|Daily equality of surgical care|
|Thursday, 29 August 2013|
Solutions for achieving seven-day care are costly and complex, but there are more simple steps the profession can take now to improve service continuity, so writes Robert Diament
As a General Surgeon working in a District General Hospital, this came as no real surprise but it is a troubling observation. The continued delivery of a seven-day service with a five-day mentality has become increasingly difficult, particularly highlighted by the current focus on in-hospital patient safety.
Patient safety programmes are underpinned by structured, multi-disciplinary attention to detail based on an objective evidence base, which has long been the principles of good surgical practice. Prior recognition of these challenges and the key role consultants play in service delivery led the Academy of Medical Royal Colleges (AoMRC) to commission the report Seven Day Consultant Present Care, with input from all Colleges and specialties, published in December 2012. I represented the Royal College of Surgeons of Edinburgh on the working party.
The landscape of general surgery has changed in recent years with the move toward more complex out-patient investigation and treatment pathways. Minimally invasive techniques and advances in anaesthesia have transformed what is surgically feasible in a dedicated short stay unit. In these dedicated units, we have almost attained the previously unattainable nirvana of ‘ring-fenced’ surgical beds allowing planned care to be delivered more efficiently albeit at the cost of a reduction in the number of inpatient surgical beds. Emergency surgery is being reorganised and reconfigured with due recognition of its importance and delivered by well-defined teams with dedicated time and resources. Services are consultant-led, increasingly consultant-delivered and dependent on consultants for continuity of care. This contrasts starkly with my own experience as a trainee in the last century.
There is, however, another side to the coin – inpatients in surgical units are generally there for good reason, which centres on clinical risk due to illness, complexity of treatment and co-morbidity. It is this highly dependent group of patients that features in the study which shows a 44% increase risk of dying after major elective GI or vascular surgery if undergoing operation on Friday as opposed to Monday. The authors in the BMJ article postulate that the observed excess mortality is due to different levels of care delivered at weekends, in the immediate post-operative period. Effective surgical care relies on regular and informed clinical review, experienced clinicians can recognise early signs of ‘failure to progress’ and react to subtle physiological triggers.
Traditionally, surgical teams of trainees and consultants had a unique overall perspective of a case with greater understanding of a patient’s physical, psychological and social factors plus a detailed knowledge of their operation and peri-operative performance. Current streamlined, predominantly nurse-led, diagnostic and pre-operative assessment processes have marginalised the role of trainees in these crucial aspects of surgical care. Trainees’ first direct contact with individual patients is often in the operating theatre or high dependency unit.
Early targeted interventions from a skilled and accessible multidisciplinary team can prevent the development of more severe morbidity and mortality. Proactive intervention is better than a reactive response but this relies on specialty-centred clinical experience. Clinically generic, out-of-hours, roaming teams of doctors and nurse practitioners following ‘fire-fighting’ protocols are unlikely to have the necessary knowledge, skills or time to pre-empt problems.
While on-call emergency surgical teams will respond to any unexpected events in an inpatient, they are fully committed to that day’s emergency workload and shouldn’t be expected to deliver routine care to elective cases. This applies just as much at the weekend as during the normal working week. Many surgeons, recognising these issues, will review their patients at weekends, often in an unstructured, unrecognised and un-remunerated fashion with the very best of intentions – I certainly have. However, this can be a ‘flying visit’ with any nurse who may be available and no accompanying medical staff. On reflection, I have come to recognise that this may be as much about reassuring me as it is for the benefit of patients, though I still enter the hospital on Monday morning with a feeling of uncertainty and trepidation.
How can we address these issues? First, we must recognise the existence of the problem and the current heightened interest in this issue should be a suitable stimulus. The Seven Day Consultant Present Care report recommends three generic cross-specialty clinical standards of care:
This is a high level, aspirational report. Compliance with these standards would incur a significant financial cost requiring more staff, reduced elective work, major service reconfiguration or a combination of all three. Without staff expansion, the social impact on senior staff of increased weekend working must also be considered.
The first of the three standards (daily review by a consultant), is an organisational issue of prioritisation which has been grasped by some surgical departments through reorganisation of rotas and reconfiguration of services. The second standard (prompt non-emergency intervention and investigation outside the normal working week) would improve quality of care directly and enhance efficient use of inpatient beds at a time of almost daily bed crises. The third and final standard (seven-day comprehensive services across all sectors of the NHS) is the most challenging. However, increased support from Professions Allied to Medicine in hospital at the weekends would have immediate clinical and organisational benefits.
Predictably, there is no easy solution but I would suggest that there is a suitable vehicle for surgeons to start to realise the report’s ambitious goals, which is the traditional ward round.
The daily ward round is the single most important event on an inpatient surgical unit. This daily assessment, treatment planning and communication with the patient and team members has been squeezed by laudable initiatives such as extended visiting, protected meal times and drug rounds. Timing and attendance on rounds is unpredictable, with consultants frequently competing for the support of medical and nursing staff within the constraints of trainee shift patterns. The practise of consultants fitting in quick rounds, with or without supporting staff, no longer meets the clinical or organisational needs of today’s complex inpatients. Contrast this with the processes in place for the emergency service in most units. We need to establish the central importance of daily, appropriately structured and staffed, consultant-led ward rounds for all elective inpatients seven days-a-week, supported by the emergency surgical team but, crucially, not delivered by the emergency surgical team. Elective and emergency ward rounds should be planned, predictable, educational, valued but separate.
Chair of RCSEd’s Surgical Specialty Group in General Surgery & Consultant Surgeon, Crosshouse Hospital, Kilmarnock