TP8.2.10 Impact of COVID-19 on General Surgery Training in a University Hospital with Ring Fenced Elective Centre

Aim Higher Surgical training was decimated by the COVID-19 pandemic with cessation of elective care. Trainees raised concerns that the elective restart and need for higher theatre activity to clear backlogs would impact on training opportunities. This study evaluated the resumption of training associated with a ring-fenced elective centre (EC). Methods The EC was established in July 2020 and three time periods were determined: pre-COVID (10/19-2/20), 1st wave of COVID (3/20-7/20) and post EC go-live (8/20-12/20). Data was collated from the E-Logbooks of General Surgery Registrars. Results The normal all-speciality pre COVID theatre-activity averaged 1052 cases/month. During the first wave elective activity decreased to 254 cases/month (24% of normal activity). Within 5 weeks of establishment of the EC, theatre activity was near normal despite a reduced number of theatres (with higher theatre utilisation). Pre COVID, trainees accessed 22.9 cases per month which then dropped to 7.7 cases during the first wave of COVID. Post the go live of the EC, trainees were able to operate on 20 cases per month almost back to normal training levels. Prior to the impact of the second wave, each trainee had developed a deficit of 90 cases during the 5 months pause. Conclusion The ring-fenced elective centre has protected training opportunities for higher surgical trainees. However, the pause in training requires a targeted training recovery plan to overcome the deficit secondary to the first and subsequent waves of COVID to ensure that the JCST target of 1200 cases can be met for CCT.

TP5.2.3 Quality improvement project to reduce turn-around times to improve vascular theatre efficiency

Aim One of the factors influencing theatre efficiency is turn-around time (TAT). The aim of this QIP was to reduce turnaround times by 25% thereby reducing financial implications of theatre idle time. Methods Baseline data was obtained from electronic theatre record system ‘Galaxy’ for the period October 2019 to February 2020. TAT (Time from the last patient going to recovery and the next one coming into the theatre) was measured and a period average was established. This QIP mapped processes and conducted interviews, to identify issues contributing to longer turnaround times. Interventions were then constructed and implemented over 6 weeks. Results One of preventable causes of delay identified from staff interviews and personal observations was inadequate patient preparation by the ward. Preintervention percentage theatre utilisation was 86% and turnaround times was 51.7 minutes. A PDSA cycle was initiated focusing on advanced warning (30 minutes prior to the end of the previous surgery) from theatres to wards and advanced preparation from wards, using a newly designed ward-based checklist. After the first PDSA cycle there has been an improvement in TAT to 42.8 minutes, a decrease of 18.2%. Whilst this did not meet our goal of a 25% reduction, this remains significant. Unfortunately due to COVID -19 the second cycle has been delayed. Conclusions Affordable and sustainable improvements will be needed in post COVID-19 recovery phase to tackle the backlog of surgeries. This project has demonstrated that advanced warning system can decrease turnaround times.

EP.FRI.992 Milking the COW: A pilot study of seven-day consultant working

Aims The Five Year Forward View, predicts a funding gap of nearly £30 billion per year by 2020/21, with continued disparity in resources and healthcare demand. Further, the view describes ever widening gaps in three main domains of healthcare; prevention, quality and efficiency. Those domains raised are echoed in the efficient operative working of a general surgical service with an aged, co-morbid population and inefficient theatre utilisation with increasing case cancellation due to lack of bed space. In 2012, the Academy of Medical Royal Colleges recommended patients have the same standard of care seven days a week, with consultant review ‘at least once every twenty-four hours’. In general surgery, will a seven-day consultant led working model with a ‘consultant of the week’ (COW) enable more rapid and appropriate decisions to be made for patients enabling their efficient treatment and reducing length of stay. Method A retrospective analysis of hospital length of stay and mortality before and after the implementation of a consultant led weekday and weekend service in general surgery was carried out looking at data in October 2017 and 2018. Results The introduction of enhanced seven-day working is associated with reductions of one fifth in length of stay but no difference in mortality. Conclusions Whilst statistically significant associations with the COW and reduced length of stay have been made, the clinical significance of one fifth of a day may be negligible. Continued data collection over a longer time period, prospectively will increase the power of the study.

EP.WE.721The effects of COVID-19 on emergency theatre utilisation

Aims The ongoing COVID-19 pandemic and subsequent lockdown have adversely affected elective care services within the NHS. Emergency Services are also affected to varying extents nationally. Due to deferred elective services our hospital was able to implement two emergency theatres running in parallel as an attempt to minimise these effects. We aimed to assess the change in delivery of essential and emergency surgeries due to the pandemic in a local district general hospital. Methods Retrospective study of emergency theatre cases performed during the month of November 2019 and November 2020. Parameters of theatre efficiency included: sending times, anaesthetic times, operating times and length of recovery, with specific attention to recovery in theatre time Results The time taken to send for patients from the wards increased by 24% (n = 124 vs 49) during the pandemic compared with before. Anaesthetic time also increased by 15% (p = 0.0072, n = 124 vs 49). Recovery time required in theatre increased by 150% (p = 0.0321, n = 124 vs 49). Total recovery time however reduced by 9%. Conclusion Our audit quantifies the effects of COVID 19 pandemic on surgical care delivery and documents delays at nearly all stages of the patient journey through emergency theatres. Alternating procedures in a second emergency theatre has mitigated the delay of theatre-based recovery.

Detailed cost of robotic-assisted surgery in the Australian public health sector: from implementation to a multi-specialty caseload

Background A barrier to the uptake of robotic-assisted surgery (RAS) continues to be the perceived high costs. A lack of detailed costing information has made it difficult for public hospitals in particular to determine whether use of the technology is justified. This study aims to provide a detailed description of the patient episode costs and the contribution of RAS specific costs for multiple specialties in the public sector. Methods A retrospective descriptive costing review of all RAS cases undertaken at a large public tertiary referral hospital in Sydney, Australia from August 2016 to December 2018 was completed. This included RAS cases within benign gynaecology, cardiothoracic, colorectal and urology, with the total costs described utilizing various inpatient costing data, and RAS specific implementation, maintenance and consumable costs. Results Of 211 RAS patients, substantial variation was found between specialties with the overall median cost per patient being $19,269 (Interquartile range (IQR): $15,445 to $32,199). The RAS specific costs were $8828 (46%) made up of fixed costs including $4691 (24%) implementation and $2290 (12%) maintenance, both of which are volume dependent; and $1848 (10%) RAS consumable costs. This was in the context of 37% robotic theatre utilisation. Conclusions There is considerable variation across surgical specialties for the cost of RAS. It is important to highlight the different cost components and drivers associated with a RAS program including its dependence on volume and how it fits within funding systems in the public sector.

Detailed Cost of Robotic-assisted Surgery in the Australian Public Health Sector: From Implementation to a Multi-specialty Caseload

Background: A barrier to the uptake of robotic-assisted surgery (RAS) continues to be the perceived high costs. A lack of detailed costing information has made it difficult for public hospitals in particular to determine whether use of the technology is justified. This study aims to provide a detailed description of the patient episode costs and the contribution of RAS specific costs for multiple specialties in the public sector. Methods: A retrospective descriptive costing review of all RAS cases undertaken at a large public tertiary referral hospital in Sydney, Australia from August 2016 to December 2018 was completed. This included RAS cases within benign gynaecology, cardiothoracic, colorectal and urology, with the total costs described utilizing various inpatient costing data, and RAS specific implementation, maintenance and consumable costs.Results: Of 211 RAS patients, substantial variation was found between specialties with the overall median cost per patient being $19,269 (IQR: $15,445 to $32,199). The RAS specific costs were $8,828 (46%) made up of fixed costs including $4,691 (24%) implementation and $2,290 (12%) maintenance, both of which are volume dependent; and $1,848 (10%) RAS consumable costs. This was in the context of 37% robotic theatre utilisation. Conclusions: There is considerable variation across surgical specialties for the cost of RAS. It is important to highlight the different cost components and drivers associated with a RAS program including its dependence on volume and how it fits within funding systems in the public sector.

Novel approach to recording theatre utilisation data using Pinpoint: a wearable real-time location services device

IntroductionInefficient theatre utilisation is costly for patients, staff and healthcare organisations. Active management projects have proven effective at identifying and streamlining delays in the perioperative patient journey.AimThe aim of this study is to assess whether a novel, wearable, autonomous, Wi-Fi-based real-time location services (RTLS) device could be used to accurately record and process theatre utilisation data.MethodsA novel RTLS device was employed in our theatre department between June and September 2017. Data were collected pertaining to time of arrival and departure from the surgical day ward, operating theatre and recovery using this device, and compared with our institution’s existing written record of theatre data.Results101 patients were enrolled, but manually recorded data were unavailable on 18 patients. Among the remaining 83 patients, mean difference in recorded start times was 0.43 min (p=0.64). Mean difference in theatre end times was 1.63 min (p=0.41). Mean difference recorded in overall time in theatre was 1.19 min (p=0.59).ConclusionThe RTLS device provided a reliable record of theatre utilisation, without requiring manual input, with potential as a tool to identify and improve inefficiencies in the theatre department.

A sub-specialised emergency general surgery on call can improve theatre utilisation

Background: Theatre efficiency and delivery of a safe emergency general surgery service are important topics in the current climate of limited funding and resources. No studies have examined the impact of restructuring a general surgery emergency on call system on theatre utilisation and efficiency.Methods: Data was collected for twelve months prior and twelve months after the introduction of a sub-specialised on call system on operating minutes, out of hours operating and which procedures were done after 10 PM using a prospectively maintained database. Theatre utilisation was calculated and compared using a paired T test.Results: In 2012, between 8 AM and 5 PM, 993 emergency procedures were done in 2012 compared 1300 in 2015 corresponding to 34585 and 90311 minutes of operating respectively and 17.5% and 45.8% of total theatre time available (p<0.05). 160 procedures in 2012 were performed after 10 PM and 106 in 2015 corresponding to 16457 and 9341 minutes respectively (p<0.0001).Conclusions: A sub-specialised emergency general surgery on call system can improve theatre utilisation.