalityScore +5

Significant co-morbidity Score +2

Clinician concern Score +5

ESW Patient Score +2

ICU/HDU Patient Score +3

Consultant performing procedureScore +1

PROBLEM: No set location for emergency surgery. Demand exceeded capacity for

emergency care with excessive numbers of operations done out of hours

CHANGE: Now have a second emergency theatre. The 2 defined set emergency theatres are

now operating side by side (theatres 6 & 7)

Next steps:

• Continue to improve utilisation

• Increase patient experience and satisfaction ratings

• Sustain utilisation of emergency list

Impact:

• Significantly reduced waiting times

for patients on the emergency list.

Doubled daily throughput of

emergency list

• Urology, Max Facs and ENT

designated slots for emergency

cases

• Standardised emergency capacity

now across two theatres

• Reduction in late stays for staff

Avg. of 7 patient complaints raised per week with PAL’s pre

Kaizen Zero complaints received to date

since kaizen week

Pre Kaizen Emx Theatre List

Management

Post Kaizen Emx Theatre List

Management

PROBLEM: Lack of prioritisation

CHANGE: Scoring system and governance arrangement in place

Impact:

• Scoring system now in place

• Reduced conflict

• Increased capacity

• Reduced out of hours cases

been completed

PROBLEM: No dedicated speciality pathway for Urology. Long waiting times for emergency

theatre access. Complaints re patient fasting times.

CHANGE: Dedicated consultant-delivered urology emergency lists.

Next steps:

Develop day of surgery transfers to ring-fenced urology emergency bed(s) to ensure high

turnover of transfers.

Impact:

• Waiting time on emergency list

reduced on average by 42hrs per stone

case.

Bed Implications:

• 40 stones per mth = 1,680 hrs

• Saving of 840 bed days per annum.

55.8

13.02

0

10

20

30

40

50

60

Pre-Kaizen Kaizen

Time on emergency list (hours)

Time (hours)

5.2

2.8

0

5

10

Pre-Kaizen Kaizen

Length of stay (days)

LOS (days)

PROBLEM: Delays in the theatre reception were delaying the anaesthetic review, nurses

returning to wards and procedure start times for Em. theatre patients.

CHANGE: Anaesthetic nurses review first Em. theatre patients on wards, ward nurses no

longer accompany up to theatres, and patients bypass reception (or go to a dedicated bay).

Impact:

• Dedicated reception bay sustained (as req.)

• Reviewed 25mins quicker (on avg.)

• Patients no longer wait at reception

(straight to bay or theatre) - prev. 10-

25mins.

• Est. 6.5hrs of ward nurse time freed up

• 1st into Em. Theatre by 08:55 (on avg.)

Next steps:

• Continue training with staff

• Continue to monitor and sustain impact

“It is invaluable to have the first patient

taken from the bedside. It allows us to

focus on patient care and the medication

round, without worrying that we are

causing delays in theatre“ - Ward CNM2

Next steps:

• Earlier start for electives (8am)

• Formalise new working rosters

• Continue to monitor using weekly data

0

2

4

6

8

10

12

17 July 24 July 31 July 7

August

14

August

21

August

5

9

12

10 10 10

No of pts recovered 17/07/17 – 25/08/17

from 2000 – 2200hrs

PROBLEM: Emergency theatre list frequently was at a standstill after 1700hrs

CHANGE: Extension of the Recovery Room opening hours from 20.00 to 22.00hrs to facilitate

patient flow from the emergency list

Impact:

• Trial change of roster period 17thJul–25th

Aug

• Significant increase in amount of pts

recovered

• 56 extra patients accommodated

• Reduction in Emergency Theatre list

numbers

• Continuation of Emergency list after

1700hrs

• Improved elective patient throughput (09-

22.00)

• Improved staff morale

• Reduction in Nursing O/T

• More flexibility around nursing rosters

• Positive change for staff (new 12hr shift)

PROBLEM: Lack of formalised written documentation for Patients on Discharge Planning

CHANGE: To ensure there is a Patient Centred Focus towards Discharge Planning at Ward

Level

Impact:

• Booklet completed and printed

• MDT involved in booklet

• First draft released

• Piloted on x1 Medical (Endas) & 1 Surgical Ward (Pius)

• Improved discharge planning

• Health Literature Review

Next steps:

• Capture patient experience and feedback

• Medical roll out

“ we (GUH) want to tell you what

you (patient) want to know”

Discharge Coordinator

90 Day Report Out

Bypass ED

Enter ED – Transfer Any Available Ward

Enter ED – Transfer Emergency Surgery Ward

0

100

200

300

400

500

600

700

800

900

Pre Kaizen Post Kaizen

Time to theatre mean for appendectomy (Minutes)

Tine to theatre mean for appendicectomy(Minutes)

Pre Kaizen average waiting

time: 13hr 04 mins

Post Kaizen average waiting

time: 4hr 50 mins

Bed Implications:

Saving average of 334

minutes on average per

emergency admission; 44%

reduction.

334 x 550 = 183,700 minutes

3061 hours = 127 bed days

Case Study : Appendectomy

The average waiting time on

emergency list (time put on list to

start of case) excluding outliers is

13.02hrs (range 2.43 to 23.2hrs).

0

5

10

15

20

25

30

35

40

45

50

Pre-Kaizen Post-Kaizen

Time to theatre

Time to theatre

Bed Implications:

Saving average of 34 hours on

average per emergency

admission (78% reduction)

34 x 550 = 18,700 hours

= Saving of 779 bed days per

annum

Case Study : Urology

5

12.5

7.7

6.8

7

6.9

4.7

5.4

8.2

4

5.7

5.2

3.6

5.3

3.8

0 5 10 15

Gen Surg

Plastics

Urology

UHG Post-Kaizen

UHG Pre-Kaizen

Dublin 3

Dublin 2

Dublin 1

52 95 78 90

75 64 44

74

90 87

126

116

85

41

0

20

40

60

80

100

120

140

July August September October November December Jan

A total of 1117 Emergency Cases carried out in Theatres 6

& 7

from 17th July 2017 to 15th January 2018

Theatre 6

498 Emergency cases carried out in Theatre 6 619 Emergency cases carried out in Theatre 7 Average Utilisation of both Theatres for the above period is 70.6%

Results After 10 PM; ◦ 4 Nurses on call

◦ Post Kaizen 5.6 hours less operating/day

◦ Cost savings 86,000 per annum

◦ Also 39.3 additional nursing hours during the week as time in lieu no longer applies

50% reduction in theatre

waiting time ◦ 4,513 days lost previously

◦ Saving of > 2,255 bed days

per annum

LOS Saving 1,166 days

Additional 10 beds in

system

Savings of 4.97 Million

Euro per annum

Pre-Kaizen Post-Kaizen Reduction

EWS LOS 166hrs 124hrs 25% (42hrs)

Sustainability & Benefits

•ED Delays

•Patient

location and

flow erratic

ED Bypass

Emergency ward

•Delays in

identification,

assessment and

treatment of

surgical patients

Acute Surgical

assessment unit

Emergency surgical

ward •3,500

emergency

operations

2nd Emergency

Theatre

>4.9 Million Euro

Saving

2,200 bed days

saved

Reduced length of

stay

20% reduction in

theatre overruns

Complaints down

Reduced out of hours

operations

Financial savings

Shorter PET

Better patient

experience/outcomes

Patient

ESW

Operation

Home

ED

SH

O

Re

g

Surgi

cal

SHO

Surgical

Reg

Consult

ant

Trolley

Ward

Data is key

Bring everyone together ◦ Informed by data they will craft solution and have

ownership

Prepare the mission statement ◦ Define outcome objectives and timeframe

No written strategy or grand plan

Executive must commit at outset

Implement as scheduled and improvise/overcome