OP E R ATING THEATR E S
number of patients were still receiving facet joint injections (injections of local anaesthetic and/or steroids to block pain) often up to three time per year – this, he pointed out, is an inappropriate use of valuable theatre time. On average between 2015 and 2018, almost 6% of patients with back pain received three or more facet joint injections in a year, at a cost to the NHS of £10.5m. By showing people the data, GIRFT has been able to drive change and tackle the time wasted in theatres for this procedure.
Impact of SSIs
He also went on to highlight the impact of surgical site infection on the use of theatre time, using the example of breast implants. Rates of implant removal within one year vary significantly between Trusts, from 1% to 28%. The Royal Devon and Exeter Hospital reduced implant loss, due to SSI, from 17% to 0%. This was achieved by introducing a new protocol, including: l Pre-op – shower with Chlorhexidine; avoid shaving/waxing.
l Intra-op – prophylactic antibiotics, minimise theatre personnel, skin prep, antibiotic cavity washout, glove changes, minimal implant handling.
l Post-op – prophylactic antibiotics, drain removal.
In fact, the implant rate loss was reduced to 0% just three months after the protocol was implemented – reducing complications and improving outcomes, while also freeing up theatre time.
‘Hot’ and cold’ sites He went on to present data from Trusts that have organised ‘hot’ and ‘cold’ sites. The Health Secretary is currently discussing ‘surgical hubs’, but this has already been achieved at some Trusts, over the past six years, with great success. “In orthopaedics, this is definitely the
way forward,” Prof Briggs asserted. He gave the example of the United Lincolnshire Trust, which reorganised services based on a model of ‘hot’ and cold’ sites. Previously, 900 joint replacements were cancelled in one year; staff morale was poor, patients were unhappy and there was a long length of stay, with average outcomes.
Two years, after creating a ‘hot’ and ‘cold’ split for elective orthopaedics, the Trust achieved exemplar length of stay, increased day case rates, a significant reduction in revision rates for THR and TKR, improved litigation rates, increased productivity (with theatre lists of five joints per day); they cleared the backlog of 900 cases, there were no complaints from patients, and staff morale improved.
No one wanted to go back to the old way of working. This approach was so successful, it was later rolled out to urology, and gynaecology is now next. “We know that if we can do things in a different way, it improves outcomes for patients, but it also makes us more efficient,” he commented. He pointed out that theatres are expensive, costing £20 per minute or £1,200 per hour. “If we don’t get it right, the figures increase even further with agency costs, additional payments and work going to AQPs [Any Qualified Provider],” said Prof Briggs. “However, there are some examples of ‘best in class’ – such as Royal Bournemouth, Gateshead and Royal Lancashire. They have very little agency or banks staff costs; they look after their staff and train and develop them. Some Trusts are the complete opposite, so we need to take people to Trusts that are working well – where they look after their staff and are efficient and effective. We need to look at how we embed this across the NHS going forward,” he continued.
Variation in theatre outputs Theatre outputs are also highly variable, he
Theatre time lost due to late starts, early finishes and delays between operations could potentially have been used by the 92 Trusts to undertake 291,327 more operations – a 16.8% increase.
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pointed out. Some Trusts stop orthopaedic operations over the winter period, but this is not universal. He pointed out that the South Warwickshire Foundation Trust, RNOHT and Conquest Hospital only see a reduction of 10% during the Winter period. If lists are cancelled on the day, as beds have been filled by elective patients or emergency patients, theatres become a “wasted asset”. Lists can also run and finish very early, as there are few admissions due to emergency admissions. “We cannot continue to do this,” he exclaimed. “If lists are inefficient, a lot of work is sent to the private sector. Patients may get their operations, but this means that, instead of paying the tariff price of around £5,500 for a hip replacement, the system is effectively paying twice – the true cost of THR then becomes around £11,000. This is not the best way of using our resources or the tax-payer’s money.”
Late starts and early finishes In November 2018, Prof Briggs led an NHS Improvement project titled: ‘Operating theatres: The key to reducing waiting lists’, which looked at 1.72 procedures and over 600,000 surgical sessions, carried out at 92 Trusts, during 2017. They found that 33% of operating lists started 30 minutes or more late and 38% finished 30 minutes or more early.
A total of 111,000 lists finished at least 60 minutes early. Day lists comprising three four-hour sessions were particularly likely to finish early. He pointed out that theatre time lost due to late starts, early finishes and delays between operations could potentially have been used by the 92 Trusts to undertake 291,327 more operations – a 16.8% increase. “This is about working smarter, not
harder,” commented Prof Briggs. Some of the reasons for lost theatre time
include: l Downtime between cases l Issues with equipment l Changes to the order of the list l Timing in sending for the patient l Cleaning of the theatre between cases l Poor scheduling l Pre-op assessment l No pool of standby patients l Individual anaesthetic/surgeon/theatre staff productivity
Six months after the publication of the report, one Trust reported an average late start of 41 minutes, with an average turnaround time of 47.8 minutes. “How acceptable is that when we have over five million patients on the waiting list? This is what we have to change!” he asserted. COVID-19 has negatively affected elective activity across all regions. In London, March/
JANUARY 2022
©Sylvain Sonnet
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