Pakistan Journal of Medical Sciences

Published by : PROFESSIONAL MEDICAL PUBLICATIONS

ISSN 1681-715X

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ORIGINAL ARTICLE

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Volume 21

October December 2005

Number 4


 

Abstract
PDF of this Article

An Audit of Reduction in waiting times for
emergency surgeries in a tertiary care teaching hospital

Masood Jawaid1, Muhammad Farhan Amin2,
Rehan Abbas Khan3 & Syed Abdullah Iqbal4

Abstract:

Objective: To estimate the waiting times for emergency surgeries after implementing recommended guidelines in a tertiary care public hospital to close the audit loop.

Settings: Surgical Unit IV, Civil Hospital Karachi.

Design: Descriptive comparative study.

Patients and Methods: Patients admitted through emergency for immediate surgery were included in the study. Guidelines previously prepared to reduce waiting time were implemented. A proforma was made to collect information like diagnosis, operation performed, time of planning immediate surgery, time of actual surgery, factors responsible for delay apart from demographic data.

Main outcome measures: Waiting times for emergency surgery, different causes responsible for the delay. Comparison of waiting times with the previous study.

Results: A total of 40 patients were enrolled in the audit study. Seventeen (42.5%) patients had to wait for more than 3 hours for surgical procedure as compared to 73.3% in the previous study. In this study 15% waited for 4 hours, 20% for 6 hours and only one patient waited for more than 12 hours. In the previous study 17.7% waited for 4 hours, 33.3% for 6 hours and 6.6% of patients waited for more than 12 hours.

Most of the delays were due to timing of admission (29.4%) and time taken to arrange blood (29.4%) followed by investigations in 23.6%. Previous study before implementing guidelines reported 33.3% delays due to doctors not performing their duty at the earliest followed by admission timing in 21.2%. Unavoidable causes were responsible for 17.6% of delayed surgeries.

Conclusion: The findings of the study showed that recommendations were implemented successfully and the outcome was encouraging, compelling the authorities to continue with the same plan to reduce the percentage of delays even further. During a meeting to present the results of this audit, all the staff was made aware of this encouraging improvement.

Keywords: Emergency surgery, waiting times, causes, surgical audit.

Pak J Med Sci October-December 2005 Vol. 21 No. 4 422-425


1. Dr. Masood Jawaid MBBS
Postgraduate Student

2. Dr. Muhammad Farhan Amin MBBS
House Surgeon

3. Dr. Rehan Abbas Khan FCPS, FRCS
Resident Medical Officer

4. Prof. Syed Abdullah Iqbal FCPS
Professor of Surgery

1-4. Surgical Unit IV,
Dow University of Health Sciences &
Civil Hospital Karachi.

Correspondence:
Dr. Masood Jawaid
E-mail: masood@masoodjawaid.com

Received for publication: March 11, 2005
Accepted: June 25, 2005


Introduction

Audit is the process by which clinical staff collectively reviews, evaluates and improve their practice with the common aim of improving standards.1 It is a fundamental part of modern surgical practice. From consultant to trainee, involvement in audit is not only desirable but is increasingly becoming compulsory.2

All cases of surgical emergency with firm diagnosis needing surgical intervention as part of management should be operated as early as possible to minimize the risks associated and decrease the post operative morbidity. Keeping this in view a small audit was planned to see waiting times of emergency surgery so that necessary action can be taken to improve quality of patient care in this respect3. In view of its findings some recommendations were suggested (Annex-I). This study was performed to observe the improvement in the quality of care after the implementation of the above guidelines.

Patients and Methods

All patients admitted during emergency after taking decision that surgery should be performed either immediately or at the earliest possible time (maximum 3 hours after diagnosis/admission) were enrolled in the study. Patients who do not require an immediate surgical management, those who were admitted for observation and patients who need prolonged initial resuscitation due to disease process or co-morbidity were excluded from the study.

According to local guideline of the unit, time taken for preparing patient for surgery which includes detailed history taking, proper clinical examination, essential investigations and to carry preoperative orders should not be more than three hours. All patients who fulfil inclusion criteria were included in the study during the month of January and February 2004. Time measured is from after the patient is admitted by the Chief RMO for emergency surgery to the start of surgery. Different causes responsible for delay of more than three hours were also observed. Results of the present study were compared with the previous study to see the difference in waiting times for surgery after implementing the proposed guidelines.

Results

A total of 47 patients were admitted through casualty during the study period. Forty patients who fulfilled the inclusion criteria were enrolled. Diagnosis of all patients are shown in Table-I. Seventeen (42.5%) patients had to wait for more than 3 hours for surgery as compared to 73.3% in the previous audit. In this study 15% waited for 4 hours, 20% for 6 hours and only one patient waited for more than 12 hours. In the previous study 17.7% waited for 4 hours, 33.3% for 6 hours and 6.6% of patients waited for more than 12 hours.

Most of the delays were due to timing of admission (29.4%) and time taken to arrange blood (29.4%) followed by investigations in 23.6% (Table-II). Previous study before implementing the guidelines reported 33.3% delays were due to doctors not performing their duty at the earliest followed by admission timing in 21.2%, immediate non-availability of cross-match blood in 18.1%, non availability of anaesthetist in 15.1% and investigations in 12.1%. Unavoidable causes were responsible in 17.6% of delayed surgeries in the present study as compared to 15.1% in the previous one.

Discussion

Audit is intended to be a dynamic process leading to improved patient care.4 To perform an audit a topic is chosen, then standards of practice applicable to it are debated and agreed. Current practice is observed which is compared with the standard. If it does not meet the standard, changes are instituted to try to bring practice up to the standard. Practice is then observed again to see if the changes have been successful. This is called ‘closing the audit loop’.

Many studies have showed that longer the waiting time for emergency surgery more is the morbidity and mortality.5-7 A study from Libreville hospital centre showed that 54.2% patients had some delays in the management of surgical emergencies8. Same trend was observed by another study from a district general hospital.9

Our previous study had showed that there is a wide area lacking professional attitude by the related healthcare workers in delivering the best possible care and significant proportion of patients waited for too long for surgery.3 Some recommendations were proposed in view of these findings (Annex-I). These were reviewed in the successive emergencies during January and February 2004.

Seventeen (42.5%) patients had to wait for more than 3 hours for surgery as compared to 73.3% in the previous audit. Though the number of patients in this study is small but even then, it gives a clear indication of the positive impact of the recommendations. The comparison shown in Table-IV confirms that the recommendations were implemented successfully and the outcome was encouraging, compelling the authorities to continue with the same protocol to reduce the delays even further.

Limitations of the Study

The time spent by the patient in the Emergency department before a decision was taken to operate was not taken into consideration.

Conclusion

The success of this audit cycle has encouraged all the doctors to work and follow the recommendations, while searching for new areas of improvement to continuously upgrade the system, keeping in view our recourses and limitations.

Acknowledgement

We are thankful to all residents and house surgeons who were responsible for patient’s management during the study period.

References

1. Thomas K, Emberton M. Modern Surgical Audit. Surgery 2000; 18(10):250-2.

2. Brown CT, Emberton M. Surgical Audit and the evaluation of surgery. Surgery 2003; 62:141-3.

3. Jawaid M, Amin MF, Khan RA, Iqbal SA. Waiting time for emergency surgeries in a tertiary care teaching hospital. Pak J Med Sci 2005; 21(2):133-7

4. Audit. In: Judith Collier J, Longmore M, Scallyeds P . Oxford hand book of clinical specialities. 6th ed. UK: Oxford University Press; 2003:448.

5. J Sampalis et al. Impact of waiting time on the quality of life of patients awaiting coronary artery bypass grafting. Canad Med Assoc J 2001; 165: 429-33.

6. Brittenden, J, Heys SD. Femoral hernia: mortality and morbidity following elective and emergency surgery. J Roy Coll Surg Edinb 1991; 36(2):86-8.

7. Fang JF, Chen RJ, et al. Small bowel perforation: is urgent surgery necessary? J Trauma 1999; 47(3):515-20.

8. Zue AS, Josseaume A. Surgical emergencies at Libreville hospital center. Ann Fr Anesth Reanim 2003; 22(3): 189-95.

9. Flook DJ and Crumplin MK. The efficiency of management of emergency surgery in a district general hospital - a prospective study. Ann Roy Coll Surg Engl 1990; 72(1): 27-31.


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