BACKGROUND
The Rotherham NHS Foundation Trust is a combined acute and community trust providing services at Rotherham Hospital and across the borough to a population of 264,700 people.
Day cases were originally carried out in a separate unit (which opened 27 years ago) at Rotherham General Hospital with two dedicated theatres. However, as the list of procedures which can be carried out on a day case basis has grown, and its benefits to patients and staff (reduced moving and handling, improved infection control) and theatre efficiency (reduced transfer times) have become more widely recognised, the Trust has now expanded the practice to its main theatre complex.
Its Clinical Lead for Day Surgery is Consultant Anaesthetist Dr Kim Russon, who is also the Immediate past President of the British Association of Day Surgery (BADS). Dr Russon is continually exploring ways to increase day surgery, mitigate the impact of winter pressures on elective surgery, and drive down waiting lists for elective procedures, with the help of other colleagues in the department including Consultant Orthopaedic Surgeon Mr Stephen Blair.
APPROACH
Like many Trusts, Rotherham has changed emphasis by moving to make day case the default approach to many elective surgery procedures, asking: ‘what are the only procedures it really isn’t feasible to plan as day cases?’
As part of this, day surgery has been extended not only to its main theatres (as mentioned previously), but where appropriate, for some emergency procedures too. For example, orthopaedic upper limb trauma, such as broken wrists, and surgical treatment of miscarriage.
For elective surgery, however, an important element of the change in strategy is preparing patients from their first consultation to ensure their mind-set is that, all being well, they will be going home the same day.
Consultant Orthopaedic Surgeon Stephen Blair makes a point of including members of the physiotherapy team in his consultations with patients before their procedures, to make sure they are comfortable with all aspects of their journey as a day case, not just the surgery itself.
He said: ’If patients are over the age of 70, or have other medical problems, the day surgery approach may not be possible, but we are now treating probably one in ten patients planned for a hip or knee replacement as day cases. For the right patient, day case hip replacement works well. There are no issues with bed availability and the operating list gets off to a flying start.
‘Also, having started with operations like anterior cruciate ligament reconstructions and then Unicompartmental (Partial) Knee Replacement, the pressures of the pandemic and rising waiting lists have driven us to move on to more complex procedures such as Total Knee or Hip Replacement with appropriate (i.e., younger, healthier) patients – and outcomes have been very successful.’
Equipment is another important factor, and one of the challenges the Trust continues to have is its mixed inventory of fixed operating tables, surgical trolleys and operating table attachments, some of which are more suited to certain specialisms than others.
For orthopaedic surgery, the key factor is the full-length sidebar for attaching clamps – and low height (so a surgical trolley rather than an operating table) is helpful, as physios work with patients to dismount the trolley themselves after their procedure.
In laparoscopic procedures such as cholecystectomy (gall bladder removal), lateral tilt is essential, but not available on early surgical trolleys. On other models, access or attachments can be the issue for other specialisms like orthopaedics and maxillofacial surgery.
Dr Russon explained: ’Ensuring that we have the appropriate trolley for a particular list always adds an extra layer of complexity for the staff setting up theatres, and they also need to take particular preferences of surgeons or anaesthetists into account.’
‘Obviously this is a historical issue – no-one has the budget to go out and replace all of their equipment at once. However, our learning would suggest that the optimum way forward is to find one common platform that can be fitted with a wide range of accessories to accommodate all of these requirements and preferences. That way, there is no issue of tying up particular trolleys – all are appropriate for our needs.’
‘Another factor is powered functions – more recent models of trolley offer electrically adjusted platform height, backrest raise and lower, and other positioning. This offers significant benefits, as it reduces the risk of lifting and handling injury to both patients and staff.’
‘The key to making the right choice about equipment is ensuring Surgeons, Anaesthetists and support staff have the opportunity to trial different models and accessory combinations. It is an investment in time, but ensuring teams are engaged with, and have confidence in, their choices – and have effective communication with procurement – will ultimately mean efficiency in theatre time.’
OUTCOME
The approaches taken at Rotherham have allowed the Trust to increase the annual number of day cases from 4,000 to 6,000, a huge achievement!
For further details on BADS, visit: bads.co.uk