At the Association for Perioperative Practice’s annual congress, delegates gained an insight into how high intensity theatre lists could provide a solution to tackling the backlog. Central to this approach is effective, multidisciplinary team working.
Great teamwork can lead to great achievements was among the take-home messages at AfPP Congress. In fact, teamwork has been central to achieving impressive results in reducing the backlog, at Guy’s and St Thomas’ NHS Foundation Trust. Dr. Imran Ahmad, Deputy Clinical Director for Theatres, Anaesthesia & Perioperative Medicine, at Guy’s and St Thomas’, provided delegates with an insight into the Trust’s recordbreaking High Intensity Theatre (HIT) Lists.
Dr. Ahmad pioneered the idea of running theatre lists like F1 pit stops, maximising theatre and surgeon efficiency safely to operate on many more patients in a day than would normally be possible. The HIT list aims to minimise surgeon down-time, enabling them to move efficiently from patient to patient without waiting for patients to be anaesthetised and theatres to be set up. (See figures 1, 2)
The HIT lists focus on one type of procedure at a time and take place at weekends. They require careful planning to select suitable patients and, in most cases, have been able to treat at least three times the number of patients compared to a regular surgical list.
The Trust has now run 23 HIT lists, treating 410 patients across 9 different surgical specialties – including gastrointestinal, gynaecology, orthopaedics, ENT and urology. Many other Trusts have followed their lead and are now running their own programmes
“NHS waiting lists were already increasing gradually, when the COVID pandemic hit. Since then, there has been an exponential increase in the number of patients on the waiting list. It has now reached over seven million. The problem is, not only the number of the patients, but the steepness of the curve – it suddenly increased, and it is only going to get worse,” commented Dr. Ahmad.
He highlighted a paper, titled: ‘At breaking point or already broken? The NHS in the UK ’,1 which pointed to Brexit, underinvestment, burnout and low morale, a sicker population, and the UK tax system as contributing factors to the crisis. The 18-week target has not been met since early 2016 and, since the pandemic, waiting times have only worsened further. He cited projections suggesting that, by 2030, the waiting list is expected to have doubled.
“Only if we increase pre-pandemic theatre efficiency by 4% will we start to see a reduction in the waiting list,” he commented.
Proposals to tackle the backlog have included building more theatres, and training and recruiting more doctors and nurses, but all of this takes time and money, Dr. Ahmad pointed out. However, we could “use what we already have differently”, he suggested. He explained that HIT lists and an increase in day-case procedures can make a significant impact. On a conventional hernia list the total number of cases done all day is around 7; on a HIT list this would be about 25. He highlighted the fact that an increase of 168% can be achieved with HIT lists. Furthermore, 20 low-risk procedures account for 70% of total need. Making day-case procedures more accessible and deliverable will address 85% of need
“With the conventional running of a list, a patient is operated on, sent to recovery, then another patient is sent for, and the process is repeated. The HIT list methodology aims to minimise the surgeon’s non-operative time and maximise the operative time. By using the principles of parallel processing, the time that the surgeon isn’t operating is almost zero, as is the turnaround time between cases,” he explained.
Dr. Ahmad pointed out that the concept behind HIT is not new, but is often referred to as ‘overlapping surgery’. He acknowledged that a paper by Pandit et al was quite negative about overlapping surgery, but a lot of the data referred to in this paper was from north America, involving major surgery, and therefore did not reflect the approach at Guy’s and St Thomas’ in the UK.2
Findings suggest that overlapping surgery is a safe and effective strategy when it is undertaken by experienced surgeons who practice it frequently. He went on to highlight a systematic review and meta-analysis published in JAMA. In the retrospective cohort study of 66,430 adults undergoing common operations, overlapping surgery was not significantly associated with differences in in-hospital mortality (adjusted rate, 1.9% vs 1.6%) or postoperative complications (adjusted rate, 12.8% vs 11.8%).3 The authors concluded that overlapping surgery, if performed under established guidelines, may be performed without increased risk to patient safety.
The HIT list involves:
- Increasing the number of anaesthetic, surgical and theatre staff in order to minimise the turnaround time between cases, making more time available for the surgeon to operate.
- Using two theatres and three teams, the surgeon can go between cases without having to wait for the patient – this allows for many more cases to be done in the same time period.
- Several multidisciplinary meetings are required for each HIT list to select suitable cases, patients and team members and to plan the equipment and order of the lists – they include managers, administration staff, therapists, nurses, pharmacists, anaesthetists and surgeons.
“Multidisciplinary team meetings are key to success with the HIT lists. Meticulous planning and preparation allow you to deliver these amazing results on the day,” commented Dr. Ahmad. “Our turnaround times are 2-3 minutes across specialties.”
Looking after the team’s wellbeing and morale is also important and the list is staffed in such a way to ensure everyone can take their breaks. HIT lists use up to 50 % more staff at an estimated mean cost of £8000 per list. However, the estimated total tariff income can range from £10,500 to £30,500.
Dr. Ahmad highlighted the potential impact of using HIT lists for clearing the backlog of hernia operations. The UK hernia waiting list is around 120,000 and at least 60,000 will be suitable to be done on a HIT list. In reality this is a conservative estimate. Around 25 hernias per HIT list can be operated on, with two HIT lists per month. Based on this, it is calculated that it is possible to treat 600 hernia per year, per hospital. If scaled up to around 100 hospitals, 60,000 suitable patients waiting for an operation could be cleared from the backlog in one year
“This is just one specialty and there are many more that are suitable. The potential is huge,” he commented. Dr. Ahmad reported on the results (see Figure 3a, 3b and 3c) and pointed out that the approach also had a positive impact on finish times and cancellations: “The lists finished either on time or early, because it was so efficient,” he explained. The cancellation rate was just 0.5% and there was just one overrun, across 23 lists, spanning 10 specialties. The Trust even broke some records, performing the most robotic prostatectomies in one day (eight) – a European record; the most ever aquablation cases done in one day (10) – a world first; and the most ever cochlear implants placed in in one day (10) – a UK record. Dr. Ahmad reported that the HIT lists have been expanded to include:
- hip replacement
- robotic surgery
- complex urology surgery
- cochlear implants
- plastics breast flaps
Reconstructive breast surgery
Guy’s and St Thomas’ recently reported that it operated on three months’ worth of breast cancer patients in five days, using an adapted version of the HIT list. Plastic surgeons at St Thomas’ Hospital carried out reconstructive surgery on 22 patients who had been diagnosed with breast cancer, were breast cancer gene carriers, or both. Many had been on the waiting list for over a year for their reconstructive surgery.
Nine of the patients had microsurgical reconstruction to create a new breast using their own tissue, known as an autologous flap. This is where tissue (skin and fat) is taken from the abdomen or upper thighs with blood vessels, disconnected and then re-connected in the chest using microsurgery to create a natural reconstruction. Using up to two theatres at a time, with additional staff over five consecutive days, including a weekend, the adapted HIT list included long and complex procedures. The team was led by consultant plastic surgeons Pari-Naz Mohanna (plastic surgery breast lead) and Maleeha Mughal, with the support of Paul Roblin (consultant plastic surgeon), Kerri Larnach (breast cancer reconstruction specialist nurse) and Charlotte Morris (plastic surgery service manager).
Months of planning for this adapted HIT list included a HIT clinic where patients had one-stop consultations with plastic surgeons, anaesthetists and breast cancer reconstruction specialist nurses ahead of their operations. They were given a presentation by a physiotherapist about post-operative rehabilitation and also had their pre-operative checks.
Miss Mohanna said: “We wanted to safely tackle the backlog of reconstructive surgery, while continuing to operate on patients with newly diagnosed breast cancers. We were inspired by the HIT list model, but we needed to adapt it for longer, more complex procedures while ensuring that the highest quality of care was maintained throughout the patient’s journey. This needed months of detailed planning between myself, Dr. Ahmad and a number of other key team members; the plastic surgery service manager, surgical admissions, theatre and recovery staff, breast cancer reconstruction specialist nurses, as well as the plastic surgery ward team led by their head nurse. This ensured patients were supported throughout their journey and we were truly blessed with unrivalled enthusiasm, passion, positive energy and commitment from all the staff involved.”
Shanta Holder, 39, was one of the HIT list patients. She had been diagnosed with stage 3 breast cancer in October 2022 and her surgery involved a right mastectomy, removal of the lymph nodes under her right arm and breast reconstruction. Shanta, a hairdresser from Swanley in Kent, said: “In between my treatments, I had a window of time to have my reconstructive surgery and was lucky that I was able to have it so promptly. All the staff at St Thomas’ were amazing... I am quite young and this surgery is a really major change for me physically and emotionally, but they reassured me. From the first moment I met Miss Mohanna, she told me ‘I understand but it will be ok’. I took that reassurance and ran with it. Everyone made me feel comfortable – there was no fear or doubt.”
Valerie, 69, had surgery to create a nipple following a previous surgery for breast reconstruction two years prior. The grandmother-of-two, from Chelsfield in Kent, said: “I couldn’t praise enough the treatment I had, and the staff have been fantastic, really lovely. It’s early days in my recovery from this, but I’m delighted to have been able to have had this surgery.”
Dr. Ahmad commented: “We started the HIT list model with relatively straightforward procedures which would be done in one day. Through time this has developed to now operating across multiple days for complex, longer and bespoke procedures, which has allowed us to expand the types of patients and procedures benefitting from the HIT list programme.”
About Guy’s and St Thomas’
Guy’s and St Thomas’ NHS Foundation Trust provides 2.6 million patient contacts in acute and specialist hospital services and community services every year. The Trust includes Guy’s Hospital, St Thomas’ Hospital, Evelina London Children’s Hospital, Royal Brompton Hospital, Harefield Hospital, and adult and children’s community services in Lambeth and Southwark.
1. Hunter, D.J., At breaking point or already broken? The NHS in the UK, NEJM, July 2023. 2. Pandit JJ, Ramachandran SK, Pandit M. The effect of overlapping surgical scheduling on operating theatre productivity: a narrative review.
2. Anaesthesia. 2022 Sep;77(9):1030- 1038. doi: 10.1111/anae.15797. Epub 2022 Jul 21. PMID: 35863080; PMCID: PMC9543504.
3. Sun E, Mello MM, Rishel CA, et al. Association of Overlapping Surgery With Perioperative Outcomes. JAMA. 2019;321(8):762–772. doi:10.1001/jama.2019.0711