To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1111/jocn.12572 or contact your DHB library, or organisational or local library for assistance.

McCloud, C., Harrington, A. and King, L. (2014), A pre-emptive pain management protocol to support self-care following vitreo-retinal day surgery. Journal of Clinical Nursing, 23: 3230–3239.

To read the full abstract, and for access to a free full text version of the article, go to: http://www.biomedcentral.com/1472-6963/14/224/abstract

Sandbaek, B. E., et al. (2014). Impact of changed management policies on operating room efficiency. BMC Health Services Research, 14, 224.

To read the full abstract, and for information on how to access the full text, go to: http://content.healthaffairs.org/content/33/5/764.abstract or contact your DHB library, local or organisational library for assistance.

Munnich, E. L., & Parente, S. T. (2014). Procedures take less time at ambulatory surgery centers, keeping costs down and ability to meet demand up. Health Affairs, 33 (5), 764-769.

For access to a free full text version of the article, go to: http://qualitysafety.bmj.com/content/23/7/589.full

Maggard-Gibbons, M. (2014). The use of report cards and outcome measurements to improve the safety of surgical care: the American College of Surgeons National Surgical Quality Improvement Program. BMJ Quality & Safety, 23(7), 589-599

A secure, web-based cardiology registry, ANZACS-QI, will help improve the quality of cardiovascular care for all New Zealanders who come to hospital with a suspected heart attack through the collection and analysis of data on their treatment and its effectiveness.

Clinical lead for the project is Dr Andrew Kerr, Head of Cardiology at Counties Manukau District Health Board. He says gathering and analysing data on clinical processes and patient outcomes will help to standardise practices, reduce disparity and ensure the right treatment reaches the right people at the right time.

‘Cardiovascular disease accounts for 40 percent of deaths annually, making it the leading cause of death in New Zealand. It therefore has a large impact on the delivery of health services.  Over 20,000 people present to hospitals with a heart attack or unstable angina each year and lifesaving care for these patients requires complex and expensive services.’

Dr Kerr says information in the registry, which is anonymised to protect patient privacy, will provide an overview of patients who undergo surgery or cardiac intervention, how they were assessed, the type of treatment received, complications encountered and details relating to risk and clinical outcomes.

‘This information will be used to determine the best treatment options for future patients and assist with their prioritisation. The registry will be a platform for cardiologists to share what they are doing well and where local quality improvement is needed. It will help identify systemic problems across the country and allow intervention at a national level, if needed.’

The cardiology registry will be rolled out across 38 public hospitals by the end of this month. All patients who attend a public hospital for a procedure to look at their heart’s arteries are being captured in ANZACS-QI. Private catheter labs also plan to adopt the tool later this year.

The other new tool is the cardiac surgery registry which will be used in the five hospitals across the country that perform cardiac surgery. It is also being offered to private surgical centres.

Clinical lead and registry project chair is Christchurch cardiothoracic surgeon Harsh Singh. He says the registry will produce standardised, reportable data on all cardiothoracic surgery, including coronary artery by-pass grafting, valve replacement and aortic aneurysm repair.

‘The cardiac surgery registry will bring New Zealand into line with countries which have similar registries, such as the United Kingdom and Australia, and allow the treatments offered and surgery outcomes here to be benchmarked against those countries. All data is anonymised and access strictly controlled to ensure patient privacy.’

Mr Singh says data collected includes information from admission to 30 days post operatively and has specific fields such as previous interventions or surgery, time in ICU and post-operative complications.

‘The registry will assist surgeons in their decision making and improve communication channels between cardiologists and cardiac surgeons. It will allow surgeons to look at priority scoring and ensure all New Zealand cardiac surgery patients have access to appropriate cardiac surgery services, no matter where they live.’

Both tools were developed through a collaborative project with cardiologists and cardiac surgeons across district health boards, the National Cardiac Network and the New Zealand branch of the Cardiac Society of Australia and New Zealand.

Photo: Members of the New Zealand Cardiac Network and the two cardiac registry project teams with Minister of Health Hon. Tony Ryall.

This study retrospectively reviewed adult patients who underwent elective cancer surgeries in the pre-ACCESS (September 2009 to June 2010) and post-ACCESS (September 2010 to June 2011) eras to assess the impact of this change in resource allocation on wait-times for elective general surgery cancer cases.A total of 732 cases were identified, with no difference in median wait-times between the eras. However, significantly fewer cases exceeded wait-time targets in the post-ACCESS era. There was a significant change in the composition of cancer cases, with fewer breast cancer operations, and more colorectal and hepatobiliary cancer cases in the post-ACCESS era. The authors suggest that shifting OR resources towards emergency surgery does not affect the timeliness of surgical cancer care.

To read the full abstract, and for access to a free full text version of the article, go to: http://www.wjes.org/content/9/1/21/abstract

Anantha, R. M., et al. (2014). Allocating operating room resources to an acute care surgery service does not affect wait-times for elective cancer surgeries: A retrospective cohort study. World Journal of Emergency Surgery, 9 (21), doi:10.1186/1749-7922-9-21.

The day stay chart was developed in response to clinician requests and is intended for use in areas where patients are undergoing treatment or procedures when the length of stay is likely to be less than six hours.

The chart is available to download from the HQSC website at:  http://www.hqsc.govt.nz/our-programmes/medication-safety/news-and-events/news/1292/

The article by two consultant anaesthetists at Great Ormond Street Hospital in London highlights the importance of good preoperative assessment and also discusses strategies to minimise postoperative pain and nausea and vomiting.

To read the full abstract, and for information on how to access the full text, go to: http://www.anaesthesiajournal.co.uk/article/S1472-0299(13)00112-4/abstract or contact your DHB library, or organisational or local library for assistance.

Navaratnarajah, J. & Thomas, M. (2013). Day surgery for children. Anaesthesia & Intensive Care Medicine, 14(6), 232–236.

• clinically excellent
• responsive to users
• cost effective
• integrated.

This document demonstrates how clinical teams in the UK have undertaken improvements in services for patients and users of the service.

NHS Improvement (2013). How to improve quality, delivery and efficiency for laboratory providers and their customers. Leicester: NHS Improvement.

The report is available to read in full text at: http://www.improvement.nhs.uk/documents/Blood_Sciences.pdf

The current aims were to prospectively describe postoperative recovery and health-related quality of life among different groups of day surgery patients and to explore the association between postoperative recovery and healthrelated quality of life 30 days after discharge.

A consecutive sample of 607 adult day surgery patients undergoing orthopaedic, gynaecological or general surgery was included. Postoperative recovery was assessed on days 1, 7 and 14 and health-related quality of life was assessed preoperatively and 30 days following discharge. 

Postoperative recovery improved from day 1 to 14 in all surgical groups. The orthopaedic patients had lower postoperative recovery on day 14 compared to the general and the gynaecological patients. Health-related quality of life was lower among orthopaedic patients, even if significant improvements over time were seen in all groups. Recovery on day 7 was associated with health-related quality of life 30 days after the day surgery.

The authors conclude that particularly orthopaedic day surgical patients seem to favour a closer follow-up in order to support recovery and thereby also positively influence health-related quality of life.

This is an open access article and is available to read in full text at: http://www.biomedcentral.com/1472-6955/11/24/abstract

Berg, K., et al. (2012). Postoperative recovery and its association with health-related quality of life among day surgery patients. BMC Nursing, 11, 24. 

Martin Anderson

TPOT Programme Facilitator

Majholm, B., et al. (2012), Partners’ experiences of the postdischarge period after day surgery – a qualitative study. Journal of Clinical Nursing, 21(17-18), 2518–2527

Participants were 60 patients undergoing day-case hemorrhoidectomy and 60 patients undergoing the same operation with improved patient information. There was a significant improvement in the patient satisfaction scores in the group who received the improved information. This group also sought medical attention significantly less and felt less need for a routine follow-up.

To view the full abstract and for information on how to access the full text, go to:
http://onlinelibrary.wiley.com/doi/10.1111/j.1945-1474.2012.00133.x/abstract or contact your DHB library, or organisational or local library for assistance.

Younis, J., et al. (2012). Reduction in hospital reattendance due to improved preoperative patient education following hemorrhoidectomy. Journal for Healthcare Quality, 3 May, doi: 10.1111/j.1945-1474.2012.00133.x [Epub before print]

This publication from the Enhanced Recovery Partnership outlines the benefits to patients and the NHS that implementation of enhanced recovery principles can present.

Enhanced Recovery Partnership (2012). Fulfilling the potential: A better journey for patients and a better deal for the NHS. [London]: NHS Improvement.

This report is available in full text online at: http://www.improvement.nhs.uk/documents/er_better_journey.pdf

For more detail on the Enhanced Recovery programme, go to: http://www.improvement.nhs.uk/enhancedrecovery/

In conjunction with New South Wales Department of Health, the ministerially appointed Surgical Services Taskforce was tasked with determining the shape and direction of surgery in Greater Sydney over the next 5 to 10 years. Consultations took place with over 400 clinicians who either attended hospitals forums or were contacted by the Surgery Futures project team.

In the first study of its kind in this country, Department of Anatomy researchers analysed 5227 treatment injury claims accepted by the Accident Compensation Corporation of New Zealand (ACC) in 2009.

The research, led by PhD student Abigail Moore and Professor Mark Stringer, identified 313 ACC claims involving inadvertent nerve injuries occurring during medical treatment and diagnosis. They found that two-thirds of these occurred in patients undergoing surgery.

Ms Moore says the research found that the most common cause of nerve injury was when a patient was incorrectly positioned on the operating table under general anaesthesia. Other situations in which nerve injury occurred commonly were when drawing blood for testing and during hip replacement.

“Many of these injuries are minor with no persistent symptoms, but sometimes they cause pain and paralysis and can be very distressing, says Ms Moore. Over a quarter of patients were delayed from getting back to work by the injury, and about 1 in 10 were referred to a surgeon for treatment.”

Accidental nerve injuries happen in all modern healthcare systems and not all such injuries are avoidable, but many could be prevented by greater awareness of which nerves are damaged and in what procedures, she says.

The findings are recently published in the International Journal of Clinical Practice (to read the full abstract and for information on how to access the full text of the article, go to: http://onlinelibrary.wiley.com/doi/10.1111/j.1742-1241.2011.02869.x/abstract or contact your local or organisational library for assistance).

Media Release: University of Otago, 28 February 2012

Other topics considered include: leadership, mangement and staff engagement; technology adoption; staff productivity; operational processes; and the external environment.

Hurst, J., & Williams, S. (2012). Can NHS hospitals do more with less? London: Nuffield Trust.

The report is available in full at: http://www.nuffieldtrust.org.uk/sites/files/nuffield/can-nhs-hospitals-do-more-with-less_full-report-120112.pdf

Lakes District Health Board has posted a 25% lift in surgery productivity in just three years following a comprehensive review of surgical services. Since 2007, Lakes has consistently been one of the top three DHBs in New Zealand for elective surgery performance.

‘When Lakes DHB started the review and improvement process, elective surgery only accounted for around 25% of all surgery’, says CE Cathy Cooney. ‘Last year it was 44%, and we exceeded our annual target for elective surgery by 10%.’

Working with specialist health consultants from Francis Group, Lakes DHB used a structured approach, and involved all theatre users to find the best ways to improve the service. Some changes were relatively easy to achieve, and others were more complex. Together they resulted in much improved efficiency, better use of theatres, much better service to patients, and a significant increase in productivity. Francis Group provided training, analysis and an improvement approach that was led by a new theatre management committee comprising clinicians and managers.

To read the full press release on Scoop, go to: http://www.scoop.co.nz/stories/GE1112/S00050/lakes-dhb-shows-the-way-in-surgical-services.htm

Primiano, M., et al. (2011). Pressure ulcer prevalence and risk factors during prolonged surgical procedures. AORN Journal, 94 (6), 555-566.

To read the full abstract, and for information on how to access the full text, go to: http://www.aornjournal.org/article/S0001-2092%2811%2900972-0/abstract or contact your local or organisational library for assistance.

They report that good progress has been made in the 13 national pilot units and that:

• The hypothesis is proven
• Clinical engagement is strong
• Positive patient feedback
• Quality is not compromised

Case studies from the thirteen clinical spread networks are available. For these and more information about the project, go to: http://www.nhsiq.nhs.uk/8237.aspx

This suggests that many patients are not being given surgery they need and that some may be undergoing operations they do not benefit from.

Even after allowing for legitimate factors that affect rates of surgery between areas, such as differences in need, significant variations were found between primary care trusts (PCTs) in the rates of common operations. Researchers found that, for example:

• in 2009/10, rates of patient admissions for routine operations such as hip and knee replacement varied by as much as 400 per cent, between the highest and lowest PCTs
• rates of coronary artery bypass grafts varied from 34 per 100,000 in Westminster PCT to 197 per 100,000 in Berkshire PCT
• surgery rates for cataract replacement – one of the most commonly performed operations in the NHS – varied by 300 per cent between some PCTs.

Even for some operations whose effectiveness has been questioned, variations in treatment between PCTs are widespread. The removal of tonsils in children has been queried since the 1930s, yet the rate of tonsillectomies in Coventry PCT in 2009/10 was ten times higher than the rate in Kingston PCT for example. 

Some variations also seem to disproportionately affect people in more deprived PCTs. Researchers found that patients from more deprived areas were less likely to have hip replacements – an operation with a strong evidence base for being effective – compared to patients from more affluent areas.

Certain variations also have implications for NHS efficiency and for delivering the £20-billion in productivity improvements the NHS needs to find by 2015. For example, operations such as varicose veins can often be done as a day case rather than requiring an overnight stay, which can be better for patients and less expensive for the NHS. But day case rates for varicose veins vary from around 90 per cent in some PCTs to as little as 30 per cent in others. 

The researchers note that variation in treatment offered for the same conditions can be justifiable, for example, where patients have opted to undergo a specific treatment rather than to take other options. The report recommends the increased use of shared decision-making about proposed treatment between doctors and patients, to incorporate the patient’s assessment of their needs and reflect their tolerance of risk.

To incentivise this, the researchers suggest that local providers of care and commissioners should also be required to publicly justify key indicators of variation in care – both between individual practitioners in their area, and as compared to their neighbouring PCTs.

Appleby, J., et al. (2011).  Variations in health care: The good, the bad and the inexplicable. London: The King's Fund.

Available in full text at: http://www.kingsfund.org.uk/publications/healthcare_variation.html

Eleven participants, 9 team members from the same team and their 2 leaders were interviewed, and seven ways of understanding operating room efficiency were identified: doing one's best from one's prerequisites, enjoying work and adjusting it to the situation, interacting group performing parallel tasks, working with minimal resources to produce desired results, fast work with preserved quality, long-term effects for patient care and a relative concept.

The authors conclude that these seven ways appear to represent both organisation-oriented and individual-oriented understanding of that concept in surgical teams. "The patient is in focus and efficiency is understood as maintaining quality of care and measuring benefits of care for the patients".

Arakelian, E., et al. (2011). How operating room efficiency is understood in a surgical team: A qualitative study. International Journal for Quality in Health Care, 23(1), 100-106.

For the abstract and details of how to access the full text of this paper, go to: http://intqhc.oxfordjournals.org/content/23/1/100.abstract or contact your local or organisational library for assistance.

The findings suggest that team training interventions have utility in enhancing team communication and cohesion, with "team training interventions that are developed in response to the nuances of the context are more likely to become embedded in clinical practice".

Gillespie, B.M., et al. (2010). Enhancing communication in surgery through team training interventions: A systematic literature review. AORN Journal, 92(6), 642-657.

For the abstract, and information on how to access the full text, go to: http://www.aornjournal.org/article/S0001-2092%2810%2900878-1/abstract or contact your local or organisational library for assistance.

They found that a patient's recovery period after day surgery is extended over a longer period than expected, with discomfort such as pain impacting a patient's daily life as long as three months after surgery.

Rosen, H.I., et al. (2010). Patients' experiences and perceived causes of persisting discomfort following day surgery. BMC Nursing, 9:16, doi:10.1186/1472-6955-9-16

The full text of this study is available at: http://www.biomedcentral.com/1472-6955/9/16

Day surgery has become more commonplace owing to advances in pharmacology, anaesthetic and surgical techniques, as it has recognized benefits, such as lower costs and reduced incidence of infection. Recent years have seen increased complexity of day surgery undertaken on a broader range of patients, but with reduced pre-surgery contact with the hospital environment. These recent service changes might have had an effect on the preparation of patients for day surgery, and this in turn might have affected their postoperative recovery. This pilot study used survey methods to examine potential associations between preoperative and postoperative anxiety, and between preoperative anxiety and postoperative recovery. Data were collected in 2008 from a convenience sample of 54 day surgery patients. The instruments used were the Hospital Anxiety and Depression Scale (HADS) and the Quality of Recovery Score (QoR-40). There was a statistically significant relationship between preoperative and postoperative anxiety (χ² = 11.899, d.f. = 1, P = 0.001). The T-test showed a statistically significant difference in the mean scores for QoR-40 score for gender, and for the postoperative anxiety and QoR-40. A relationship between preoperative anxiety and postoperative recovery was not shown. Although challenging to implement in view of restricted timescales, appraisal and revision of pre-assessment processes to incorporate an anxiety measurement tool, such as the HADS, should be considered.

Well done to all the Gisborne Hospital staff involved!

The goal of The Productive Operating Theatre programme is to increase safety, improve reliability and staff wellbeing, and add value and efficiency in operating theatres.

This can improve the patient’s experience in theatre, and their health outcome. To achieve these goals, frontline staff identify problems with their operating procedures and find ways of solving them.

Access the full case study by opening the attached file.

This article appeared in the HIIRC Update, December 2010

Related articles from that issue:

HIIRC Profile: Teresa O'Connor, co-editor of Kai Tiaki Nursing New Zealand

Releasing Time to Care: The Productive Ward Programme

Interview with Auckland DHB staff involved in the Releasing Time to Care: Productive Ward programme

Well done to the Invercargill team!

Hope it creates some interesting discussions?

A report from the Hospital Infection Society Working Group on

Infection Control in the Operating Theatres

K Woodhead, RGN, DMS.  Chair, National Association of Theatre Nurses

E W Taylor, FRCS.  Consultant General Surgeon, Greenock

G Bannister, MD, FRCS.   Consultant Orthopaedic Surgeon, Bristol

T Chesworth, RGN,  BSc.   Infection Control Nurses Association

P Hoffman,  BSc.  Senior Scientist, Public Health Laboratory Service

We will be encouraging particpating DHBs to also upload their monthly reports for sharing and discussion within all DHBs.

Note that periodic reporting according to your TPOT funding agreement does not require this template.  Please check your TPOT funding agreement.

As you all know the DVD copies of "Just a routine operation" was in short supply on our training days. I have asked the NHSI for mor copies but they have no more and no plans to comission any more copies. Here is a link:

According to figures from the Ministry of Health more patients were seen by surgical specialists in the past year than ever before.

The Whanganui District Health Board has completed 5997 first specialist assessments (FSAs) in the 2009/10 year, an increase of more than 1300 patients on the previous year.

Source: Wanganui Chronicle

For full article go to:

http://www.wanganuichronicle.co.nz/local/news/hospital-recruiting-paying-dividends/3925763/

MHANZ aims to support health consumers, its members and the wider health sector by:

• Providing a collaborative, multi disciplinary support, communication and learning network
• Promoting safety in moving and handling practices across the New Zealand health, disability and social service sectors

Putting pieces together in Orthopaedics

When Chris O’Meeghan came to Waikato Hospital to work as an orthopaedics registrar in the early 1990s, he thought it would only be for a short stint.

Nearly 20 years later, O’Meeghan is now the new clinical unit leader of orthopaedics at the hospital and talks enthusiastically about the young department he heads.

Only one surgeon in the department is over 50, and it’s not him.
It’s a busy department and likely to get busier because the survival rate for traumatic events.

“We are busy here – you could say we are applied carpenters,” says O’Meeghan.

Orthopaedics is much like putting lego pieces together.

“There’s two extremes too. There’s a young trauma patient and the old arthritic patient.

“The appeal is of taking the older person’s pain away, they do work well, and they get a good bang for our buck.

“Then there’s the young trauma victim. We put the jigsaw back together again and get them back up again.

“We look after patients across the whole age spectrum. The child with a bone that isn’t straight, the young trauma patient to the older arthritic patient.”

O’Meeghan grew up in Christchurch - one of five children, three of whom became doctors, attended Christ’s College and graduated from Otago with a Bachelor of Medicine and Bachelor of Surgery.

“Becoming a surgeon is a choice I’ve never regretted and I would make the same choice again.”

Once qualified he had a couple of years in Nelson as a house surgeon, returned to Christchurch where he dabbled in neurosurgery, plastic surgery, accident and emergency, intensive care, orthopaedics and spinal injuries.

A year in Invercargill followed and from there to the Waikato.

In 1997, he became a fellow of the Royal Australasian College of Surgeons and then completed his fellowship training at hospitals in England and Canada.

His areas of specialisation are the upper limb, shoulder, elbow, hand and wrist including arthroplasty, hip and knee replacements and knee arthroscopy/anterior cruciate ligament reconstruction. He deals with many sport injuries and works closely with other sports physicians.

Orthopaedics is big business at Waikato. The department has 72 in-patient beds catering for a diverse range of elective cases including upper and lower limb joint replacements as well as trauma cases and complex pelvic reconstructions.

The beds are in three wards, one of which is for paediatric patients.
The majority of elective cases attend pre-admission clinics prior to theatre. Twice a week there are structured multi-disciplinary teaching sessions for patients undergoing total joint replacement surgery. These have been very successful in ensuring that discharge planning starts as soon as possible.
The outpatient area sees approximately 1400 patients per month in fracture clinics and consultant clinics and the plaster room, while there are more than 300 inpatient admissions per month.
There is a high trauma caseload with dedicated theatre lists. It is the busiest acute hospital in the country.

“People survive more accidents these days but with extensive chest, abdominal, and head injuries for example.”

The relationship between the patient and medical staff can often be a long one and for the most part very rewarding.

The orthopaedic doctors are part of a multidisciplinary team including nurses, theatre staff, receptionists, plaster technicians, therapists, typists and many others.

“It is vital we all work together for the benefit of the patient,” he said.
“The orthopaedic department is generally a pretty happy one which is a reflection of the great staff we work with.”

His goal is to see Waikato established with a regional hand unit like those in Middlemore and Christchurch.

“There’s a definite need for that here,” he says.

“Longer term we would like to see the establishment of a “bone shop” model where the orthopaedic department deals with the more minor fractures, dislocations etc which we tend not to see as much as we used to.”

The formation of a regional hand unit would do wonders for the treatment of hand injuries in the Waikato, he says.

O’Meeghan says he’s where he wants to be and is proud to lead one of the country’s busiest orthopaedic teams.

Orthopaedics: (www.waikatodhb.govt.nz/orthopaedics )
• Clinical unit director

• nine consultant orthopaedic surgeons
• 12 registrar positions, including four trainee registrars
• Six house officers
Four clinical nurse managers (includes outpatients).

ENDS

NHS Evidence – QIPP is a collection of evidence to support quality and productivity at a local level in England.

NHS Evidence – QIPP is a collection of real examples of how health and social care staff are improving quality and productivity across the NHS and social care. The QIPP collection also has Cochrane topics drawn from systematic reviews by the Cochrane Collaboration that may help inform local initiatives to address the quality and productivity challenge.

Last updated 05:00 09/07/2010

Balancing the demands of being a surgeon with having children keeps women out of the profession, female doctors say.

A Royal Australasian College of Surgeons work force report shows 7.5 per cent of New Zealand's surgical fellows are women, up from 6 per cent in 2005.

In Australia, 7.7 per cent of surgeons are women.

Christchurch surgeon Jane MacDonald was the second woman in New Zealand to qualify as a urological surgeon in 2001.

http://www.stuff.co.nz/the-press/news/3900198/Women-cut-surgical-careers-for-family

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