Professor Ray McLaughlin
University Hospital Galway.
TTT Overall General Urology Plastics Vascular
Number 3,600 1,600 490 892 130
All age groups 26 25 47 20 40
< 16 years 10 11 1:17 25 N/a
Total No.
of
Operations
No. of
Operations
working
hours
No. of
Operations
out of
Hours
Appendicectomy 1090 528(48%) 562(52%)
Endoscopy 538 323(60%) 215(40%)
Laparotomy 380 177(47%) 203(53%)
I & D 184 97(53%) 87(47%)
Hernia Repair 86 42(49%) 44(51%)
EUA 78 48(62%) 30(38%)
General Electric/HSE Patient Flow Project
Preparation work (Including Training)
VSM Kaizen
Sustainability
Project Timeline
Project
Scoping
& Planning
VSM Kaizen
Prep
for Kaizen
Basic
Training (For Project
Team)
Process
Obs & Data
Collection
30 Day
report
60 Day
report
90 Day
report
Sustainability Check Points
October 2016 November 2017
July 2017
Emergency surgery - Why change?
Before Kaizen:
Multiple points of delay along the patient pathway:
• Long waits in ED to be diagnosed & admitted
• No dedicated Acute Surgical Assessment area
• Long waits for access to emergency surgery -
frequently 30+ patients on the list
• Emergency Theatre pausing due to downstream
flow issues in recovery
• Delays in accessing surgical beds on wards
Emergency
Department
Access
Assesment
Unit and
Emergency
surgery
Ward
Emergency
operating
Theatre
4 Sub-teams
ASAU Access & ED
Emergency Theatres &
Governance
Recovery
❶
❷
❸
Ward-level
Fiona Gleeson-Keane
Síle Kelly / Mairead
McCormick
Ray McLaughlin
Michelle McNamara
Ciara Breen
TEAM LEAD: SUB-TEAM:
❹
Team Summary
KEY CHANGES:
1. Access criteria
2. Priority diagnostics
3. Bloods at first triage
4. Flag for surgical pathway from RAN
PROBLEM: ASAU opened and now requiring criteria to identify suitable patients.
CHANGE: Criteria developed agreed upon and signed off by surgical consultants and ED
consultants
• Total patients 455
• PET Times – 73.63% under
6hr
Reduce inappropriate
admissions
• 37% Not deemed for
admission
Better patient care.
Better patient satisfaction
48%
15%
37%
0%
ASAU Patient Outcomes
Admitted to ESU
Admitted to Other
Discharged Home
Left Department
PROBLEM: Delays in acquiring blood samples and review of their diagnostic results may
increase Patient Experience Times and obscure patient experience.
CHANGE: Nurses obtaining and requesting routine bloods from laboratory as per consultant
led protocols.
Impact: • No issues or time delays with
routine blood tests to date.
• 26% of cannulae sited and blood
tests taken in the Emergency
Department.
• Remaining 74% of done in the
Acute Surgical Assessment Unit.
Next steps:
• Continue to monitor developments and manage any
delays to initiating treatment.
• Monitor demand for extra blood tests to be added
to protocols if need arises.
26%
74%
% Bloods completed in
ED / ASAU
17/07/2017
to
25/08/2017
% completed in ED
% completed in MAUASAU
30 Day Report Out
Team Summary
KEY CHANGES:
1. Prioritisation & Governance of Emergency
Theatres
2. Re-instate theatres 15 & 16 (on 3rd Floor)
3. Create 2nd Emergency Theatre (Now 6 & 7)
4. Dedicated specialty pathways for Emergency
(Em.) Theatres (Urology/ENT/MaxFax)
5. Alternate areas to expedite central lines
6. Anaesthetic nurse reviews on wards
7. Extended recovery hours and changed practices
Code Category Description Target time to theatre Expected location Example Scenarios Typical procedures
1 Immediate Immediate (A) lifesaving or (B) limb or organ-saving intervention. Resuscitation simultaneous with surgical treatment.Minutes Next available Ruptured aortic aneurysm Repair of ruptured aortic aneurysm
Score 5 Surgeon and team must be available May displace electivesMajor trauma to abdomen or thorax Laparotomy/ thoracotomy for control of haemorrhage
to perform case immediately Fracture with major neurovascular deficitFasciotomy
Compartment syndrome
Testicular torsion
2 Urgent Acute onset or deterioration of conditions that threaten life, limb or organ survival; fixation of fractures; relief of distressing symptoms.Hours Emergency list Appendicectomy
Score 4 Surgeon and team must be available Perforated bowel with peritonitis Laparotomy for perforation
to perform case at 20 minutes notice Critical organ or limb ischaemia Embolectomy
Bowel obstruction Strangulated hernia repair
Abscess drainage
Incarcerated hernia
Perforating eye injuries
3 Expedited Stable patient requiring early intervention for a condition that is not an immediate threat to life, limb or organ survival24 Hours emergency list Tendon and nerve injuries Repair of tendon and nerve injuries
Score 3 Surgeon and team must be available Stable & non-septic patients for wide range of surgical proceduresExcision of tumour with potential to bleed or obstruct
to perform case at 1 hour notice 9am-5pm Flexible cysto
Renal stone
Retinal detachment
CABG
Carotid procedures
4 Pending Surgical procedure planned or booked in advance of routine admission to hospitalPlanned Theatre re-instatementEncompasses all conditions not classified as immediate, urgent or expedited.Elective AAA repair
Score 2 surgeon and team to discuss timing or spare emergency capacityCentral line insertion Laparoscopic cholecystectomy
Change of dressings
Second look laparotomy
Note Additional weighting to be given for ;
Clinically Unwell Patients Score +5
Children Score +1.5
Diabetics Score +1
Early warning score abnormalityScore +5
Significant co-morbidity Score +2
Clinician concern Score +5
ESW Patient Score +2
ICU/HDU Patient Score +3
Consultant performing procedureScore +1
PROBLEM: No set location for emergency surgery. Demand exceeded capacity for
emergency care with excessive numbers of operations done out of hours
CHANGE: Now have a second emergency theatre. The 2 defined set emergency theatres are
now operating side by side (theatres 6 & 7)
Next steps:
• Continue to improve utilisation
• Increase patient experience and satisfaction ratings
• Sustain utilisation of emergency list
Impact:
• Significantly reduced waiting times
for patients on the emergency list.
Doubled daily throughput of
emergency list
• Urology, Max Facs and ENT
designated slots for emergency
cases
• Standardised emergency capacity
now across two theatres
• Reduction in late stays for staff
Avg. of 7 patient complaints raised per week with PAL’s pre
Kaizen Zero complaints received to date
since kaizen week
Pre Kaizen Emx Theatre List
Management
Post Kaizen Emx Theatre List
Management
PROBLEM: Lack of prioritisation
CHANGE: Scoring system and governance arrangement in place
Impact:
• Scoring system now in place
• Reduced conflict
• Increased capacity
• Reduced out of hours cases
been completed
PROBLEM: No dedicated speciality pathway for Urology. Long waiting times for emergency
theatre access. Complaints re patient fasting times.
CHANGE: Dedicated consultant-delivered urology emergency lists.
Next steps:
Develop day of surgery transfers to ring-fenced urology emergency bed(s) to ensure high
turnover of transfers.
Impact:
• Waiting time on emergency list
reduced on average by 42hrs per stone
case.
Bed Implications:
• 40 stones per mth = 1,680 hrs
• Saving of 840 bed days per annum.
55.8
13.02
0
10
20
30
40
50
60
Pre-Kaizen Kaizen
Time on emergency list (hours)
Time (hours)
5.2
2.8
0
5
10
Pre-Kaizen Kaizen
Length of stay (days)
LOS (days)
PROBLEM: Delays in the theatre reception were delaying the anaesthetic review, nurses
returning to wards and procedure start times for Em. theatre patients.
CHANGE: Anaesthetic nurses review first Em. theatre patients on wards, ward nurses no
longer accompany up to theatres, and patients bypass reception (or go to a dedicated bay).
Impact:
• Dedicated reception bay sustained (as req.)
• Reviewed 25mins quicker (on avg.)
• Patients no longer wait at reception
(straight to bay or theatre) - prev. 10-
25mins.
• Est. 6.5hrs of ward nurse time freed up
• 1st into Em. Theatre by 08:55 (on avg.)
Next steps:
• Continue training with staff
• Continue to monitor and sustain impact
“It is invaluable to have the first patient
taken from the bedside. It allows us to
focus on patient care and the medication
round, without worrying that we are
causing delays in theatre“ - Ward CNM2
Next steps:
• Earlier start for electives (8am)
• Formalise new working rosters
• Continue to monitor using weekly data
0
2
4
6
8
10
12
17 July 24 July 31 July 7
August
14
August
21
August
5
9
12
10 10 10
No of pts recovered 17/07/17 – 25/08/17
from 2000 – 2200hrs
PROBLEM: Emergency theatre list frequently was at a standstill after 1700hrs
CHANGE: Extension of the Recovery Room opening hours from 20.00 to 22.00hrs to facilitate
patient flow from the emergency list
Impact:
• Trial change of roster period 17thJul–25th
Aug
• Significant increase in amount of pts
recovered
• 56 extra patients accommodated
• Reduction in Emergency Theatre list
numbers
• Continuation of Emergency list after
1700hrs
• Improved elective patient throughput (09-
22.00)
• Improved staff morale
• Reduction in Nursing O/T
• More flexibility around nursing rosters
• Positive change for staff (new 12hr shift)
PROBLEM: Lack of formalised written documentation for Patients on Discharge Planning
CHANGE: To ensure there is a Patient Centred Focus towards Discharge Planning at Ward
Level
Impact:
• Booklet completed and printed
• MDT involved in booklet
• First draft released
• Piloted on x1 Medical (Endas) & 1 Surgical Ward (Pius)
• Improved discharge planning
• Health Literature Review
Next steps:
• Capture patient experience and feedback
• Medical roll out
“ we (GUH) want to tell you what
you (patient) want to know”
Discharge Coordinator
90 Day Report Out
Bypass ED
Enter ED – Transfer Any Available Ward
Enter ED – Transfer Emergency Surgery Ward
0
100
200
300
400
500
600
700
800
900
Pre Kaizen Post Kaizen
Time to theatre mean for appendectomy (Minutes)
Tine to theatre mean for appendicectomy(Minutes)
Pre Kaizen average waiting
time: 13hr 04 mins
Post Kaizen average waiting
time: 4hr 50 mins
Bed Implications:
Saving average of 334
minutes on average per
emergency admission; 44%
reduction.
334 x 550 = 183,700 minutes
3061 hours = 127 bed days
Case Study : Appendectomy
The average waiting time on
emergency list (time put on list to
start of case) excluding outliers is
13.02hrs (range 2.43 to 23.2hrs).
0
5
10
15
20
25
30
35
40
45
50
Pre-Kaizen Post-Kaizen
Time to theatre
Time to theatre
Bed Implications:
Saving average of 34 hours on
average per emergency
admission (78% reduction)
34 x 550 = 18,700 hours
= Saving of 779 bed days per
annum
Case Study : Urology
5
12.5
7.7
6.8
7
6.9
4.7
5.4
8.2
4
5.7
5.2
3.6
5.3
3.8
0 5 10 15
Gen Surg
Plastics
Urology
UHG Post-Kaizen
UHG Pre-Kaizen
Dublin 3
Dublin 2
Dublin 1
52 95 78 90
75 64 44
74
90 87
126
116
85
41
0
20
40
60
80
100
120
140
July August September October November December Jan
A total of 1117 Emergency Cases carried out in Theatres 6
& 7
from 17th July 2017 to 15th January 2018
Theatre 6
498 Emergency cases carried out in Theatre 6 619 Emergency cases carried out in Theatre 7 Average Utilisation of both Theatres for the above period is 70.6%
Results After 10 PM; ◦ 4 Nurses on call
◦ Post Kaizen 5.6 hours less operating/day
◦ Cost savings 86,000 per annum
◦ Also 39.3 additional nursing hours during the week as time in lieu no longer applies
50% reduction in theatre
waiting time ◦ 4,513 days lost previously
◦ Saving of > 2,255 bed days
per annum
LOS Saving 1,166 days
Additional 10 beds in
system
Savings of 4.97 Million
Euro per annum
Pre-Kaizen Post-Kaizen Reduction
EWS LOS 166hrs 124hrs 25% (42hrs)
Sustainability & Benefits
•ED Delays
•Patient
location and
flow erratic
ED Bypass
Emergency ward
•Delays in
identification,
assessment and
treatment of
surgical patients
Acute Surgical
assessment unit
Emergency surgical
ward •3,500
emergency
operations
2nd Emergency
Theatre
>4.9 Million Euro
Saving
2,200 bed days
saved
Reduced length of
stay
20% reduction in
theatre overruns
Complaints down
Reduced out of hours
operations
Financial savings
Shorter PET
Better patient
experience/outcomes
Patient
ESW
Operation
Home
ED
SH
O
Re
g
Surgi
cal
SHO
Surgical
Reg
Consult
ant
Trolley
Ward
Data is key
Bring everyone together ◦ Informed by data they will craft solution and have
ownership
Prepare the mission statement ◦ Define outcome objectives and timeframe
No written strategy or grand plan
Executive must commit at outset
Implement as scheduled and improvise/overcome