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Data clearly showed that most deaths occurred when senior surgeons were not available due to their routine clinical commitments. Since changing our rotas, death rates have gone down and the less experienced surgeons now feel more supported.

Mr Tan Arulampalan Gastro-laparoscopic Surgeon

Small change, big difference

The medical director at Essex Rivers routinely checks clinical outcomes using Real Time Monitoring. The system triggers a red alert to warn that there may be a problem that needs investigating. Dr Woods saw an alert for lower gastrointestinal surgery indicating a high mortality rate.

[more info] In-hospital mortality for lower gastrointestinal surgery, 2002 - 2005 with alerts indicating there was a problem. The rates were normal for planned surgery but higher than expected for emergency admissions. A change to the surgical rota solved this.

Solution

After looking more closely at the data behind the alert, Dr Woods examined clinicians' notes. She saw the emergence of a pattern. Most deaths occurred on days when there were no senior surgeons present. She checked the surgical staff rota for confirmation.

Mr Tan Arulampalan, gastro-laparoscopic surgeon, said, "Data clearly showed that most deaths occurred when senior surgeons were not available due to their routine clinical commitments."

"Our trust was flagged as having above average in-hospital death rates for surgery to the large bowel. The tool we were using allowed us to analyse the deaths in more detail, and we found that the rates were within the normal range for planned surgery, but higher than expected for emergency admissions on certain days. It turned out that these were days when senior staff were not rostered to the emergency operating theatre or free of planned activities (clinics and so on) and therefore not readily available to support the juniors on the on call rota," said Medical Director, Dr Marion Woods.

Dr Woods worked with her colleagues to create a new rota for operations that ensured that the most experienced surgeons were always available for operation on the most severe cases.

[more info] Mortality rates for procedures on lower digestive tract (with confidence intervals). The surgical rota was changed in 2003. Confidence limits determine the significance of the relative risk. If the lower limit is greater than 100, there's a 97.5% chance that performance is worse than expected. If the upper limit is less than 100 , there's a 97.5% chance that performance is better than expected.

Outcome

"Since changing our rotas, death rates have gone down and the less experienced surgeons now feel more supported. They still get to use their skills and learn on complex cases, but with a senior surgeon, like myself, on hand for advice and to take over if required," said Arulampalan.

Jane Hendricks, laparoscopic nurse practitioner, added, "Changing the rotas has made such a difference to our hospital. It has meant that everyone in the surgical team gets the support they need, which is crucial to the running of our department. It also means a great deal to the patient, as they can feel confident and safe in the knowledge that there will be a senior surgeon in the operating theatre with them at all times."

As a result of those changes, death rates for lower gastrointestinal surgery dropped to the expected national average.

Tool

Real Time Monitoring