The Feasibility of Implementing the Flexible Surge Capacity Concept in Bangkok: Willing Participants and Educational Gaps

The management of emergencies consists of a chain of actions with the support of staff, stuff, structure, and system, i.e., surge capacity. However, whenever the needs exceed the present resources, there should be flexibility in the system to employ other resources within communities, i.e., flexible surge capacity (FSC). This study aimed to investigate the possibility of creating alternative care facilities (ACFs) to relieve hospitals in Bangkok, Thailand. Using a Swedish questionnaire, quantitative data were compiled from facilities of interest and were completed with qualitative data obtained from interviews with key informants. Increasing interest to take part in a FSC system was identified among those interviewed. All medical facilities indicated an interest in offering minor treatments, while a select few expressed interest in offering psychosocial support or patient stabilization before transport to major hospitals and minor operations. The non-medical facilities interviewed proposed to serve food and provide spaces for the housing of victims. The lack of knowledge and scarcity of medical instruments and materials were some of the barriers to implementing the FSC response system. Despite some shortcomings, FSC seems to be applicable in Thailand. There is a need for educational initiatives, as well as a financial contingency to grant the sustainability of FSC.

494 Streamlining the Minor Operations Process - The Effect of Better Documentation

Introduction Plastic Surgery Minor Operations is a fast paced, rapid turnover operative environment. It is reliant on effective communication, accurate surgery, and time efficiency. It was noticed in our department that there was confusion regarding booking and operative intentions leading to delays in surgery and over-running lists. This was worsening patient experience and leading to delays in patient care. Method In response to the delays and confusion in booking, a new booking form was created, so all patients have a standardised booking containing the necessary information. This form was disseminated across all the booking clinics and formed a vital part of the pre-operative check in process. Results The audit was carried out at the time of introduction, and then re-audited a year later to see if the form has improved care for patients. Results showed that with the new booking form, people were not having to cancel or rearrange patients. Patient booking forms were sufficient, and a copy of the clinic letter no longer required for the operation to proceed or for clarity. It was noted that more senior advice was sought. Conclusions The new form has improved patient flow and quality of patient care, whilst streamlining the booking process.

Antimicrobial Stewardship

Antimicrobial stewardship (AMS) is a healthcare- system- wide approach to promoting and monitoring the judicious use of antimicrobials (including antibiotics) to preserve their future effectiveness and optimize outcomes for patients. Put simply, it is using the right antibiotic, at the right dose, via the right route, at the right time, for the right duration (Centres for Disease Control, 2010). Antimicrobial resistance (AMR) is a serious and growing global public health concern. Antibiotics are a unique class of drug as their use in individual patients may have an impact on others through the spread of resistant organisms. Antibiotics are essential for saving lives in conditions such as sepsis, and without effective antibiotics even minor operations could be life-threatening due to the risk of resistant infections. Across Europe approximately 25,000 people die each year as a result of hospital infections caused by resistant bacteria, and others have more prolonged and complicated illness. By 2050, AMR is predicted to be one of the major causes of death worldwide. Protecting the use of currently available antibiotics is crucial as discovery of new antimicrobials has stalled. Studies consistently demonstrate that 30–50% of antimicrobial prescriptions are unnecessary or inappropriate. Figure 18.1 shows some of the reasons behind this. As well as driving increasing resistance, unnecessary prescribing leads to unwanted adverse effects, including avoidable drug reactions and interactions, Clostridium difficile-associated diarrhoea, and healthcare-associated infections with resistant micro-organisms, all of which are associated with adverse clinical outcomes, including increased length of hospital stay and mortality, with increased cost to healthcare systems. Prudent use of antibiotics improves patient care and clinical outcomes, reduces the spread of antimicrobial resistance, and saves money. There are a number of global and national guidelines outlining what a robust AMS programme should consist of (see Further reading and useful resources), including: ● Infectious Diseases Society of America (IDSA): Guidelines for Developing an Institutional Programme to Enhance Antimicrobial Stewardship. ● National Institute for Health and Care Excellence (NICE): Antimicrobial Stewardship: Systems and Processes for Effective Antimicrobial Medicine Use [NG15]. ● Department of Health (DoH): Start Smart Then Focus, updated 2015. ● DoH: UK 5- Year Antimicrobial Resistance Strategy 2013 to 2018.

Audit of compliance with WHO surgical safety checklist and building a shared mental model in the operating theatre

BackgroundThe use of the checklist has been shown to reduce patient death and postoperative complications and is mandated for use with all National Health Service (NHS) surgery. The aim was to obtain quantitative and qualitative data on compliance with WHO surgical safety checklist during operations in an NHS hospital.MethodData collection was by prospective observational audit of 34 operations using WHO checklist and 5 qualitative criteria to establish efficacy of use: (a) Staff stopped tasks to engage; (b) Staff attentive and listening; (c) Audible to all team; (d) Understanding was checked in briefs and questions/feedback asked; (e) All required staff present.Categorisation: grade 3 (all criteria), grade 2 (three to four of criteria), grade 1 (one to two of criteria). Checklist use was recorded by stage use (eg, Sign In) and component steps.ResultsChecklist stages used were Brief (7/8), Sign In (32/34), Time Out (30/34), Sign Out (18/34) and Debrief (2/8). Checklist component steps were completed more fully in major versus minor operations (17.3/28 vs 8.4/28). Mean qualitative grade was greatest in major surgeries (2.2 vs 1.6) and using general anaesthesia (1.8 vs 1.3). 3/34 of operations achieved Grade 3.ConclusionSign Out and Debrief compliance was low, as was full compliance with component steps of the WHO checklist, especially during minor operations. A focused checklist specific for minor operations could be introduced to remove unnecessary steps and mitigate against excessive omission. Improved qualitative use of the checklist is required to maximise effectiveness and facilitate a shared mental model.

Task-shifting of orthopaedic surgery to non-physician clinicians in Malawi: effective and safe?

There is a shortage of orthopaedic surgeons in Malawi. Orthopaedic clinical officers (OCOs) treat trauma patients and occasionally perform major orthopaedic surgery. No studies have assessed the efficacy and safety of their work. The aim of this study was to evaluate their contribution to major orthopaedic surgery at Zomba Central Hospital. Data about orthopaedic procedures during 2006–2010 were collected from theatre books. We selected major amputations and open reductions and plating for outcome analysis and collected details from files. We compared patients operated by OCOs alone (‘OCOs alone’ group) and by surgeons or OCOs assisted by surgeons (‘Surgeon present’ group). OCOs performed 463/1010 major (45.8%) and 1600/1765 minor operations (90.7%) alone. There was no difference in perioperative outcome between both groups. OCOs carry out a large proportion of orthopaedic procedures with good clinical results. Shifting of clinical tasks including major orthopaedic surgery can be safe. Further prospective studies are recommended.

Analgesia and Anaesthesia

Seventy per cent of patients who present to the ED have pain as their main complaint—and most of the time as a sign of injury or inflammation. Therefore, early assessment by scoring at the point of triage and offering the appropriate analgesia are the first steps towards the management of such patients. The College of Emergency Medicine guidelines suggest that at least 98% of patients in severe pain (pain score of 7–10) should be offered appropriate analgesia within 60min of arrival, or triage, whichever is earlier. In 90% of these patients, the status of pain should be re-evaluated within 60min of receiving the first dose of the analgesic. Despite this clear-cut standard and the availability of a wide variety of analgesics, achieving such a target remains, occasionally, elusive. It must also be realized that a positive experience for the patient largely depends on relief of pain as early as possible. Consequently, one of the primary areas for a new FY1 to focus on is the pain management. Remember it is simple and straightforward in most circumstances. GA may be required in the ED for various clinical indications, for example, cardioversion, facial trauma or burns, and acute respiratory failure (such as in asthma). In an emergency situation it may be a challenging procedure even for an experienced anaesthetist and could be dangerous for the patients. An FY1/2 will never be expected to perform this, but it is important to know when to call for help when the situation demands. Local anaesthesia is widely used in the ED, and is one of the skills foundation trainees learn in the early days. It is comparatively safe if the doctor is aware of how to perform the procedure and the upper limit of the dose for a particular patient. Finally, conscious sedation is also widely used in the ED for reducing fractures and/or dislocations and minor operations. However, it carries the same risks as GA and should be carried out by a doctor who is trained in the procedure as well as in resuscitation. A risk assessment should be performed as a patient with high risks (previous cardiac or respiratory diseases) must be sedated with extreme caution.