Acute Surgery – The Auckland City Hospital Experience
Li Hsee
Outline Acute Care Surgery in NZ
The Auckland City Hospital Experience
Li Hsee, FRACS
Acute Surgical Unit
Auckland City Hospital
Acute Surgery in Crisis?
* Scope of problems in NZ & worldwide
> Access block in ED (delay in surgical assessment)
> Lack of timely access to acute surgical care
> Generalist vs. Sub-specialist
> Shortage of Surgeons
> ? sub-specialisation post fellowship
> Pressure to ? elective throughput
> Potential for erosion of surgical skills in emergency surgery
Acute Surgery in Crisis?
> Lack of Consultant input in managing acute cases
> Consultant commitment while on call
> Lack of timely access to OR
> Non essential acute work after hours
> Disruption of elective theatres
> Lack of resources, funding and understanding at the government and area district health boards levels
Solutions?
* No single best solution but
> Engage in research and study the acute workload to assess needs
> Exchange information and benchmark other hospitals
> Collaborative approach to incorporate hospital Managers, Surgeons and other
disciplines
> Acute workload can be measured and planned
* The hospital's aim is to develop appropriate strategies to manage acute
patients
The NZ Setting
* Recognised as a growing problem to manage acute patients in public hospitals
* Most hospitals manage acute surgical patients differently with no uniformity
* At Auckland City Hospital
- ACUTE SURGICAL UNIT
Surgical Workload
Acute Surgical Unit
> Aim: ? timeliness of clinical assessment & management of emergency surgical
patients in appropriate time frame
ASU Working Principles
> Consultant led service
> Dedicated operating theatre
> Separation of acute and elective workloads
> Robust handover process
> Engage the subspecialists for their expertise
> Enhance training for Registrars in ES
> Promote advanced roles of nursing and allied health professionals
ASU Team
* Mon-Fri (0730-1700)
* Consultant Surgeon
* Trauma/ASU Fellow
* 2 SET 4 Trainees Routine referrals
* 1 Trauma Registrar
* 2 House Officers
* 1 Nurse Specialist
Acute Patient Flow
Handover
* Discuss all surgical admissions and consults over last 24 hours at 730am
* Chaired by Acute Surgeon and On Call Surgeon
* Patient responsibilities are assigned
* Cases for OR identified and prioritised
* Less formal handover @ 4pm and 10pm
Acute Operating Room
* Dedicated operating room for ASU
* Utilise additional OR as available
* On going prioritisation of acute patients
* Meetings with OR coordinator/Anaesthetist
* Assign cases to appropriate Registrars
Impact on Training
* ? level of experience for a high volume emergency/trauma post fellowship
Surgeon
* Dedicated rotation for SET training in acute care surgery with supervision
* Clinical experience for House Surgeons, Trainee Interns and Medical Students
* Multi-disciplinary approach to acute care surgery
SET Training in ACS
* 2 current positions, 6 months rotation
* Aim >100+ major cases
* Primary operator >80% cases
* Close supervision and assistance by Acute Surgeon and Clinical Fellow
* Develop skills in triaging and communication
* All acute GS cases+ competency in emergency trauma procedures
Steering Group Committee
* Meets regularly
* Members: DS, CD, Service Manager, ASU Surgeon, Surgeons from each surgical
unit and Nurse Specialist
* Developed handover guidelines
* Reinforce acute booking criteria/prioritisation
* Acute Surgeon's role
* Junior staff role and responsibility
ASU Outcome Indicators
* Participation in surgical audit
* Timeliness to acute surgery
* Timeliness of surgical assessment and decision making in ED
* ? acute cases during working hours and ? after hour acute operating
* Patient & staff satisfaction
* Registrars training and job satisfaction
Key Performance Indicators
Key Performance Indicators
Key Performance Indicators
Key Performance Indicators
Key Performance Indicators
Future Directions
* ASU service perspective
> Refine the service
> Further Acute Surgeon appointment
* Job satisfaction
* Work/life balance
* Appropriate remuneration
> 24/7 acute surgical service
> Complete separation of elective and acute streams
> Research and evidence based practice
Future Directions
> Training perspective
- Set standards for acute surgery expertise in NZ
- Career goal
Summary
* Acute surgical program at ACH is necessary and positive
* More data on the performance indicators are necessary
* Evolving service that will bring further change in the future
* Aim to benefit acute surgical patients, trainees, surgeons and health services
Thank You
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Ministry of Health
