- Email: [email protected]
Delays in emergency oral and maxillofacial operations: 5 years later
Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery 50 (2012) 141–143
Delays in emergency oral and maxillofacial operations: 5 years later A. Kalantzis a,b,∗ , M. Weisters c,d , N.R. Saeed e,b a
23 Castle Mews, St Thomas Street, Oxford, OX1 1JR, United Kingdom Oral and Maxillofacial Surgery, Oxford Radcliffe Hospitals, United Kingdom c 24 Bicester Road, Long Crendon, Aylesbury, Bucks, HP18 9BP, United Kingdom d Vascular Surgery, Oxford Radcliffe Hospitals, United Kingdom e Department of OMFS, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, United Kingdom b
Accepted 3 January 2011 Available online 26 February 2011
Abstract Delays in emergency oral and maxillofacial operations lead to prolonged discomfort for patients and increase the burden on acute hospital services. A published prospective study in our unit in 2003–2004 identified appreciable delays, which were primarily attributed to general surgical cases taking priority (system delay). Our aim in the present study was to assess progress since then by making a prospective audit of delays in emergency oral and maxillofacial operations over a 6-month period. Data collected included duration and reason for delays, and these were correlated with type of operation, and compared to the performance in the same hospital 5 years previously.A total of 222 patients were booked on to the emergency list, which indicated that the workload had doubled during the 5 years. Mean delay had also increased, with 60% of patients waiting more than 12 h, and 29% more than 24 h. Fractured mandibles were most likely to be left. System delay accounted for 83% of delays. There had been no lessening of the delays in emergency operating, despite increased use of elective lists for emergencies. This may be attributed to the large increase in workload without matching increases in the number of staff or availability of theatres. In addition, problems with communication between specialties, the number of staff in theatre and recovery, and over-running of elective lists, contributed to the use of theatres that did not match their capacity. Since the end of the audited period there have been signs of improvement as a result of an interspecialty initiative to improve the productivity of emergency theatres, and the addition of a dedicated trauma list for oral and maxillofacial surgery. © 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Maxillofacial trauma; Emergency operating; Emergency list; Delays
Introduction Delays in operating on emergency cases may lead to increased morbidity and mortality.1,2 Delays in operating on oral and maxillofacial emergencies are at a cost to the patient and the hospital, but delayed treatment of facial injuries, includ-
∗ Corresponding author at: Oral and Maxillofacial Surgery, Oxford Radcliffe Hospitals, United Kingdom. Tel.: +44 07879677870. E-mail addresses: [email protected] (A. Kalantzis), [email protected] (M. Weisters), [email protected] (N.R. Saeed).
ing those caused by dog bites, has not been associated with an increase in complications, other than technical ones.3–7 As a result, these patients may be low priority on an emergency theatre list, thereby increasing the waiting times and prolonging patients’ discomfort. A prospective audit was made over a 6-month period in 2003–2004 to analyse the reasons for delay in operating on emergency oral and maxillofacial patients at the Oxford Radcliffe Hospital.8 Delays then were mainly the result of inadequate access to emergency theatres and lack of beds (system delays). The authors of that paper reported that the problem was getting worse because the number of patients
0266-4356/$ – see front matter © 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2011.01.017
142
A. Kalantzis et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 141–143
Table 1 Categories of urgency, 1 being the most urgent and 5 the least urgent. Category of urgency
Example
1
Compromise of airway, excessive bleeding Fracture of white eye Abscess and fracture in a child Fractured mandible, abscess, laceration, tracheostomy Orbitozygomatic and nasal fracture
2 3 4 5
Acceptable delay (h) 1 4 12 24 48
Table 3 Emergency oral and maxillofacial operations during the 6 months. Emergency operation
Number
Tracheostomy Fractured mandible Abscess Laceration Midfacial fracture Other
57 51 45 37 22 10
Total
222
Results was increasing as a result of centralisation of the service, and reductions in out-of-hours operating to comply with NCEPOD guidelines. After that audit our department tried to secure a dedicated oral and maxillofacial trauma list, and there was a push from all specialties for a second emergency list, but neither had materialised. However, attempts to improve communication had been made, with the introduction of “categories” of urgency (Table 1). The aim of the present study was to assess the extent of the problem 5 years later.
Methods Data were collected prospectively from forms that were filled in by staff in the emergency theatre as part of an exercise to monitor performance and improvement. Data collected included patients’ clinical and personal details, type of injury or illness, operation required, booking time, time of arrival in theatre, and reason for any delay. Forms relating to oral and maxillofacial procedures between 10 November 2008 and 9 May 2009, a similar 6-month period as that studied previously, were used for analysis. The data were cross-referenced with electronic theatre records to avoid any errors or omissions. The “doorstep-to-table” delay was recorded, and related to the type of injury or illness, and results were compared with those of the previous study. The causes of waits beyond the agreed acceptable waiting times (Table 1) were classified as “system delay”, “patient delay”, or “surgeon delay” (Table 2). The casenotes of those patients whose operations were considered to have been delayed were reviewed retrospectively for any complications associated with late treatment.
Table 2 Reasons for delay in emergency operating. System delay Patient delay Surgeon delay
Other emergencies took priority Emergency list halted Patient unsuitable for theatre (not fasted) Patient initially refused operation No surgeon available
Of a total of 261 patients who required emergency oral and maxillofacial operations, the data for 222 were analysed. The remainder (mainly orbitozygomatic fractures) were excluded as they were booked directly on to elective lists. The operations done over the 6 months are listed in Table 3. For comparison, there were 109 cases from the older study (only 61 were analysed because records were incomplete), although tracheostomies were not included in that study. Delays in treatment were subdivided into the ranges 0–6, 6–12, 12–24, and over 24 h (Table 4). When they were compared with those of the previous study the commonest “doorstep-to-table” delay was still 12–24 h, with a mean waiting time of 22 h and 30 min for Category 4 cases, which included the 4 commonest procedures (Table 1). Sixty per cent of patients waited over 12 h and 29% over 24 h. Delays in relation to each procedure were also analysed. Notably, many more patients with fractured mandibles had to wait more than 24 h than was previously the case (45% of patients waited over 24 h compared with 28% in the previous study (8)). With dentoalveolar infections, and infections of the deep spaces of the neck, performance was better than that for fractured mandibles, with waiting times similar to the previous study. No data existed for comparison of delays with tracheostomy, but in our study these followed the usual pattern (Table 5). We usually managed to suture lacerations within 24 h, as most involve young children who are given priority. Overall, 67 of our patients (30%) were delayed longer than was acceptable (Table 5). System delays, primarily because other cases took priority, accounted for 83% of the delays, although the cause was not always recorded (Table 6). Delays were not associated with complications in the present study.
Table 4 Duration of delay to emergency operations. Data are number (%) of operations. Time (h)
2003–2004 (n = 61)
2008–2009 (n = 222)
0–6 6–12 12–24 >24
6 (6) 6 (10) 28 (6) 11 (18)
48 (22) 26 (12) 87 (39) 60 (27)
A. Kalantzis et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 141–143 Table 5 Number (%) of unacceptable delays according to type of operation, 2008–2009. Operation
Number
Abscess Fractured mandible Tracheostomy Midfacial fracture Suture of lacerations Other
45 51 57 22 37 10
No delay 33 28 38 17 33 7
Delay 12 (27) 23 (45) 19 (33) 6 (7) 4 (11) 3
Table 6 Reasons for unacceptable delays. Cause of wait
Number affected
System delay Patient delay Surgeon delay Unknown
29 6 0 32
Total
67
Discussion During the 5 years since the first audit there has been an approximately 2-fold increase in workload, primarily because the unit has expanded and there has been further centralisation of service, with our department now covering a population of about 2.2 million (previously less than 1.5 million). An increase in the incidence of trauma, and a more aggressive approach to certain injuries (fractured condyles and transcranial trauma) may also have contributed. As a result, a large proportion of our emergency patients still have unacceptable delays. We must emphasise that although patients booked directly on to elective lists were excluded from this study, many of the patients initially booked on to the emergency list (and therefore included in the study) were actually operated on during elective lists (with subsequent cancellation of elective cases) to avoid further delays. Without this practice things would have been far worse. When we compared the two audited periods we found that our number of consultants had increased from 3 to 5, there were still 2 specialist registrars, and the number of senior house officers had increased from 6 to 8. The consultant on call is now always on site and as a result there were no “surgeon delays”. The main reason for the delays was access to theatres, as we had to compete with general surgery and other specialties for the same theatre space. There had been no increase in theatre staffing or recovery facilities, and there were still delays to emergency lists when elective lists overran. Although some efforts to improve have been made there is still inadequate communication and planning, leading to poor organisation of theatre time. Similar problems have been reported by others.9–11 Clearly our resources do not allow
143
us to treat emergency patients in a timely fashion. Since the completion of the second audit there has been an interspecialty initiative to audit and improve the use of emergency lists, with communication meetings and visual aids. There are also now two urgent bookable lists each week primarily used by general surgery, and a dedicated oral and maxillofacial trauma list once a week. Whether this will be enough to improve performance remains to be seen. Oral and maxillofacial surgery is the preferred specialty to which facial injuries are referred by accident and emergency departments in the UK.12 In our department the number of patients continues to increase, but the numbers of staff lag behind. It is of note that the number of consultants in oral and maxillofacial surgery in the UK has not been increasing at the same rate as numbers in other surgical specialties.10 In future the problem may shift from one of availability of theatres to one of availability of surgeons.
References 1. National Confidential Enquiry into Patient Outcome and Death. Who operates when? (1995/96). London; 1997. Available from http://www.ncepod.org.uk/1995 6.htm. 2. Lankester BJ, Paterson MP, Capon G, Belcher J. Delays in orthopaedic trauma treatment: setting standards for the time interval between admission and operation. Ann R Coll Surg Engl 2000;82: 322–6. 3. Press BH, Boies Jr LR, Shons AR. Facial fractures in trauma victims: the influence of treatment delay on ultimate outcome. Ann Plast Surg 1983;11:121–4. 4. Solas J, Marx O, Rebindaine. Delayed mandibular osteosynthesis (in French). Rev Stomatol Chir Maxillofac 1984;85:416–8. 5. Biller JA, Pletcher SD, Goldberg AN, Murr AH. Complications and the time to repair of mandible fractures. Laryngoscope 2005;115: 769–72. 6. Furr AM, Schweinfurth JM, May WL. Factors associated with longterm complications after repair of mandibular fractures. Laryngoscope 2006;116:427–30. 7. Akhtar N, Smith MJ, McKirdy S, Page RE. Surgical delay in the management of dog bite injuries in children, does it increase the risk of infection? J Plast Reconstr Aesthet Surg 2006;59:80–5. 8. Reuther WJ, Saeed NR, Bond SE, Van Eeden SP. Delays in emergency oral and maxillofacial operating—a prospective audit. Ann R Coll Surg Engl 2004;86(Suppl.):20–2. 9. Barlow AP, Winkinson DA, Wordsworth M, Eyre-Brook IA. An emergency daytime theatre list: utilisation and impact on clinical practice. Ann R Coll Surg Engl 1993;75:441–4. 10. National Confidential Enquiry into Patient Outcome and Death. Who operates when? II. London; 2003. Available from http://www.ncepod.org.uk/2003wow.htm. 11. National Confidential Enquiry into Patient Outcome and Death. Deaths in acute hospitals: caring to the end? London; 2009. Available from http://www.ncepod.org.uk/2009dah.htm. 12. Allonby-Neve CL, Okereke CD. Current management of facial wounds in UK accident and emergency departments. Ann R Coll Surg Engl 2006;88:144–50.
British Journal of Oral and Maxillofacial Surgery 50 (2012) 141–143
Delays in emergency oral and maxillofacial operations: 5 years later A. Kalantzis a,b,∗ , M. Weisters c,d , N.R. Saeed e,b a
23 Castle Mews, St Thomas Street, Oxford, OX1 1JR, United Kingdom Oral and Maxillofacial Surgery, Oxford Radcliffe Hospitals, United Kingdom c 24 Bicester Road, Long Crendon, Aylesbury, Bucks, HP18 9BP, United Kingdom d Vascular Surgery, Oxford Radcliffe Hospitals, United Kingdom e Department of OMFS, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, United Kingdom b
Accepted 3 January 2011 Available online 26 February 2011
Abstract Delays in emergency oral and maxillofacial operations lead to prolonged discomfort for patients and increase the burden on acute hospital services. A published prospective study in our unit in 2003–2004 identified appreciable delays, which were primarily attributed to general surgical cases taking priority (system delay). Our aim in the present study was to assess progress since then by making a prospective audit of delays in emergency oral and maxillofacial operations over a 6-month period. Data collected included duration and reason for delays, and these were correlated with type of operation, and compared to the performance in the same hospital 5 years previously.A total of 222 patients were booked on to the emergency list, which indicated that the workload had doubled during the 5 years. Mean delay had also increased, with 60% of patients waiting more than 12 h, and 29% more than 24 h. Fractured mandibles were most likely to be left. System delay accounted for 83% of delays. There had been no lessening of the delays in emergency operating, despite increased use of elective lists for emergencies. This may be attributed to the large increase in workload without matching increases in the number of staff or availability of theatres. In addition, problems with communication between specialties, the number of staff in theatre and recovery, and over-running of elective lists, contributed to the use of theatres that did not match their capacity. Since the end of the audited period there have been signs of improvement as a result of an interspecialty initiative to improve the productivity of emergency theatres, and the addition of a dedicated trauma list for oral and maxillofacial surgery. © 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Maxillofacial trauma; Emergency operating; Emergency list; Delays
Introduction Delays in operating on emergency cases may lead to increased morbidity and mortality.1,2 Delays in operating on oral and maxillofacial emergencies are at a cost to the patient and the hospital, but delayed treatment of facial injuries, includ-
∗ Corresponding author at: Oral and Maxillofacial Surgery, Oxford Radcliffe Hospitals, United Kingdom. Tel.: +44 07879677870. E-mail addresses: [email protected] (A. Kalantzis), [email protected] (M. Weisters), [email protected] (N.R. Saeed).
ing those caused by dog bites, has not been associated with an increase in complications, other than technical ones.3–7 As a result, these patients may be low priority on an emergency theatre list, thereby increasing the waiting times and prolonging patients’ discomfort. A prospective audit was made over a 6-month period in 2003–2004 to analyse the reasons for delay in operating on emergency oral and maxillofacial patients at the Oxford Radcliffe Hospital.8 Delays then were mainly the result of inadequate access to emergency theatres and lack of beds (system delays). The authors of that paper reported that the problem was getting worse because the number of patients
0266-4356/$ – see front matter © 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2011.01.017
142
A. Kalantzis et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 141–143
Table 1 Categories of urgency, 1 being the most urgent and 5 the least urgent. Category of urgency
Example
1
Compromise of airway, excessive bleeding Fracture of white eye Abscess and fracture in a child Fractured mandible, abscess, laceration, tracheostomy Orbitozygomatic and nasal fracture
2 3 4 5
Acceptable delay (h) 1 4 12 24 48
Table 3 Emergency oral and maxillofacial operations during the 6 months. Emergency operation
Number
Tracheostomy Fractured mandible Abscess Laceration Midfacial fracture Other
57 51 45 37 22 10
Total
222
Results was increasing as a result of centralisation of the service, and reductions in out-of-hours operating to comply with NCEPOD guidelines. After that audit our department tried to secure a dedicated oral and maxillofacial trauma list, and there was a push from all specialties for a second emergency list, but neither had materialised. However, attempts to improve communication had been made, with the introduction of “categories” of urgency (Table 1). The aim of the present study was to assess the extent of the problem 5 years later.
Methods Data were collected prospectively from forms that were filled in by staff in the emergency theatre as part of an exercise to monitor performance and improvement. Data collected included patients’ clinical and personal details, type of injury or illness, operation required, booking time, time of arrival in theatre, and reason for any delay. Forms relating to oral and maxillofacial procedures between 10 November 2008 and 9 May 2009, a similar 6-month period as that studied previously, were used for analysis. The data were cross-referenced with electronic theatre records to avoid any errors or omissions. The “doorstep-to-table” delay was recorded, and related to the type of injury or illness, and results were compared with those of the previous study. The causes of waits beyond the agreed acceptable waiting times (Table 1) were classified as “system delay”, “patient delay”, or “surgeon delay” (Table 2). The casenotes of those patients whose operations were considered to have been delayed were reviewed retrospectively for any complications associated with late treatment.
Table 2 Reasons for delay in emergency operating. System delay Patient delay Surgeon delay
Other emergencies took priority Emergency list halted Patient unsuitable for theatre (not fasted) Patient initially refused operation No surgeon available
Of a total of 261 patients who required emergency oral and maxillofacial operations, the data for 222 were analysed. The remainder (mainly orbitozygomatic fractures) were excluded as they were booked directly on to elective lists. The operations done over the 6 months are listed in Table 3. For comparison, there were 109 cases from the older study (only 61 were analysed because records were incomplete), although tracheostomies were not included in that study. Delays in treatment were subdivided into the ranges 0–6, 6–12, 12–24, and over 24 h (Table 4). When they were compared with those of the previous study the commonest “doorstep-to-table” delay was still 12–24 h, with a mean waiting time of 22 h and 30 min for Category 4 cases, which included the 4 commonest procedures (Table 1). Sixty per cent of patients waited over 12 h and 29% over 24 h. Delays in relation to each procedure were also analysed. Notably, many more patients with fractured mandibles had to wait more than 24 h than was previously the case (45% of patients waited over 24 h compared with 28% in the previous study (8)). With dentoalveolar infections, and infections of the deep spaces of the neck, performance was better than that for fractured mandibles, with waiting times similar to the previous study. No data existed for comparison of delays with tracheostomy, but in our study these followed the usual pattern (Table 5). We usually managed to suture lacerations within 24 h, as most involve young children who are given priority. Overall, 67 of our patients (30%) were delayed longer than was acceptable (Table 5). System delays, primarily because other cases took priority, accounted for 83% of the delays, although the cause was not always recorded (Table 6). Delays were not associated with complications in the present study.
Table 4 Duration of delay to emergency operations. Data are number (%) of operations. Time (h)
2003–2004 (n = 61)
2008–2009 (n = 222)
0–6 6–12 12–24 >24
6 (6) 6 (10) 28 (6) 11 (18)
48 (22) 26 (12) 87 (39) 60 (27)
A. Kalantzis et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 141–143 Table 5 Number (%) of unacceptable delays according to type of operation, 2008–2009. Operation
Number
Abscess Fractured mandible Tracheostomy Midfacial fracture Suture of lacerations Other
45 51 57 22 37 10
No delay 33 28 38 17 33 7
Delay 12 (27) 23 (45) 19 (33) 6 (7) 4 (11) 3
Table 6 Reasons for unacceptable delays. Cause of wait
Number affected
System delay Patient delay Surgeon delay Unknown
29 6 0 32
Total
67
Discussion During the 5 years since the first audit there has been an approximately 2-fold increase in workload, primarily because the unit has expanded and there has been further centralisation of service, with our department now covering a population of about 2.2 million (previously less than 1.5 million). An increase in the incidence of trauma, and a more aggressive approach to certain injuries (fractured condyles and transcranial trauma) may also have contributed. As a result, a large proportion of our emergency patients still have unacceptable delays. We must emphasise that although patients booked directly on to elective lists were excluded from this study, many of the patients initially booked on to the emergency list (and therefore included in the study) were actually operated on during elective lists (with subsequent cancellation of elective cases) to avoid further delays. Without this practice things would have been far worse. When we compared the two audited periods we found that our number of consultants had increased from 3 to 5, there were still 2 specialist registrars, and the number of senior house officers had increased from 6 to 8. The consultant on call is now always on site and as a result there were no “surgeon delays”. The main reason for the delays was access to theatres, as we had to compete with general surgery and other specialties for the same theatre space. There had been no increase in theatre staffing or recovery facilities, and there were still delays to emergency lists when elective lists overran. Although some efforts to improve have been made there is still inadequate communication and planning, leading to poor organisation of theatre time. Similar problems have been reported by others.9–11 Clearly our resources do not allow
143
us to treat emergency patients in a timely fashion. Since the completion of the second audit there has been an interspecialty initiative to audit and improve the use of emergency lists, with communication meetings and visual aids. There are also now two urgent bookable lists each week primarily used by general surgery, and a dedicated oral and maxillofacial trauma list once a week. Whether this will be enough to improve performance remains to be seen. Oral and maxillofacial surgery is the preferred specialty to which facial injuries are referred by accident and emergency departments in the UK.12 In our department the number of patients continues to increase, but the numbers of staff lag behind. It is of note that the number of consultants in oral and maxillofacial surgery in the UK has not been increasing at the same rate as numbers in other surgical specialties.10 In future the problem may shift from one of availability of theatres to one of availability of surgeons.
References 1. National Confidential Enquiry into Patient Outcome and Death. Who operates when? (1995/96). London; 1997. Available from http://www.ncepod.org.uk/1995 6.htm. 2. Lankester BJ, Paterson MP, Capon G, Belcher J. Delays in orthopaedic trauma treatment: setting standards for the time interval between admission and operation. Ann R Coll Surg Engl 2000;82: 322–6. 3. Press BH, Boies Jr LR, Shons AR. Facial fractures in trauma victims: the influence of treatment delay on ultimate outcome. Ann Plast Surg 1983;11:121–4. 4. Solas J, Marx O, Rebindaine. Delayed mandibular osteosynthesis (in French). Rev Stomatol Chir Maxillofac 1984;85:416–8. 5. Biller JA, Pletcher SD, Goldberg AN, Murr AH. Complications and the time to repair of mandible fractures. Laryngoscope 2005;115: 769–72. 6. Furr AM, Schweinfurth JM, May WL. Factors associated with longterm complications after repair of mandibular fractures. Laryngoscope 2006;116:427–30. 7. Akhtar N, Smith MJ, McKirdy S, Page RE. Surgical delay in the management of dog bite injuries in children, does it increase the risk of infection? J Plast Reconstr Aesthet Surg 2006;59:80–5. 8. Reuther WJ, Saeed NR, Bond SE, Van Eeden SP. Delays in emergency oral and maxillofacial operating—a prospective audit. Ann R Coll Surg Engl 2004;86(Suppl.):20–2. 9. Barlow AP, Winkinson DA, Wordsworth M, Eyre-Brook IA. An emergency daytime theatre list: utilisation and impact on clinical practice. Ann R Coll Surg Engl 1993;75:441–4. 10. National Confidential Enquiry into Patient Outcome and Death. Who operates when? II. London; 2003. Available from http://www.ncepod.org.uk/2003wow.htm. 11. National Confidential Enquiry into Patient Outcome and Death. Deaths in acute hospitals: caring to the end? London; 2009. Available from http://www.ncepod.org.uk/2009dah.htm. 12. Allonby-Neve CL, Okereke CD. Current management of facial wounds in UK accident and emergency departments. Ann R Coll Surg Engl 2006;88:144–50.