Patients benefit from innovation in specialty surgical care

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The Surgical Program at Vancouver’s St. Paul’s Hospital (SPH) is employing innovative strategies to centralize intake processes; dramatically reduce referral times; improve surgery wait times; increase capacity for more surgical procedures; and shorten recovery times for patients needing foot and ankle and hand and wrist surgeries (also known as distal extremity surgeries).

“The benefits of our initiative are already apparent,” says Dr. Thomas Goetz, a St. Paul’s hand and upper extremity surgeon whose wait list had grown to two years. “We have dramatically lowered wait lists for consultations and surgeries.”

By opening the new Foot and Ankle Screening and Triage (FAST) Clinic and significantly expanding the Pacific Hand and Upper Extremity (Hand & Wrist) Clinic in the fall of 2008, St. Paul’s expects to see 5,000 new referral patients annually.

At the FAST Clinic, patients are first seen by primary care physicians who assess, educate, and refer them directly to other services and specialties as required so they do not have to return to their GPs for another referral. When appropriate, the physician refers the patient to a foot and ankle surgeon on an expedited basis. As a result of effectively screening and triaging all referrals, the surgeons only see consults that are appropriate.

The average wait time for a FAST Clinic appointment from GP referral is now two to 14 days, down from an average of many months. Similarly, the wait to see an orthopedic surgeon after being assessed at the clinic averages two weeks compared to previous waits of up to two years. Foot and ankle surgeons who had closed their practices to new referrals due to long backlogs have now started taking new referrals.

The Hand & Wrist Clinic has been expanded into a high-efficiency examination room, significantly increasing the volume of patients that can be seen. The clinic’s multidisciplinary team includes orthopedic and plastic surgeons who specialize in hand and wrist surgery, certified occupational therapy/physiotherapy hand therapists, a cast technician and nurses. This collaborative approach between orthopedic and plastic surgeons is unique to St. Paul’s and is contributing to faster access and better patient care.

The clinic now operates four days a week, providing streamlined intake and rapid access for acute hand and wrist injuries (same or next day service) and expedited access for elective upper extremity injuries. For acute injuries, patients can be referred next day by their GP or directly from the St. Paul’s Emergency Department or other Vancouver area emergency departments. Referrals to specialists now occur within one to four weeks (within one to two days if urgent).

The rapid access made possible by the high-volume clinics is complemented by an innovative “swing room” concept in the main operating room (OR) where one surgeon works in adjacent ORs concurrently, eliminating the down-time between cases. The swing room concept will allow the main OR to handle 450 new distal extremity surgeries by March 2010. Already, this innovation has allowed surgeons to nearly double their surgical cases (from 3.3 per day in September 2008 to 5.6 per day in December 2008).

Additionally, a renovation of the Outpatient Department led to the construction of two new satellite operating rooms. The ORs, which opened in February 2009, also operate as swing rooms and will allow the hospital to handle an additional 1,000 surgical cases annually. When combined with the 450 new cases in the main OR, that’s almost 1,500 new surgical cases per year.

Surgical patients are also benefiting from a cutting-edge technique called a regional anesthetic block. This highly localized anesthetic technique avoids the need for general anesthetic. It allows for a speedier, less stressful and less painful recovery, leaving patients fully alert during and after their surgeries.

The regional anesthetic blocks result in faster turnaround time for surgical cases and better patient care. Furthermore, the lack of general anesthetic means patients are no longer sent to a post-operative recovery room staffed by specialized nurses, saving the health-care system money. The application of the regional anesthetic block technique requires highly specialized anesthesiologist training, and carefully planned collaboration between nurses, surgeons and anesthesiologists. St. Paul’s is the only facility in British Columbia running two operating rooms that rely exclusively on this technique.

The positive impact of the Distal Extremity Surgical Project’s innovations is being felt beyond St. Paul’s. While this project is an initiative of Providence Health Care (the operator of St. Paul’s Hospital), it is benefiting patients and care providers right across Greater Vancouver, with better integration of services for all. By increasing capacity for distal extremity surgeries and reducing the time it takes to access care, the project is lessening demand on other Vancouver hospitals, such as Vancouver General Hospital, which can now focus on more timely care of larger trauma cases.

“Now patients have rapid access to care for their foot and ankle problems. Their care gets initiated and then completed within a matter of months as opposed to waiting years and that kind of unclogging is a model not only for other parts of the system but other places in the country as well,” says Dr. Murray Penner, one of British Columbia’s three full-time foot and ankle sub-specialists. As the project’s improvements gain momentum, other surgical departments across the country are taking note of the unique approach underway at SPH.