Background
Part of University Hospitals Dorset NHS Foundation Trust, Poole Hospital is an Acute General Hospital serving a population of more than 800,000 and employing 9,000 staff.
Although there are plans to make it the elective hub, with emergency becoming centred on the Royal Bournemouth Hospital, it currently offers acute care, including in its dedicated Trauma and Orthopaedic Ambulatory Care Unit (TOACU).
The unit is where Consultant Trauma and Orthopaedic Surgeon, Miss Joanna Higgins, has recently set up a special 'Hand Hub' — bringing together skills and resources to conduct relatively simple hand procedures. Not only saving significant time in main theatres, this 'Hand Hub' brings a triple benefit of increasing patient throughput (thus reducing waiting lists), saving money for stretched NHS budgets and of course, offering an excellent service for patients.
Specialising in hand surgery, Miss Higgins, who is Deputy Director of Medical Education at the Trust as well as being an RCSEng Surgical Tutor, is a keen contributor to the HandsFirst Collaborative (now in its third iteration). This initiative involves 25 Trusts across England (in the first round), sharing ideas — particularly the desire to drive efficiencies by finding small spaces where these hand procedures can be carried out in an outpatient / ambulatory setting. Her challenge was finding somewhere in her own hospital to turn that concept into reality.
Approach
She homed in on an area originally used for day surgery, which had been mothballed when services were reconfigured. Ideally located next to the Trauma and Orthopaedic Ambulatory Care Unit (TOACU), she liaised with the Unit Charge Nurse, Chris Haskell, and Service Manager, Lindsey Sturman, and together they identified a room where she could stage a 'Proof of Concept' to demonstrate the merits of the approach.
The trial, which included two sessions, each with four patients, carried our procedures such as nail bed and tendon repairs, wound debridement and terminalisations.
Explained Miss Higgins: 'All the patients concerned would have gone to main theatres, so it demonstrated the potential for a massive saving in capacity which could instead be allocated to major surgeries such as hip fixation.
'It's so much better for patients too. If they were going to main theatres, they would need to arrive at 7:30am (having not eaten for several hours), for a nine-minute operation that might not have started until 4:30pm!
'Instead, we have normalised the procedure being done in a minor operations room, making the environment more like going to the dentist. The patient can eat and drink normally beforehand and the whole experience probably takes less than an hour — reducing anxiety and providing a better, swifter recovery.'
Part of the success of this approach has been the development of a special operating table accessory by Plastics Consultant, Mr Matthew Gardiner, in collaboration with Anetic Aid. His innovation was to enable patients to have their hand surgery in a sitting position — something that was simply not possible with a traditional arm table.
Explained Miss Higgins: 'At Poole, we were using a simple narrow arm rest which wasn't ideal. I already knew Matt and his work, and I saw him present his Gardiner Hand Surgery System at a British Society for Surgery of the Hand (BSSH) event in Scotland.
'Although his focus is Plastics and Hand Surgery, I could instantly see how well it would work from an Orthopaedic point of view too: the patient isn't lying flat which makes them feel far less vulnerable and most procedures can be carried out under local anaesthetic.'
Miss Higgins contacted Anetic Aid's Regional Account Manager, Will Barnes, who organised the Hospital to trial the equipment for several weeks. This enabled all staff including Consultants, SHOs, Registrars, Surgical First Assistants, Nursing team members and HCAs to test the equipment and see how it could work for them. The verdict was universally positive: they liked it!
Said Miss Higgins: 'The kit is very versatile — intuitive and easy to adjust. We made our case to the Trust and the result was that we bought the equipment specifically for the Hand Hub. We found patients were more relaxed, some were even taking photos on their phone or watching the football during their procedures!
'There was also an occasion with a patient with COPD, who needed to go to main theatres for a wrist procedure where — as result of using the Gardiner Hand Surgery System — the anaesthetist was able to administer sedation in the slightly seated position ensuring the patient had less chest issues. For the future, if it's better for patients, the Gardiner Hand Surgery System is simple and portable enough to be taken wherever its needed.'
Outcome
The real proof of the Hand Hub and its benefits is now showing in key data gathered by the Trust — specifically how it has helped free up main theatre capacity to improve the percentages of patients with a Fractured Neck of Femur (NoF) achieving surgery within 36 hours of admission.
As the graphs show below, the opening of the Hand Hub in January 2024 made a significant impact.
December 2023 results
December 2024 results
(Summer months are always affected by the Trusts location as a holiday destination, and an increase in trauma admissions from out of area).
Explained TACT (Trauma Assessment and Co-Ordination Team) Lead, Emma Rogers: 'Approximately 20% of our NoFs admitted are not fit for surgery on admission so we will never get to 100%, but the Hand Hub has made a huge difference in taking the smaller injuries (lacerations, tendon / nailbed repairs / terminalisations) out of our main theatres. Although known as the 'Hand Hub', we have also done the occasional foot!
'Jo has done an amazing job in getting the Hand Hub up and running and the impact has not just been our NoFs but general trauma too - and a reduction of patients going through our day case beds.'
The Future
So what next? Miss Higgins (who was given an 'Unstoppable Hero' award by the HandsFirst Collaborative in 2023) is already thinking about how the Hand Hub concept could be extended into other areas.
She explained: 'Another extension of the scope of the Hand Hub could be around the use of WALANT (Wide-awake Local Anaesthesia No Tourniquet) procedures — where a patient can't tolerate the tourniquet or for longer procedures requiring a 'field block'.
'In this we use adrenaline with the local anaesthetic to reduce blood loss, and higher volumes. We could then include procedures such as finger and wrist fractures, potentially extending the concept to the elective, planned care procedures.
'I think the Hand Hub is also good for ad hoc, same day emergency care. If we can fix a problem at that acute stage rather than scheduling a procedure at a later date, it would be another great result for the patient and a terrific time saver for the hospital.'
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