Emergency Surgery Framework

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A framework for emergency

surgery in Victorian publichealth services



4 Clinical review of area mental health services 1997-2004



A ramework or emergency

surgery in Victorian public

health services



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using the National Relay Service 13 36 77 i required, or email: [email protected]

This document is also available in PDF ormat on the internet at: www.health.vic.gov.au/surgery

© Copyright, State o Victoria, Department o Health 2012

This publication is copyright, no part may be reproduced by any process except in accordance with

the provisions o the Copyright Act 1968.

Authorised and published by the State Government o Victoria, 50 Lonsdale Street, Melbourne.

February 2012 (1201020)

Print managed by Finsbury Green. Printed on sustainable paper.

Acknowledgements

The ramework was developed in consultation with the Emergency Surgery Working Group.

Thanks to the ollowing working group members or their contribution:

Associate Proessor Daryl Williams – Melbourne Health

Ms Cath Cronin – Alred Health

Mr Martin Smith – Eastern Health

Associate Proessor Elton Edwards – Alred Health

Mr Frank Miller – Northeast Health Wangaratta

Ms Paula Foran – South West Health Care Warrnambool

Associate Proessor Melinda Truesdale – Melbourne Health

Associate Proessor Bob Spychal – Peninsula Health

Associate Proessor Nerina Harley – Melbourne Health

Proessor David Watters – Barwon Health

Proessor Russell Gruen – Alred Health

Mr Dhan Thiruchelvam – St Vincent’s Health and Eastern Health

Mr Denis O’Leary – Peninsula Health

Dr Martin Lum – Department o Health

Mr Mark Gill – Department o Health

Mr Terry Symonds – Department o Health

Ms Sue O’Sullivan – Department o Health

Ms Sandy Bell – Department o Health

Ms Lisa Clough – Department o Health



iii

Purpose 1

Dening emergency surgery 2

The Victorian context 4

Principles underpinning provision o emergency surgical services 5

Translating principles into practice 6

Appendices 19

Reerences 27

Contents



1

The availability o timely and high-quality emergency surgery is critical to the unctioning o the public

health system and is a high priority or the Victorian community.

The ramework has been developed by the department in collaboration with the Emergency Surgery

Working Group, a sub-group o the Ministerial Advisory Committee on Surgical Services and other

key stakeholders.

Implementing continuous improvements and innovation in health services is a priority area o the

Victorian Health Priorities Framework 2012–2022: Metropolitan Health Plan. The ramework contains

broad principles that underpin the delivery o sae, high-quality emergency surgical services. These

principles have been drawn rom published research, expert opinion and the advice o clinical

experts on the ESWG. The ramework aims to share this up-to-date inormation and identies a

number o key activities that will assist health services to optimise the quality o their emergency

surgery services.

The ramework will inorm the development o uture emergency surgery initiatives, particularly in

relation to access, health service capacity and capability and planning or emergency surgery demand.

Purpose



2

In Victoria, emergency surgery is generally dened as the provision o a surgical procedure which,

in the opinion o the treating clinician, is necessary and admission or which cannot be delayed.

Emergency surgery is oten about saving lives, organs and limbs. Examples o conditions that may

require emergency surgery include:

• trauma,includingbrokenbonesandbluntpenetratinghead,chestandabdominalinjuries

• gastrointestinalhaemorrhagecompromisingthepatient’sbloodsupply

• strangulatedhernia

• acuteappendicitis

• emergencycaesareansection.

Emergency surgery also encompasses other types o urgent surgery or which there are potential

threats and risks to quality o lie, such as ractured neck o emur.

Following a review o literature and consultations with expert stakeholders, the ollowing denition

was agreed or emergency surgery in Victoria:

Emergency surgery

‘Surgery where, in the opinion o the treating clinician, the admission or procedure cannot be

delayed. This is inscribed with varying degrees o urgency’

The denition o emergency surgery used or the purpose o the ramework has some crossover

with the denition o elective surgery. In Australia, elective surgery is commonly dened as surgerythat,inthejudgementofaspecialist,isnecessaryandadmissionforwhichcanbedelayedforat

least 24 hours.

An example o the intersection between emergency and elective surgical practice exists in instances

where patients arrive at the hospital in an unplanned manner and require surgery within the ollowing

week. Oten it may be sae or these patients to be sent home and return or admission via an

elective surgery pathway within the seven-day timerame. Another example can be ound in cases

where patients are admitted to hospital under a non-surgical specialty and are then ound to require

unplanned surgery.

The denition o emergency surgery used in this ramework deliberately includes these groups o

unplanned patients because the challenges o surgical scheduling or these groups are similar tomore urgent emergency patients. Moreover, these groups are oten accommodated via the same

processes and resources that are used or urgent emergency surgery patients.

Defning emergency surgery



3

A set o denitions used in relation to emergency surgery has been developed and is outlined below

in Table 1.

Table 1: Denitions relating to emergency surgery

Term Denition

Emergency surgery Surgery where, in the opinion o the treating clinician, the admission

or procedure cannot be delayed. This is inscribed with varying degrees

o urgency.

Standard-hours surgery In most hospitals, the standard-hours operating period is between 8 am

and 5 pm Monday to Friday. There are minor variations in start or nish

times between hospitals.

Twilight sessions Some hospitals have extended operating hours to 8 pm or 10 pm. These

are oten reerred to as twilight sessions.

Ater-hours surgery In most hospitals, ater-hours surgery occurs between 5 pm and 12 am

Monday to Friday and all weekend.

Night-time hours In most hospitals, the hours between 12 am and 8 am Monday to Friday

are considered night-time hours.

Elective surgery The Australian Institute o Health and Welare National health data

dictionary (2008) denes elective surgery as ‘surgery that, in the opiniono the treating clinician, is necessary and admission or which can be

delayed or at least twenty-our hours’.



4

Analysis o the data on emergency surgery in Victoria shows that:

• in2010–11,24percent(58,546separations)ofacutepublichospitalsurgicalseparations

were emergency surgery cases

• in2010–11,87percentofallemergencysurgerywasperformedinthepublicsector

• atsomelargemetropolitanhealthservices,theproportionofemergencysurgeryadmissions

has been as high as 38 per cent

• overthelastveyearshealthservicesinVictoriahaveexperiencedsteadygrowthinemergency

surgery demand

• growthisgreatestinmetropolitanhealthservices

• ataspecialtylevel,thegreatestgrowthhasbeeningeneralsurgery,neurosurgeryand

plastic surgery

• overthelastveyears,tertiaryhealthserviceshavetreatedmorecomplexemergency

surgery patients

• therehasbeenagradualdecreaseinlengthofstayforemergencysurgeryseparations

at most Victorian health services.

Some o the actors contributing to the increased demand or emergency surgery are:

• ariseinchronicandcomplexillnesses

• agrowingandageingpopulation

• ariseinratesoftrauma

• thedevelopmentofnewsurgicaltreatmentoptionsfromadvancesinmedicaltechnology.

More detailed descriptions o trends in the provision o emergency surgery are documented in

Appendix 1.

The work o surgical services in Victoria is underpinned by a suite o documents which set

directions or provision o clinical services more broadly. These documents include:

Victorian clinical governance policy ramework: a guidebook (Department o Health 2009b)

www.health.vic.gov.au/docs/doc/Victorian-clinical-governance-policy-ramework

Promoting eective communication among healthcare proessionals to improve patient saety and

quality o care (Department o Health 2010b)

www.health.vic.gov.au/qualitycouncil/downloads/communication_paper_120710.pd

Victorian Health Priorities Framework 2012–2022: Metropolitan Health Plan

(Department o Health 2011d) www.health.vic.gov.au/healthplan2022/

The emergency surgery ramework has been developed to complement these resources.

The Victorian context



5

The department encourages health services to consider applying the ollowing nine principles to

the delivery o emergency surgical services in Victoria. The principles are relevant to all emergency

surgical services in Victorian public hospitals, including all surgical specialties. These principles have

been drawn rom published research, expert opinion and the advice o clinical experts on the ESWG.

1. Emergency surgery demand, access and perormance is routinely measured by health

services.

2. Balancing access to elective and emergency surgery is integral to optimal patient

care and health service perormance.

3. Emergency surgery capacity is matched to demand, and where demand necessitates,

elective and emergency surgery streams are separated.

4. Where clinically appropriate, emergency surgery is scheduled in standard hours.

5. Emergency surgical services are consultant-led.

6. Health service policies and processes or emergency surgery use a single statewide

system or urgency categorisation.

7. Health services have local escalation plans to support optimal team communication,

resource utilisation and confict resolution to support prompt access to surgery.

8. Health services use common emergency surgery measures or benchmarking and

continual service improvement.

9. Health services have local policies and processes or communication with patients

and amilies. This includes inormation about consent.

While applying these principles to the delivery o emergency surgery services, enough fexibility

needs to be maintained to respond to the needs o local communities, organisational arrangements

and priorities.

Positive leadership rom senior medical, nursing and management sta will be required to acilitate

the adoption o these principles. These sta will be important leaders o change to drive local

innovation and service-delivery improvements. Health services can also draw on a range o multi-

dimensional strategies available through redesign, service improvement and clinical saety resourcesto implement the above principles.

The department will work closely with health services to implement the ramework. The ESWG will

guide and oversee the implementation o key strategic elements o the ramework. In addition, the

department will engage with individual health services to support implementation o the key activities

required to urther enhance the quality o emergency surgery services.

Principles underpinning provision

o emergency surgical services



6

Principle 1: Emergency surgery demand, access and

perormance is measured by health services routinely.

A number o studies in Australia have conrmed that emergency surgery demand is measurable,

and at a statewide and local health-service level the demand is predictable, with peaks and troughs

in activity occurring at similar times o the year, days o the week and times o the day. Additionally,

at a health-service level, emergency surgery demand shows less variability over consecutive years

when compared to elective surgery. The predictable nature o emergency surgery means that health

services can plan or emergency surgery demand and design models o care that eectively address

this demand.

Although the overall demand or emergency surgery has increased, Figures 1 and 2 demonstrate the

consistency in demand or emergency surgery in Victoria. Figure 1 shows consistent patterns o the

volume o emergency surgery occurring rom 2008/9 to 2010/11, with peaks and troughs occurring

at similar times each year. This predictability in demand also occurs at a health-service level, however

it may be more variable at the speciality-unit level.

Figure 1: Volume o emergency surgery perormed in Victoria by month, 2008/9 to 2010/11

135

143

151

159

167

175

2010/11

2009/10

2008/09

JunMay Apr Mar FebJanDecNovOctSep AugJul

S e p a r a t i o n s

e a c h

d a y

Month

Translating principles into practice



7

Patients requiring emergency surgery come rom many sources, such as transers rom other

hospitals, inpatient wards, transers rom specialist clinics, elective surgery cases with complications,

or presentations to the emergency department (ED). The most common pathway is presentation to

the ED.

The number o emergency surgery arrivals via the ED is airly consistent across all seven days o the

week, with emergency surgery patients consistently arriving in the ED at around midday on each day

o the week (Figure 2). One-third o all emergency surgery patients present to the ED between 10 am

and 2 pm, with nearly 60 per cent presenting between 8 am and 4 pm.

Figure 2: Volume o emergency surgery patient arrivals in the ED, by time o day and day

o the week

0

100

200

300

400

500

0 2 : 0 0

0 1 : 0 0

2 4 : 0 0

2 3 : 0 0

2 2 : 0 0

2 1 : 0 0

2 0 : 0 0

1 9 : 0 0

1 8 : 0 0

1 7 : 0 0

1 6 : 0 0

1 5 : 0 0

1 4 : 0 0

1 3 : 0 0

1 2 : 0 0

1 1 : 0 0

1 0 : 0 0

0 9 : 0 0

0 8 : 0 0

0 7 : 0 0

0 6 : 0 0

0 5 : 0 0

0 4 : 0 0

0 3 : 0 0

0 2 : 0 0

0 1 : 0 0

A r r i v a l s e a c h h o u

r o f e a c h d a y o f t h e w e e k

Arrival time in the ED

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Health services can use ED data to increase understanding o emergency surgery demand and planor this demand accordingly. However, the management o emergency surgical services requires

considerationofchallengesalongtheentirepatientjourney,frominitialpresentationathospital

through to transer o care.

Key activities and next steps:

• SystematicallycollectandanalyseEDdatainordertounderstandemergencysurgerydemand

and its impact on elective surgery and ED perormance.

• Planandallocatehealthserviceresourcestomeetanticipateddemand.



8

Principle 2: Balancing access to elective and emergency surgery

is integral to optimal patient care and health service perormance.

Patient-centred surgery: strategic directions or surgical services in Victoria’s public hospitals

2010–15 (Department o Health 2009a) identies the issues in managing the oten competing

demands o emergency and elective surgery and the current constraints in delivering timely

emergencysurgery.Thedocumentreectsthewholesurgicaljourney,whichincludesthepatient

reerral, assessment, treatment and recovery processes, and outlines reorm directions or

emergency and elective surgical services.

It is important to note that emergency surgery demand has direct fow-on eects to other areaso a health service, such as elective surgery, the intensive care unit and the ED. Any service-delivery

model or emergency surgery needs to take into consideration these interrelated areas.

Perormance targets in interacing areas such as the ED and elective surgery can impact on

access to emergency surgery.

A key challenge encountered by health services is balancing elective and emergency surgery

demand while ensuring optimal patient care and health service perormance. I the allocation

o operating theatre time or emergency surgery does not correlate with demand or it, this may

have an unintended negative impact on elective surgery perormance due to postponements

and longer waiting times.

In many health services, both elective and emergency caseloads share the same operating theatres,

surgeons and teams. In these situations, elective and emergency surgery are inherently linked in

spite o the dierences between the patient caseloads. A balanced approach in the provision o

emergency and elective surgery can acilitate improved access, and result in improved patient

outcomes, decreased cancellations o elective and emergency surgery, shorter waiting times and

reduced rates o emergency surgery being undertaken ater-hours.

There is no one-size-ts-all approach to determining the appropriate model o care. Balancing the

two streams o surgery in a health service needs to be considered in light o local capacity, demand

and constraints. The department does not allocate specic unding or emergency surgery to health

services. Health services are responsible or allocating unds internally to procedures or clinical areas,

such as emergency surgery, in response to changing demands. This unding model allows clinical

decisions to be made at the local level.


• Improvetheutilisationofoperatingtheatresandotherhigh-costassetsandinfrastructure

by matching capacity with demand.

• Developtoolsforprioritisingelectiveandemergencysurgerypatientgroupswithinand

between clinical specialities.

• Minimisenon-operatingtimethroughefcientpatientturn-around.

• Designsurgicalrosterstotakeaccountofbothelectiveandemergencycommitments.

• Improveaccesstosupportservicessuchasradiologyandpathology.

• Minimisemultiplecancellationsofemergencysurgerycases.• Considertheinfrastructurerequiredforemergencyandelectivesurgerywhenredeveloping

existing acilities or developing new acilities.



9

Principle 3: Emergency surgery capacity is matched to demand,

and where demand necessitates, elective and emergency surgery

streams are separated.

Increased demand and complexity mean managing emergency surgery poses a number o

challenges or the healthcare system. Emergency surgery models o care need to be fexible so that

services can respond to change over time.

One way o minimising the impact o emergency surgery on elective surgery is to separate the two

streams, either physically or administratively. This allows or a high volume o elective procedures

to be undertaken without cancellations or delays due to emergency surgery demand. Separatingelective and emergency surgery is accepted internationally as a way o improving access. Sta can

plan a more ecient program o surgery while providing greater certainty to patients.

The National Health and Hospitals Reorm Commission (2009) has reported that separating elective

rom emergency surgery in purpose-built centres is a way or public hospitals to gain eciencies in the

provision o surgical services. In a recent paper, Surgery utures: a plan or Greater Sydney , NSW Health

reported an ‘increase in both procedural and patient-fow eciencies o 10 to 20 per cent’ in sites that

separated elective and emergency surgery. Victorian health services have also shown improvement in

surgery perormance since quarantining elective and emergency surgery. This can be demonstrated by

reductions in postponements, length o stay and patients waiting longer than clinically recommended.

Victoria has unded two purpose-built, stand-alone elective surgery centres at Alred Health and

Austin Health. Alred Health established the Alred Centre in 2007, which is a separate theatre suite

used to treat elective surgery patients, connected to the main campus via a walkway. A slightly

dierent model operates at Austin Health, which has dedicated one o its two hospital campuses

to elective surgery only. By removing elective surgery rom the main campuses, Alred Health and

Austin Health have been better able to manage their respective emergency surgery loads. For

health services with high surgical demand, this can be an eective strategy or balancing elective

and emergency surgery streams. This approach may not be warranted at health services with lower

levels o emergency surgery demand, where administrative separation may be more appropriate.

It is important that administration procedures are complementary and not duplicated when elective

and emergency surgical streams are separated.

Where caseloads are high in particular specialties (such as orthopaedics, general surgery, obstetrics orplastic surgery) it may be appropriate or health services to allocate specic operating theatre times or

emergency cases in these specialties (based on the level o demand and available surgical capacity).


• Systematicallycollectandanalysesurgerydatatodetermineifdemandnecessitates

separating emergency surgery and elective surgery streams, either physically or

administratively.

• Identifyanddevelopgoodpracticeinthemanagementofelectiveandemergencysurgery,

including potential new models o care and workorce organisation or high-volume conditions

requiring surgery.

• Supportclinicianstoaccessandapplyevidenceaboutsurgicalproceduresandmodels

o care.

• Evaluatetheseparationofelectiveandemergencysurgerystreamsregularlytobuildan

evidence base or eective delivery o both elective and emergency surgery.



10

Principle 4: Where clinically appropriate, emergency surgery

is scheduled in standard hours.

Health services may perorm emergency surgery out o hours in an eort to reduce the impact o

emergency surgery cases on scheduled elective cases, particularly where resources are ully utilised.

However, out-o-hours surgery is oten associated with higher risks to the acility.

There is evidence that prolonged hours o work and work at night carry a greater risk o undermining

surgical perormance and urther increase the risk o serious errors that can lead to death or serious

morbidity. In recognition o the potentially serious consequences o atigue, the Royal Australasian

College o Surgeons (2007) developed guidelines or sae working hours. These guidelines includeon-call and shit rostering, handover, and the responsible management o stress and atigue.

The Royal Australasian College o Surgeons Divisional Group o Rural Surgery (2005) identied

that continuous working periods greater than 14 hours, and a lack o sucient breaks during and

between work periods, will increase the risk o atigue and atigue-related errors.

In order to assist hospitals and sta to measure the risks associated with their work hours, the

Australian Medical Association (2005) published guidelines around sae working hours or doctors

working in hospitals. These guidelines incorporate a risk-assessment checklist or surgeons.

One o the key principles o the emergency surgery ramework is that where clinically appropriate,

emergency surgery should be scheduled in standard hours. Any re-alignment o operating theatre

templates should incorporate perorming as much emergency surgery within standard hours as

possible. Due to the nature o emergency surgery, there will always be a proportion o complex lie-,

limb- or organ-saving emergency surgery that must occur at night (Faiz et al. 2007). Emergency

surgical services need to recognise and incorporate this need. However, other emergency surgical

cases are best perormed during standard hours.

Evidence rom New South Wales and Western Australia indicates that the establishment o specic

emergency surgery models which incorporate dedicated in-hours surgeons and access to dedicated

in-hours operating theatre time has led to improved time to assessment in the ED, aster admission,

aster time to surgery, decreased number o elective surgery hospital-initiated postponements due

to emergency surgery, and decreased length o stay (Parasyn et al. 2009; Cox et al. 2010).

Evidencefromthesesamejurisdictionshasalsoshownthatbringingemergencysurgeryinto

standard hours is clinically sae, cost-neutral and may even save money or the organisation in the

long term (Parasyn et al. 2009; Cox et al. 2010). Necessary out-o-hours emergency surgery must

be balanced with sae working hours, and health services should instigate operational strategies

to manage this balance.


• Redesignoperatingtheatretemplatestoscheduleasmuchemergencysurgeryaspossible

within standard hours.

• Monitortheatredatatoreviewpatternsoftheatreuseandtodemonstratereformstobring

surgery within standard hours.

• Supportclinicianstoaccessandapplyevidenceaboutemergencysurgerymanagement o patients and overall models o care to support more surgery being undertaken within

standard hours.



11

Principle 5: Emergency surgical services are consultant-led.

Evidence suggests that eective emergency surgery models o care are contextually appropriate

and based on principles o consultant leadership.

The value o consultant-led emergency care is well recognised and supported by evidence

(Parasyn et al. 2009). The benets o consultant leadership include:

• moreaccurateandtimelydecisionmaking

• reductioninunnecessaryclinicalinvestigations

• greatertraineesupervisionandsharingofexpertise

• betteraccesstoday-timeemergencysurgery(wheredesignatedin-hoursoperatingtheatre time is available) and less night-time surgery

• apotentialformorecost-effectivedecisionmakingandnancialsavingswithinthehealthservice

• increasedstaffsatisfaction.

It is important to note that clinical leadership does not reer exclusively to surgical sta. Senior

medical sta and senior nursing sta are very important in the provision o eective emergency

surgical services. For example, a number o health services in Victoria use the leadership o senior

anaesthetists to determine the scheduling o emergency surgery cases when several patients o the

same clinical priority require surgery.

The Acute Surgery Unit is a model o consultant-led emergency surgery service delivery that has

been established in a number o health services in Australia. These health services have reported

benets such as those outlined above. Acute Surgery Unit models vary slightly according to local

requirements, however common eatures include:

• aconsultantrosteredonforaperiodofatleast24hours,includingbeingon-siteinstandard

hours to provide clinical support or all stages o patient care

• aformalisedhandoverprocesswithinformationbasedonastandardsetofkeyprinciples

• dedicatedemergencytheatresessionsinstandardhours

• aconsultantbeingpresentwhensurgeryisbeingperformedforteachingandsupervisionpurposes

• agreedclinicalguidelinesorprotocolsforcommonemergencysurgeryadmissions

• designatedAcuteSurgeryUnitbedsforassessmentandmanagement.

Contextual constraints o individual health services mean that dierent consultant-led models o care

will be appropriate at dierent health services. Strategies to improve emergency surgery services sit

alongside, and should be complemented by, a range o inrastructure initiatives and new operational

models o emergency care.


• Engageleadclinicianstoinvestigatethefeasibilityofestablishingaconsultant-ledemergency

surgery service.

• Whenconsideringaconsultant-ledmodelofcare,healthservicesshouldconsultwithhealth

services that have already established consultant-led models to learn rom their experience.

• Whereaconsultant-ledmodelistobeintroduced,healthservicesshould:

– support a reorganisation o both the model o care and the working arrangements

o medical sta

– establish health service agreement about theatre and bed access

– build clinical guidelines or common procedures over time.



12

Principle 6: Health service policies and processes or emergency

surgery use a single statewide system or urgency categorisation.

The clinical urgency o a case underlies every decision about priority or emergency surgery. These

decisions take place in a high-pressure environment that involves non-negotiable time stress, with

potentialformajorpersonalconsequencesandadversepatientoutcomes(Fitzgerald,Lum&Dadich

2006). Each patient’s priority must be considered alongside that o others awaiting emergency

surgery, as cases oten require rescheduling to make way or those deemed more urgent.

Standardised categories o clinical urgency would acilitate consistent decision making and reconcile

differencesinprofessionalopinionsrelatingtopatientpriority(Fitzgerald,Lum&Dadich2006),thereby contributing to quality patient care.

A single statewide system or emergency surgery categorisation will improve the consistency o

decision making across the state, improve communication regarding the relative urgency o patients,

and improve the allocation o theatre resources within health services. Furthermore, a single system

enables benchmarking across similar health services in Victoria.

The six-level emergency surgery urgency categorisation system documented in Appendix 2 includes

indicative time rom booking to arrival in the operating suite. This system is based on the current

system used in a number o health services in Victoria and in New South Wales (NSW Health 2009).

Within this system, there is the opportunity or health services to include more detailed descriptions

as required. At health services where obstetric cases share operating theatre resources with other

surgical specialties, emergency surgery urgency categorisation should include obstetrics.


• Adoptthesix-levelemergencysurgeryurgencycategorisationsystemdocumentedin

Appendix 2.

• Monitorhealthserviceactivityagainsttheassignmentofurgencycategoriesandpatient

treatment times.

• Evaluatemodelsofcareinrelationtotheurgencycategorisationsystemandbuildanevidence

base or eective delivery o emergency surgery.



13

Principle 7: Health services have local escalation plans to support

optimal team communication, resource utilisation and confict

resolution to support prompt access to surgery.

Emergency surgery patients oten have complex and challenging problems. These patients can

present at any time o the day or night, regardless o stang levels. The management o emergency

surgery must take into account unique threats to lie, limb and organ unction. In many cases, these

threats increase with the passage o minutes and hours.

A number o electronic tools exist or communicating about emergency surgery cases. The most

commonly used system in Victoria is the emergency theatre booking system, which allows real-timescheduling, increased transparency o patient bookings, better patient tracking systems and data

collection.

Clinical guidelines (also known as clinical protocols) provide a comprehensive care path or surgical

teamsandaimtoensureroutinemanagementforthemajorityofpatients.Clinicalguidelinesfacilitate

consistentmanagementofemergencysurgerypatientsbutdonotreplaceactiveclinicaljudgement,

which is required to determine when a clinical guideline is appropriate or when variation in care is

required. Clinical guidelines provide an eective and ecient system or monitoring and recording

variances in care or the purpose o reviewing and improving patient care (Earley et al. 2006;

Tallis&Balla1995).

Clinical handover is an essential component o all surgical care, including emergency surgery. The Victorian Surgical Consultative Council has developed guidelines or clinical handover (see

<www.health.vic.gov.au/vscc/practice-statements.htm> or details). Additionally, the Australian

Commission on Saety and Quality in Healthcare (2010) has developed the Organisational

leadership, simple solution development, stakeholder engagement, implementation and evaluation

and maintenance (OSSIE) guide to clinical handover improvement . This guide is designed to assist

organisations to implement a standardised process or handover that is customised to the local

context (see <www.saetyandquality.gov.au> or details). Clinical handover processes have been

incorporated into Acute Surgery Units and have been ound to aid inormal peer review and improve

communication between sta.



14

The key eatures o an eective governance structure or emergency surgical services are:

• aclearstatementofrolesandresponsibilities

• cleardelegationsandlinemanagement

• participationinqualityassurancesystems.

Health services have a responsibility to ensure that all services provided to patients are sae,

appropriate and within the capability and role o the service (Department o Human Services 2009).

Credentialing and dening scope o practice is a mechanism by which the community can be

assured that a competent workorce is providing their care (Department o Human Services 2007).

A useul checklist to guide the delivery o sae surgical services has been developed by the WorldHealth Organisation and has been adapted or the local context by the Australian and New Zealand

surgical community. This checklist can be ound at: www.anzca.edu.au/resources/endorsed-guidelines


• Considertheuseofemergencysurgerytheatrebookingsystemstoidentifyandprioritise

emergency surgery patients.

• Useclinicalguidelinestofacilitateconsistentemergencysurgerypatientmanagement.

• Implementstandardisedclinicalhandoverprocesses.

• Developaneffectivegovernancestructureforemergencysurgerytosupportcliniciansto

make decisions about clinical prioritisation and to enable escalation where required.



15

Principle 8: Health services use common emergency surgery

measures or benchmarking and continual service improvement.

The capacity to monitor and evaluate perormance is a critical building block or system-wide

improvement o healthcare delivery and improved patient outcomes. To inorm ongoing service

improvement and enable standardised measurement o emergency surgery perormance or

benchmarking across similar health services, a set o timestamps (Tables 3 and 4) and measures

has been developed. Denitions o timestamps are provided to ensure consistency in measurement.

These items are based on surveys o Victorian health services and similar work conducted interstate

and overseas.

The timestamps in Table 2 allow analysis o the time taken to achieve a denitive treatment decision

(using timestamp 1 and 2) and analysis o access to the operating theatre or patients once a

denitive plan or surgery is made (timestamps 2, 3 and 4). Timestamps specic to the operating

theatre and recovery period (Table 3) allow identication o times and time intervals related to the

procedure in theatre, rather than the process o accessing the required procedure (Table 2).

Table 2: Timestamps or measurement o emergency surgery access

Timestamp Denition

1. Patient arrival in

the emergency

department

Time the patient was rst registered or triaged (whichever comes rst) by

a clerical ocer, triage nurse or doctor in the ED. This is consistent with

the Victorian Emergency Minimum Dataset (VEMD) denition (Department

o Health 2011c), and is the closest reliable measure or when a patient

arrives in the ED.

2. Time o surgery

booking

Time that the booking or surgery is entered in the theatre booking

system.

This provides a proxy measure or the time that the decision or surgery

was made.

3. Patient arrival in

operating theatre

Time when the patient arrives in the anaesthetic bay, or i there is no

anaesthetic bay, the time when the patient arrives in the operating theatre

or procedure room.

4. Procedure start time Time when the procedure is begun (or example, incision or a surgical

procedure, insertion o scope or a diagnostic procedure). This is

consistent with the Victorian Admitted Episodes Dataset (VAED) denition

(Department o Health 2011b).



16

Table 3. Additional operating theatre timestamps

Timestamp Denition

Anaesthetic start Time when anaesthetist begins preparing the patient or an anaesthetic.

Position or prep start Time when the nursing or surgical team begins positioning or prepping

the patient or the procedure.

Procedure or surgery

stop

Time when all the instruments and sponge counts are completed and

veried as correct; all postoperative radiological studies to be done in the

operating or procedural room are completed; all dressings and drains are

secured and the surgeons or physicians have completed all procedure-

related activities on the patient.

Anaesthetic stop

(anaesthetic handover)

Time when anaesthetist hands over care o the patient to a post-

anaesthesia care team.

Patient leaves recovery Time patient leaves recovery.

Time that ‘time out’

was commenced

Timeoutisadeliberatepauseinactivityjustbeforesurgerycommences.

All members o the surgical team veriy the ollowing details:

• presenceofthecorrectpatient

• typeofproceduretobeperformed

• correctproceduresitemarked• anticipatedcriticalevents

• availabilityofrequiredequipment.

Health services are encouraged to review current timestamps and denitions being used, and to

consider incorporation o those outlined in Tables 2 and 3 into local systems. Measurement o

the time periods between timestamps may allow identication o particular points o delay in the

emergencysurgerypatientjourney.

In addition to the timestamps outlined above, collection and analysis o the ollowing measures o

emergency surgery perormance is suggested:

• lengthofhospitalstayforindexprocedures(forexample,emergencycholecystectomy,fractured

neck o emur, acute appendicitis)

• measurementofafter-hourssurgicalactivity(forexample,percentageofnon-life-,limb-or

organ-saving emergency surgery that is perormed between 12 am and 7 am)

• percentageofpostponementsofbookedemergencysurgerycasesthatarenotduetoclinical

reasons. This will include cancellations or reasons such as lack o theatre, surgeon, equipment or

post-operative bed

• pre-operativewaitingtimeforindexconditions(measuredfromtimeofarrivalintheEDtosurgery

start time).

It is important to note that these measures should be considered as base measures only, and health

services may opt to collect additional measures i they have a specic element o care they wish

to monitor. A guide to surgical services redesign measures or improvement (Department o Health2011a) provides an extensive list o possible emergency surgery measures.



17

Use o consistent timestamps, denitions and measures to monitor trends and perormance will

allow targeted actions to be undertaken to achieve high standards o emergency surgery care within

each health service. Ongoing measurement will allow monitoring o changes in perormance over

time. Monitoring will also allow health services to benchmark emergency surgery perormance with

similar health services and to share innovations in service delivery. Consistency in measurement will

help ensure that standards o patient saety are uniormly applied across the state.

The Victorian Audit o Surgical Mortality annual report 2009 (Royal Australasian College o Surgeons

2009) reported that o the audited deaths, delays in reerral to a surgical unit were requently

commentedon.Themajorityofsurgicaldeathsinthisauditedseriesoccurredinelderlypatientswith

underlying health problems, admitted as an emergency with an acute lie-threatening condition otenrequiring surgery.

The most common issues reported were delay in transer to a surgical unit, inappropriateness

o the decision to operate and unsatisactory pre- or post-operative assessment. It should be

acknowledged that a number o these were ‘areas o consideration’ and were thereore relatively

minor criticisms. These ndings indicate an opportunity to improve the timeliness o reerrals to

surgical units. Evidence suggests that consultant-led models, such as Acute Surgical Units, are

another possible strategy to address this.

The benets o sharing innovations in emergency surgery service delivery, models o care and

benchmarking perormance across health services was identied in the literature review which

inormed the development o this ramework. The Good practice in management o emergency

surgery: a literature review (Department o Health 2010a) can be downloaded rom: www.health.vic.

gov.au/docs/doc/good-practice-in-management-o-emergency-surgery:-a-literature-review


• Reviewcurrenttimestampsanddenitionsanddecideonappropriatemeasuresofemergency

surgery perormance.

• Systematicallycollectdatatomonitorperformanceandtrendstoidentifyareasrequiring

improvement.

• Evaluatemodelsofcaretobuildtheevidencebasefortheeffectivedeliveryofemergency

surgery and target actions to address areas requiring improvement.

• Benchmarkemergencysurgeryperformancewithsimilarhealthservicestoshareinnovations

in service delivery.



18

Principle 9: Health services have local polices and processes

or communication with patients and amilies. This includes

inormation about consent.

Health services with eective emergency surgical services demonstrate good communication, which

is acilitated through organisational support, systems, resources, polices and processes and regular

sta education. Receiving timely and adequate inormation ensures consent is inormed, and assists

in preparation o patients or surgery by reducing patient and carer anxiety and providing a more

positive experience or patients and carers.

Prior to surgery, patients and their carers should receive inormation about:

• thesurgicaltreatmentandcarerequired

• pre-surgeryfastingrequirements

• thewaitingprocessforsurgery

• thepossibilityofsurgerytimebeingchangedifmoreurgentcasesarise.

Inormation to patients should be provided both verbally and in writing. Written inormation should be

supported with translated material and training or sta and delivered in a culturally sensitive manner.

To improve communication with patients and carers, one health service in Victoria has established an

Emergency Surgery Coordinator. The role o the Emergency Surgery Coordinator is to:

• facilitatetimelyaccesstoemergencysurgerybymaximisingin-hoursemergencysurgerywithoutnegatively impacting on elective surgery throughput

• actasaresourceforsurgicalteamstoexplorealloptionsavailabletoenablesurgeryintheright

setting as quickly as possible

• actasaconduitbetweenpatients,carers,surgeons,anaesthetistsandnursingstafftomanage

patient care

• minimisecancellationsofelectivesurgerypatientsonthedayofsurgeryduetoemergency

surgery demand

• investigatepatientcomplaintsassociatedwithemergencysurgicalservices

• coordinatetheintroductionoftheemergencytheatrebookingsystem.


• Supportpatientstobeactivepartnersintheircareandprovidehighqualityandaccessible

inormation about their emergency surgery.

• Reviewpracticesforcommunicatingwithpatientsandcarers.

• Provideinformationbothverballyandinwriting,includingtranslatedmaterialforpatientsand

carers rom culturally and linguistically diverse backgrounds.



19

Appendix 1: Analysis o emergency surgery in Victoria

Victoria’s emergency surgical services

In 2010–11, 24 per cent o acute hospital1 surgical separations were emergency surgery cases,

which equates to 58,546 emergency surgery procedures according to Victorian Admitted Episodes

Dataset (VAED) data. At some large metropolitan health services the proportion o emergency

surgery admissions can be as high as 38 per cent. Figure 1 shows the proportion o emergency

surgery separations in acute public hospitals in Victoria and shows a gradual increase in demand

or emergency surgery. In 2010–11, 87 per cent o all emergency surgery procedures perormed in

Victoria were provided in the public sector.

Figure 1: Proportion o emergency surgery in acute hospitals in Victoria

S e p a r a t i o n s

P e r c e n t t h a t i s e m

e r g e n c y

Emergency surgery separations

Percent of surgery that is emergency

45,000

47,000

49,000

51,000

53,000

55,000

57,000

2006-072005-06 2007-08 2008-09 2009-10 2010-11

20%

21%

22%

23%

24%

25%

26%

Years

Twomajorfactorsthathaveledtothegrowthindemandforemergencysurgeryhavebeenan

ageing Australian population and increasing rates o trauma.

1 An acute hospital is a hospital with an emergency department.

Appendices



20

Ageing and population growth

An important impact o an ageing population is the increase in the number o older patients with

higher acuity and multiple comorbidities undergoing emergency surgery. Figure 2 shows that in

Victoria, older patients require proportionally more emergency surgery than younger patients.

Figure 2: Emergency surgery separations by age and gender, with comparison to

Victorian population

C o n t r i b u t i o n

o f e a c h c o h o r t

Male surgery Female surgery Male population Female population

0%

1%

2%

3%

4%

00-04 05-09 85+10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84

Age

Trauma

Since the Victorian State Trauma Registry (VSTR) has had ull statewide coverage, the rate o trauma

hasincreased(DepartmentofHealth2010c).TheVSTRrecorded2,646hospitalisedmajortrauma

patientsin2008–09comparedto2,379in2007–08.Theoverallannualrateofhospitalisedmajor

trauma in Victoria was 49 per 100,000 population, compared to 44 in 2007–08, 46 in 2006–07, and

42 in 2005–06. Since 2001–02, there has been an average annual increase in the rate o hospitalised

majortraumaof8.0percent.Whilethemajorityofmajortraumacasesaretypicallyyoungpeople,

there has been a substantial increase in cases involving people aged 75 years and over, rom 10.3

per cent in 2001–02 to 19.1 per cent in 2008–09. This change could be explained by improved

coverage o the VSTR, improvements in case identication, changes in approaches to diagnosis

and management in the elderly, and the ageing population (Department o Health 2010c). This is

demonstratedbytheriseinpercentageofhospitalisedmajortraumapatientsrelatedtolowfallsof

24.6 per cent in 2008–09 compared to 19.6 per cent in 2005–06.



21

For the purposes o analysis, the 58,546 emergency surgery procedures perormed in Victoria in

2010–11 have been broken down into our hospital clusters: tertiary, metropolitan, regional and

sub-regional (Table 1).

Table 1: Victorian hospitals by cluster

Tertiary Metropolitan

Austin Hospital

Geelong Hospital

Monash Medical Centre – Clayton

The Royal Children’s Hospital

The Royal Melbourne Hospital

St Vincent’s Hospital

The Alred Hospital

Box Hill Hospital

Casey Hospital

Dandenong Hospital

Frankston Hospital

Maroondah Hospital

Mercy Hospital or Women

Mercy Public Werribee

The Royal Women’s Hospital

The Royal Victorian Eye and Ear Hospital

Rosebud Hospital

Sunshine Hospital

Sandringham and District Memorial Hospital

The Northern Hospital

Western Hospital

Williamstown Hospital

Regional Sub-regional

Ballarat Hospital

Bendigo Hospital

Goulburn Valley Health Care

Latrobe Valley Health

Bairnsdale Regional Health Service

Central Gippsland Health Service

Echuca Regional Health

Hamilton Base Hospital

Northeast Health Wangaratta

Mildura Base Hospital

Swan Hill District Hospital

South West Healthcare Warrnambool

West Gippsland Healthcare Group

Wimmera Base Hospital

Wodonga Regional Health Service

Wonthaggi and District Hospital

When considered in these clusters, 84 per cent o emergency surgery is perormed by the tertiary

and metropolitan hospitals, with 16 per cent being perormed by regional and sub-regional hospitals

(Table 2). Although Geelong Hospital is usually classied as a regional hospital, data would suggest

that or the purposes o this analysis, due to the high numbers o emergency surgery cases, it should

be included in the tertiary cluster.



22

Table 2: Emergency surgery separations by hospital cluster, 2010–11

Hospital cluster Total emergency surgery

separations

Contribution to state total

Tertiary 24,154 41.3%

Metropolitan 24,844 42.4%

Regional 5,517 9.4%

Sub-regional 4,031 6.9%

(Peter MacCallum Cancer Centre and Albury Hospital not included).

Growth in emergency surgery

The greatest volume o emergency surgery is in the specialties o general surgery, orthopaedics

and plastic surgery (Figure 3). The greatest growth in emergency surgery over the last ve years is

demonstrated in the specialties o general surgery, neurosurgery and plastic surgery.

Figure 3: Surgical specialties with highest volume o emergency surgery activity in Victoria,

2006–07 to 2010–11

A n n u a l s e p a r a t i o n s

General surgery

Orthopaedics

Plastic surgery

Cardiac surgery

ObstetricsNeuro surgery

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11

Year



23

In Victoria, there has been a steady increase in demand or emergency surgery since 2006–07

(Figures 4 and 5). Data indicates that this growth has been greatest at metropolitan hospitals. Figure

5 shows the growth over ve years at the our metropolitan hospitals that had the most number o

emergency surgery separations in 2010–11.

Figure 4: Emergency surgery activity by hospital cluster, 2006–07 to 2010–11

A n n u a l s e p a r a t i o n s

Tertiaryhospitals

Metropolitanhospitals

Regionalhospitals

Sub-regionalhospitals

2006-07 2007-08 2008-09 2009-10 2010-110

5,000

10,000

15,000

20,000

25,000

Year

Figure 5: Emergency surgery activity in selected health services, 2006–07 to 2010–11

E m e r g e n c y s u r g e r y s e p a r a t i o n

s

0

5,00

1,000

1,500

2,000

2,500

3,000

3,500

4,000

Geelong Hospital Dandenong Hospital Frankston Hospital The Northern Hospital

2006-07

2007-08

2008-09

2009-10

2010-11

Health service



24

Trends in acuity

Data shows that higher Weighted Inlier Equivalent Separation (WIES) weight is distributed to tertiary

health services, refecting the higher complexity o their emergency surgery patients (Figure 6).

Figure 6: Emergency surgery average WIES by hospital cluster, 2006–07 to 2010–11

A v e r a g e W I E S

Tertiaryhospitals

Metropolitanhospitals

Regionalhospitals

Sub-regionalhospitals

2006-07 2007-08 2008-09 2009-10 2010-11

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

Year



25

Trends in length o stay

Figure 7 demonstrates that or all hospital clusters there has been a reduction in length o stay

or emergency surgery since 2006–07.

Figure 7: Emergency surgery length o stay by hospital cluster, 2006–07 to 2010–11

A v e r a g e l e n g t h o f s t a y ( d a y s )

Tertiaryhospitals

MetropolitanhospitalsRegionalhospitalsSub-regionalhospitals

2006-07 2007-08 2008-09 2009-10 2010-11

4

5

6

7

8

9

10

11

Year

Table 3: Emergency surgery separations, average length o stay and acuity or surgical

specialties with the largest volume o separations, 2010–11

Specialty

Emergency surgery

separations

Average length o

stay (days)

Acuity

(average WIES)

General surgery 16,740 7.35 2.53

Orthopaedics 11,436 7.86 2.85

Plastic surgery 10,313 4.31 1.55

Cardiology 3,485 5.39 3.39

Obstetrics 2,750 1.48 0.62

Neurosurgery 2,448 10.57 5.03

Table 3 demonstrates that general surgery accounted or the greatest volume o emergency surgery

separations in 2010–11 (16,740 separations). O the six surgical specialties with the greatest

volumes o emergency surgery separations, neurosurgery cases had the longest average length o

stay and acuity.



26

Appendix 2: Emergency surgery urgency categorisation system

Urgency categories as agreed in stakeholder consultations are outlined in Table 1 below. This

documentshouldbereadinconjunctionwiththeVAEDmanual(DepartmentofHealth2011b)and

the VEMD manual (Department o Health 2011c) which provide data items, denitions and codes

relevant to data submissions to the VAED and the VEMD.

Table 1: Emergency surgery urgency categorisation system

Priority

level

Timerame or surgery

(time rom booking

to arrival in operatingtheatre)

Obstetric cases Denition

1 < 15 minutes; immediate

lie-threatening

Category 0 and 1

(includes code green)

Immediate lie-threatening

The patient is in immediate risk o

loss o lie, shocked or moribund,

resuscitation not providing positive

physiological response.

2 < 1 hour; lie-threatening Category 2 Lie-threatening

The patient has a lie-threatening

condition, but is responding to

resuscitative measures.

3 < 4 hours; organ- /

limb-threatening /

obstetric morbidity

Category 3 Organ- / limb-threatening /

obstetric morbidity

The patient is physiologically

stable, but there is immediate

risk o organ survival or systemic

decompensation.

4 < 8 hours; non-critical,

emergent

Includes Category 4 Non-critical, emergent

The patient is physiologically stable

but the surgical problem may

undergo signicant deterioration

i let untreated.

5 < 24 hours; non-critical,

non-emergent, urgent

Non-critical, non-emergent,

urgent

The patient’s condition is stable.

No deterioration is expected.

6 < 48 hours; semi-urgent,

not stable or discharge

Category 5 Semi-urgent, not stable or

discharge

The patient’s condition is stable.

No deterioration is expected but

the patient is not suitable to be

discharged.



27

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Cox MR, Cook L, Dobson J, Lambrakis P, Ganesh S and Cregan P 2010, ‘Acute surgical unit:

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Reerences



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Australian Journal o Public Health, vol. 19, no. 2, pp. 155–159.



29



4 Clinical review of area mental health services 1997-2004

Emergency Surgery Framework

Documents

Transcript of Emergency Surgery Framework