INTERÉS CIENTIFICO DEL TRABAJO

Introduction

Tonsillectomy procedure, i.e. removal of tonsils under general anaesthesia, requir- ing in-patient services, is the most common ENT operation performed in Salmaniya Medical Complex (SMC). The following table shows the percentage of tonsillectomy cases in comparison to 5 other most common ENT procedures done at SMC:

Despite the increase in the number of Otolaryngologist consultants (from 3 at the end of the 1980’s to 8 in 2001), the number of ENT beds has not increased and remains as 38 beds for in-patients and 2 beds for day-case patients.

At the end of the 80’s, patients admitted for a tonsillectomy procedure used to stay for a period varying from 6-7 days. In the 90’s this period had been reduced to 4-6 days and currently varies between 3-5 days (average 4 days). The updated cost esti- mation to the Ministry of Health (MOH) per patient for bed utilization is BD 110 and the cost per patient for a tonsillectomy procedure is BD 40-50, regardless of their length of stay in hospital.

Post-tonsillectomy hemorrhage is the major morbidity that concerns surgeons with international figures varying between 0.8-2.5% (these figures depend on how hem- orrhage is defined and which investigator is reporting). An unpublished study con- ducted in Bahrain quotes a range of 5-6%, but we don’t have any statistics about the timing of hemorrhage occurrence. Internet literature review shows a range of 0-6.8 hours for the primary hemorrhage, with the confidence interval of the upper limit is 5.2-8.4 hours, meaning that it is safe enough to discharge the patient after 12 hours of performing a tonsillectomy.

Many hospitals in the USA, Canada, some centers in the UK and some hospitals in Arab countries are adopting day-case tonsillectomy surgery (based on several stud- ies and researches that looked at the safety of patients, the timing of hemorrhage and patient satisfaction towards these changes).

More than 70% of patients requiring tonsillectomy are children between the age of 2-10 years of age. Several studies have stressed that hospitalization of children for prolonged periods can lead to psychological impact upon and that needs to be addressed.

Problem Statement

By analyzing these facts, we conclude that the problems facing the department are: 1. Increased demands on the waiting list for tonsillectomy.

2. Increased demand on financial resources.

Procedure 1997 792 (23%) 765 (21%) 840 (23%) 713 734 791 138 150 164 145 184 163 194 136 106 3424 3508 3603 1998 1999 Tonsillectomy Adenoidectomy Myringotomy Grommets EUA-PNS Total

3. Increase in number of patients and consultants with no corresponding increase in number of beds.

4. Increasing the number of operating sessions to cover all consultants from 5 to 8 sessions per week has led to pressure and stress on staff, patients/relatives dissatisfaction, problems with bed availability, cancellation of operations, crowded nursing stations in the wards on a daily basis and deterioration in staff-patient relationship.

Commencing in January 2000, after being promoted to a Consultant, I have started my own list with the criteria of keeping patients in hospital for 2 nights only, i.e. day 1 is admission/preparation for surgery, day 2 is day of operation and day 3 is when the patient goes home - a total of 2 nights spent in hospital.

The team, consisting of 8 ENT Residents and myself, devised, implemented and standardized this protocol with the aim of continuous quality improvement and cost reduction, reducing the length of hospitalization for tonsillectomies from 4 to 2 days over a period of 20 months (Jan. 2000 - Oct. 2001).

Root Cause Analysis

The team used the brainstorming technique to generate ideas, find causes and solu- tions, explore problems and minute details, with one member keeping written records. The following are the results of the fishbone and pareto analysis:

1. The Procedure:

a. Is it safe enough to be performed as an overnight stay or even a day- case basis?

b. Lack of research and studies on the risk of hemorrhage, pain, nausea and vomiting.

2. Other Consultants: a. Lack of awareness.

b. Concentrating on the risks and of losing ENT beds to other departments. 3. The Staff:

a. Lack of awareness. b. Very low motivation. 4. The Patient’s Relatives:

a. Lack of awareness about costs, psychological effect on their children. b. Very low sharing of responsibility threshold.

c. No education about the role of the parent. 5. The System:

a. Lack of auditing system.

b. Inefficient quality assurance system.

c. Resistance to change to new policies such as bed utilization. d. No clear goals.

6. The Day-Care Unit:

a. Very limited number of beds.

b. Unavailability of efficient overnight stay program services.

Alternative Solutions

After gathering the information and details of the problem, the team was able to identify many different solutions to these problems:

1. Expansion of day-case unit and provision of more facilities to the ENT

Department: This will be expensive, time-consuming and needing decisions

case unit for ENT procedures and requires a great deal of study/discussion. 2. Overnight stay program: Patients are admitted to hospital on the day of the

procedure and discharged the following day (if their condition permits). This requires a great deal of awareness by the doctors, staff and relatives. It also requires the cooperation of the Anaesthetist in order to evaluate patients on the procedure day, that all hematological and radiological investigations are ready and trained staff to cope with such a policy. In fact, 17 (16%) of our sample patients followed this policy.

3. Reduce in-patient services cost by reducing hospitalization of tonsillectomy

patients from an average of 4 days to an average of 2 days: We

found out the incidence rate of developing post-tonsillectomy hemorrhage and the timing of hemorrhage at the same time.

The team adopted this solution, as we had collected good data on which to build the project and obtained good results; and it seems a reasonable policy for patients, rel- atives and staff although we have been faced with many restraining forces.

Implementation

The team decided to follow Lewin’s model of unfreezing, implementation and refreezing. Since being made Consultant, I had the authority to make decisions, unfreeze the system and began to implement my ideas from Jan 2000. Using a team- work approach, sharing my vision with others, promoting decision-making, reduc- ing restraining forces, empowering others to act on the new vision and adjusting to any obstacles along the way, we were able to standardize the project of having patients hospitalized for 2 nights only (unless their condition requires otherwise). Our results will help us consolidate more improvements and will increase the cred- ibility of our project among staff and other consultants to promote change in the sys- tem.

Results

Based on data obtained from medical records for the 20 months of the study and comparing our results with the other 8 ENT firms, we found the average length of stay (LOS) for the whole department for a tonsillectomy procedure to be 3.6 days with a variation between 2.5-4.7 days. We did manage to reduce the LOS of our firm to 2.5 days for 105 patients who underwent tonsillectomy, but we have been unable to achieve our smart goal of 2 days hospitalization.

Post-tonsillectomy hemorrhage cases were compared with a previous unpublished study and found that the incidence rate was similar (5.7% in our study, 5-6% depart- ment study), with the timing varying between 3rd - 10th post-operative days. This indicates that the most likely cause for bleeding is infection in the fossae of the removed tonsil and means that minimizing hospitalization following tonsillectomy will not increase incidence rate of hemorrhage.

Although our firm had less patients/LOS when compared to other firms, we found the cost is similar in each firm. The total cost for all patients who underwent tonsil- lectomies is equal to BD 618,530 for 1,567 patients operated, of which our firm accounted for BD 28,490 for 105 patients. If other firms agreed upon the protocol of our project, we could save up to BD 107,394 per year as the following table shows: