Does a dedicated orthopaedic day surgery list improve delivery of trauma services?

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1 KEYWORDS Day surgery / Trauma / Finance / Orthopaedics / Fracture Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication January Does a dedicated orthopaedic day surgery list improve delivery of trauma services? by JS Bhamra, BS Dhinsa, S Patel, C Davies and M Oliver Correspondence address: Baljinder S Dhinsa, FRCSEd (Tr & Orth), Consultant Orthopaedic Surgeon, William Harvey Hospital, Kennington Road, Willesborough, Ashford, TN24 0LZ. bsd14@hotmail.com Our aim was to implement a 23-hour pathway for uncomplicated trauma to overcome delays and improve efficiency. A retrospective review of a single surgeon series of 105 consecutive patients operated on between July 2010 and July 2011 was performed. With recently revised trauma tariffs, we believe an efficient day surgery trauma list improves theatre utilisation, reduces inpatient bed demands, prioritises major and sub-specialist trauma and delivers patient satisfaction. Introduction With the increased burden of trauma cases, day surgery trauma lists have become a popular approach to reduce the demand on inpatient NHS services. Several trauma conditions are now included in the Directory of ambulatory emergency care for adults (version four, updated September 2014) (NHS Elect 2014), which provides tariffs associated with day case surgery for payment by results to NHS trusts. The benefits of day case surgery are vast. The day surgery unit (DSU) provides a multitude of economic and patient-focused advantages. In the current climate of bed crises and financial strains within hospitals nationally, a dedicated day surgery trauma service may be a key tool in reducing inpatient admissions and generating income. Many acute uncomplicated trauma patients in trauma units are subject to unnecessary admission and delays in surgery as a result of higher priority cases or delays in theatre due to complex cases. A DSU trauma list was set up within our trust and, after an initial successful pilot scheme, we were able to develop this into a dedicated afternoon list with appropriate levels of theatre staffing. In 2010 the trauma day surgery list became an orthopaedic consultant-led service with the input of consultant anaesthetists with interest in regional anaesthesia. An inpatient coordinated trauma pathway was established. The principle of this pathway was to admit, operate and discharge patients within 23 hours on a one-session afternoon list weekly. The aim of our study was to perform a retrospective comparison of a series of patients operated via this 23-hour dedicated trauma pathway, with patients admitted via a conventional inpatient trauma service. We report our experience of the trauma day surgery unit (TDSU) service with analysis of the number of cases, range of procedures, complications and cost comparison of this approach to trauma surgery. Materials and methods We performed a retrospective review of a single surgeon series of patients operated on between July 2010 and July Patients were assessed for suitability for the 23-hour pathway and given a scheduled operation date on the next trauma list and telephone preoperative assessment. Exclusion criteria for the 23-hour pathway were: patients who were ASA grade >2, had uncontrolled chronic medical conditions, BMI >40, patients who would require extended postoperative monitoring, imaging or additional postoperative care arrangements postop (Table 1). In addition to these exclusion criteria, patients were required to be able to mobilise within six hours of surgery and to have care arrangements in place prior to discharge. Patient data was collected from clinical coding records, hospital software systems (Patient Line) and patient notes. Within the sample (n=105), a sub-cohort of 33 patients (group A) who were operated upon between April 2011 and July 2011 were further analysed to generate income and cost per patient episode values. A concomitant group of 38 patients (group B) admitted as inpatients over the same time period were analysed for comparison. This time period and sub-cohort patient group was chosen for ease of comparison and was deemed sufficient to convey our message of cost savings between both groups. Both patient sub-groups were ASA II or less and of comparable size and case mix. In retrospect, group B also fulfilled the inclusion criteria for the 23-hour pathway for day surgery(table 2). >> 263

2 Does a dedicated orthopaedic day surgery list improve delivery of trauma services? Continued ASA grade >2 Uncontrolled chronic medical conditions BMI >40 Patients requiring extended postoperative monitoring Patients requiring postoperative imaging Patients requiring additional care arrangements postoperatively Table 1 Exclusion criteria for admission to 23-hour trauma day surgery pathway Group Patients ASA grade Surgical procedure Removal of metalwork 17 A (23- hour pathway) B (Inpatient pathway) 33 I 22 II 11 III 0 IV 0 38 I 25 II 13 III 0 IV 0 ORIF* wrist 7 ORIF ankle 4 Achilles tendon repair 2 ORIF hand fractures 1 MUA** forearm/wrist 1 Wound debridement 0 Open joint washout 0 Arthroscopic washout 0 ORIF patella 1 Removal of metalwork 20 ORIF* wrist 8 ORIF ankle 3 Achilles tendon repair 1 ORIF hand fractures 2 MUA** forearm/wrist 2 Wound debridement 1 Open joint washout 1 Arthroscopic washout 0 ORIF patella 0 Table 2 Sub-cohort groups A and B comparison * ORIF open reduction internal fixation; ** MUA manipulation under anaesthesia (MUA) Income was calculated using the Health Regulation Guideline (HRG4) code generated for each surgical procedure (DH ); a cumulative total was calculated for all of the cases in each group and a mean average taken. Cost for each procedure was calculated on a per case basis and included any periods of inpatient admission and preoperative assessment. Cost data included the cost of theatre and staffing costs for each case. All income and cost data were verified by a costing accountant before analysis of the data was performed. Given the retrospective nature of this study, formal consent was not deemed a requirement, however consent for procedures was obtained as according to formal guidelines. Results A total of 105 patients were included in the study group. The mean age was 35 years (range 4-85), and mean operating time was 60.7 minutes (range minutes). The majority of all patients operated were ASA grade I (Table 3). The range of procedures performed is outlined in Table 4. These were considered as routine low risk trauma cases and in addition fulfilled our selection criteria. Almost half of procedures were for removal of metalwork, with a further 20% of cases being open reduction and internal fixation (ORIF) of wrists. In total, 93 out of 105 patients were discharged on the day of surgery (88.6%). Admissions of the remaining patients were due to inadequate postoperative pain control or late finish of list. More importantly, we had no case cancellations and all patients attended on their designated date of surgery. Because our day case lists were held during afternoon sessions, it may be that the number of patients with delayed discharged could be reduced by extending the service to a morning or all day list instead. Two patients had postoperative complications. The first complication was due to fracture displacement following removal of K-wires from a distal radius fracture. This was managed conservatively in a plaster cast and the fracture remodelled. The second complication was a 264

3 The other key reasons for dedicated day surgery procedures are improved patient satisfaction and the advantages of reduced length of stay with the ability to allow recovery in the patient s own home ASA Grade Number of patients (% of total) Group A Group B I 71 (67.1%) II 33 (31.4%) III 2 (1.9%) IV 0 (0%) Table 3 Breakdown of operated patients by ASA grade Number of patients Total income 75, ,224 Total cost 54,459 79,010 Surplus (income cost) + 21, ,214 Mean income/case 2,302 3,400 Mean cost/case 1,650 2,079 Procedure Number of cases Mean surplus/case ,321 Removal of metalwork 50 Table 4 Range and numbers of procedures performed (Total 105) ORIF* wrist 21 ORIF ankle 10 Achilles tendon repair 6 ORIF hand fractures 6 MUA** forearm/wrist 5 Wound debridement 3 Open joint washout 2 Arthroscopic washout 1 ORIF patella 1 Table 4 Range and numbers of procedures performed (Total 105) bleeding wound that occurred immediately postoperatively after plating of a mid-shaft radius fracture. A compression dressing was applied and the patient was admitted for overnight observations and consequently discharged safely the following day. Analysis of the sub-cohort groups demonstrated that all the patients in group A were discharged on the day of surgery. However, in group B the mean preoperative delay on the wards was 1.8 days, with an average of 2.5 bed days used. Moreover, only 10% were discharged on the day of surgery. Financial analysis We performed a cost comparison for the groups A and B. The cost and revenue generated for each group is shown in Table 5. In group A the surplus revenue generated (calculated as total income earned minus cost) was 21,516, while in group B the surplus revenue was 50,214. While group B did generate higher surplus revenue, in group A there was also a saving of 75 bed days compared to group B over the period of April 2011 to July 2011, resulting in a saving of 18,450 simply from the number of bed days saved (based on a bed day cost of 246/day as published in the Department of Health NHS Reference Costs ) (DH ). Updating the cost comparison using the NHS Reference Costs showed that the difference in revenue between the two groups was even smaller (data not shown), suggesting that at the current time there is even greater financial benefit to day surgery trauma. Discussion The use of day surgery is becoming increasingly prevalent in the NHS for both trauma and elective surgery. In the current climate of austerity and need for cost-effective service provisioning, there is a constant drive to increase the range of procedures that can be performed under the remit of day surgery (Lloyd et al 2012). This can be extrapolated to many healthcare systems worldwide. The other key reasons for dedicated day surgery procedures are improved patient satisfaction and the advantages of reduced length of stay with the ability to allow recovery in the patient s own home. Delays in the system For many patients it is frustrating to wait for surgery. It is often not appreciated by institutions how difficult it is for a patient to remain nil by mouth and await a phone call to come in for surgery with no guarantee of a operation, many operations being postponed for days or even weeks. It is becoming all too frequent that patients are waiting more than two weeks for their surgery to take place. In some cases, patients are even brought in for surgery and then cancelled due to over-runs or lack of theatre space. We strive to improve patient care and satisfaction, but all too often fall short of this. >> 265

4 Does a dedicated orthopaedic day surgery list improve delivery of trauma services? Continued For the trust, day surgery also brings the benefit of reduced inpatient bed occupancy, freeing beds that can then be used for increased elective surgery capacity and for emergency medical and surgical admissions. Elective surgery cases carry a higher tariff and can profit the trust, thus decreasing the burden on the waiting list initiatives and weekend lists. Types of cases which benefit from day surgery Several previously published studies have shown that a day surgery unit model for trauma is efficacious and safe (Chandratreya et al 2006, Colegate-Stone et al 2011). Our study shows that a wide variety of trauma procedures can be carried out as a day case. Moreover, we showed that in our unit, there is a potential need for a list dedicated to the removal of metalwork, as this formed almost half of all procedures carried out on the 23- hour pathway. This is likely to be the case nationally across the majority of trauma units. We also found that a large proportion of cases involved upper limb trauma, in these cases there was no effect on patient mobility and so these patients were well suited to a day surgery model. Financial implications With the introduction of the HRG4 tariff codes in 2010 for calculating procedural payments, the reimbursement achieved for day surgery was slightly less than that of inpatient procedures. Over the study period there was a mean average cost benefit of 670 per case for inpatient procedures versus day case. However, since then the HRG tariff rates have been revised and day surgery tariff rates have become more favourable. Moreover, the benefit of reduced bed occupancy with day surgery means that these beds can be utilised more efficiently for complex trauma cases, which are likely to generate even more income for the trust. Therefore, although at face value day surgery appears to generate less surplus revenue, the added bonus of available inpatient beds means that there is potentially a much greater capacity for generating added inpatient revenue on top of the revenue generated from trauma day surgery lists. In addition to the benefit of reduced bed occupancy, the presence of a day surgery list for trauma means that operating time is freed up on the main trauma list, thus allowing for more inpatient trauma cases to be done without minor trauma cases clogging up the system. Thus, it allows for the inpatient trauma list also to run more efficiently, potentially reducing preoperative delays and therefore length of stay in hospital. Training opportunities The trauma day surgery list also provides a unique opportunity for trainees, allowing them to carry out routine trauma cases (index procedures) regularly, under the supervision of a senior surgeon/ consultant. This potentially allows junior trainees to develop their skills on routine low risk patients undergoing relatively straightforward procedures. In this way, the trauma day surgery list carries a significant secondary purpose as a training list. In the current climate of increased demand for service provisioning and reduced opportunity for training, this method of delivering training proves to be a highly beneficial adjunct to assisting consultants on elective and complex trauma lists. Staffing and patient selection From our experiences in running a day case trauma service, we have found that the leadership of a senior skilled surgeon and trauma anaesthetist are essential to ensure the smooth running of the pathway. Involvement of a theatre sister and trauma co-ordinator liaison ensured smooth running of the trauma list and minimised delays between presentation and operation. Key to the 23-hour pathway is appropriate patient selection; this relies greatly on the experience of the booking clinician in ensuring that the exclusion criteria highlighted previously have been stringently applied. We found that none of the patients booked for the 23-hour pathway required admission or cancellation due to poor selection, hence, we are confident that the patient-related criteria we have set are appropriate. In order to avoid inappropriate patient selection, all patients booked into the 23-hour pathway were discussed with a senior surgeon or in the daily trauma meeting. Our study demonstrates a role for dedicated trauma day surgery across orthopaedic units. Other studies also support this (Howells et al 2010). Crucial to the efficient running of the trauma day surgery unit is effective communication between the booking clinician, senior surgeon and trauma co-ordinator.by appointing a dedicated trauma co-ordinator we could ensure that patients were appropriately pre-assessed and booked into a designated list, any required kit and intraoperative imaging was ordered and any special postoperative requirements, for example physiotherapy or orthotics were arranged to avoid unnecessary admission. Study limitations We recognise that there are potential deficiencies in our study. Patients in the sub-cohorts were not matched for procedure performed, therefore, there may have been disparities in the tariff calculations. However, this was minimised by selecting inpatients of similar ASA grade and only simple trauma cases were selected for comparison. The tariff calculations were based on the 2011 HRG4 tariff rates. The values may therefore now be out of date, given that the updated rates are more favourable towards day surgery. Patient satisfaction While we did not assess differences in patient-reported satisfaction between the two groups, our unit has previously published a study showing high rates of satisfaction reported by patients admitted to a day surgery service (Krishnan et al 2007). In support of our observed satisfaction rates with this service, it is difficult not to argue that patients who are given a date for their procedure are happier than those who are frequently cancelled due to over-runs, lack of theatre space, and those who wait for days or weeks in anticipation of a potential date with no guarantee of having their surgery that day. 266

5 Conclusion In conclusion, we have shown that while higher tariffs are associated with inpatient procedures, the cost per patient is less using the 23-hour trauma pathway. We believe that an efficient trauma day surgery list improves theatre utilisation, reduces inpatient bed demand, provides unique training opportunities and helps achieve prioritisation of major and sub-specialist trauma while delivering high rates of patient satisfaction. Our goal is to achieve a Best Practice Tariff for this care model. References Chandratreya AP, Spalding TJ, Correa R 2006 Development and efficiency of an acute knee trauma list Injury 37 (6) Colegate-Stone T, Roslee C, Shetty S et al 2011 Audit of trauma case load suitable for a day surgery trauma list and cost analysis Surgeon 9 (5) Department of Health NSRC4 NHS Trusts and PCTs combined reference cost schedules Available from: government/publications/ reference-costspublication (Accessed January 2017) Howells N, Hughes A, Livingstone J et al 2010 A role for day case surgery in orthopaedic trauma care? Bone and Joint Journal 92-B (SUPP IV) 549 Krishnan P, Ntima O, Armanious S, Davies C 2007 Patient satisfaction with day surgery service in a busy district general hospital Journal of One Day Surgery 17 (Supplement) Lloyd J, Lockhart J, Sisak K, Middleton R 2012 How to cut overnight stays and improve trauma pathways how-to-cut-overnight-stays-and-improve-traumapathways-/ article (Accessed September 2017) NHS Elect 2014 Directory of ambulatory emergency care for adults Available from: www. ambulatoryemergencycare.org.uk/file_download. aspx?id=16666 (Accessed January 2017) About the authors Jagmeet Singh Bhamra MRCS Specialty Registrar in Trauma and Orthopaedics, University Hospital Lewisham, London Baljinder S Dhinsa FRCSEd (Tr & Orth) Consultant Orthopaedic Surgeon, William Harvey Hospital, Willesborough, Ashford. Sohil Patel MRCS Specialty Registrar in Trauma and Orthopaedics, Royal National Orthopaedic Hospital, Stanmore Chi Davies FRCA Consultant Anaesthetist, William Harvey Hospital, Willesborough, Ashford Matthew Oliver FRCS (Tr & Orth) Consultant Orthopaedic Surgeon, William Harvey Hospital, Willesborough, Ashford No competing interests declared Members can search all issues of the BJPN/JPP published since 1998 and download articles free of charge at Access is also available to non-members who pay a small fee for each article download. 267

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