Report on General Emergency Surgical Services Worcestershire Acute Hospital NHS Trust 23-24 January 2014

The Trust should closely monitor and review the effectiveness of the new surgical pathway for the management of general emergency surgical patients. It is important that any problems with the pathway are responded to in a timely manner.

The Trust should ensure that any changes to the surgical pathway are effectively communicated to all members of staff that use the pathway. The Trust should consider whether, for its own reassurance, mechanisms for ensuring that staff have read and understood the pathway are introduced, such as a sign off on a register.

Capacity and issues such as the availability of ambulances to transfer patients should be closely monitored to ensure that this is not having an adverse impact on patient care.

The Trust need to closely monitor and review the outcome data available to them and respond to any causes for concern in a timely manner. This should be reviewed once a month as a minimum.

The Trust needs to update the delivery of the current general surgical service at the Alexandra so that this meets current national standards. The number of procedures undertaken laparoscopically is likely to improve with the updating of equipment, however, increasing the number of procedures undertaken as day cases and establishing an Enhanced Recovery programme still requires further work.

The Trust should ensure that there is consistently senior input out of hours. If it is not already the case, the ‘consultant of the day’ provision should be extended to seven days a week as well as through the night. Senior input must be available during nights and weekends.

The Trust should ensure that there is senior input available out of hours to middle grades and that middle grades are proactive in identifying complications and consulting senior doctors

The Trust should review the care pathways for complex upper GI and acute bowel obstructions to ensure that any patients who require emergency procedures without delay are not being operated on outwith the skill set of the on-call consultant and are being referred to neighbouring Trusts if required.

The review team supported the interim measures that the Trust introduced for the emergency service at the Alexandra hospital, however, the Trust should monitor the uptake of these and ensure that there are consequences for those who do not adhere to them.

A pathway for reporting concerns about the emergency surgery service needs to be developed. Establishment of the Clinical Lead for Emergency Surgery will be crucial to this.

The Trust should undertake work with the middle grade doctors to identify any training needs they may have. It is considered that the middle grades should have attended either the RCS ATLS (Advanced Trauma and Life Support) or CcRISP (Care of the critically ill surgical patient) in the past and should maintain their skills and keep up to date in these areas in particular. It is expected that they should be shown to be competent in six months.

The Trust should review the current protocols for requesting scans out of hours to ensure that there are no unnecessary delays in establishing diagnosis. e.g. double checking requests from middle grade doctors with the consultants.

Adoption of pathways such as the amber pathways by all staff needs to be addressed. Consideration should be given to introducing these as part of mandatory training.

The number of forms required for insulin prescriptions for diabetic patients needs to be reviewed and unambiguous protocols for care of diabetic patients need to be in place.

The Trust should establish an Enhanced Recovery Programme at the Alexandra Hospital.

End of life care and decision making was highlighted as a concern in Name redacted’s review; the Trust should give further consideration to ways to improve this provision and whether any additional training needs to be given to staff to address these concerns.

Establishment of a county-wide team has begun with some of the Worcester Royal surgeons starting to operate at the Alexandra site. Work needs to be done to ensure that this is an inclusive programme and requires the full input of the Alexandra consultants.

The Trust should ensure that there is a forum for the views of middle grade surgeons to be heard and that they are more actively involved in departmental meetings with attendance mandatory. Consideration should be given to assigning a mentor to each of the middle grades. Active steps are needed to improve the morale and functioning of this group, on which the surgical service so much relies.

Now that the reconfiguration plans have been agreed, the Trust needs to continue to put in place a stable workforce to provide the general and emergency surgical care.

The Trust needs to establish a template for the audit meetings and ensure that these are looking at key datasets such as HSMR, NELA and NBOCAP.

The consultants should be free of any elective commitments during audit meetings with annual attendance for each member agreed (it is suggested this should be around 60 per cent), and progress against this discussed during their appraisal.

Audit meetings should involve staff from all levels to ensure that they are aware of the outcomes of the department and areas that require improvement.

The governance structure in place for addressing complaints and dealing with SUIs needs to be reviewed. It is important that these are being handled in a timely manner and any backlogs of Datix incidents are dealt with. Any actions taken to address issues arising from these should be logged and reviewed. There are a number of Department of Health policy documents on matters such as how to investigate an SUI and the reporting of never events and the Trust should review their current processes to ensure they are in line with current best practice.

The Trust should not view complaints and incidents as single events. Work should be undertaken to look at any potential trends in this data. In the interests of patient safety, sufficient resources need to be allocated to enable this to be performed effectively.

Adherence to pathways such as the amber pathway should be addressed. The Trust should regularly review any pro formas that are used to monitor its use and take action accordingly with those who do not comply.

It is important that the Trust addresses their current completion rates for appraisals and ensures that each of the consultant surgeons are having annual appraisals.

Review of incident outcomes by the named clinician is a fundamental component of the appraisal process for medical staff and ensures that reflective practice is undertaken. The appraisal process should therefore review any complaints or Datix incidents that are relevant to the individual along with actions taken to address any issues.

The job planning for the middle grade doctors needs to be reviewed. Six weeks rolling notice of work plans should be given to this group.

The consultant job plans will need continuous monitoring and review as the reconfiguration process continues to ensure that there is a smooth transition. The Trust should ensure that the Alexandra consultants will not encounter any clashes which would prevent them from attending key meetings such as audit, MDT and M&M meetings.

The Trust needs to improve communication across the current structure. It is clear that the Trust has a vision for the service but they will need to engage their staff in the process of implementation of these plans in order for it to be a success and to operate safely.

The priority for the Trust should first and foremost be patient safety but the Trust should not lose sight of the needs of its catchment population and in particular transportation issues for relatives as well as patients.