Optimising the ‘engine’ of the hospital through investment in surgical infrastructure

RCSI Vice-President Prof Deborah McNamara speaks to Denise Doherty about a number of important projects that aim to significantly improve access to surgical care

Perioperative and surgical teams in Ireland work diligently to provide an efficient and safe service for patients against a background of staff shortages, insufficient bed numbers, and long waiting lists.

However, staff have “hit the limit” of what can be achieved through existing efficiencies, according to Prof Deborah McNamara, RCSI Vice-President and Consultant General and Colorectal Surgeon at Beaumont Hospital, Dublin.

Prof McNamara told the Medical Independent (MI) that staff have worked assiduously to improve efficiency. Measures have included the greater use of day-case/ambulatory surgery where appropriate, and increasing the number of procedures performed in model 2 hospitals. But the ongoing efforts of healthcare staff are simply not enough to fully address the barriers to optimal and timely surgical care.

Hope is on the horizon, however. Surgical infrastructure has received “desperately needed” investment for “the first time in a generation” and this is expected to have a significant and lasting impact, according to Prof McNamara.

The RCSI is playing an integral role in implementing a number of initiatives to improve access to surgery. Measures include the development of surgical hubs, the roll-out of the National Perioperative Patient Pathway Enhancement Programme (NPPPEP), and continued input from the “often unrecognised” and highly skilled frontline workforce.

Surgical hubs – ‘part of the solution’

Prof McNamara expressed her delight at the recent announcement by the Minister for Health Stephen Donnelly that sites have been selected for several new surgical hubs, which she described as “one part of the solution”. She anticipates that the surgical hubs will have “a huge and positive impact on waiting lists” when operational. The estimated cost of the project is €100-120 million in terms of revenue and capital requirements.

The surgical hubs are being developed in key locations on-site or on sites operated under the governance of model 4 hospitals, with the intent of having an impact on day-case waiting lists in advance of the development of regional elective hospitals.

The locations selected by the Minister for the hubs are: Merlin Park University Hospital, Galway; Cork University Hospital; Dublin north (site being finalised); Dublin south (Mount Carmel); Waterford University Hospital; and Limerick (site being finalised).

Prof McNamara explained that most patients on surgical waiting lists are waiting for ambulatory care/day-case procedures. 

The surgical hubs will be modelled on the hugely successful Reeves Day Surgery Centre at Tallaght University Hospital, Dublin. The Reeves centre comprises a 25-bedded unit with four operating theatres and sits separately from the main hospital. It is for patients that need elective surgery under general or local anaesthesia or sedation and are scheduled to go home on the same day of their procedure.

In the initial two years of operation, the total number of patients waiting on day-case surgery reduced by 58 per cent. The number waiting more than three months reduced by 91 per cent.

“I would give great credit to the team at Reeves, who have worked incredibly hard to get their surgical hub up and running,” Prof McNamara commented. “They’ve shown the huge willingness of their surgeons, nursing, and anaesthesiology staff to put their shoulders together and look after the patients…. It just shows that when the system of care is going properly, and when you have the infrastructure, a lot can be done.”

Prof McNamara envisioned that the surgical hubs will “make a huge difference” to the experience of patients and staff, and to patient flow within the hospital setting.

Surgical hubs will be structurally separate from the main hospital, and it will not be feasible for them to accommodate overflow patients from the emergency department. This problem frequently occurs in many day units and is associated with an array of difficulties for staff and negative outcomes for patients. Prof McNamara warned that day units are not appropriate settings for inpatient care, but that the bed crisis has “totally normalised” the use of these areas to accommodate overflow inpatients. She said the “mixing of patients” with varying care needs does not facilitate delivery of optimal care.

“Day wards in our model 3 and model 4 hospitals are designed to deliver day surgery care…. The needs of emergency inpatients are really very different than the needs of day surgery patients, and the opposite of that is true as well. In terms of our day patients, we’re not as efficient as we could be in delivering day-case care because nurses are being pulled in many different directions on day wards that also have very sick emergency patients. So, it’s really hard for our day wards in bigger hospitals to turn over beds as frequently as they should, to do the early ambulation, and to help patients recover and get the advice and information they need to make a good recovery.”

The RCSI recently hosted a conference that focused on the workforce requirements of the new surgical hubs. The College predicts that this expansion of services will provide an opportunity to develop an innovative approach to recruitment and retention of nursing and medical staff. Opportunities may include the development of a career pathway for perioperative nursing, expansion of the physician associate workforce, and the introduction of new roles in the operating theatre, among others.

The first hubs are expected to be operational by the end of 2023 or early 2024 if “ambitious” timelines are met. Prof McNamara predicted that this will be achieved because of the momentum and support the initiative is receiving. “It’s incredibly gratifying to see that the Minister and Department of Health are 100 per cent behind the development of surgical hubs. That sort of drive behind it is really helping to implement the programme.”

Prof McNamara acknowledged that the surgical hubs will only address some of the barriers to better care provision. There will still be patients on waiting lists who need more complex surgery in a major hospital. The recently launched NPPPEP will seek to improve operating theatre access and flow to better facilitate the needs of these patients.

NPPPEP – ‘answers in the data’

The NPPPEP aims to enable a more efficient and effective use of HSE theatre and procedure room resources. It is an 18-month, data-driven programme, which will bring together knowledge and insights from theatre staff and operating departments in hospitals across Ireland.

The NPPPEP is a collaborative initiative between the HSE Clinical, Strategy and Planning, and Operations functions; the RCSI; the National Clinical Programme for Surgery; the National Clinical Programme for Anaesthesia; and participating Hospital Groups and hospitals.

The programme “creates a system of capturing data that helps to drive improvement locally”, according to Prof McNamara. It is about “enabling theatre teams to do the work that they want to do more efficiently”. The overall goal is to optimise “the engine of the hospital”.

“If that engine isn’t working properly, we’re not flowing patients through the hospital as quickly as we need to,” noted Prof McNamara. “If you can’t get patients out to beds, it means you can’t get the next patient into the theatre, and that translates into patients who are admitted for emergency operations like appendicectomy waiting longer than they need to wait. It also translates into difficulties in doing our major cancer surgery, which is obviously very important for people waiting for that.”

The NPPPEP is examining the barriers to the patient accessing care and will “help staff to act on those barriers in ways that are very objective”. This practical element is expected to alleviate some of the unsatisfying professional experiences of perioperative staff.

“Everybody who works in an operating theatre knows that some days can be dreadfully frustrating, when you know there’s someone [waiting] you really want to get down to operate on,” remarked Prof McNamara. “Helping to develop a system where you can identify those barriers to the smooth flow of patients into and out of operating theatres is really important.”

The NPPPEP is “very much grounded in the experiences of the frontline staff”, emphasised Prof McNamara. It will gather “real life” knowledge and insights “to drive change in the right direction” for both patients and healthcare professionals. “Answers are often in the data, in looking at it, sharing it, and acting on it,” according to Prof McNamara. “Systems like this help us work together and learn from the experience of other hospitals…. Sometimes it’s not the norm…. Everywhere is unique, but some of the challenges we face are common. It’s when we start to work together and get all the brains working together that we can really start to make an impact.”

As the technical partner for the programme, RCSI will provide guidance on programme design, development, and delivery with specialised input into the measurement system used to achieve the programme’s objectives of increased overall theatre effectiveness and throughput; ensuring procedures are undertaken in the most effective locations within hospitals; utilising any additional capacity created to reduce surgical waiting lists; and designing a target theatre optimisation model.

Prof McNamara explained that the NPPPEP is “building on more than a decade of experience in the RCSI and theatre efficiency and improvement studies”. These initiatives include the earlier Theatre Quality Improvement Programme (TQUIP), and more recently, “a huge piece of work” with the South/South West Hospital Group called Transforming Theatre, which also looked at issues around efficiency.

“Transforming Theatre really helped to engage nursing, anaesthesiology, and surgical staff in operating theatre departments to try to increase efficiency of the work that we do and to identify the barriers to being more efficient,” Prof McNamara told MI.

“One of the really interesting things about Transforming Theatre with South/South West Hospital Group was that we really worked as a team with that Hospital Group and together we learned so much because it was very much based on the experience of staff. One of the nice things about that programme was that we developed networks of staff across operating theatres in different hospitals so that they could share their experience and talk about what worked for them, and what didn’t work.”

The NPPPEP will be rolled out across all Hospital Groups over 18 months, with two Groups joining in each of the three six-month phases. The first phase of the programme is currently mobilising in Dublin Midlands Hospital Group and Saolta University Health Care Group. 

Prof McNamara said there is much enthusiasm for the programme, which would also demonstrate the great work that staff are undertaking.

‘Diligent workforce’

The surgical hubs, the NPPPEP, and other developments such as the Waiting List Action Plan are predicted to play major roles in improving the current state of surgical services. However, Prof McNamara strongly emphasised that “one of the biggest sources of hope” is the workforce, which continues to work diligently and creatively to optimise patient care and outcomes.

“I think in all the talk of recruitment and retention, it’s easy to forget the really great people we have in the health service already. It’s really important that we recognise the work they’re doing to deliver better care to the individual patient…. I think a lot of the work they do every day just isn’t recognised; it ‘just happens’.”

Prof McNamara also recognised those who have contributed to the “massive progress” in surgery over the last decade. She paid a particular tribute to “all the young consultant surgeons that have come home with new techniques in laparoscopy and robotics”. 

“They come home from abroad, they put their shoulders to the wheel; they start innovating and delivering change with no real additional investment,” she said. “One of the biggest sources of hope we have in the health system is that we are still getting really highly trained surgeons coming home and delivering world-class operations to their patients. It’s easy to forget that because they’re so busy working they’re not really drawing attention or credit to themselves.”

Operations utilising laparoscopic, robotic, and other advanced techniques “often take longer to do and are technically very demanding”, but can contribute to better patient outcomes.

“[These techniques] reduce the amount of time patients need to stay in hospital, give patients such better quality-of-life, and so much less post-operative pain, with just as good oncological outcomes…. They have a huge impact on the requirement for beds, they reduce length-of-stay…. That’s a massive contribution to reducing waiting lists and creating bed capacity for other things like emergency admissions that often goes unrecognised.”

Prof McNamara expressed hope that the level of clinical excellence and efficiency among perioperative teams, and the ongoing investments in surgical services, will help bring significant and
lasting change.