AUGIB services:

The South West

Perspective David Parker

Gastroenterologist

BSG Regional Representative

for South West England

Geography

Gloucestershire, Wiltshire, Bristol, Somerset,

Devon, Cornwall

The M4/M5/A30 corridor

A361, A303, A353

Severn Deanery Trusts

Swindon

Gloucestershire Cheltenham

Gloucester

North Bristol Southmead

Frenchay

University Hospitals Bristol (BRI)

Weston-super-Mare

Taunton

Yeovil

Peninsula Deanery Trusts

North Devon (Barnstaple)

Exeter

Torbay (Torquay)

Plymouth (Derriford)

Royal Cornwall (Treliske, Truro)

Some Golden Standards of Care

Underpinned by NICE, SIGN, BSG

24/7 rota staffed by suitably skilled people

If not available in-house, a formal network

Suitably qualified/experienced nurses on call

All forms of therapy available 24/7 Banding, dual (triple?) therapy, glue

All high risk patients endoscoped within 24h

All unstable patients endoscoped within 2 h of adequate resuscitation

(All acute GI bleeds endoscoped within 24h)

A problem: definitions

NCEPOD audit confusion “GI bleeding” codes

Lower GI bleeds are included in data searches

How do you define “acute UGI bleed”?

High risk bleeds or all bleeds?

Therapeutic cases only?

Coffee ground vomits? Scoring systems

Out of hours workload or all cases?

When does OOH start?

A problem: measuring workload

Non-responders

Out of hours workload or all cases?

When does OOH start?

Daily bleed lists/slots

What we know

6 trusts have 24/7 rota staffed by Gastroenterologists

1 has regular Sat AM list

3 trusts 24/7 rota shared with Surgeons

1 trust has regular Sunday AM list

1 trust 24/7 rota shared between gastro and surgery but

gaps

Reliant upon goodwill?

2 trusts have ad hoc arrangements shared with Surgery

both 5/7, but one has timetabled Sunday AM bleed list

Planning formal 24/7 rotas

Reliant upon goodwill?

Comments

Various solutions Large trusts OK (heavy workload; 500 pa)

1 “network”

Various problems Still some gaps in 24/7 cover

Surgeons still need to help

Level of therapeutic experience?

Isolated trusts

Small trusts

Three Case studies

Split site

Example of networking

Small trust

Needs to network?

Isolated trust

50+ miles / 1 hour 15 minutes from nearest neighbour

Case 1: split site (1) One trust

2 DGH hospitals: 600k population

Both take acute unselected admissions

One rota covers both sites

Bleeds done on both sites

Rota 24/7: Gastroenterologists

Weekday bleed lists 0800/1230

100 out of hours bleeds pa

In-pat and new pat scoped <24h

Case study 1: Split site (2)

Problems:

Access to theatres

Sometimes have to wait for a gap between

surgical/orthopaedic cases

No instances of having to be in two places at

once (yet)

Lack of familiarity with unit/kit not an issue

Hospitals 8 miles/20 minutes apart

Case study 2: Small trust (1)

Population 180k

1 site

Rota 1 in 8 (3 gastro, 5 surgeons)

2 AM slots daily Mon-Fri for in-patients

OOH cases usually done in theatre

Endoscopy Nurse on call

~140 cases pa but most scoped in hours

All high risk cases scoped <24h

~45 therapeutic interventions pa.

Case study 2: small trust (2) Problems:

None of the surgeons want to do it

Some of the surgeons do low numbers of diagnostic OGD

Not all on the rota can/willing to band/glue

Other physicians do 1 in 11. No extra pay for the gastroenterologists.

Some rota gaps: dependent on goodwill (Gaps are paid for) Once in past year management had to ask neighbouring trust

to cover

Prospect of networking not popular Significant workload if have to participate in cover at larger

trust

Risk of in-comers lack of familiarity with kit/unit

Case study 3: Isolated trust (1)

1 site

160k population

1 in 8 rota

3 gastro, 5 surgeons

Other physicians do 1 in 11

Gastro gets extra 0.125 PA extra

Endoscopy nurse on call

Case study 3: Isolated trust (1)

Potential Problems:

Isolation

50 miles from nearest neighbour

A roads

1 hour 15 minutes in winter; longer in summer

months

Network not practical

No issues yet

Rota in infancy

Summary & conclusions (1) 10 trusts have a formal rota

Large trusts Gastroenterology

Small trusts shared with surgery

Others working towards rotas

Surgeons seem disinclined to participate

Skill set not always complete

Low numbers of routine OGDs

Networks challenging

Distance

Potential “two places at once”

Participation in onerous rotas not popular

Summary & conclusions (2)

Where do we go from here:

Support training of consultants on rotas

JAG accredited courses are costly

Limited Study leave

Press for Gastroenterology to come off

medical take?

Unlikely in smaller trusts

Other ideas?