Irish Medical Organisation

Improving Efficiency and Reducing Length Of Stay - Irish Medical Journal - June 2013

With the increased volume of emergency admissions placing pressure on limited hospital resources a new study published in the Irish Medical Journal highlights a number of key areas in which improved efficiency could be achieved.

The aims of the study were to assess the practice and attitudes of members of the Irish Association of Coloproctology in relation to appropriate Length Of Stay (LOS) for a selection of general and colorectal surgical operations and to assess the current status of day case and day of surgery admissions (DOSA) within the Irish healthcare system.

The research carried out by Dr Solon et al assessed national practices and resources for initiatives to reduce LOS in hospitals and thereby improve efficiency of resource utilisation. Surgeons are supportive of improving efficiency within the health care system through a number of means including reducing length of stay.

Most surgeons (90%) could refer patients for pre-operative anaesthetic assessment if day case surgery was planned. This facility was less developed for patients requiring longer admissions with only 65% of respondents having access to pre-assessment in this setting. Day of surgery admission (DOSA) is recognised by surgeons as being a useful strategy in reducing LOS. Only 55% of consultants had access to DOSA for patients undergoing major surgery.

International best practice, personal experience and unique local factors are used by surgeons to determine the appropriate LOS for patients following elective surgery. While initiatives to reduce LOS can improve the utilisation of limited available resource the authors state that “it is imperative that the correct infrastructure and support processes are available prior to implementation of system-wide changes to avoid adverse patient outcomes.”

The research carried out highlighted that a limiting factor to performing procedures as day cases was the inability to re-admit patients who experience a post-operative complication directly to a surgical ward. The non-availability of an immediate bed not only potentially compromises the outcome but it also reduces patient satisfaction.

The authors noted that centralisation of cancer surgery has resulted in some surgeons practicing on multiple sites. Such surgeons may out of necessity adapt their practice to ensure patient safety depending on the services and staffing available at each centre and their personal commitments on each site.

Out-patient pre-operative assessment ensures that patients are optimally prepared for surgery and significantly reduces the risk of cancellation on the day of surgery. Availability of timely pre-assessment for 5 or 7 day admission cases could optimise medical conditions, reducing the risk of cancellation or postponement on the day of surgery, thereby improving utilisation of scarce theatre time and reducing patient distress. This area of practice is currently a priority for development in most anaesthetic departments.

In keeping with modern international practice, the majority of patients can be admitted on the day of their planned elective surgery. “This has the potential to reduce LOS for every elective patient by at least 1 day, but careful planning is necessary for this to be introduced as routine practice” say Solon et al.

Most operating theatres commence work at 8am, so efficient administrative, medical and nursing processes are necessary to ensure patients are ready for surgery in good time. Such systems were available to only half of consultants in the present series.

The authors note that the introduction of successful day of surgery admission policies require hospital-wide changes including greater out-patient workup, guaranteed bed availability on the day of surgery and changes in work practices so that relevant staff are available earlier in the day.

The introduction of a number of factors such as pre-assessment clinics, increasing day surgery and more day of surgery admissions can all combine to result in significant cost savings. However the authors stress that “it is imperative that the correct infrastructure and support processes are available prior to implementation of system-wide changes to avoid adverse patient outcomes and to prevent inefficient use of theatre time which would lead to theatre overruns or the cancellation of operations”.

All references and author names are contained in the full article in this month’s IMJ, p. 169
Title: Length of Stay Following Elective Surgery – Can We Improve Efficiency?

For further information contact:
Communications Unit, Irish Medical Organisation,
10 Fitzwilliam Place, Dublin 2.
Tel. 01 676 7273 

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