towards better outcomes a rural/regional perspective · towards better outcomes a rural/regional...

Graeme Campbell Chief Surgical Officer

Bendigo Health Vice President RACS

Towards better Outcomes A Rural/Regional Perspective

Loddon Mallee Region

What makes safe surgical practice?

Case selection Good surgery and aftercare Early recognition of problem Rescue

Case 1 68 y.o. female Found at home

unconscious, 2 days after low fall

GCS=3 Fixed dilated pupil

Case 1 (cont.)

Urgent craniotomy Evacuation of very large haematoma Transfer planned during procedure, liaison by

ED consultant who came to theatre Two phone calls with consultant neurosurgeon

during case Paramedic helicopter transfer

Case 1 (cont.)

Repeat CT on arrival, satisfactory appearance on operated side

Small contralateral collection drained Patient did not recover

Case 2 52 y.o male, 140 kg Past History: lap band, sleeve gastrectomy,

Roux en Y to leaking sleeve gastrectomy, duodenal switch, large incisional hernia

In hospital with proven pulmonary embolus, on enoxaparin 120mg b.d.

Massive haematemesis with shock Unable to see anything but blood at

gastroscopy

After 5 hours operating by 2 surgeons on what appeared to be a false aneurysm of the splenic artery:-

Ongoing venous ooze pH 7.12, Temp 35.5 Exhausted supplies of blood and blood

products (25 units given so far)

Management Discussion between tertiary unit surgeon and

intensivist, regional surgeon & intensivist & ARV doctor

Waited 6 hours, ongoing replacement including factor 7

Retrieval Repeat laparotomy in tertiary centre the

following day

CLINICAL EMERGENCY STRATEGY

PATIENT Physiology Pathology Probability Projection Progress

ASSESS

PERSONNEL Availability Experience Fatigue

ENVIRONMENT Facilities Equipment

More information needed… with targeted investigation

PROCEDURE

Immediate

Optimise & Proceed

Scheduled

DECIDE NON-OPERATIVE

TREATMENT With active observation

Larger regional hospitals do have

Anaesthetics ICU Modern CT scanners, MRI Trainees A range of surgical specialties Comprehensive cancer care Onsite cardiology

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Larger regional hospitals may not have

Interventional radiology 24/7 Vascular surgery Neurosurgeons Trainees in smaller specialties

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Smaller regional hospitals may depend on

GPs anaesthetists obstetricians emergency physicians

Visiting surgeons Limited junior staff Teleradiology

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Transport Many of our patients travel considerable

distance to get to us Inter-hospital transfers are SLOW Road is quicker than air

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Bendigo Health AGSU 8-10 admissions per day Nearly half need a procedure

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5 Years of Emergency Procedures 780 procedures 17 deaths (2.2%)

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Deaths following emergency procedures (2.2%)

Ruptured AAA Retroperitoneal bleed Necrotizing fasciitis (2) Dead bowel Varices PD peritonitis Clostridial liver abscess

Perf DU with delay Anastomotic leak (2) SB resection (2) Missed enterotomy Iatrogenic SB injury Gangrenous GB Colon stent perforation

Operation & Transfer, what order?

Anaesthetists will often demand ICU A post operative ventilated patient can paralyze a

rural hospital’s recovery area Easy option is then to defer surgery This may not be the best option for the patient,

especially if they have -bleeding -severe sepsis -high ICP

What were the lessons?

Centralization of ambulance call systems has

caused lack of local knowledge Communication should be between senior

doctors Rapid transport might be better than waiting

for retrieval

How should I communicate?


I S B A R


Identification Situation Background Assessment Request The assessment should be accurate

The request must be clear

What is my request?

Reassurance Advice Transfer Come and help

If I want advice or reassurance A picture may well be worth a thousand words

When transfer is required, I want

Single contact person Rapid decision, not “I will ring you

back.” Transport mobilized now, even if all

details of ultimate destination still not worked out

Consultant to consultant communication

Essential for advice or reassurance Can occur after transfer is organized

Quality in Health Care, Consumer Perspective

access appropriateness continuity responsiveness safety effectiveness efficiency

qualityhealth.org.nz

Be careful comparing apples with oranges

Be careful comparing apples with oranges

We all need to work together

Conclusions Rural/regional patients may choose to

undergo healthcare in less than ideal settings Emergencies can present major challenges Even well planned & executed operations can

result in unexpected complications Patient rescue may involve transfer Good communication is the key

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towards better outcomes a rural/regional perspective · towards better outcomes a rural/regional...

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