Dr Cathy Armstrong F.F.A.R.C.S.I.

Anaesthetic Lead CAWT DS Project

Member BADS (IRE)

Consultant Anaesthetist

BADS / CO-OPERATION AND WORKING TOGETHER

(CAWT)

IMPROVING DAY SURGERY IN BORDER REGION

HISTORY- DAY SURGERY

Over last decade in UK

elective surgical procedures performed as day cases have

increased from 55% to over 70%

Short stay surgery has also gained momentum

Drivers for change

Government /NHS planning

Public demand

Facilitators of successful change

Multidisciplinary approach

BRITISH ASSOCIATION OF DAY SURGERY

UK , day surgery defined as

Admission of patient to hospital that is planned as a day case procedure and patient successfully returns home on the

SAME CALANDER DAY

Typical stay is 6-8hrs

Extended opening times 12 -14hrs (8am-9)

THE BEGINNING-1ST

James Henderson Nicoll ,Glasgow

1898-1908 -- 9000- day of surgery discharge/children

½cases under 3yo

1st published BMJ 1909 ‘Surgery of Infancy’ 50y

? Motivation---radical practice

shortfall beds

high levels cross infection

financial considerations over 100yrs ago

??Sounds familiar??

HX

During 1900 s slow to embrace—UK

1916 USA 1st Day case clinic in Iowa

1940s early mobilisation post surgery

1955 Eric Farquharson ,Edinburgh

Lancet , series 458 consecutive hernia repairs performed on a day

case basis

1969 First free-standing Ambulatory Surgical Centre

opens in Arizona

PRE-BADS

• 1969 Prof. James Calnan, Hammersmith,London

converted army hut and installed it in car park of

Hammersmith hospital

10,000 pts treatred in first 10 years

• 1969 First dedicated day unit opened UK 10y

DAY SURGERY UK

By 1970/80 there were sufficient numbers of proactive

units with good results to encourage the RCS to publish a

report

‘Guidelines for Day Case Surgery’ in 1985

PERI-BADS 1985 RCS suggest

50% target for elective surgical procedures to be performed as day cases.(national aver 15%)

1989 British Association of Day Surgery formed-like minded

Dr. Paul Jarrett Prof Day Surgery, Kingston Hospital, London

1991 Audit commission publish ‘Basket of 25’

1995 BADS joined IAAS International

Association

Ambulatory

Surgery

11 countries promoting Day Surgery Worldwide

ASM 2 DAY CONFERENCE

BADS 24 YRS DRIVING CHANGE PUBLICATIONS

*Journal of One Day Surgery—published every Quarter

*Web site for patients, managers, clinicians.

Plus a discussion room for members.

BADS

2006 First Directory of Procedures published

??? Offers indicative percentages for length of stay for over 200

individual surgical procedures for day, 23 hr or short stay (up to 72 hrs)

2012 Forth edition Directory of Procedures published

2012 e-directory of Procedures

• Electronic assessment tool

to enable units to assess

and record performance

against those procedure

rates in BADS directory

E DIRECTORY

DIRECTORY OF PROCEDURES

ACHIEVABLE ASPIRATIONAL RATES

RESOURCES BOOKLETS *A number of Guideline booklets covering all aspects of

Day/short stay procedures. From, operational

management, pre-operative assessment through to Nurse

Led Discharge

COLLABORATIVE WORKS

RESOURCES-TEXTBOOK 2012

BADS TEXTBOOK

ADVISORY ROLE

Has been involved with government and

D of H (UK) advisory role and as experts in driving enhanced

recovery in UK.

Instrumental in incorporating day surgery into surgical/anaesthesia curriculum.

Day case principle is the ultimate in enhanced recovery

MAIN RESOURCE---MEMBERS

Regular Guest Speakers at

AAGBI WSM

ESA AGM

ASA WSM

IAAS AGM

BADS

Goal: Promotion of health and

wellbeing of all members of the E U

EUROPEAN HEALTH CARE

STRATEGY

EUROPEAN HEALTH CARE STRATEGY

EU COMMISSION

E U Health Strategy, ratified by Maastricht treaty 1991

Interregional funding * secured *

Special subdivision , cross border division

Main goal is to ‘deliver universal health care through EU to all EU citizens.

in any border region , between any member states, to guarantee

equal access to quality care

CAWT –ROLE AND REMIT

The Cross border health and social care BODY is CAWT

Established 1992- Ballyconnell Agreement

CAWT structures: Management Board,

Secretariat,

Project Boards

Strategy Groups,

Development Centre

CAWT PARTNERS

• Northern Ireland

– Southern Health and Social Care Trust

– Western Health and Social Care Trust

– Health and Social Care Board

– Public Health Agency

–

• Republic of Ireland

– Health Service Executive West - border counties

– Health Service Executive Dublin North East - border counties

EU FUNDING

CAWT(CAWT- CROSS BORDER HEALTH AND SOCIAL CARE PARTNERSHIP)

CAWT --- Co-operation and working together

1996-2000 Eu Special Support programme for

peace and reconciliation

2002-2008 EU interreg111A -£6.74 million

Peace11 £ 1.08million

2009-2014 EU interreg1Va (12) £90 million

£2.7billn ewide

2014--2020 EU interreg £100 million

‘Putting Patients, Clients and Families First’

THE CAWT PARTNERSHIP

• Co-operation and Working Together

• Over 50 cross border projects implemented with EU funding to date

• EU INTERREG IVA funding

• 12 large scale projects to be

completed by 2013

• ‘Putting Patients, Clients

and Families First’

EUROPEAN HEALTH STRATEGY

• Since 1993, Ireland, EU members have had access to

• Peace fund 188million euro

• Intereg (IV) 256 million euro Health/CAWT in this section

Population of 1.6 million

Accounts for about 25%

Of total area of Island of Ireland

Similar

demographics ,age,health,illness

Infrastructures, dist to specl centres

CAWT TERRITORY OF IRELAND

CAWT REGION IRELAND

RATIONALE FOR CAWT

1.6 million residents sharing

Common demographic

Similar health status

Work/across two jurisdictions:

Goal Maximise value for money

Reduce duplication of scarce resources

equipment/people

Funding for procedures for Public Patients

DAY SURGERY AND CAWT

Using BADS Support and resource's,

enabled me to approach the

CAWT partnership ,

with

Day Surgery project idea.

CAPACITY

Available? Theatre Capacity (vacant)

Could Erne accommodate a pilot?

??? MATH: 15%(3w)--42.5%/month(9w) unused o r sesn/week £££££££

£10/min-£2,400 session

£600/hr x 24hrs = £14,400/day

£7,200--£21,600/week! Av loss £14,000/m

ACUTE SERVICES-ERNE

This Day Surgery pilot project encompassed 3 strands:

--- Using Local Surgical Skills—

Ear, Nose and Throat

Urology (including Uro-gynae)

Vascular

project worth €9 million in EU funding

EU INTERREG IVA PROJECTS (2009 – 2014)

‘PUTTING PATIENTS, CLIENTS & FAMILIES FIRST’

Acute Hospital Services - £5,874,164

Sexual Health Services / GUM clinics - £1,742,141

Development of Eating Disorder Services - £2,582,540 ‘Time IVA Change’ – Border Region Alcohol Project - £1,632,341 ‘Turning the Curve’ – Autism Support Project - £1,332,554 Improving Outcomes for Children and Families - £670,794

Support for Older People - £1,899,453

‘UP4IT!’ - Preventing and Managing Obesity - £971,852

‘Citizenship’ - Support for People with a Disability - £2,259,258 Tackling Social Exclusion and Health Inequalities - £1,904,662

Tackling Diabetes in High Risk Clients - £2,313,575 Cross border Workforce Mobility - £816,665

ORGANISATIONAL ISSUES

‘Variation is enemy of quality’

Used BADS guidance

TEAM WORK

Patient Focused process

To make patient journey as easy and as

un-disruptive as possible.

Lead surgeon Lead anaesthetist

Lead manager -DSU ,WL staff

Secretarial, Nursing staff,

Local Ownership – will to succeed!

PROCESS -PATIENT JOURNEY

Selection to After Care-3 STOPS First Surgical Appointment sent with

pre-op assessment questionnaire. (www.bads.co.uk)

1.Combined surgical (+consent/scans.)

+-pre-operative assessment clinics, (+investig) in DPU

Consultant run, all patients seen and walk around unit to familiarize for admission --------------- op date set

2.Admission,procedure, discharge.

3.Follow up surgical appointment date-- on discharge.

PRE-OPERATIVE ASSESSMENT-START Information two way process

Patient is informed to understand their role

In day surgery process

Hospital informed to treat the patient efficiently

• Patient Preparation

• Fully informed of their role AND what

to expect post op(wc)

• Fasting

• PONV

• Anxiolysis(p/c)

• Carer o/n

• escort home/phone

• Hospital Preparation

• Medical info,

• Co morbidities optimisation

• prescribed drug -

• Referrals—specialist/gp(cvs)

• Investigations

• Airway assessment

PRE-OPERATIVE ASSESSMENT 2 WAY

PROCESS TO GAIN INFORMATION

WHO SUITABLE?

Inclusion criteria----Expanding!

Physiological functional status+ proposed surgery

Setting of unit , stand alone(default) or acute hosp site

**Exclusion criteria-- -no transport

---no carer

---no phone

---high risk/unstable

PRE-OPERATIVE ASSESSMENT

Time for Optimisation, or exclusion

Protocol Driven-

co-morbidities stabilised (referral to specialist or GP)

Formation of ‘short notice, patients list for cancellations

VTE prophylaxis, VTE ,Reducing the risk NICE Jan 2010

Diabetic patient HbA1C<8%

MRSA decolonisation,

antibiotic cover, PPI

Anti-platelet medication, omits am of surgery

Priority on list schedule

Pregnancy test am of surgery

BENEFITS OF PRE ASSESSMENT • Reduction of cancellations on D of S

• Reduction in DNA on D of S

• Reduction in unplanned admissions

• Increase in theatre time utilisation-reduce delays

• Increased patient satisfaction

• Reduction in patient/carer anxiety with admission, treatment, after

care

• Empowers patient> confidence in care

D ‘S

Distance NO LIMIT - 5MINS-2 HRS top Donegal

<1mile—100 miles

Duration of surgery No Limit 40mins—160 mins

INTRA OPERATIVE-ANAESTHESIA

• Anaesthetic agents (S/D-TIVA)

• Anti-emetics (www.bads.co.uk)

• Analgesia NSAIDS+ (pre-emtive NSAID)

• Hydration

• Antibiotics

• VTE prophylaxis NICE 2010 VTE: reducing the risk

• O2/AIR

normothermia(T=>36C) NICE 2008 Perioperative Hypothermia

L.A. use

Minimal morphine ( 3xponv)

‘ Variation is the enemy of quality’

PONV *** RISK FACTORS ***

PATIENT RISK FACTORS SURGICAL

Female Laparoscopic surgery

Non smoker Oral or ENT surgery

Hx Motion sickness or PONV Squint surgery

Peri-operative opioids

LOW RISK INTERMEDIATE RISK HIGH RISK

0 or 1 risk factor 2or3 risk factors >3 risk factors

General measures Gen Measures + Gen Measures+

Fluids (20ml/kg) 5HT3 antagonist 5HT3 antagonist

pre-emtive

non-opioid or and

analgesics Dexamethasone(4-8mg) Dexamethasone(4-8mg)

www.bads.co.uk

PONV

Persistent PONV

cyclizine 50 mgs +/-

Prochlorperazine12.5mgs

+20mls/kg i.v. over 30 mins NaCl 0.9% to correct Hypovolaemia

Self limiting-------admission if risk of dehydration,

distance v long

RECOVERY

• PONV-- UNPLANNED ADMISSIONS

********* PERI-OP OPIATES *********

• Stage one Recovery

I.V. Fentanyl (25ug bolus) q 2mins up to max 100ug

> anaesthetist

York Health Service ,I Jackson, 2006

www.bads.co.uk

POST OPERATIVE

• TTA PARACETAMOL

co-ccodamol 8/500-+laxative (senna)

ibuprofen 800 or diclofenac 50,ppi

odansetron 4mg sl

AFTER CARE

• LOCAL CONTACT NOS -Emerg - local hospital CAWT

• OUR CONTACT NOS - anytime- anaesthetist on call

• DAY 1 follow up phone call---- case anaesthetist

• POST OP CLINIC DATE on discharge

DISCHARGE

Nurse led

CAPITAL EQUIPMENT INVESTMENT

Letterkenny 600,000 euro—urology

Sligo 160,000 euro--urology

Enniskillen 110,000 euro—vascular

Craigavon 160,000 euro—ENT

€1,030,000 until 2011

NEW STAFF EMPLOYED

LETTERKENNY- 1C,3 nchd,1 nurse (U)

ENNISKILLEN- 4 nurse, 2s.local C

CRAIGAVON- 2 C, 4 nurse 3nchd

MONAGHAN- 2 C , local staff

• Vascular

• Urology

(incl urogynae)

• ENT

Opthalmology

• PROJECTED TOTAL

COMPLETED TOTAL

634 patients treated

2116

10,620

1036

6700 patients

14,417 patients

(216%)

SO FAR…

First All Ireland Day Surgery Conference

Farmleigh, Dublin 2010

CONFERENCE DAY SURGERY (FUNDED)

SUMMARY

• Day and short stay surgery –Priority North+South

Efficiency***saving

Financial***saving

incorporating best practice advancements in anaesthetic/surgical techniques

Change in practice, outside ‘comfort zone’

Team approach vital

•

FUTURE

Developed strong networks for overcoming challenges of service delivery

cross border

.

• Broaden case mix DS

• Secured funding for:

• Nurse preop assessment training course

• Dr. AE Bourke

• Day Surgery Conference October 2013

FUTURE

Exciting opportunity for everyone

in health care provision

Next round interreg funding to include recruitment and retention

Especially now, $$ tight

FUTURE

Day surgery, better care, safer care

RAF

‘ Knowledge eliminates fear’

‘If you live in the past,

while in the present,

you have no future’

CO-OPERATION AND WORKING TOGETHER

(CAWT):

INFO

British Association of Day Surgery

35-43 Lincoln’s Inn Fields, London,WC2A3PE

www.bads.co.uk

CAWT

CAWT Development Centre,

Riverview House,Abercorn Road,Londonderry, BT486SB

cawtinfo@westhealth.n-i.nhs.uk