Who is responsible for proritising surgery in a hospital?

blatantrereg

Hi
Who is responsible for setting the order of emergency surgery in a hospital? -For cases where surgery needs to be carried out as soon as possible, such as appendectomies.
Thanks

Victor

I imagine there is a medical / surgical committee, primarily comprised of the senior doctors, who prioritise needs on a medical basis.

On a day to day basis, I imagine the surgical team sets their own schedule, depending on what is most practical, e.g. straightforward surgeries that are unlikely to have complications might be put at the start of the day's schedule. Surgeries where complications are more common might be allocated on a different day or at the end of the day - if it runs on, you don't have another bunch of cases in pre-op. Several short-duration surgeries might be scheduled on the one day, but more complicated surgeries might be allocated a day / morning / afternoon to themselves

Certain types of surgeries, e.g. leg surgeries, might all be done on the one day, so that they can have the most appropriate personnel scheduled.

blatantrereg

I'm actually thinking about emergency procedures, like appendectomies, where they need to be carried out as soon as possible. Sorry I know I didn't specify that in the original post.

ZombieMed

they go on the emergency surgery list for that day/night. You've got about 36 hours from start of symptoms to appendix bursting but it's more emergent than say a broken leg which needs to be reset. If 10 appys were to come in at once they'd schedule based on who's be symptomatic the longest.

micosoft

If you are talking in general terms hey don't prioiritise non elective (emergency) admissions given the simple fact the patient would might die or suffer severe complications if there were any significant delay. They just do them as quickly as reasonably possible. Staff are on call at all times for emergency admissions. What you will find is that elective admissions (planned non-emergency admissions) are delayed all the time due to emergency admissions being automatically prioritising.

The only time when you might get a possibility of prioiritising is a disaster where the system is overwhelmed. A triage system is setup where doctors and nurses prioritise those needing treatment first. This is ad hoc and would very rarely happen in a serious way (though always ongoing in A&E for minor ailments because we allow people abuse the system).

Interestingly - from a statistical point of view, it is much easier to plan for non-elective then elective admissions. This is because accidents or medical emergencies happen in a volume that is statistically predictable and the human choice element is taken out of it. On the other hand elective medicine has constant no shows etc. because of the human choice element. So in matter of fact out A&E should be easily predictable and our elective beds much harder to predict demand. Despite this HSE constantly trot out the line that "random" demand is the cause of the A&E issue.

blatantrereg

ZombieMed wrote: »

they go on the emergency surgery list for that day/night. You've got about 36 hours from start of symptoms to appendix bursting but it's more emergent than say a broken leg which needs to be reset. If 10 appys were to come in at once they'd schedule based on who's be symptomatic the longest.

It's over 48 hours now. 35 hours since we arrived in the ER (with a referral letter). 24 hours since we were originally told she needed emergency surgery. They changed to saying she was going to go for scans at some point after that, before a senior doctor said the original diagnosis was correct and that the examination and blood samples were sufficient for it.

I'm pretty concerned. They just say the surgery is busy.

Just got a text right this moment saying she's going in now. Somewhat relieved..

ZombieMed

They have obviously been monitoring her symptoms and tests and fitted her in where appropriate. Glad to hear you're relieved anyway:)

blatantrereg

I hope you are correct, but I wouldn't say 'obviously'. There was a delay of several hours in the initial diagnosis because Microbiology hadnt returned the blood test results and were not answering the phone. Then there was the confusion over whether she was having scans or tests. And she kept being told she was about to go into surgery since yesterday afternoon.
The place is severely under-resourced and very busy. A doctor and nurse in the ER separately commented that it was particularly bad that night. That sort of severe ongoing pressure can lead to mistakes, and there appears to be some communication issues there too.

his_dudeness

Its quite possible that you were put on the emergency list from the time you came in, but that your "turn" didn't come around until it did.

It is quite possible that there were cases on the list already that may have been postponed from previous days. While the comments above about time to "bursting" of the appendix are generally right, rushing in to surgery could have more ttrouble than waiting. The CEPOD (Confidential Enquiry into PostOperative Death) enquiry in the UK about 12 years ago showed that operations performed overnight when there would be less staff around i.e. more than just the oncall teams, leaded to higher rates of death and complications, and suggested that only "life-threathening and limb-threatening" surgery be performed overnight, and everything else be put off until the next day if possible. As a result, in alot of hospitals, there won't be much happening in operating theatres after midnight than is absolutely necessary.

The scans/tests you were being sent for may have been to reaffirm the decision to take you to theatre rather that change the decision; a lot of appendicectomies have a very characteristic clinical presentation and extra scans aren't always necessary.

Hope it all turned out ok.

blatantrereg

his_dudeness wrote: »

The scans/tests you were being sent for may have been to reaffirm the decision to take you to theatre rather that change the decision; a lot of appendicectomies have a very characteristic clinical presentation and extra scans aren't always necessary.

I meant I think she should never have been scheduled for the extra scans, and that it might have created an extra delay.

Hope it all turned out ok.

Yes it did thanks

Gurgle

blatantrereg wrote: »

I think she should never have been scheduled for the extra scans, and that it might have created an extra delay.

The problems with the health services are all between the front desk and the experts.

Once you've managed to get in front of the consultant, the care is every bit as good as anywhere in the world. Don't stress yourself out second guessing them, they know what they're doing.

yellowlabrador

Gurgle wrote: »

The problems with the health services are all between the front desk and the experts.

Once you've managed to get in front of the consultant, the care is every bit as good as anywhere in the world. Don't stress yourself out second guessing them, they know what they're doing.

I totally agree. My son was rushed in with a suspected burst appendix and 3 different doctors hmmd and ahhd. The consultant decided it was something else and kept him in under observation.He was right. They do have our best interest at heart. I always think that when you're seriously ill, the hse is like a rolls royce but if you are 'in the outpatient system' you're on the slow coach. I waited patently for 2 years for my appointment for rheumatoloy only to turn up and find the doctor on holiday

Victor

micosoft wrote: »

If you are talking in general terms hey don't prioiritise non elective (emergency) admissions given the simple fact the patient would might die or suffer severe complications if there were any significant delay.

Surely head injury > thorax injury > limb injury ?

First Aid Ireland

Victor wrote: »

Surely head injury > thorax injury > limb injury ?

There's a vast spectrum of severity within each of those categories, so there's absolutely no way you can prioritise so simplistically.

RobFowl

yellowlabrador wrote: »

I always think that when you're seriously ill, the hse is like a rolls royce but if you are 'in the outpatient system' you're on the slow coach. I waited patently for 2 years for my appointment for rheumatoloy only to turn up and find the doctor on holiday

After 20 years experience and 10 in the Irish system i'd completely agree with you on this one. Urgent/Emergency care is usually excellent but the delays as the OP described can be extremely stressful.

Glad to hear all turned out well in the end.

I'd love to see a link to the UK confidential enquiry report if anyone has one btw.

byhookorbycrook

Gurgle wrote: »

The problems with the health services are all between the front desk and the experts.

Once you've managed to get in front of the consultant, the care is every bit as good as anywhere in the world. Don't stress yourself out second guessing them, they know what they're doing.

Hmmmm...like the consultant who told me it was def NOT my appendix as they had removed it 3 years before??They hadn't, it was and it had ruptured.

Victor

First Aid Ireland wrote: »

There's a vast spectrum of severity within each of those categories, so there's absolutely no way you can prioritise so simplistically.

I realise, but I think you understand my point that the other user wasn't right in saying that there is no prioritisation of emergency cases.

blatantrereg

According to an ER nurse, appendectomies are usually given almost top priority, only behind serious blood loss. Also my gf was operated on before another person in the ward who was there first, so they do prioritise.

According to a solicitor specialising in malpractice, there would have been a very strong case for negligence if something had gone wrong. I emailed them details [more than I put here] when I wrote the original post. I wasn't chomping on the bit to sue someone or anything; I just was worried and frustrated and had decided I needed to speak to the hospital staff - being able to say you've contacted a solicitor shows you're serious with stuff like that.

his_dudeness

RobFowl wrote: »

I'd love to see a link to the UK confidential enquiry report if anyone has one btw.

This is a link to the website. They've loads of reports, each a couple hundred pages long.

First Aid Ireland

blatantrereg wrote: »

According to an ER nurse, appendectomies are usually given almost top priority, only behind serious blood loss. Also my gf was operated on before another person in the ward who was there first, so they do prioritise.

According to a solicitor specialising in malpractice, there would have been a very strong case for negligence if something had gone wrong. I emailed them details [more than I put here] when I wrote the original post. I wasn't chomping on the bit to sue someone or anything; I just was worried and frustrated and had decided I needed to speak to the hospital staff - being able to say you've contacted a solicitor shows you're serious with stuff like that.

Appendicetomies do sometimes wait until the following day. That wouldn't be an off the wall thing to happen.

byhookorbycrook

First Aid Ireland wrote: »

Appendicetomies do sometimes wait until the following day. That wouldn't be an off the wall thing to happen.

They thought I was having a heart attack at first ,once they decided I wasn't, despite the ER nurse being convinced it WAS appendix,I was left overnight, despite explaining I am immuno-compromised due to my meds.When the drs actually looked up my meds, panic set in apparently.

I still saw no reason for litigation, the hospital system is so badly underfunded, I'm alive and in future, will be a lot more bull-ish about exactly what my meds mean!!

blatantrereg

First Aid Ireland wrote: »

Appendicetomies do sometimes wait until the following day. That wouldn't be an off the wall thing to happen.

It was two days though, and I was concerned it would stretch to more.

Gurgle

byhookorbycrook wrote: »

Hmmmm...like the consultant who told me it was def NOT my appendix as they had removed it 3 years before??They hadn't, it was and it had ruptured.

I'd be inclined to blame that type of fcuk up on record keeping.

Consultants don't have x-ray vision. If the medical history in his hand says you don't have an appendix, he's hardly going to check for appendicitis.

gbee

Gurgle wrote: »

Consultants don't have x-ray vision. If the medical history in his hand says you don't have an appendix, he's hardly going to check for appendicitis.

Of course he would. If for nothing else to reassure the patient. Mixed records and mistakes are common.

drzhivago

blatantrereg wrote: »

According to a solicitor specialising in malpractice, there would have been a very strong case for negligence if something had gone wrong. I emailed them details [more than I put here] when I wrote the original post. I wasn't chomping on the bit to sue someone or anything; I just was worried and frustrated and had decided I needed to speak to the hospital staff - being able to say you've contacted a solicitor shows you're serious with stuff like that.

To be honest I don't think this is the best way to approach the problem contacting a solicitor

They probably won't be able to take the appendix out any quicker (joke and probably in poor taste) BUT in a public hospital surgeons and junior surgeons in general want to operate not make people wait

In some instances I have to hold people back from operating until they know exactly what they are getting into and what the exit strategy is if the problem doesn't turn out to be as initially thought -- see post above from someone who must have had a scar in appendix area without having appendix removed

I know that I and many colleagues don't respond well to being threatened by solicitor for trying to do my job, how would you feel if I walked into your workplace or phoned your workplace threatening same to you personally and not to your employer

It is not the best way to get the best from people

If faced with this situation I would do the surgery but not want to speak to you at all and explain to your relative that we have no difficulty doing the surgery but that would prefer you not to be present for future consultations.

with respect to medical negligence I really doubt any such case against the surgeon would be successful on the basis of delay as the surgeon themselves do not staff the hospital and are not responsible for the number of operating theaters available, more likely there would be a successful action against the institutions for pain and suffering but negligence not necessarily

Then again the solicitor and barrister would love a trip to the 4 goldmines as they never lose but you might as you (or the party taking the case) would be responsible for the costs of an unsuccessful action

Capt'n Midnight

The threat of being sued is affecting health care decisions and the costs of health care

http://www.ncbi.nlm.nih.gov/pubmed/19169125

Relationship between malpractice litigation pressure and rates of cesarean section and vaginal birth after cesarean section.
...
These estimates imply that a $10,000 decrease in premiums for obstetrician-gynecologists would be associated with an increase of 0.35 percentage points (1.45%) in the VBAC rate and decreases of 0.15 and 0.16 percentage points (0.7% and 1.18%) in the rates of cesarean section and primary cesarean section, respectively; this would correspond to approximately 1600 more VBACs, 6000 fewer cesarean sections, and 3600 fewer primary cesarean sections nationwide in 2003.

j.mcdrmd

drzhivago wrote: »

To be honest I don't think this is the best way to approach the problem contacting a solicitor

They probably won't be able to take the appendix out any quicker (joke and probably in poor taste) BUT in a public hospital surgeons and junior surgeons in general want to operate not make people wait

In some instances I have to hold people back from operating until they know exactly what they are getting into and what the exit strategy is if the problem doesn't turn out to be as initially thought -- see post above from someone who must have had a scar in appendix area without having appendix removed

I know that I and many colleagues don't respond well to being threatened by solicitor for trying to do my job, how would you feel if I walked into your workplace or phoned your workplace threatening same to you personally and not to your employer

It is not the best way to get the best from people

If faced with this situation I would do the surgery but not want to speak to you at all and explain to your relative that we have no difficulty doing the surgery but that would prefer you not to be present for future consultations.

with respect to medical negligence I really doubt any such case against the surgeon would be successful on the basis of delay as the surgeon themselves do not staff the hospital and are not responsible for the number of operating theaters available, more likely there would be a successful action against the institutions for pain and suffering but negligence not necessarily

Then again the solicitor and barrister would love a trip to the 4 goldmines as they never lose but you might as you (or the party taking the case) would be responsible for the costs of an unsuccessful action

I think that patients are becoming increasingly scared to go into hospital because they are starting to realise that they are being treated, quite often, by doctors who are obviously stressed and overtired.

Patients do not want to go the legal route, in general, they would prefer "best effort" from professional staff who are working within the law and have proper breaks, meals and sleep.

Try telling relatives that you are about to perform surgery, but you have been awake for 24 hours+ and haven't eaten for the last 12 and perhaps the outcome will be compromised, however, the alternative is worse!

There is a cultural problem in medicine that needs to be addressed especially from a patients point of view.

drzhivago

j.mcdrmd wrote: »

I think that patients are becoming increasingly scared to go into hospital because they are starting to realise that they are being treated, quite often, by doctors who are obviously stressed and overtired.

Patients do not want to go the legal route, in general, they would prefer "best effort" from professional staff who are working within the law and have proper breaks, meals and sleep.

Try telling relatives that you are about to perform surgery, but you have been awake for 24 hours+ and haven't eaten for the last 12 and perhaps the outcome will be compromised, however, the alternative is worse!

There is a cultural problem in medicine that needs to be addressed especially from a patients point of view.

Not sure the hours thing is cultural but structural, HSE finds it cheaper to do this

j.mcdrmd

drzhivago wrote: »

Not sure the hours thing is cultural but structural, HSE finds it cheaper to do this

I can't think of any justification for subjecting human beings to the current working conditions.

It starts to become the norm through thinking such as "everyone is doing it", or "it was always like that". Then it becomes accepted even though it is detrimental to the health of patients and doctors.

Mistakes will always be made as in all walks of life, however, expecting people to work in a permanent crisis situation results in a greater than average error rate imo.