What are we trying to achieve?
The aim of the First Elective Surgical Patient of the Day Project is to identify and remove unnecessary delays for the first elective patient in each theatre each day, by improving processes and teamwork.
With the increasing demand for elective surgeries, improving the efficiency of theatres, maintaining clinical safety and protecting patient experience is becoming more and more important. While there are many other factors affecting overall theatre efficiency, starting off the day well can have a positive impact on the rest of the day.
What did we find?
There are more than 10 groups of staff involved in admitting and preparing each patient and theatre for elective surgery every morning. This has to be achieved in a tight timeframe and the teams felt that the process was not working very well. Below were the steps required to prepare a patient and theatre for surgery:
Patient arrives at North Shore Hospital
- Most elective surgical patients arrive the day of their surgery and come to the surgical admissions area at the time specified
- Some patients are asked to arrive the day before surgery and are admitted to a ward overnight
Admissions nurse prepares the patient
- Patients are taken into an exam room by an admissions nurse, who ensures that all pre-operative activities are done using a checklist, such as appropriate fasting, all jewellery is removed, blood or other tests are completed
- This is also when patients change into their theatre gown, cap and booties and their belongings are safely stored in lockers until after surgery
- Once the pre-operative checklist has been completed, the admissions nurse brings the patient into the bed space that has been assigned to them in the pre-operative area and hands over to the nurse for that area
- For patients that have been admitted the day before, the ward staff complete the pre-operative checklist and accompany an orderly who brings the patient down from the ward to the pre-operative area
- The ward nurse then completes a handover to the nurse for the pre-operative area and returns to their ward
Anaesthetic and surgical consent is completed
- Patients are seen in the pre-operative area by both the anaesthetic and surgical teams
- A member of each team comes to see the patient separately, after reviewing their notes and the results of any tests that have been completed e.g. blood tests or x-rays
- The anaesthetist or surgeon talks to the patient about the type of anaesthetic or surgical proceedure they are having, the associated risks of each and what to expect following surgery
- At the end of each of the discussions, patients are asked to sign a form providing consent to proceed with the surgical and anaesthetic components of their care
Theatre nurse completes final check
- In addition to the surgical and anaesthetic teams, each theatre has a team of nurses and an anaesthetic technician. One of the nurses is responsible for preparing the theatre and getting the patient from the pre-operative area
- Before the patient goes into theatre, the theatre nurse reviews the checklist with the patient to ensure all activities have been completed, including consent
Orderly assists nurse to move patient into theatre
- Once the checklist has been completed and the theatre confirms that they are ready for the patient, the nurse requests an orderly to help them push the patient on their bed through to theatre
What have we done?
Representatives of the fifteen teams (including six surgical specialties) involved in getting patients into the theatre worked together to fully understand the problems and identify the right solutions. While the main steps in the process have remained unchanged, the teams identified more than 25 improvement opportunities, examples of which are below:
Creating a shared vision
- Lack of understanding of what other teams do and what part each team plays in the overall process
- Project teams were set up to set up to ensure that all groups involved in the process were equally represented on the project
- Each of these project team members then championed the project with their teams and encouraged teams to work closer together
- We have up to eight theatres available but only five exam rooms and five admissions nurses. It takes on average thirty minutes to prepare a patient for theatre so there was not enough time to prepare up to eight patients within half an hour
- Three of the five admissions nurses started 30 minutes earlier, to allow for up to three additional patients to be prepared before 7.30am when the anaesthetic and surgical teams arrive to consent patients
- Some patients require blood tests to be done the morning of their surgery. With patients arriving at 7am, there was not enough time to have blood results available before the theatre start time, resulting in delayed starts
- We now have a dedicated phlebotomist in the pre-operative area to ensure that all blood samples are taken in a timely manner. This ensures results are available before patients need to go into theatrered before 7.30am when the anaesthetic and surgical teams arrive to consent patients
- Traditionally patients who are admitted on a ward prior to surgery are accompanied to theatre by a ward nurse and an orderly to complete a handover to the theatre staff at approximately 7am. This is a very busy time on the wards which can result in delays
- A review of patient safety guidelines was undertaken to ensure that only patients that needed additional support were accompanied by a nurse. This allowed for more nursing time on the ward while ensuring that patient safety was maintained
- Delays in entering requests for orderlies to retrieve patients from wards meant that these patients often only arrive in pre-operative area just before 8am
- Theatre staff now enter requests for orderlies the night before, meaning that patient transport is the orderlies’ first job of the morning and patients are brought down to the pre-operative area before 7.30am, ready for anaesthetic and surgical consent
- With patient admissions taking an average of 30 minutes each, the admissions nurses would often get interrupted by the anaesthetic or surgical teams wanting to complete consent
- Anaesthetic and surgical teams would often be unable to see a patient to complete consent because the patient was busy with another member of staff, for example the anaesthetic team might be with the patient when the surgical team arrives, so they would need to go away and come back
Teams were allocated time slots with the patient to avoid interruptions and delays
- Admissions nurses now prepare the patients and move them into the pre-operative area before 7.30am, followed by anaesthetic and surgical teams completing consent between 7.30am and 8am
- Theatre nurses or anaesthetic technicians then have 10 minutes to check that everything has been completed and move the patient into theatre
Time slots allocated to teams within theatre
- Theatre nurses started at 8am, not allowing enough time to prepare the theatre, complete the final checklist with the patient in the pre-operative area and move the patient into theatre within 10 minutes
- Theatre nursing rosters were changed to ensure that one nurse from each theatre now starts at 7.30am to allow enough time to prepare the theatre and check in the patient
- Greater teamwork has been encouraged between the anaesthetic technicians and theatre nurses to ensure that there is always one or the other available to check in the patient between 8am and 8.10am
- All patients would be given a bed in a pre-operative area regardless of their condition. Delays were caused because there were only two orderlies to help move these eight patients in beds into theatre
- The majority of elective surgical patients walk into the pre-operative area and walk out later the same day. Therefore three of the eight beds were replaced with Lazy Boy chairs for these patients, which relieved the pressure on the orderlies and removed delays in getting patients into theatre on time
Did we make a difference?
In the 15 weeks since the project went live, we have seen the following improvements:
- 28% increase in the number of patients into theatre on time (from 8% to 36%)
- 60% reduction in the average number of minutes past ‘into theatre’ target (from 15 to 6 minutes)
- 25% increase in the number of surgical lists starting on time (from 11% to 36%)
Performance against 'Into Theatre' target over 15 weeks since start of project
Chart showing improvement in minutes past 'Into Theatre' target since project implementation
Where to from here?
There are two areas for improvement that still need to be completed:
- Departmental meetings:
There are scheduled training and meeting slots for each surgical specialty, anaesthetic and nursing teams. These are currently run independently of each other and potentially impact the efficiency of theatres. A review is being undertaken to see if there is an alternative approach that would ensure that staff could still attend these important sessions without impacting theatres.
- Performance reporting:
A reporting system needs to be developed to make sure that staff can see how they are tracking against the target. This information needs to be easily available in a timely manner to ensure staff have the right information at hand to celebrate their success or investigate further if performance drops.
The members of the project teams will continue to champion getting patients into theatre on time within their own teams and encourage even greater teamwork to continue to further improve performance.