List Planning

Everything you need to know:

List planning was a new addition to the 2014 trauma and orthopaedic recruitment round.  It was well liked by the interview panel and was thought to accurately demonstrate those candidates who had been on the ‘shop floor’ and showed potential to be registrar material.

Most days you are in the hospital you will be involved in planning a list.  Be it an emergency operating list, an elective operating list, and prioritising patient to review when oncall, etc.

Key steps to consider when organising a list:

  • Priorities patients
  • Create a clear plan
  • Be aware of the resources you have available and are you using them to your advantage?
  • What kit will you need?
  • Will you need image intensifier?  Is this going to be needed in more than one list?  Can you do the ‘x-ray cases back to back on your list so the machine is made available following this for other theatres to use?
  • Do you have the right staff and are the being utilised effectively?

Cases that need emergency surgery, i.e. need to go to theatre now are:

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  • Compartment syndrome
  • Fracture with neurovascular compromise (liaise with other specialities i.e. vascular)
  • Septic joint
  • Dislocated native joint – not reduced
  • Cauda Equina

Cases that are urgent but can wait:

  • 8700882292_9309b30ff2_mYoung fractured neck of femur
  • Open fracture (again liaise with other specialities, i.e. plastics)
  • Supracondylar fracture in child
  • Off ended fracture – not reduced

Other considerations

  • ITU Patients
    • 6465029767_b64ac1b2aa_zGenerally if someone is coming to theatre from ITU its usually urgent
    • If someone is returning to theatre from ITU its usually a big deal and eats up alot of time
    • If ITU say they are fit for the operation now is the time to do it, therefore these patients are high priority.
  • Latex allergy
    • latexUsually in elective practice these patients are first on the list.  If they are being operated on later on the list the theatre needs to be latex free for the whole list
  • Children

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    • Where possible young children are placed at the start of the list to minimise starvation time
    • The operating theatre temperature should be increased for children

 

 

  • Diabetics
    • Where possible diabetics are operated on early on the list to allow for less disruption to usual insulin regime
  • Special kit or personnel
    • If special equipment / or a certain member of the team is required for a procedure and their availability (as long as no other cases take clinical priority)
  • Infected cases
    • Generally performed at the end of the list to allow time for the theatres to be decontaminated and air to cycle so its clean again.
    • It takes 1hour for the theatre to be clean and ready for use
    • MRSA & other infections require extra procaution to avoid contamination between patients, thought needs to be give to where they are recovered and the theatre needs to be decontaminated following use.
  • Other operating lists
    • Think outside the box, if there are lot’s of cases needing theatre are there other lists that can be utilised, what is happening on the emergency / CEPOD list, is there a space on one of the elective lists, is there too much trauma and not enough capacity?  If so should elective cases be cancelled.
  • Other considerations
    • Patient factors such as awaiting results of a scan
    • Pacemaker or operating on an end digit then use bipolar diathermy

Duration of operation

The duration of an operation usually includes anaesthetic time, theatre turnaround time (ie time to clean and change operating table / set up equipment) and the actually time to perform the operation.

Generally speaking in a half day list you will get two cases done. Unless you have 2 bigger cases and then 1 very small very quick case.

  • Hip hemiarthroplasty – 2hrs
  • Dynamic hip screw – 1hr 30mins
  • Ankle fracture – 1hr
  • Distal radius MUA +_ k-wires – 1hr
  • Distal radius ORIF – 1hr 30mins
  • Wound Debridement, ex-fix, & VAC – 2hrs
  • Supracondylar fracture child – 1hr 30mins
  • Femoral nail – 2hrs
  • Flexor sheath washout – 1hr
  • I&D abscess – 45mins
  • Wound closure / Debridement / second look – 45mins

Urgency

  • Emergent – straight to theatre – life / limb threatening – compartment syndrome / neurovascular compromise
  • Urgent – within 24hrs – open fracture
  • Scheduled – within 2 weeks – ankle fracture / wrist fracture (no neurovascular compromise
  • Elective – can wait Moore than 2 weeks – routine hip or knee replacement

Everything you need to do:

There will not be a 100% correct answer for the order of any operating list.  This is simply a case of making a decision and then having a logic thought process to why you have placed patients in the order you have chosen.

Be prepared for the panel throwing a spanner in the works, i.e. you have a patient with a femoral fracture coming round from ITU for a femoral nail, they report that he has suddenly deteriorated and has low oxygen saturations.  What are the differentials? You decide to delay surgery as he is not physiologically fit enough to tolerate the operation.  What could you do (i.e. consider use of external fixator to stabilise bones and allow nursing care and pain relief until fit for surgery)?

When operating on an ankle check the swelling.

When discussing hip fractures they should be operated in within 36hours as per BOAST 1 guideline. This is evidence based and also generated a best practice tariff.

When discussing an open fracture this is an emergency case and needs to take priority.  When you used the words open fracture you should also use the term BOAST 4 guidelines.

Children should be done as soon as possible but emergencies are emergencies and as such come first.

If you are cancelling a patient then you should see and asses them first to ensure they do not have a neurovascular compromise. Patient safety is paramount!

All patients that you cancel you should suggest an appropriate plan. Such as trying to list them to come in on a scheduled trauma day surgery list.

Do what’s right for as many patients as possible but decide the order based upon clinical priority. Don’t over fill the list, if the list is 4 hours don’t put 10hours of operation on it. Be sensible and reasonable. It’s ok to suggest hold a patient in reserve in case say the NOF is not fit for theatre, but in doing so you should say that you will explain that to the person in reserve that they may not get to theatre today, but it’s soon as you know you will either let them eat or do the operation.

Make sure all patients are marked and consetnetd and reviewed by yourself if you are the operating surgeon on the list.

Explore the option of other operating lists.

Summary

Set out you priorities and how you plan to achieve them.  Make a plan and make sure you are using all resources available to you to the best of your ability.    Patient safety is paramount, lee / limb threatening operations first, then urgent operations, then scheduled, then routine elective work.

Join our question bank for instant access to questions and tips to prepare you for the ST3 Ortho Interview!

 List Planning Questions

 

The images have been sourced from:

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