Using an under-utilised rural hospital to reduce surgical waiting lists

Setting

The Illawarra Shoalhaven Local Health District (ISLHD), sought to utilise existing human resources and infrastructure (including same-day surgery) to increase surgical capacity. As a result, it implemented a pilot program that introduced specialist, day-surgery services at its most rural site, a small rural (MM4) hospital with a single, unutilised operating theatre. It was a level two hospital with an 11-space emergency department seeing approximately 15,000 presentations per year, and a 25-bed inpatient ward. The inpatient ward worked on a general medicine model, and had four monitored beds plus capacity for two over-census beds to monitor post-operative patients if required. There was also an outpatient renal dialysis unit, an outpatient oncology infusion unit and outpatient allied health services.

The pilot program was intended to create additional operating capacity, and thereby reduce surgical waiting lists, improve timely access to surgical services and reduce the need for travel by patients and their overnight admission. A multi-disciplinary committee comprising nurses, anaesthetists, surgeons and administrators designed the pilot program. Suitable patients for ambulatory surgery were selected based on strict anaesthetic, surgical and social criteria.

Patient selection

Patients were selected from the waiting list for the closest larger referral hospital, with preference given to those residing locally or for whom travel to this larger hospital would be burdensome. Prospective patients were excluded if they presented with any of the following anaesthetic criteria: body mass index >35 kg/m²; high risk of severe obstructive sleep apnoea (OSA) score at ≥5 on STOPBANG screening (Snoring, Tired, Observed, Pressure, Body Mass Index, Age, Neck size, Gender); known OSA with poor compliance, tolerance of, or access to continuous positive airway pressure (CPAP); known OSA with CPAP requiring long acting opioids for pain management post-operatively; American Society of Anesthesiologists (ASA) physical status classification system score >3 requiring sedation or general anaesthetic; past history of post-operative delirium, significant dementia, cognitive impairment or other risk factors for post-operative delirium; and a potentially difficult airway.

Surgery inclusion criteria were: duration <2 h; anticipated blood loss <200 mL and low risk for bleeding; no deep space surgery (e.g. intra-abdominal procedures, deep cervical spaces); likely discharge on oral analgesia or less and with normal enteral diet; very low risk of intra-operative or immediate complications; and surgery not likely to significantly impede daily living (e.g. bilateral arm immobilisation).

Social criteria for selection included: patient having a competent carer staying in their home overnight post-operatively; not a principal carer for another person; lived within a 1-h drive of the study site; and would be contactable by phone for 48 h following surgery.

All patients who received surgery during the study required their surgery to be performed in a local hospital setting rather than as office-based surgery, with the latter being offered by consultant surgeons in a clinic adjacent to the hospital. Specific requirements for hospital surgery were for a variety of reasons such as access to particular medical equipment, the need for sedation, tolerance of local anaesthesia, or the extent and complexity of surgery. If a patient were eligible for an office-based procedure they were not booked on the public waiting list and were thus excluded from the pilot study.

Staff training

The nursing staff engaged had usually been assigned to emergency departments or inpatient wards, and most had minimal theatre experience. Skills shortfalls were addressed by appropriate re-training and in-service training in scrub, scout and anaesthetic duties, however, most upskilling training was provided to staff during theatres by the existing theatre nurse clinical nurse educator or clinical nurse specialist.

A general practitioner (GP) visiting medical officer (VMO) provided anaesthetic services and was supported by a supra-numerary specialist anaesthetist who also provided teaching and supervision to medical and nursing staff. The specialist anaesthetist was also present every fortnight in a supervisory capacity and to provide further teaching and upskilling both of nursing and medical staff.

Pilot program logistics and evaluation

Surgery was conducted by one general and one plastic surgeon. The general surgeon resided in the local area (MM4), while the plastic surgeon routinely visited the area on a monthly basis. No surgical trainees were involved, however there were medical students and GP registrars. Peri-operative logistics (e.g. request for admissions (RFA) screening, management of blood thinners and patient scheduling) were managed by a larger regional (MM3) hospital located within the district. This enabled the study site operating theatre to function as a ‘satellite theatre.’ Most procedural supplies were maintained at the study site, though some sterilisation services and instruments were also provided by the larger regional hospital.

Patients selected for surgery based on suitable procedure type and anaesthetic assessment were operated on at the study site between May 2021 and May 2022. All selected patients were offered their procedure at this rural study site in lieu of either a larger regional (MM3) hospital (61 km or approximately 1 h drive away) or the nearest metropolitan (MM1) hospital (138 km or 2 h drive away). The day-surgery patient information outlined communication options if patients had concerns, which was to the surgeon’s office if during business hours or to the study site’s emergency department (ED) if after hours or the surgeon was not contactable. The study site had a 24 h staffed ED with on-call support to the nearest referral centre with a 24 h surgical registrar available. Existing patient information sheets and day surgery website information that had been developed at a Local Health District (LHD) level were used during this pilot program.

In the event of an unexpected adverse event, escalation of care was at the direction of the surgeon or anaesthetist, and would depend on the nature and seriousness of the event. Options included: admission to the study site for simple observation; road transfer to the nearest regional hospital for admission to ward/intensive care unit and/or return to theatre; or if a case required cardiac, neurology or other subspeciality care, either air or road transfer to the nearest metropolitan referral hospital was available.

Between 2 and 7 days following their procedure, a total of 50 patients completed an anonymous, five-question patient satisfaction survey. The pilot program was reviewed monthly in an open forum in terms of case numbers, complications, morbidity and mortality events.

Ethical considerations

This project was reviewed by the LHD’s Low and Negligible Risk Research Review Committee and was deemed exempt from further ethical review according to the NSW Office for Health and Medical Research Guideline GL2007_020: Quality Improvement & Ethical Review: A Practice Guide for NSW.

Clinical outcomes

Of the 161 operations, 100 were performed under sedation and locoregional anaesthesia and 61 under general anaesthesia. Eighty-six (53.4%) were excisions of malignant skin lesions, including melanoma, squamous cell carcinomas and basal cell carcinomas (Table 1). Of these 61 (37.9% of the total procedures) also required either a skin graft or local flap repair.

There were no mortality events or major morbidity events either during the study period or subsequently to the time of writing. No patients required overnight admission or return to theatre, nor were there any re-presentations to the study hospital within 48 h of operating. Two superficial surgical site infections were reported (one skin excision and one carpal tunnel), and both were managed conservatively with oral antibiotics.

Patient experience

Of the 50 survey questionnaires completed, all respondents expressed satisfaction with their care at the study site (Table 2). None indicated that they needed to see a doctor following discharge. Almost all respondents (n = 48, 96%) reported adequate pain relief post-discharge and satisfactory control of nausea.