Nottingham Elective Orthopaedic Services Surgery - East Midlands

Making Theatres work

efficiently in Winter
Emeritus Professor W Angus Wallace
Consultant Orthopaedic Surgeon, Nottingham University Hospitals NHS Trust
RCSEng Director for Professional Affairs - East Midlands
With contributions from
Tony Westbrook, Consultant Surgeon & NEOS Chair,
Mandy Bull, Theatre Sister & Sarah Wade Theatre Scheduling Sister
 What is the cost of running an active
Operating Theatre
“Running costs for an operating theatre average
approximately £1,200 per hour. Therefore, the greatest
efficiency gains in most acute trusts can be achieved
through improved session utilisation.”1,2

1) The Productive Operating Theatre - Improving quality

and efficiency in the operating theatre. NHS Institute for
Innovation and Improvement (2009)
2) ISD Scotland Information on theatre running costs and
usage. www.isdscotland.org/Health-
Topics/Finance/Costs/Detailed-Tables/Theatres.asp
What is the cost of running an empty
Operating Theatre

Not known but probably £500 per hour

 Monitoring Theatre Usage

• Starting on time – WHO Briefing at 08.15 for 08.30 start

This means anaesthetists and surgeons start at 07.30
• Avoiding gaps in Theatre usage
Our theatre efficiency is improved by having anaesthetic
assistants
• Ensuring all equipment is available in advance
Equipment is now ordered one week in advance
• Ensuring the WHO check-list is adhered to
This has significantly changed things for the better
(if done properly)
• Finishing on time with a WHO Summary
Learning from out mistakes
 Getting the Patient to Theatre
• Sort out the “Patient Pathway”
• Patient transfer with porters
• Patient checks – why do you need ALL these check –
1) Check all patient details with a nurse before leaving the ward
2) Check all patient details at the theatre reception area
3) Check all patient details on entering the anaesthetic room
4) Check all patient details prior to the operation

• Each step builds in a delay

• Multiple checks indicate that you do not trust your system
• We must make these checks quicker and simpler
Theatre Scheduling Meetings
Theatre Management Analysis using ORMIS

Good Management Not Good Management

 Theatre Management Analysis

Percentage of Lists Percentage of Lists

Number of Insession Session Percentage Elective Emergency with a Completed with a Completed
Lists Utilisation Utilisation Booked Number Number Brief De-Brief

Apr-13 58 75% 94% 56% 192 1 93% 93%

May-13 60 81% 96% 58% 218 1 93% 93%
Jun-13 56 82% 95% 63% 227 2 95% 95%
Jul-13 68 74% 98% 58% 251 5 96% 96%
Aug-13 68 82% 97% 64% 261 5 96% 96%
Sep-13
Oct-13
64
73
83%
83%
98%
96%
Access to 5 Operating Theatres
61%
63%
241
281
1
5
98%
95%
98%
95%
Nov-13 62 80% 100% 61% 254 2 100% 100%
Dec-13 45 82% 98% 64% 181 2 96% 96%
Jan-14 62 81% 100% 64% 259 1 100% 100%
Feb-14 65 85% 99% 67% 253 1 98% 98%
Mar-14 59 82% 98% 62% 228 1 98% 98%
Apr-14
May-14
66
58
84%
83%
100%
98%
Access to only 4 Operating Theatres
63%
62%
256
222
4
1
100%
98%
100%
98%
Jun-14 60 81% 100% 60% 241 6 100% 100%
Jul-14 72 79% 98% 59% 315 2 97% 97%
Aug-14 66 79% 100% 60% 265 5 100% 100%
Sep-14 72 80% 99% 63% 295 9 99% 99%

Oct-14 73 78% 100% 66% 312 11 100% 100%

Theatre Utilisation Reports
Bluespier Theatre
Management

www.bluespier.com
 Helps clinicians provide better quality of care and
safer outcomes within a surgical environment through
effective data capture.

 Helps Trusts and hospitals manage, utilise and

optimise their theatres more effectively to enable
streamlined, end to end management of patient
episodes and events.
 Utilisation reports for continuous improvement

• Allocated hours
• Actual hours
• Patients
• Early and late starts
• Early and late finishes
• Cancelled lists
• Available lists
• Disparity between allocated minutes and actual minutes used per theatre
• Percentage of allocated time against available time
• Calculated list time based on tracking times e.g. arrive in theatre to enter
recovery
• Staff brief time
• Early/late reasons and variances
 This results in:

• Increased efficiency
• Reduced clinical risk
• Accessibility and visibility for clinicians
• Reduced unnecessary cancellations
• Cost savings
• A positive impact on patient experience
Nottingham Elective Orthopaedic Services

Health Service Journal Submission

Specialist Service Redesign Category

Thursday 8th October 2015

 Orthopaedic Services In Nottingham
‘Elective Orthopaedic Board’ established at NUH
• Stand alone ‘business’ unit outside the Directorate
structure
• Service redesign
• Devolved clinician led management team
Outcome:
• Single site working at NCH
• 62 ring fenced beds (reduced from 80)
• 4656 procedures (1750 total joint replacements)
• £25m business
 Nottingham Elective Orthopaedic Services
– Design, Build, Operate 4 New Theatres
Design
• 4 new ‘state of the art’ specialist ortho theatres Build and
Operate
• Solar energy contribution to NUH New
Theatres
• Award winning design for thermal efficiency (BREEAM)
• Patient and consultant involvement in design
• Activity increase of 7% in first five months
• Innovation in process and theatre ‘set up’
• Capacity for Consultant expansion
• Hip & knee, foot & ankle, shoulder and elbow
Nottingham Elective Orthopaedic Services
Design
Improve
Creation of Build and
the Quality
Operate
of Patient the Elective
New
care Orthopaedic Theatres
Board

Improving
Improve
Revision
the
Surgery
Improve Efficiency
Through
Patient of Theatres
Networking
Access to
Orthopaedic
Consultants
Nottingham Elective Orthopaedic Services
– Design, Build, Operate 4 New Theatres
Design
Build and
Operate
New
Theatres
Nottingham Elective Orthopaedic Services
– Overhaul Theatre Patient Pathway
Design
Build and
Operate
New
Theatres
 Nottingham Elective Orthopaedic Services
– Improved Theatre Efficiency Improve
the
• Weekly scheduling meeting Efficiency
of
• Senior nursing surgical and management Theatres

leadership
• Rolling four week cycle with feedback to each
team
• Spare theatre lists re allocated to be ‘back filled’
by other consultant teams
Nottingham Elective Orthopaedic Services
– Improved Quality of Care
Improve
the
• Improvement in PROMs Quality of
Patient
• Response to infection challenge care

• Reduced infection rate

• Reduction in pressure ulcers
• Reduction in falls
• Improvement in Friends & Family both in
response rate and recommendation
Nottingham Elective Orthopaedic Services
– Improved Theatre Efficiency Improve
the
Efficiency
2013/14 – 2014/15 of
Theatres
• 17% increase in procedure numbers
• Regular operating days with 5 total joint
replacements per theatre
• Peer Trusts achieve 3 joints plus a minor case
• Increased activity with existing ‘tertiary referral’
case mix complexity
 Winter Pressures & Elective Operating

• Closing down your most profitable production line during the

winter months is totally illogical
• Private Hospitals - the BMI, Spire or Circle Group would
never consider this option because it would bankrupt them
• NHS hospitals have a different mind set – they believe it is
logical to shut down elective general surgery & orthopaedic
surgery in order to use beds allocated to these patients
• This results in theatre staff & senior surgeons being minimally
employed and still being paid. Junior surgeons may be
deployed to look after medically ill patients but this may be
outside their comfort zone and they are losing out on their
surgical training during this period.
 Winter Pressures & Elective Operating
• If car production lines were closed down for some weeks in
the winter the company (in this case Nissan in Sunderland)
would become bankrupt

Empty operating theatre

Plant not used & staff still paid!

• NHS hospitals do close down operating lists when winter

pressures hit and “Surprise, Surprise” most NHS hospitals in
England are bankrupt at the present time. We really need
business men to influence the running of our hospitals.
 The Solution

• The ideal is to separate elective and emergency work as

has been done at the Northumbria Specialist Emergency
Care Hospital (NSECH)
 If Emergency and Elective Care
cannot be separated

• Elective theatres should still be scheduled

to run all year
• Elective patient beds MUST be ring-fenced
• Winter pressures plans MUST include
opening up additional ward space
• We all need to work smarter – not harder
 Nottingham University Hospitals NHS Trust
Cancelled Operations January to March 2012
www.nuh.nhs.uk/communications-and-media/trust-talk/cancelled-operationone-year-on/
Angus’s Concluding thoughts - NHS Theatres
• The staff working in theatres are working too hard
• The processes and pathways before during and after
theatres need to be completely revised
• We all need to work smarter, not harder

• Our Future Aims should be to produce an

operating theatre environment which makes
our work fun
• Everyone in theatre (including ODAs and
cleaners) should go home feeling they have
enjoyed their day and contributed to good
patient care
Questions?