SOFTWARE-ASSISTED IMPROVEMENT OF SURGICAL

MANAGEMENT AT CARLOS HAYA REGIONAL

UNIVERSITY HOSPITAL IN MALAGA, SPAIN

Julio Díaz, Juan Cano

Hospital Regional Universitario Carlos Haya, Avda. Carlos Haya, s/n, Málaga, Spain

Adolfo Jiménez, Antonio Alonso

Hospital Regional Universitario Carlos Haya, Avda. Carlos Haya, s/n, Málaga, Spain

Keywords: Performance, Operating rooms, Surgery, Waiting lists, Management, Software.

Abstract: This paper reports the features of a computer program (AQuA) developed to improve surgical management

at the Carlos Haya Regional University Hospital in Málaga, Spain. Several factors have forced the devel-

opment of this digital solution: i) our hospital is made of four buildings some 5 km apart, ii) there are 41 op-

erating rooms attended by 319 surgeons and 72 anaesthesiologists and, most important, iii) some predefined

pathologies are protected by law in our region and have a guaranteed limited waiting time (LWT) before

surgery. In this complex milieu our program was conceived, developed and put to work. It has been running

for just over a year with progressive implementation in surgical departments. Some facts that seem to indi-

cate the usefulness of the program: the number of patients with diseases with LWT that have received op-

erations has increased in 14 months from 1,145 to 1,564 patients/month (36.59% increase) and surgical per-

formance has increased from 65.93% to 71.80% in the same period. Since all other conditions related to

surgical activity have remained unchanged the improvement seems to be attributable to the AQuA program.

AQuA is a comprehensive, flexible, friendly and open program capable of dealing with most hospital set-

tings.

1 INTRODUCTION

The arrival of Information Technologies has pro-

vided a very powerful tool in many areas of society.

In health services, where there is a permanent social

demand to improve its quality, the application of

information technology is one of the key elements

that can help improve management, optimize re-

source utilization, better control of health spending

and, consequently, offer better services to society.

(Informe SEIS, 2010).

In the past 15 years, the Spanish health institu-

tions have incorporated many experiences leading to

an improvement in the know-how in technological

terms. This strategy is just beginning to provide

results. (Gutiérrez, 2009).

A successful implementation of these technolo-

gies will enable institutions to make significant steps

towards achieving greater efficiency.

The hospital environment generates large

amounts of information of different nature (clinical,

administrative, management, etc.) which need to be

processed.

The trend is to manage that information in a way

that allows on one hand, increase process efficiency

and on the other, making it available securely from

any location. In addition, analysis of information is

particularly useful for improving medical knowledge

and making the most appropriate management deci-

sions. (Informe SEIS, 2007).

Surgical treatment is not only vital to the

achievement of the objectives of the hospital but is

also the centre of many inter-related activities.

In addition, the resolute character of surgery

makes it a first-rate care component being the oper-

ating room one of the more expensive and scarce

resources of a hospital. The operating room, with its

high concentration of technology and highly quali-

131

Díaz J., Cano J., Jiménez A. and Alonso A..

SOFTWARE-ASSISTED IMPROVEMENT OF SURGICAL MANAGEMENT AT CARLOS HAYA REGIONAL UNIVERSITY HOSPITAL IN MALAGA,

SPAIN.

DOI: 10.5220/0003112401310137

In Proceedings of the International Conference on Health Informatics (HEALTHINF-2011), pages 131-137

ISBN: 978-989-8425-34-8

 2011 SCITEPRESS (Science and Technology Publications, Lda.)

fied personnel, usually becomes the bottleneck of

clinical practice.

But the surgical activity also creates a great de-

mand and it is difficult to accommodate such de-

mand at the optimum level required by the user, so

the waiting lists generated must be controlled and

monitored.

In-depth knowledge of the surgical activity be-

comes, therefore, the key to the hospital manage-

ment. Two main elements form the backdrop: surgi-

cal waiting list and activity of operating rooms.

1.1 The Surgical Waiting List

In hospitals of the Andalusian Public Health System

a computerized record system is in use since 2001

called AGD. It is configured to monitor the proce-

dures covered by the “surgical delay time assurance

program". These delay times were established taking

into account the relative frequency of the relevant

processes in the local population and their clinical

relevance. Data recorded in this system is transpar-

ent for both the patients and the health authorities.

The AGD is therefore a list of users awaiting for

a surgical intervention. The time in the waiting list is

guarantied by regional laws to a maximum of 180

days. Meeting this deadline has proved to be a diffi-

cult task. (SAS, 2010).

1.2 The Activity of Operating Rooms

The operating rooms are one of the areas that gener-

ate the largest costs to a hospital as they consume

about 15 percent of the budget. (Quecedo, 2009).

It has been estimated that the optimal occupancy

rate of surgical block should be around 85 percent

and that every unit of percentage below 85 costs

€10,000 per operating room and year. In other words

the drop of surgical rate in one unit means loosing

11 surgical interventions per operating room per

year.

Therefore, the surgical block inactivity causes a

loss of considerable economic and social opportu-

nity, so it is essential to increase production capacity

and performance of the surgical block through

knowledge of the actual time of use of operating

room and their shortcomings for efficient manage-

ment.

1.3 The Need for a Change.

AQuA, not to Sink but to Float

Until recently the Carlos Haya Regional University

Hospital in Malaga was not supported by any com-

puter application that integrates the four key aspects

of the surgical schedule:

1. Waiting list (AGD) and some other processed

outside the AGD.

2. Management of operating rooms assigned by

the Medical Director.

3. Anaesthesiologists Planning.

4. Preoperative visit carried out by the

anaesthesiologist.

The computer application covered by this paper

aims to improve the efficiency of the operating

room, assisting the surgical schedule to sort out the

availability of operating rooms. This action will

prevent a bottleneck. (Ramolla, 1999).

We must also mention the point in time where

this program has been implemented. One of the

barriers that traditionally stood in the way of pro-

gress for implementation of information technology

was the health staff. (Riesgo, 2007). Currently, this

staff has evolved and is now more receptive to new

information technologies.

Among them, the "doctors", which have tradi-

tionally been the major obstacle, now show a more

positive disposition towards informatics. This posi-

tive attitude is a conditioning factor for the imple-

mentation of medical bioinformatics since they now

accept that their role goes beyond the cure.

2 MATERIAL AND METHODS

2.1 The Structural Complexity of our

Hospital

Carlos Haya Regional University Hospital is a pub-

lic institution belonging to the Andalusian Autono-

mous Community. For historical, reasons it is organ-

ised in four major buildings some 5 km apart from

each other, three of them with surgical activity. All 4

buildings are under the same management and cover

for the health needs of the east of Malaga (348,656

inhabitants). In addition it is “reference for the prov-

ince” (1,517,523 inhabitants) for obstetrics end pae-

diatrics matters and “reference for the region” in 5

surgical and 6 medical specialties, including trans-

plants.

The main building (A) has 590 beds, 15 operat-

ing rooms and 141 surgeons. It houses the most

HEALTHINF 2011 - International Conference on Health Informatics

132

15 operating rooms

141 surgeons

8,000+ operations/year

13 operating rooms

12 delivery rooms

98 surgeons

9,000+ operations/year

13 operating rooms

80 surgeons

10,000+ operations/year

21 surgeons

Figure 1: The complexity of our hospital complex.

complex medial and surgical specialties. Building B

(women and children) has 520 beds and 13 operating

rooms. Building C has 147 beds and 13 operating

rooms. The activity of this building focuses on alter-

natives to traditional hospitalization such as major

ambulatory surgery and short stay surgery. Building

D is a high-resolution outpatient service.

The name given to the program presented in this

paper is AQuA (Actividad QUirurgica Asistencial =

Surgical Care Activity) and its task is to facilitate the

flow of patients awaiting for surgical intervention

taking into account all these factors, allowing simul-

taneously complete freedom to clinicians to intro-

duce exceptions whenever necessary, as outlined in

figure 2.

Once the relevant surgical specialist has decided

to operate the patients enter an unique waiting list

but with some privileges, i.e., some predefined pa-

thologies are protected by law in our Autonomous

Community and have limited waiting time (LWT)

before surgery.

Two categories of LWT exist, 180 and 120 days.

The system is so strict that if the public social

security hospital does not meet the corresponding

LWT the patient is free to seek care at a private

hospital and pass the cost to the Social Security

administration.

Needless to say the complexity of organising the

surgical activity in such a complex multi-building

hospital with the legal limitations of maximum LWT

for many pathologies.

In this setting AQuA was conceived, produced

and put to work with a great success as outlined

below.

2.2 The AQuA Program.

Applied Technology

AQuA has been designed for ORACLE database,

with client-server technology, and developed in a

modular programming in Object-Pascal language

under the Delphi platform, making the maximum

use of object-oriented paradigm, and the environ-

ment Fast Reports generator.

The general features of AQuA are:

1. Capture and transfer of data daily from the

patients’ waiting list, with control and error

correction, allowing automatic loading system

that coordinates the input and update of new

data on patients enrolled in the centralized

waiting list (AGD). This allows simultaneous

and permanent updating in AQuA of local

data.

Any discrepancies in patient identification,

diagnostic code, procedure or prescribing

physician, is detected and corrected immedi-

ately. In addition to CIE9MC encoding, si-

multaneous descriptions of diagnostic and

procedures with terminology of the relevant

department can be used.

2. Multifunctional management of waiting lists

by the relevant services.

Complete treatment in a single screen of pa-

Surgical

waiting lists

A B

AQuA

Hospital

management

72 anaesthesiologists

Clinical Laboratory

Radiology

Morbid anatomy and others

SOFTWARE-ASSISTED IMPROVEMENT OF SURGICAL MANAGEMENT AT CARLOS HAYA REGIONAL

UNIVERSITY HOSPITAL IN MALAGA, SPAIN

133

AQuA

Operating

rooms

assignment

Operatingrooms

schedule

Anaesthesiologist

assignment

Pre‐anaesthesia

checkup

Hospital

management

Anaesthesiology

Waitinglists

withlimited

waitin

time

Customer

service

Automatic

download

Operatingrooms

programming

Surgical

indication

Surgical

Departments

Surgical

reports

Figure 2: AQuA general’s scheme.

tients’ waiting list for every department, with

interactive upward and downward classifica-

tion of any column.

Classifications and searches can be done us-

ing multi-filters with more than 10 different

criteria simultaneously, that allow shortening

the list by physicians, diagnostic procedures,

anaesthesia and waiting times.

It includes two main choices:

 Current status of approval by the an-

aesthesiologist

 Date of appointment for the Pre-

Anaesthesia check.

The possibility of filtering and sorting data

provides a transcendental tool not only for

printing but also for exporting information to

spreadsheets for further internal or external

treatment.

At the same time, each patient record is in-

terconnected with the applications that pro-

vide their medical history, radiology and

laboratory tests and an intercom service be-

tween relevant hospital areas dealing with

major events related to that patient.

3. Control of pre-operative anaesthesia appoint-

ments.

Daily or periodical planner of pre-operative

anaesthesia appointment, (from where alloca-

tion is channelled approval of anaesthesia) or

any other important fact about the patient.

Access to patient history and tests is also al-

lowed from this position.

Scheduled assignment of anaesthesiologists to

relevant surgeries. It is carried out by the head

of department of anaesthetics. Through a

simple drag-and-drop system, anaesthesiolo-

gists are assigned to an operating room on any

date. Holidays, sick leaves, and others, are

taken into account by the program.

4. Management of surgical lists

This process allows a fast programming of

any surgery once the operating room features

and type of activity are configured.

The user just “captures” the patient from

the Department’s waiting list (or from any

other Dept, privileges necessary).

After that, simply assign the surgical team,

intervention order and any necessary en-

dorsement, as blood supply, reserve bed in in-

tensive care or preparation of special instru-

ments needed.

It allows the immediate transfer of the pa-

tient from an operating room to any other

HEALTHINF 2011 - International Conference on Health Informatics

134

available operating room, provided the cur-

rent user has the relevant privileges to access

it.

The surgical list is now ready for printing

and copies of it (hard or soft) will be distrib-

uted to the different areas involved: operating

rooms, general services, blood bank and hos-

pital management, amongst others.

5. Operating Room Module

It is a window that shows the surgical activity

scheduled for that current day. It allows navi-

gation between operating rooms and patients.

Information can be classified by both criteria

and reports permanently in a colourful fashion

of the situation of every patient.

This module is the gateway to the “Man-

agement of Surgical Intervention" or the form

based on the WHO’s “Surgical Safety Check-

list” (World Health Organization, 2008).

6. Management of surgery in all aspects and

professional areas: Medical, Nursing, Anaes-

thesiology.

It is a complete record of the events that occur

and actions taken during surgery.

Collects information produced by the an-

aesthesiologist, surgeons and nurses, allowing

a reconsideration of the original diagnoses

and procedures, as well as adding secondary

diagnoses and procedures.

The result is the dynamic creation of a re-

port that finally becomes the “discharge re-

port” in patient undergoing major ambulatory

surgery and the “surgery report” in the rest of

patients.

This report is supplemented with many aux-

iliary procedures: contextual help in drafting

parts of the report, issuing labels, generation

of department-specific documents, direct ac-

cess to the patient's history, processing of ur-

gent intra-operative biopsies, registration of

any prosthetic implants used, etc.

If circumstances had forced the depro-

gramming of an intervention the AQuA pro-

gram requests accurate information about the

causes involved enabling a later analysis of

the situation.

Every department involved can create a set

of complementary documents that can be re-

trieved from this screen in a privilege-

dependent fashion.

7. Patients’ module with full integration with the

relevant hospital applications.

A powerful search engine provides access to

the patient’s administrative data, from which

the medical history, the waiting list, addi-

tional tests, and others, can be accessed.

Some other documents can easily be gener-

ated within AQuA, i.e. the patient’s written

consent.

Urgent surgery can be directly entered indi-

cating the appropriate operating room. The

patient’s surgical history and the relevant re-

ports can be seen from this screen.

8. Management of patients already operated

AQuA is connected with the hospital central-

ized program dealing with “appointment for

surgery”. When surgical intervention is com-

pleted or a definitive deprogramming takes

place the patient is withdrawn from the wait-

ing list for that particular surgery. Other pos-

sible surgeries in the waiting list for the same

patient are not affected.

This process also allows for the gradual im-

plementation of the program because it will

temporarily close a surgical intervention to

provide statistical information immediately,

without having to fill in all the clinical infor-

mation of the intervention.

9. Total security management.

Management of events (logs) with users

maintenance, access profiles and access con-

trol to the program and/or each of the options

that have been considered necessary to con-

trol.

10. Statistics module

Large catalogue of statistical modules. Dy-

namic listings and 100% integrated exporta-

tion of data to Excel, Dbase, Paradox and text

formats.

2.3 Results

The AQuA program has been designed and devel-

oped to work in and within our hospital. Nonetheless

a great effort has been made to produce an open

program adaptable to a variety of settings. The aim

of presenting it in this HEALTHINF 2011 Confer-

ence is to seek suggestions to improve a final ver-

sion able to fully accommodate to any demands.

The program used has been implemented pro-

gressively in different hospital departments as it was

produced. Many changes, improvements and correc-

tions have been made along the way. It has been a

difficult task, not only by the intrinsic complexity of

surgical activity but also by the multi-building lay-

SOFTWARE-ASSISTED IMPROVEMENT OF SURGICAL MANAGEMENT AT CARLOS HAYA REGIONAL

UNIVERSITY HOSPITAL IN MALAGA, SPAIN

135

out of our hospital. But today we are proud of pre-

senting a comprehensive program covering any

possible aspect of surgical activity.

If there is a point that reflects the usefulness of a

program, beyond the obvious result, that is its ac-

ceptability. This program has spread along the hos-

pital with a tremendous avidity. Its easy friendly use

and the fact that many users had had the opportunity

to introduce or change an aspect concerning their

particular activity has paved the way to success.

The operating rooms' performance has increased

progressively since the introduction of the program.

The vertical dotted arrow in figure 3 indicates the

point at which the program started running in two

surgical departments and the continuous arrow indi-

cates the point when 75% of the surgical activity

was under the control of AQuA. As a whole, from

launching in April 2009 to date the surgical per-

formance has increased from 65.93% to 71.80%.

Since any other conditions related to surgical activ-

ity have remained unchanged the improvement

seems to be attributable to the AQuA program.

Figure 4 shows the percentage of patients oper-

ated on before 90 days of waiting time, from April

2009 to May 2010. As can be seen the percentage

has increased from 54.06% to 67.13%.

60%

62%

64%

66%

68%

70%

72%

74%

may'

l'09

oct'

dic

feb'

r'1

pr'10

may'10

Figure 3: Operating rooms performance.

40%

45%

50%

55%

60%

65%

70%

apr'09

may

jun'09

jul'09

p'09

oct'09

nov'

dic

feb

mar '10

pr'

'10

Figure 4: Patients operated within 90 days from diagnosis

(%), from April 2009 to May 2010.

Finally, it is important to note that the number of

patients with diseases with guaranteed limited wait-

ing time, that have received operation, has increased

from 1,145 patients/month to 1,564 patients/month

in 14 months, representing a 36.59% increase, as

show in figure 5.

This result is complementary to those shown in

Figure 4 and is a valuable piece of information since

the surgical activity has been shifting gradually

toward patients with maximum waiting time limited

by law.

500

750

1.000

1.250

1.500

1.750

apr'09

may

jun'

jul'09

p'09

oct'09

nov'

dic

feb

mar '10

pr'

'10

Figure 5: Number of patients protected by the “Limited

Waiting Time law” operated from April 2009 to May

2010.

3 CONCLUSIONS

AQuA is a multitask computer program developed

to improve surgical management in our hospital. It is

running in all surgical departments in all 4 building

of our hospital.

It receives input from patient’s waiting lists,

availability of operating rooms, surgeons, anaesthe-

siologists, and many other concepts.

The program has shown to be very valuable in

the handing of patients on the waiting list with sur-

gical pathologies covered by law by certain privi-

leges i.e, depending upon the disease, some patients

have the right to seek private attention and pass the

bill to the social security administration after 120 or

180 days on the waiting list.

The introduction of AQuA in the Carlos Haya

Regional University Hospital in Malaga has intro-

duced a set of improvements in the management of

surgical activity that can be summarized as follows:

 Real time monitoring of a set of quantitative

indicators, such as, total number of surgical

interventions carried out, operating room per-

formance and use, deprogrammed surgical in-

terventions, entries to, and exists from the

waiting lists, and so on.

 Planning of operating rooms 15 days in ad-

vance.

AQuA started running in

two surgical departments

75% of the surgical activity was

under the control of AQuA

AQuA started running in

two surgical departments

75% of the surgical activity was

under the control of AQuA

HEALTHINF 2011 - International Conference on Health Informatics

136

 Improved control of pre-operative studies

leading to a 20% reduction in the number of

studies that are due to expire.

 The pre-operative anaesthesia appointment

may obtain lists of patients as they are ap-

proaching the date of surgery.

 Surgical departments can perform a surgical

schedule with updated information of patients,

operating rooms, pre-operative anaesthesia

and others.

In addition, AQuA, has helped unify two impor-

tant aspects regarding the clinical documentation:

 Surgical schedule forms are now the same for

all operating rooms of all 4 hospitals build-

ings. The change from the previous obsolete

procedure to the actual one, handled by

AQuA, was achieved in less than three

months.

 Surgical reports have now the same format for

all surgical departments. This has been

achieved through the "intra-operating room

module" a flexible piece of the program that

allows adaptation of the report to different

needs in the context of a general layout.

ACKNOWLEDGEMENTS

We would like to acknowledge all those related to

the development and the use of the program, spe-

cially the Medical Directors of all 4 buildings of the

hospital, the Informatics Department, Heads of Sur-

gical Departments and the general staff that has not

only facilitated the use of the program but also sug-

gested many of its present features.

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UNIVERSITY HOSPITAL IN MALAGA, SPAIN

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