Taking the long way to theatres: assessing delays in trust internal transfer of acute surgical patients

Background:

Over the COVID-19 pandemic acute surgical services at our trust were moved from running at two sites to running to a single site. This was done in order to protect Site A elective operating capacities. This quality improvement project was inspired by cases whereby significant time delays resulted in poorer patient clinical outcomes

Aims: o To assess the times and delays in the transfer of an accepted and fullyassessed acute surgical patient o To identify the risks of patient safety and outcomes resulting from delays in transfer o To identify if there is an existing trust policy / guideline(s) in place o setstandards for acute surgical patientstransfer

Interventions: o Presentation of results at SurgicalQuality and Safety Governance meeting o Setting standards for transfer methods and time limits o Creation of formal transfer proforma to be filled in for every transferred patient, including clear instructions on the steps required o Creation of easy-to-follow flow-chart including contact numbers of key staff members o Education of key staff members

The following data was collected from clinical notes, electronic patient records, radiology, endoscopy and theatre software for a 3-month period:

1. Demographic information

2. Time & Date seen by A&E

3. Time & Date referred to surgical team

4. Time & Date seen by surgical team

5. Diagnosis

6. Time & Date decision to transfer

7. Type of transfer i. Ambulance ii. Blue light ambulance iii. Independent transport on following day (TCI)

8.Time & Date arrival at Site B

9.Time, Date & category of CEPOD booking

10.Time & Date first procedure* after arrival

11.Nature of first procedure after arrival

12.Complications

13.Discharge date

*first procedure at secondary site as marker of delay

Decision to transfer to arrival at site B 9:16h

Decision to transfer to procedure 43:38h

Decision to transfer to life saving op. 8:38h

CEPOD booking to procedure 12:23h

Findings:

Introduction of the iCough programme at RUH Bath in patients undergoing elective colorectal surgery to reduce post-operative pulmonary complications .

Author: Mrs Nina Stuckey Surgical Team Lead & Clinical Specialist Physiotherapist

Co-Authors: Miss Ella Cottle Physiotherapist & Miss Petra Silverwood Physiotherapist

Introduction

Postoperative pulmonary complications (PPC’s) are common, associated with increased length of stay (LOS), morbidity and increased healthcare costs postoperatively(2,3)

‘iCough’ is an evidence-based pulmonary care programme shown to reduce PPC’s (1)

It has 6 elements shown in Figure 1

Recent research shows Threshold Inspiratory Muscle Trainer (IMT) devises e.g PowerBreathe( figure 2), are superior to Incentive Spirometry (4), with increased impact on inspiratory muscle strength demonstrated by Maximum Inspiratory Pressure (MIP). We therefore chose to implement these as part of an iCoughprogramme.

Aims:

50% reduction in incidence chest infections over 6 months by implementing the iCoughprogramme.

Secondary aim: 1 day reduction in LOS.

Methodology:

Elements of the iCoughprogramme were implemented for patients undergoing elective major colorectal inpatient surgery between March -August 2021.

Patients were given the PowerBreathe IMT device set to 40% of MIP in preoperative assessment with instructions on use. Both ward staff and ITU therapists were provided with specialist training on iCough practises to enable consistency in the delivery of iCough

Patients were provided with a daily goals logbook to enable active engagement in iCough

All elements of iCoughwere implemented and upheld by the Ward Therapist, with the support of all ward staff, including nurses and HCA’s.

Baseline measures were collected including compliance with each of the iCoughelements as well as ongoing compliance which were fed back to the team as well as use of IMT device.

Outcome measures:

-Maximum Inspiratory Pressure (MIP): Baseline ( pre-op clinic), Day 0 (pre-op), Day 1 and Day 3 post-op.

-Number of postoperative chest infections and LOS ( from electronic data and note review)

Regular feedback supported learning and improved compliance resulted from several tests of change such as patients being told to bring in mouthwash, including this item on the ward stock list, putting up coloured routes on the ward to aid mobilisation targets and several adaptations to the patient diary tests.

“ I’m not as breathless climbing stairs”

Results:

“

“Using the power breathe at home before my surgery I noticed improvements in my breathing”.

80 patients were included. Only 54% received an IMT, due to Covid19 delays. Learning from testing resulted in reliable implementation of the basic iCough elements. See figure 4 for process measures: compliance with mobility, mouthwash, head elevation and implementation of PowerBreathe IMT.

PowerBreathe IMT effectiveness:

Of the 54% of patients with PowerBreatheimplantation, 92% used it effectively –see patient comments in bubbles above.

Outcome measures :

Use of the PowerBreatheIMT resulted in a 33% improvement in Maximum Inspiratory Pressure.

As expected MIP reduced following surgery, but remained higher than the pre IMT level and started to improve by day 3 ( figure 5) No patients developed a documented chest infection over 6 months. (Baseline rate March -August 2019: 3 chest infections)

Length of stay reduced on average 0.5 days

Lessons learnt :

-The Ward Therapist Role was integral to maintaining the implementation of iCoughprinciples.

-To support consistency with mouthwash use -a ward stock should be readily available.

-Powerbreathewas acceptable and easy to use by patients.

-Implementation of the PowerBreatheIMT resulted in increased inspiratory muscle strength as demonstrated by increased MIP.

-This increase in respiratory muscle strength is likely to have resulted in the decreased postoperative complications shown.

Next Steps:

• Future funding is being investigated to use IMT as routine pre-hablilitationas well as having therapy presence in the pre-operative clinic.

• Future funding is being explored for mouthwash to become regular stock on the ward.

• Information decimation to other surgical areas to enable wide opportunity of access to the benefits of iCough.

• To collect further qualitative feedback from patients to further investigate the benefits of implementing iCough.

• To collect staff feedback on ease of implementation.

• Development of education videos for patients and staff to increase involvement of preoperative nurses and increase sustainability and decrease dependence on therapist.

• Implementation of electronic recording of iCoughelements and monthly reports for ease of feedback and monitoring of compliance.

• Development of ‘enhanced recovery co-ordinator’ role to oversee training, compliance and spread to other specialities.

Acknowledgement: Sister Claire Drury, RUH Colorectal Ward Staff, Mr Stephen Dalton, RUH Colorectal Enhanced Recovery Lead, Dr Lesley Jordan, Consultant Anaesthetist and Patient Safety Lead.

References:

(1)Cassidy, M.R., Rosenkranz, P., McCabe, K., Rosen, J.E. and McAneny, D., 2013. I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA surgery, 148(8), pp.740-745.

(2) Canet, J. and Mazo, V., 2010. Postoperative pulmonary complications. Minerva anestesiologica, 76(2), p.138.

(3)Kulkarni, S.R., Fletcher, E., McConnell, A.K., Poskitt, K.R. and Whyman, M.R., 2010. Pre-operative inspiratory muscle training preserves postoperative inspiratory muscle strength following major abdo minal surgery–a randomised pilot study. The Annals of The Royal College of Surgeons of England, 92(8), pp.700-705.

(4)Owen, R.M., Perez, S.D., Lytle, N., Patel, A., Davis, S.S., Lin, E. and Sweeney, J.F., 2013. Impact of operative duration on postoperative pulmonary complications in laparoscopic versus open colectomy. Surgical endoscopy, 27(10), pp.3555-3563.