Organisational models

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There are three separate organisational models for delivering high volume short stay (HVSS) surgery. Each has benefits and limitations.

The resourcing, infrastructure and wider surgical service models at each facility will influence which is the most appropriate model to use.

Distinct

The distinct HVSS surgical unit is a standalone surgical service in a dedicated building. This unit is physically separated from other acute care streams and includes:

  • separate theatres
  • dedicated staff and patient facilities
  • dedicated post acute care unit (PACU) stage 1 and 2
  • separate ward facilities.

Clinical and support staff work exclusively within the unit.

This service exclusively performs planned surgery. It can accommodate a discrete scope of specialties and procedures.

Physical separation of wards and staff helps stop resources from being redirected to manage:

  • medical patient overflow
  • emergency surgery demand
  • lack of beds available in the emergency department (ED) or intensive care unit (ICU).

High theatre throughput as no emergency surgery disrupts planned surgical lists.

High degree of consistency in workloads and team composition. This leads to increased staff satisfaction.

Improved use of criteria-led discharge through:

  • the use of documented care pathways
  • explicit protocolisation of care pathways.

Due to separation from services and departments, the distinct HVSS unit has limited access to:

  • support services
  • hospital resources
  • care escalation pathways.

Consider how you will manage:

  • access to emergency and critical care services for deteriorating patients
  • access to pharmacy, imaging and pathology services
  • transfer arrangements for patients who are unsuitable for discharge after 72 hours
  • storage of sterile stock, equipment and consumables
  • decontamination and sterilisation of reuseable medical devices
  • integration of information and technology within the wider hospital IT system.

Integrated

The integrated HVSS surgical unit is a designated unit for planned surgery within an existing hospital.

This service exclusively performs planned surgery. It can accommodate a discrete scope of specialties and procedures.

It is separated to a degree from other acute services in the building, including:

  • designated theatres
  • designated clinical staff
  • designated PACU Stage 1 and 2.

Dedicated beds, theatres and staff are not used to support external bed pressures or medical patient overflow.

The unit is likely to have access to the hospital’s:

  • non-clinical support staff
  • staff facilities
  • storage and equipment
  • pharmacy
  • pathology
  • critical care services.

Dedicated wards and staff are at low risk of being redirected to manage:

  • medical patient overflow
  • emergency surgery demand
  • lack of beds available in the ED or ICU.

Using existing infrastructure and sharing administrative, medical and allied health services with the hospital is a more efficient use of resources.

Ready access to emergency and critical care services, when needed.

Greater flexibility in workforce management. Staffing models can enable skill development across multiple roles and specialties. This provides opportunity for professional development.

Consider strategies to maintain separation from collocated surgical services. This is critical during periods of high demand.

Coordinate with the hospital to manage shared staff, services and facilities effectively.

Document and make available:

  • scope of the HVSS unit
  • inclusion and exclusion criteria
  • escalation pathways
  • criteria for discharge.

This supports consistency and use of criteria-led discharge practices.

Ring-fenced

The ring-fenced HVSS surgical unit exists as a dedicated area within an existing hospital.

This service exclusively performs planned surgery. It can accommodate a discrete scope of specialties and procedures.

Ring-fenced beds, theatres and staff are not used to support external bed pressures or medical patient overflow.

Facilities are often shared with other hospital and operating suite services. Dedicated equipment and storage is necessary.

Service model can adapt to accommodate demand, staff and bed capacities.

Ability to adjust case mix easily to accommodate evolving surgical demand.

Emergency and critical care services are collocated for ease of access.

Strong relationships with other key hospital departments including:

  • booking office
  • pre-admission services
  • theatres.

Put in place strategies to maintain separation from collocated surgical services. This is critical during periods of high demand.

There is a risk of resources being redeployed including:

  • theatres used to manage ICU or emergency surgery demand
  • staff and beds used to manage overflow of medical patients or to ease ambulance ramping from emergency departments.

Coordinate patient flow, resources and staff with concurrent planned and emergency surgical streams.

References

  1. Getting It Right First Time. Surgical hubs. England, UK: NHS England; 2023 [cited 13 Feb 2024].
  2. Queensland Government. Business Case for Significant Change – Surgical, Treatment and Rehabilitation Service (STARS). Australia: Queensland Government; 2019 [cited 17 Mar 2022].
  3. Royal College of Surgeons in Ireland. Surgical hubs clinical guidance. Dublin, Ireland: RCSI; 2023 [cited 14 Feb 2024].
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