Protocol for the Management of the Emergency Surgical Patient
[With effect from March 2006]
1.0: Application:
This cross-directorate protocol applies to all members of the multi- disciplinary team [Trust permanent and temporary employees] involved in the admission and management of patients admitted to the Trust for emergency surgery.
2.0: Clinical audit and monitoring of the protocol:
The protocol will be reviewed annually in conjunction with the Trust Clinical Governance Audit Team.
The protocol will be monitored by the Directorate Clinical Governance Committee [Directorate of Surgery and Anaesthetics]
Emergency Theatre usage will be regularly audited
3.0: Review of the protocol:
The protocol will be reviewed annually by a sub group of the Directorate Clinical Governance Committee with consultant surgeon, consultant anaesthetist and theatre management representation.
4.0: Definition of the emergency patient:
The nationally used definition for a surgical emergency and urgent operation is the CEPOD classification.
Emergency:
Immediate operation usually within one hour of surgical consultation usually lifesaving, resuscitation simultaneously with surgical treatment.
Urgent:
Operation as soon as possible after resuscitation usually within 24 hours of surgical consultation.
Emergency cases requiring a great deal of logistical co-ordination should be discussed with the Theatre Manager and Anaesthetic Services Co-ordinator
5.0: Emergency Theatre Provision:
A 24-hour emergency operating theatre is provided on the Charing Cross Hospital site.
Emergency cases will be operated on at anytime.
Urgent cases will be operated on between the hours of 0830 - 2200 hours.
Emergency operations will take precedence over all other cases
6.0: Transfers of patients into the Trust that require emergency surgery:
The surgical team admitting the patient for emergency surgery must consider the following prior to confirming acceptance of the patient:
In cases where the surgical team intend to accept a tertiary referral the availability of operating theatres, intensive care bed, and ward beds is a key consideration
Once a transfer has been agreed, the emergency list should not be stopped to await the transferred patient.
6.1: Admission of neurosurgical emergency patients:
Ventilated patients:
If no Level 3 bed is available it is unit policy to direct the referral to a unit with an available level 3 bed, however:
Patients with an imminently life-threatening condition are accepted for emergency neurosurgery without an available level 3 bed.
Patients are accepted for emergency neurosurgery without an available level 3 bed where there is no level 3 bed in Greater London.
Patients are accepted for emergency neurosurgery without an available level 3 bed with an agreement to transfer out of Charing Cross Hospital postoperatively
Unventilated patients
Unventilated patients are accepted by the neurosurgical unit.
6.2: Admission of emergency patients for vascular surgery:
There is a protocol for the admission of vascular patients into the trust that is covered by a network of hospitals [Kingston / West Middlesex/ Hammersmith and Ealing Hospitals].
Under the vascular protocol patients from the above mentioned hospitals are treated as if they are being admitted to the Trust Accident and Emergency Department.
6.3: Following life saving surgery
Patients covered by Points 6.1 and 6.2 should, if appropriate, be transferred to a level 3 bed in another unit if there are no local level 3 beds available
7.0: Notification of consultants:
No patient should enter theatres without the consultant surgeon responsible for the case and consultant anaesthetist being informed. It is the responsibility of the Surgical SpR to inform both the Consultant surgeon and Consultant anaesthetist.
The surgical consultant responsible for the care of the patient must be informed of a patient’s admission and involved with any subsequent management decisions. It is the responsibility of the Surgical SpR to inform the Consultant surgeon.
8.0: Booking emergency / urgent cases with theatres:
All cases should be undertaken in the order that they are booked with theatres, unless medical re-prioritisation occurs.
A patient cannot be booked onto the Emergency Theatre list unless they have fulfilled the following criteria:
Consent Form completed
Patient has an in-patient bed or is being transferred directly from A+E
All appropriate diagnostic investigations have been performed
The Patients Consultant has been informed
Relevant clinical information about the patient must be clearly communicated to theatres and the duty anaesthetist when the surgical team makes the booking.
A competent surgeon must be available at all times to undertake the case.
If the operating surgeon is not available when theatres wish to send for the patient then the case will be removed from the list and a clinical incident report will be completed. It is then the responsibility of the surgical team to re-book the case.
Special requirements such as prosthesis and image intensification need to be clearly stated when the booking is made. Radiographer must be booked by the Surgical team
The consultant surgeons responsible for the care of the patients and the consultant anaesthetist must be kept updated about all bookings to ensure good clinical management to the patient. It is the responsibility of the Surgical SpR to inform both the Consultant surgeon and Consultant anaesthetist.
Consultant staff with daytime "on call” emergency commitments must be available for emergency cases.
Urgent cases booked must not be postponed or cancelled without discussion with the consultant surgeon and consultant anaesthetist involved.
The surgical team must rebook the urgent case and ensure that the duty sister [emergencies] and the duty anaesthetist are informed about the decision.
However, urgent cases can only be rolled over to the next day on one occasion. If a second cancellation is required the case or cases should be transferred to an elective list of that speciality.
Urgent cases booked on to elective lists should be scheduled before elective cases.
Cancelled cases from elective lists can not be transferred to the emergency list, and urgent cases should be scheduled first on elective lists.
8.1: Changes to the order of bookings:
Changes to the order of emergency bookings may only be implemented following discussion with the consultant surgeons and consultant anaesthetist involved.
Once a change in the order of the list has been agreed it is the responsibility of the surgical team taking priority to inform the theatre sister [emergencies], duty anaesthetist, and the surgical teams that are to be displaced.
If an urgent case is cancelled from the list consideration must be given to placing the patient on the next available elective list of that clinical speciality.
9.0: Preoperative assessment of the patient by the surgical and anaesthetic
teams.
Appropriate preoperative assessment and consent of the patient by the surgical team and the anaesthetic team must be undertaken in all cases.
The anaesthetist or emergency pre-op assessment Charge Nurse must see all patients prior to operation. (appendix 1)
A surgeon competent of performing the operation must have seen the patient prior to induction of anaesthesia.
If emergencies on the previous night did not finish until the early hours of the morning, it is the responsibility of the anaesthetists to have at least reviewed the next patient’s case notes and results to ensure that the patient is ready for surgery the next day.
As each “on call” team completes their shift there must be a comprehensive hand over of relevant clinical information about each patient on the emergency list to reduce the risk of inconsistent preoperative clinical management of the patient.
10.0: The opening of a second emergency theatre:
A second emergency room may only be opened following the assessment of clinical priorities by the consultant surgeons and consultant anaesthetist.
In the case of a life saving emergency occurring during normal working hours, an elective list will have to stop to provide the staff and facilities to open the second emergency theatre.
The consultant surgeon and consultant anaesthetist may decide to open a second emergency operating room to clear the backlog of urgent cases between 17:00 – 2030 hours on weekdays or for a life saving emergency.
If a second emergency operating room is opened out of hours to clear a backlog of cases, then the cases selected should be urgent cases of short duration. [Less than 30 minutes].
It is the responsibility of the consultant surgeon and consultant anaesthetist that makes this decision to ensure that the theatre sister [emergencies] and duty anaesthetist have been informed.
Both emergency lists will require the attendance of both surgical consultants in the requisite operating rooms.
The second anaesthetic room and operating room must be available for resuscitation and surgery within 30 minutes of the joint decision to open a second operating room.
If a decision were made to open a third emergency operating room this would necessitate invoking the Major Incident Procedure, as no additional resources would be available on site.
11.0: Ventilated patients in theatre when no Level 3 bed is available:
During daytime hours this may necessitate cancellation of an elective list.
Out of hours the admission of the ventilated patient occupies the first emergency operating room.
12.0: Travel arrangements for non-resident theatre and recovery staff:
Theatre, recovery and medical staff should be available to attend the hospital within 30 minutes for emergency cases.
In the case of consultant staff with offsite commitments the 30-minute rule applies.
It is the responsibility of the anaesthetic consultant “on call” from 1700 hours [weekdays] to contact the anaesthetist running the emergency list by 1600 hours to assess whether they are likely to be required to attend.
Staff should use local taxis and be reimbursed following their ‘on call’ duty.
13.0: Theatre and recovery staff skillmix:
The theatre management will commit to ensuring that theatre; anaesthetic support and recovery staff receive the appropriate training and experience to cover emergencies.
The theatre management will undertake regular reviews of the staffing skillmix to meet the fluctuating demands of emergency surgery.
Theatre and anaesthetic support staff will rotate to gain additional clinical experience in demand led clinical specialities.
It is the responsibility of the theatre management to ensure that all the previously agreed equipment required to deal with the emergency and urgent patients will be available.
Clinical Governance Committee Emergency Protocol Sub Group.
Mr. A. Davies
[Chair: Clinical Governance Committee: Directorate of Surgery and Anaesthetics]
Dr. P. Doyle
[Chief of Service: Anaesthetics CXH]
C/N J. Mulrooney
[Emergency surgery Practitioner/Co-Ordinator]
Sr. A. Sexton
[Theatre Manager]
Mr. N. Theodorou
[Chief of Service: Acute and Emergency Surgery]
Mr. D. Peterson
[Lead Clinician: Directorate of Neurosciences]
Mr. M. Pearse
[Acting Chief of Service: Orthopaedic Surgery]
Mr. J. Abbott
[Assistant General Manager [Anaesthetics]: Directorate of surgery and Anaesthetics]