1. Trauma Theatre Efficiency Tim White Edinburgh

2. More patients Sicker patients Unpredictability MTC

3. More patients Sicker patients Unpredictability MTC Insufficient theatre time No reserve Too few geriatricians, Too few OTs, Physios Insufficient downstream capacity Declining efficiency

4. More patients Sicker patients Unpredictability MTC Insufficient theatre time No reserve Too few geriatricians, Too few OTs, Physios Insufficient downstream capacity Declining efficiency Delays to theatre Morbidity and mortality Effect on other services

6. More patients Sicker patients Unpredictability MTC Insufficient theatre time No reserve Too few geriatricians, Too few OTs, Physios Insufficient downstream capacity Declining efficiency Delays to theatre Morbidity and mortality Effect on other services

8. Initial scoping exercise Range of views Favourites – Lack of reserve – Anaesthesia delays – Ward delays – Check lists and bureaucracy – CSSD – Recovery capacity

10. Current data

11. Theatre Audit Two nurses Six weeks, three theatres, 456 patients

15. Findings – initial data Morning start Earliest Sent for08:08

16. Findings – initial data Morning start EarliestAverageLatest Sent for08:0808:5110:58

17. Findings – initial data Morning start EarliestAverageLatest Sent for08:0808:5110:58 Anaes start08:3309:1611:15 Knife to skin09:0009:4811:43

18. Reasons for start delays Anaesthetist seeing patients No surgeon to do the brief

19. Change over Next patient in anaesthetic room before previous patient out: 34% Why? – Sent too late – Ward delay – DSU delay

20. Anaesthetist in trauma theatre

21. Throughput main theatres LowestAverageGreatest 20 (trauma 12 hours)25.89 21 (trauma 4 – 8 hours)23.66

22. Narrative comments First case each day not sent for until after 0900. ?why when theatre staff start shift at 0730/0800 Afternoon case had to be recovered in theatre as there was no space in recovery room. Back up in recovery as elective cases waiting for beds in appropriate wards. There were 6 patients boarding within the orthopaedic wards from other specialities that were blocking beds for potential elective cases.

23. Narrative comments First case each day not sent for until after 0900. ?why when theatre staff start shift at 0730/0800 Afternoon case had to be recovered in theatre as there was no space in recovery room. Back up in recovery as elective cases waiting for beds in appropriate wards. There were 6 patients boarding within the orthopaedic wards from other specialities that were blocking beds for potential elective cases.

24. Communication needs to be improved Surgeons could attend leadership/management workshop, to stimulate thought to their role within the theatre team. Th20 often has 3 different anaes for each session, this can impact on pt flow. Some daytime anaes will review pts who are scheduled for evening session which increases the potential for more effective working and more than 1 case after 5pm, some do not Pts who have working venflons can save initial anaes time; ?all pts to have IV access prior to Th

25. Communication needs to be improved Surgeons could attend leadership/management workshop, to stimulate thought to their role within the theatre team. Th20 often has 3 different anaes for each session, this can impact on pt flow. Some daytime anaes will review pts who are scheduled for evening session which increases the potential for more effective working and more than 1 case after 5pm, some do not Pts who have working venflons can save initial anaes time; ?all pts to have IV access prior to Th

26. Communication needs to be improved Surgeons could attend leadership/management workshop, to stimulate thought to their role within the theatre team. Th20 often has 3 different anaes for each session, this can impact on pt flow. Some daytime anaes will review pts who are scheduled for evening session which increases the potential for more effective working and more than 1 case after 5pm, some do not Pts who have working venflons can save initial anaes time; ?all pts to have IV access prior to Th

28. Understanding these problems Leadership Communication and coordination Availability of surgeons Effective scheduling of anaesthetists Support for anaesthetists Coordination of starting times

31. Planned SOPs First patient Change over Anaesthetist cover Anaesthetist duties Preparing the list Consultant responsibilities Coordination – trauma nurse coordinators Other issues: Hospital facilities: recovery, CSSD Mismatch between admissions and theatre slots

32. Planned SOPs First patient Change over Anaesthetist cover Anaesthetist duties Preparing the list Consultant responsibilities Coordination – trauma nurse coordinators Other issues: Hospital facilities: recovery, CSSD Mismatch between admissions and theatre slots

33. Planned SOPs First patient Change over Anaesthetist cover Anaesthetist duties Preparing the list Consultant responsibilities Coordination – trauma nurse coordinators Other issues: Hospital facilities: trauma sessions, recovery, CSSD Mismatch between admissions and theatre slots

34. Timetable for addressing problems 5 th May – Draft report – Draft SOPs 25 th May – Multidisciplinary meeting to agree SOPs June – Implementation of SOPs September – Re-audit

35. Next project Ward care process – Orthogeriatrics – Fluids / fasting / admission assessments – OT / PT provision – Downstream beds / facilities / services Non-operative trauma patients