Standard Operating Procedure for Non-Elective Surgery at ...

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StandardOperatingProcedureforNon-ElectiveSurgeryattheWesternGeneralHospital

Dateofdraft:26/10/17

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Objective

Topromotetheefficientandeffectiveutilisationofemergencytheatres,ensuringthatnopatientwaitslongerthanisclinicallyacceptablefornon-electivesurgery.

Location

MainTheatreCdeliversservicetoallclinicalteamswithintheWesternGeneralHospital,excludingNeurosurgery.Occasionallyitmayberequiredtomovelocationaccordingtoclinicalneed(e.g.radiologyinRoom8).

DCN–Non-electiveworkloadisdeliveredbyTheatres16/17.Occasionallyitmayberequiredtomovelocationaccordingtoclinicalneed(e.g.DCNAngioSuite/MRI).

Access

NonElectiveServicesattheWesternGeneralareavailabletoallclinicalteamsbasedonclinicalneedandprioritisedaccordingtourgency.Noelectivecaseshouldbecarriedoutonanon-electivelist.

Booking

Bookingapatientfornon-electivesurgeryistheresponsibilityoftherespectivesurgicalteam.Consequently,thesurgicalteamwillberesponsibleforhostingtheformandwillberequiredtocompletebasicidentifyingandclinicalinformation(detailedatAppendix1-CEPODBookingForm),aswellastheSurgicalUrgencyClassification(seetablebelow).Thebookingsurgeonwillworkcloselywiththeon-callanaesthetist–thesecliniciansmustbeaminimumofregistrarlevel–toensurecliniciantocliniciancontactthroughoutthebookingprocess.Aseniorreviewbyaregistrarorconsultantsurgeonmusthavetakenplacepriortotheinitiationofthebookingprocess.

Thebookingprocessshouldonlybeinitiatedonceboth:

a)adefinitedecisionhasbeenmadethatapatientrequiressurgery;and

b)thepatientisinapositionwheretheycanbeanaestheticallycleared.

Theprocessforbookinganon-electivepatientforsurgerywhichrequiresgeneralanaestheticisasfollows(alsoseeAppendix2A):

1. Onceadefinitedecisionhasbeenmadethatapatientrequiressurgery,thesurgicalteam initiates a bookingby completing the relevant sectionsof thebooking form,beforecontactingtheanaestheticteamtoinformthemoftheneedforsurgeryand

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discusstherelevantdetailsofthecase.WhenbookinganAcase,thiscontactmustbe with the consultant anaesthetist directly. The booking form stays with thepatient, filed in the patient notes folder. The surgeon also phones the CEPODcoordinator to provide basic case details (name, CHI,ward andprocedure) and tocommunicate that the anaesthetist has been informed. This allows the CEPODcoordinatortomaintainanaccurate ‘patientclearance’ listasanaidememoirefortheCEPODanaestheticteam.

2. Theanaesthetistvisitsthepatientassoonasispossibletoreviewthebookingform,ensuring that all required fields are completed. Should there be a discrepancybetweenurgency classificationprovidedon the formandurgency classificationonthepre-agreedlistbyspecialty,theanaesthetistwilldiscussthisbyphonewiththesurgeon and ensure that a reason for this discrepancy is provided on the bookingformunder‘Indications’(whereavailable).Thebookingformwouldalsobeflaggedinthisinstance.

3. The anaesthetist decideswhether the patient is ready for surgery. This should bedone as soon as is possible, in order to have the shortest timeframe between‘decisiontooperate’and‘patientdeclaredready’.

a. Ifready,thedateandtimeofdecisionisnotedonthebookingformandthebookingformispassedtotheCEPODcoordinator.

b. If not ready, the patient remains on the ‘patient clearance list’ until thepatient is ready and the anaesthetist communicates this with the relevantsurgeon.Aplanforfurthermanagement/investigationsisagreed,includingatimeframeforfurtherreview.Theformremains inthepatientnotesfolder.Oncethepatientisdeemedready,theanaesthetistthenfollowsstep3a.

4. TheCEPODcoordinatorwillqualityassurethebookingform,ensuringthatallfieldsare completed and will contact the relevant surgeon to request the missinginformationifrequired.Thebookingformmustbefullycompletebeforeabookingformcanbemade. Oncefullycomplete,CEPODcoordinatorwillconfirmwiththesurgicalteamthatthepatienthasbeen‘booked’andcaseisaddedtotheCEPODlistontheTheatreCWhiteboard.

Theprocessforbookinglocalanaestheticcases(2B)andoutofhourscases(4A-B)aredetailedinappendicesbelow.

OutofHours(3am-8am)bookingprocess

Ifapatientpresentsovernight,thebookingprocessisasduringstandardworkinghours,withtheexceptionoftheinitialphonecalltoCEPODcoordinator.However,insteadofthebookingformbeingreturnedtoCEPODcoordinator,thebookingformmustbeplacedinthe‘OOHbookingwallfile’bytheanaesthetistorsurgeon,dependingwhetherthecaserequiresGA(seeAppendix4A)ornon-GA(seeAppendix4B),respectively.ShouldthecasebeclassifiedasA,BorC,thecasecangototheatre.However,ifthecaseisclassifiedasD,E,F

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orG,thecasecannotbeginbefore8am.Whetherthecaseis‘pending’or‘booked’,thebookingformmustbeleftinthe‘OOHbookingwallfile’andwillbepickedupbyCEPODcoordinatorat8am.Anycasewhichhasyettobecompletedisaddedtothe‘CEPODMasterList’andbookingformsforcompletedcasesarefiledintherelevantfolder.

Outofhourspatientselectionfortheatre

Outsideof8amto6pm,thereislessmedicalandnursingcoveravailableforcases.After11pm,coverisagainless.CasesplannedforovernightshouldbemostlyA,BorCinurgency.TherewillalsobesomeDorEcaseswhohavebreachedtheiroptimalmaximumwaitsandmayrequireoutofhourssurgery.Thisisaclinicaldecisionwhichneedstobediscussedbetweensurgeryandanaestheticsandthebestdecisionforthepatienttaken.Iftheclinicalpicturehasdeteriorated,thepatient’surgencyshouldbereclassified.Thisreclassificationshouldbeonthewhiteboard,leavingtheoriginalbookingformaloneforthepurposesofdatacollection.Alldecisionsregardingschedulingcasesoutofhoursareclinicalandmustbetakenbetweentheconsultantsurgeonandconsultantanaesthetist.

OutofhoursAnaestheticcover

Agreedcoverforoutofhourscasesisasfollows:

ConsultantshouldbepresenttoassistST3/ST4traineesif:

• ASA3/4laparotomy• Septic/cardiovascularlyunstablepatient• PatientsrequiringICUsupport• Urologypatientswithdeterioratingrenalfunctionegfr<45• Anyotherpatientthetraineeneedshelpwith

ConsultantshouldbepresenttoassistST5+traineesif:

• Septic/cardiovascularlyunstablepatient• Anyotherpatientthetraineeneedshelpwith

Communicatingachangeinpatientcondition

WhileaSurgicalUrgencyClassificationmustbeassignedatthepointofbooking,thisurgencycanbeexpeditedorreducedwhilethepatientwaitsinthequeue,onlyshouldthepatient’sconditiondictatethisasnecessary.Thebookingsurgeonmustcommunicatethischangebyphone(07779967325)withtheCEPODcoordinatorascloseaspossibletothisdecision,providingaclinicalrationaleforthischangeintheformofanindicatori.e.sepsis,bleedingetc.ThischangeinSurgicalUrgencyClassificationshouldbeaddedtothebookingforminthe‘FinalClassification(ifdifferentfromoriginal)’boxandupdatedinthecorrespondingfieldinthedatacollectionspreadsheet.

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PrioritisationandQueuing

Casesbookedonanon-electivelistwillbedealtwithinorderdeterminedbyclinicalneed,asexpressedbytheparentclinicalteam.ThisshouldconformtotheSurgicalUrgencyClassificationoutlinedbelow.

IMMEDIATE

A <1hr

URGENT

B <3hrs

C <6hrs

D <12hrs

E <24hrs

F <48hrs

EXPEDITED

G <5days

SurgicalUrgencyClassifications(Appendices6A-D)

Eachclinicalteamhasprovidedalistofcommonlyperformedemergencyprocedureswithanagreedurgencyclassification(seeyourclinicalleadfordetails).Thisshouldbeusedinconjunctionwiththepatient’sclinicalstatustodecideonanindividual’surgencyclassification.

Ifapatient’sSurgicalUrgencyClassificationdoesnotmatchthepre-agreedclassificationforthatprocedure,aclearreasonmustbegivenatthetimeofbookingbytheSurgicalteamanddocumentedonthebookingform.SuchcaseswillbeflaggedbytheCEPODcoordinatorforfuturereviewbytheappropriateHeadofService(Appendices3A&3B).

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QueueManagement

ItisnottheroleoftheCEPODcoordinatorortheanaestheticteamtodecidepriority(althoughtheanaestheticteammayhaveinputtothisif,forexample,theythinkthatfurtherresuscitationisrequiredorconsiderthattheurgencyofthecaseisnotrecognisedorappreciatedbyoneoftheteamsinvolved).

Patientswillbequeuedforthenon-electivetheatrebasedfirstonurgencyclassificationandthenbasedontimeofbookingi.e.:

• AnAcasewillhavepriorityoveraBcase,aBcaseoveraCcaseetc.• If2caseshavethesameclassification,theonebookedfirstwilltakepriority(based

onthetimedeemedreadybyanaesthetist)

However,bookingsmadethepreviousday,orearlier,mustalsobeconsideredwhenqueuingpatientseachdaytoavoidthebreachingofwaitingtimes,where:

• Clockstartisfromthetimeofanaestheticclearance(GAcases)ortimeofdecisiontooperate(non-GAcases);and

• Clockstopisfromthetimethepatiententerstheanaestheticroom.

Incasesofdispute,theConsultantsfromtheclinicalteamswillbeexpectedtodiscussandcometoanagreementonpriority.Ifthisisnotpossible,theConsultantAnaesthetistwillhavethefinalsay.

Ifbothcasesrequireimmediate(CategoryA)accesstotheatrethentheTheatreCoordinatorwillmakeadecisiononthemostappropriateelectivelisttobreakinto(0800-1700Weekdays)ortoopenasecondemergencytheatre(1700-0800andSaturday/Sunday).

Ifopeningasecondtheatre(Weekdays1700-0800andWeekends),thesecondteamwillcomefromDCN/Maindependingonthelocationoftheemergency.Thissecondteammaynotbeavailableiftheothersiteisalreadyworking.Theonlyotherstaffmemberavailableisthenursefromthenonbeatingheartdonorteam.TheTheatreCoordinatorcancontact‘off-call’staffathome,butthisisonanadhocbasisandthereisnoguaranteethatstaffwillbeavailable.

OnceapatienthasbeenbookedontotheCEPODlist,itisexpectedthattherewillbeamemberoftheteamavailabletoperformtheprocedureinatimelymanner.ItistheresponsibilityoftheparentteamtoadviseCEPODstaffofanyclinicalchangerequiringreallocationofpriority/urgency(see‘Communicatingachangeinpatientcondition’section).

The‘ClinicalPriority’case

TomaximisetheefficientutilisationofCEPODresourceandinparticularatimelystarttoCEPODactivity,a‘ClinicalPriority’casemaybeidentifiedintheeveningasthefirstcasefor

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thenextday,ifrelevant.The‘GoldenCase’mustbebookedandwilllikelybeacasewhichwasunabletoaccesstheatreonthedaytheywereclearedanaesthetically.Theon-callregistrarsfrombothColorectalandUrologywillidentifyandagreeasingle‘ClinicalPriority’patientthepreviouseveningandcommunicatethiscasetotheCEPODcoordinatorandrelevantward.

OrganRetrieval

Occasionally,theatreswillberequiredtocoverorganretrievalactivity.Thisrequiresclosecooperation/communicationbetweentheTheatreCoordinator/TransplantCoordinatorandIntensiveCare.Wherepossible,thetimingandlocationoforganretrievalshouldbesuchastominimisetheimpactonCEPODtheatre.Theon-callAnaesthesiateamarerequiredtocoverorganretrievalsonarollingmonthlyrotasharedbetweenDCNandMain(seemonthlyanaestheticrotafordetails).

ClassificationReviewProcess

AreviewprocesshasbeenputinplacetoensurereliableuseoftheUrgencyClassificationsystem.EachsurgicalcasewillbereviewedinlinewiththeagreedUrgencyClassification(seeAppendices6A–6D).Atrealtime,anydeviationfromtheagreedUrgencyClassificationwillbeflaggedonthebookingform(usingtheboxprovided)bytheCEPODcoordinator.Thisdiscrepancywillthenbereflectedintheelectronicdatacapture.TheseflaggedcaseswillbecollatedandcommunicatedonaweeklybasisforreviewbytherelevantHeadofService.

ThefullprocessisdetailedinAppendix3A.

Timing

Non-electivelistsareavailable24hoursperday,7daysaweektodealwithlifeandorganthreateningillness.OnlycategoryA,BandCpatientsshouldbeoperatedonbetween2300and0800hours.IfaD,E,ForGcasehasnotbeenstartedby2300,thepatientwillwaituntilthefollowingmorningfortheirprocedure.

SupporttoCEPOD

ItisintheinterestsofpatientsandstaffthatCEPODcasesaremanagedeffectivelyandefficiently.ElectiveliststhatfinishearlyshouldexpecttobeallocatedcasesfromCEPODwhereappropriate.

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ContactNumbers

CEPODCoordinator–31656or07779967325

On-callAnaesthetistbleep-8155

IntranetLinks

Urology:

Colorectal:

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APPENDIX1–CEPODBOOKINGFORM

CEPODCOORDINATORPHONENUMBER:07779967325

CASEFORFLAGGING £

SURGEONTOCOMPLETEDATEOFDECISIONTOOPERATE*

TIMEOFDECISIONTOOPERATE*

HASTHEREBEENASENIORREVIEW?

YES/NO BOOKEDBY(SURGEON/FY/SHO)

PATIENTNAME

SPECIALTY&CONSULTANT

CHINUMBER/DOB* WARD

PRIMARYDIAGNOSIS*

SURGICALURGENCYCLASSIFICATION* A<1HOUR £B<3HOURS £C<6HOURS £D<12HOURS £E<24HOURS £F<48HOURS£G<5DAYS £

FINALCLASSIFICATION(IFDIFFERENTFROMORIGINAL):

PROPOSEDPROCEDURE*

RADIOGRAPHERINFORMED?

YES/NO/NA INDICATIONS:

SIGNIFICANTMEDICALCONCERNS(RELATIVETOTHEATRES)

INFECTIONS?MRSA£C.DIFF£HEPB/C£HIV£VRE£NOKNOWN£OTHER:ALLERGIES?HDU/ITUREQUIRED?YES/NO

ISBEDBOOKED?YES/NO BLOODORDERED?YES/NO/NA

GA/LA/SEDATION/NONE

RELEVANTINVESTIGATIONSCOMPLETE?FBC£U&E’S£COAGS£ECG£ECHO£CXR£GROUP&SAVE£FASTEDTIME CONSENTED? NAMEOFANAESTHETISTINFORMED

DATE&TIMEANAESTHETISTINFORMED

ANAESTHETISTTOCOMPLETEADDITIONALINVESTIGATIONSREQUIRED?

FBC£U&E’S£COAGS£ECG£ECHO£CXR£GROUP&SAVE£

DATEPATIENTDECLAREDREADYBYANAESTHETIST*

TIMEPATIENTDECLAREDREADYBYANAESTHETIST*

BOOKINGCOORDINATORTOCOMPLETEDATE&TIMEADDEDTOCEPODLIST*

NOTES

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APPENDIX2A–GABOOKINGPROCESSFLOWCHART

DefinitedecisionmadethatapatientrequiressurgeryunderGeneralAnaestheticandcanbeanaestheticallycleared:

DATACOLLECTION/ORSOSSOP CLASSIFICATIONREVIEWSOP

1.Surgeoncompletesrelevantsectionsofbookingform,phonesanaesthetisttodiscusscaseand files formwith patient notes.Whenbooking anA case, this contactmust bewith theconsultantanaesthetistdirectly.

Surgeon also phones CEPOD coordinator to communicate patient name, CHI, ward andprocedureandthattheanaesthetisthasbeencontacted.

2.Anaesthetistvisitspatient, reviews form (inpatientnotes)anddecideswhetherpatient isreadyforsurgery.Discussion(byphone)initiatedbyanaesthetisttounderstandrationaleforanydiscrepancyinurgencyclassification(whereappropriate).

4.CEPODcoordinatorqualityassuresthebookingform,ensuringthatallfieldsarecompletedandwill contact the relevant surgeon to request themissing information if required. Oncefully complete, CEPOD coordinator will confirmwith the surgical team that the patient hasbeen‘booked’andcaseisaddedtotheCEPODlistontheTheatreCWhiteboard.

3a. If ready, the time of anaestheticclearanceisrecordedontheformbythe anaesthetist. The anaesthetistpasses the form to CEPODcoordinator.

3b. If not ready, patient remains on‘patient clearance list’ untilanaesthetist declares patient ready.This is communicated to surgicalteambyanaesthetistandactionplandeveloped to get patient ready. Theformstaysinpatientnotes.

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APPENDIX2B-NON-GABOOKINGPROCESSFLOWCHART

Definitedecisionmadethatapatientrequiressurgeryanddoesnotrequiregeneralanaesthetic:

1. SurgeonphonesCEPODcoordinatortoprovidecasedetails(patientname,CHI,procedureandward).

2. Surgeoncompletesbookingform,excluding‘Anaesthetisttocomplete’section.

3. SurgeontakesformtoCEPODcoordinator,whoassuresthecompletenessofthebookingform.

4. Thecaseisbooked,with‘Timeofdecisiontooperate’theclockstarttimefortheassignedurgencyclassification.CEPODcoordinatoraddsthepatienttotheCEPODlist.

DATACOLLECTION/ORSOSSOP CLASSIFICATIONREVIEWSOP

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APPENDIX3A–CLASSIFICATIONREVIEWFLOWCHART

OnceacasehasbeenbookedandthebookingformhandedtoTheatrecoordinator:

1. Theatre coordinator reviews booking form to decide whether there is a discrepancybetween the assigned surgical urgency classification (SUC) for the case and the agreedclassificationsystem(Appendices6a–6d).

2. Should the Theatre coordinator judge there to be a discrepancy in SUC, the Theatrecoordinatorshoulddiscusswiththebookingsurgeonattheearliestpossibleopportunityanddetailanyreasongivenfordifferingurgencyinthe‘Indications’sectionofthebookingform.IfthisinformationisnotdeemedsufficienttowarrantachangetotheSUC,thecaseshouldbeflaggedbytickingthe‘CaseforFlagging’boxinthetoprightcornerofthebookingform.Thisactionshouldbecommunicatedtothebookingsurgeon.

4.Therespectiveclinicalleadshoulddiscusscase(s)withbookingsurgeon,gatherandaddtheinformationrequestedinthetworedcolumnsandreplywithin7days.

3.Theatrecoordinatorentersrelevantdataintable(Appendix3B)atreal-time.Attheendofeach week, this table is emailed to the relevant clinical lead for Colorectal and Urology,respectively.Areplyisrequestedwithin7days.

5.Theprojectsupportteam,whowillbecopiedintotheemailcommunications,willbeawareofanychangestoSUCafterreviewandamendthedatacollectionspreadsheetaccordinglyonaweeklybasis,toensurethatthemostaccuratedemanddataisbeingrecorded.

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APPENDIX3B–CLASSIFICATIONREVIEWTEMPLATEEMAIL

‘Pleasefindbelowcasesthathavebeenflaggedforreviewwithinthelast7days.Pleasecouldyoudiscussandreviewthesecaseswiththebookingsurgeonassoonaspossible.

Afterthisdiscussionhastakenplace,couldyoupleaserecordyourfindingsintheboxesinredand“replytoall”onthisemailtosendyourresponsewithin7days.’

CHI DateofDecision

toOperate

NameofBookingSurgeon

BookingSUC(onbooking

form)

DefaultSUC(in

classificationsystem)

Diagnosis ProposedProcedure

Indication(s)/Anyfurtherclinicalinformation

ReasonfornotusingdefaultSUC

FinalSUCafterreview

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APPENDIX4A–OOHGABOOKINGPROCESSFLOWCHART

DefinitedecisionmadethatapatientrequiressurgeryunderGeneralAnaesthetic(between3am–8am):

1.Surgeoncompletesrelevantsectionsofbookingform,phonesanaesthetisttodiscusscaseandfilesformwithpatientnotes.

2.Anaesthetistvisitspatient, reviews form (inpatientnotes)anddecideswhetherpatient isreadyforsurgery.Discussion(byphone)initiatedbyanaesthetisttounderstandrationaleforanydiscrepancyinurgencyclassificationandflagging(whereappropriate).

4.Anaesthetist takesbooking formtoanaesthetic room in theatreCandplaces in the ‘OOHBookingwallfile’by7am.

3a. If ready, the time of anaestheticclearanceisrecordedontheformbytheanaesthetist.

3b. If not ready, patient remains on‘patient clearance list’ untilanaesthetistdeclarespatientisready.This is communicated to surgicalteambyanaesthetistandactionplandevelopedtogetpatientready.

6.At8am,CEPODcoordinatorchecks‘OOHBookingwallfile’andaddsanyoutstandingcaseto‘MasterList’,indicatingwhethertheyare‘Pending’or‘Booked’.

5a. If A, B or C, the case can begin.Anaesthetist writes in the notessectionofthecorrespondingbookingform that the case is complete andleavesin‘OOHBookingwallfile’.

5b. If D, E, F or G, the case cannotbeginbefore8am.

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APPENDIX4B–OOHNON-GABOOKINGPROCESSFLOWCHART

DefinitedecisionmadethatapatientrequiressurgerywithoutGeneralAnaesthetic(between3am–8am):

1. Surgeon completes booking form, excluding ‘Anaesthetist to complete’ section. Patientmustbereadyfortheatre.

2. Surgeon takesbooking form to theatre andplaces in the ‘OOHBookingwall file’ ondeskoppositeCEPODtheatreby7am.

4.At8am,CEPODcoordinatorchecks‘OOHBookingwallfile’andaddsanyoutstandingcaseto‘MasterList’as‘Booked’case.3a. If A, B or C, the case can begin.Surgeonwritesinthenotessectionofthecorrespondingbookingformthatthe case is complete and leaves in‘OOHBookingwallfile’.

3b. If D, E, F or G, the case cannotbeginbefore8am.

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APPENDIX5–ESCALATIONPLANFORISSUESOFNON-COMPLIANCE

Right-sizingEmergencyTheatres

EscalationPlantoaddressSOPnon-complianceissues

1. Eachindividualisresponsibleforescalatingtothenextstage,only.

2. Issuesshouldbeescalatedascloseaspossibletothetimeofoccurrence.

3. Issuesshouldonlybeescalatediftheycannotberesolvedattherelevantstage.

4. Ifescalated,issuesshouldbeattemptedtobeaddressedassoonaspossibleandwithinamaximumof3days.

Keyissuesforescalationare:

a. FailingtofollowSOP(e.g.refusaltocompleteform,wrongprioritisationofcases);

b. Retrospectivelychangingcaseurgencywithoutclinicalrationale;

c. CommencingD,E,ForGcasesafter23:00withoutconsultanttoconsultantdecision-makingprocess.

1.CEPODLEAD

5.GENERALMANAGER

(SURGERY)

4.SERVICEMANAGER/CD

(SURGERY)

7.AMD/MD

5.GENERALMANAGER

(DATCC)

2.THEATRECOORDINATOR

4.SERVICEMANAGER/CD

(DATCC)

6.SITE/SERVICEDIRECTOR

ISSUEOFNON-COMPLIANCEWITHSOP

3.THEATRECNM

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APPENDIX6A–BREASTSURGICALURGENCYCLASSIFICATIONS

Diagnosis A<1hr B<3hrs C<6hrs D<12hrs E<24hrs F<48hrs G<5daysBleedingafterLDFlap

X

BleedingafterMastectomyand/orAxillaryNodeClearance

X

Infected/Extrudingimplantrequiringremoval

X

DrainageofBreastofAxillaryAccess

X

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APPENDIX6B–COLORECTALSURGICALURGENCYCLASSIFICATIONSProcedure Diagnosis A<1hr B<3hrs C<6hrs D<12hrs E<24hrs F<48hrs G<5daysLaparotomy Bleedingpostop X Otherpostoptakeback X Peritonitiswithshock X X Peritonitis X GIBleeding X X StrangulatedHerniaunstable X StrangulatedHerniastable X ObstructedHerniawithpain X ObstructedHernia(reduced/non-strangulated) X Toxicmegacolonwithshock X Toxicmegacolonstable X Fulminantcolitiswithshock X Fulminantcolitisstable X Impendingfulminantcolitis X X BowelObstructionwithshock X Uncompensatedbowelobstruction X X CompensatedBowelobstruction X X ImpendingBowelObstruction X UnresolvedDiverticulitiswithsepsisandunstable X UnresolvedDiverticulitiswithsepsisbutstable X UnresolvedDiverticulitis X X Ischaemic/retractedstomaunstable X Ischaemic/retractedstomastable X XAppendicectomy Acuteappendicitiswithperitonitisandshock X Acuteappendicitiswithperitonitisbutstable X Acuteappendicitisstable X Earlyappendicitis X I&DAbscess Necrotisingfasciitis X Abscesswithriskofnecfasc/sepsis X Abscesswithsepsis X Abscesswithoutsepsis X EUA/Scope UncontrolledGIBleeding X X ControlledGIBleeding(highrisk) X ControlledGIBleeding(lowrisk) X ForeignBody/WoundDebridement/Anastomosis X Examination X FlexibleSigmoidoscopy Volvulus(withabdominalpain) X Volvulus X Prolapseoperation Unreducedprolapse X Recurringprolapse XLineInsertion X LineRemoval Withsepsis X Withoutsepsis X

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APPENDIX6C–GISURGICALURGENCYCLASSIFICATIONS

Diagnosis A<1hr B<3hrs C<6hrs D<12hrs E<24hrs F<48hrs G<5daysMassiveUpperGIBleed(Acute)

X

UpperGIBleed(someunderGA)

X

Non-urgentUGIEorColonoscopyunderGA

X

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APPENDIX6D–UROLOGYSURGICALURGENCYCLASSIFICATIONS

Procedure Diagnosis A<1hr B<3hrs C<6hrs D<12hrs E<24hrs F<48hrsCystoscopy Urinaryretention(unabletocatheterise) X X X Chronicurinaryretention X Haematuria(haemodynamicallyunstable) X X X Haematuria X Diagnostic XStenting Obstructioninapatientwithasinglekidneywithrenal

impairment/anuria X

Obstructedkidney(s)withrenalimpairment X X Stentingforrenaltrauma X Uretericstonewithpersistantpain(withoutsepsis) X Stenting/Nephrostomy Drainageofobstructedinfectedkidney X Nephrectomy Trauma(unstable) X Trauma(stable) X X Sepsis X X Priapism X Re-explorationforbleeding(withhaemodynamic

compromise) X

SuspectedTesticularTorsion X Fournier’sGangrene X X Intra-peritonealBladderPerforation X BurstAbdomen X X Clotretention X Fracturedpenis X OpenCystotomy X Paraphimosis X PenoscrotalTrauma X X Testiculartraumawithsuspectedrupture X X ScrotalAbscess(withsepsis) X ScrotalAbscess–drainage(withoutsepsis) X X Post-ophaematomadrainage(penoscrotal) X

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APPENDIX7A–UROLOGYPRE-THEATRECHECKLIST

AllPatients

FBC,U&E □

ECG(over50s,cardiachistory,diabetes,hypertension) □

VenousCO2ifchronicallyhypoxic □

Echo(newmumur&abnormalECG,newAF,moderate/severeaortic □

stenosisonechowithinlast12months)

UretericStentingBaselineinvestigationsplus: □

Coag,Group&Save □

UretericStentInsertionRetrograderequestedonTrak □

Cystoscopy+/-Washout,Biopsy&DiathermyBaselineinvestigationsplus: □

Coag,Group&Save □

Womenage13-55Urinaryβ-hCG □ScrotalExploration+/-OrchidopexyBaselineinvestigationsonly □

ScrotalAbscessBaselineinvestigationsonly □

Fournier’sGangreneBaselineinvestigationsplus: □

Coag,Group&Save □

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APPENDIX7B–COLORECTALPRE-THEATRECHECKLIST

AllPatients

FBCandU&E □

ECG(over50s,cardiachistory,diabetes,hypertension) □

VenousCO2ifchronicallyhypoxic □

Echo(Echo(newmumur&abnormalECG,newAF,moderate/severeaortic □

stenosisonechowithinlast12months)

AbdominalpainBaselineinvestigationsplus □

CRP,LFT,Amylase □

Urinedipstick □

LowerGI/PRbleedBaselineinvestigationsplus □

CRP,LFT,Coagulation □

BTS □

Womenage13-55Urinaryβ-hCG □

SepsisBaselineInvestigationspus□

Lactateandbloodcultures □

AbscessBaselineInvestigationsonly

Appendix

Baselineinvestigationsonly □

Hernia

Baselineinvestigationsonly □

Laparotomy/bowelresectionBaselineInvestigations □

Coagulation □

BTSx2 □

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