Transcript SAME DAY / 23 HOUR AMBULATORY SURGERY BREAST …

SAME DAY / 23 HOUR AMBULATORY
SURGERY BREAST CARE MODEL
IS IT FEASIBLE?
Jo Marsden, Terri Baxter
King’s Breast Care,
Kings College Hospital
Foundation Trust, London
BREAST SURGERY SAME DAY/23 HOUR MODEL
•
Why did we change practice at King’s College Hospital?
– Patient demand
•
How did we change practice?
– We examined the patient pathway and patient experience
•
Is it safe and do patients like it?
– Yes
•
What are we doing now to improve service?
– Ensuring continual patient feedback
BREAST SURGERY SAME DAY/23 HOUR MODEL
Non-reconstructive breast cancer
surgery
• Breast conservation
• Mastectomy
• +/- sentinel node biopsy / axillary
dissection
•
No evidence of adverse physical /
psychological recovery compared
with in-patient stay
•
Nationally variation in length of stay
– Day surgery rates in London
range from 20% to > 80%
– Average LOS for breast surgery
UK 4.8 days
MEAN LENGTH OF IN-PATIENT ADMISSION
MASTECTOMY (NO RECONSTRUCTION),
OTHER EXCISION 2008-2009
SAME DAY DISCHARGE FOR BREAST CANCER
SURGERY AT KING’S BREAST CARE (KBC)
Ambulatory surgery has been offered at KBC since March 2006
• Same day discharge / 23 hour stay
• All non-reconstructive breast cancer surgery
– Breast conservation +/- sentinel node biopsy / axillary
dissection
– Mastectomy +/- sentinel node biopsy / axillary dissection
The service was introduced in direct response to patient demand
following a change in surgical practice
• Cessation of routine use of wound drains (April 2005) removing
the need for in-patient admission
MAPPING THE PATIENT PATHWAY
(before and during admission)
Historic Pathway
Same day / 23 hour stay
Diagnosis
Pre-admission
Diagnosis
Nurse-led preassessment
Surgeon
consent
Anaesthetic
review
In-patient admission
day 1 pre-op
Theatre
Post-op in-patient
stay 2-4 days
Breast CNS
Wound + drain care
Arm exercises
Doctor-led ward discharge
after drain removal
TTO’s
Drain removal
Pre-assessment clinic 1-2 weeks
before surgery
Pre- assessment
DSU nurse
Breast CNS
Discharge planning
Physiotherapist
Pre-admission
Consultant (consent)
Breast CNS
Pre-admission clinic the day
before surgery
DSU admission on the
day of surgery
Nurse-led same day or 23 hour
discharge
ENSURING PATIENT SAFETY FOLLOWING DISCHARGE
Results clinic, date for preassessment and surgery
Nurse-led pre-admission clinic.
Decision for same day / 23 hr
discharge based on DSU medical
and social criteria
Community nurse
home visit for
social assessment.
Documentation
faxed to KBC
Initial care pathway
developed with
community nurse
PCT leads
Pre-admission clinic day 1 pre-op
(consent, CNS review)
Admit to DSU for surgery
Same day: CNS-led discharge
23 hour stay CNS-led discharge
Post-discharge support.
CNS (9am-5pm Mon to Fri)
DSU senior nurse (5pm-9am) 24/7
bleep holder
Day 1 post-op
Community nurse
telephone follow-up
or home visit
(patient choice)
KING’S BREAST CARE POST DISCHARGE QUESTIONNAIRE
DEVELOPING THE AMBULATORY PATHWAY
•
There have been 3 phases in service development
March ’06
Same day discharge introduced
• Initially one half day list on alternate weeks
• 6 month audit
• 44% women used service
• Reasons for not using service
• Lack of DSU list (26%)
• Lack of overnight-stay facility (17%)
• No re-admissions for complications
• Women deferred surgery until DSU available
Nov ’06 - March ‘07
Commenced weekly all day list in DSU
Introduction of 23 hour stay
July ’07 – Jan ‘08
Qualitative focus group research with Breast Cancer
Care to assess patient and carer needs
•
At all times KBC co-ordinated continuity of care
KING’S BREAST CARE: DEVELOPMENT OF PATHWAY
FEEDBACK FROM FOCUS GROUP DISCUSSIONS
Results clinic, date for preassessment and surgery
Nurse-led pre-admission clinic.
Decision for same day / 23 hr
discharge based on DSU medical
and social criteria
Pre-admission clinic day 1 pre-op
(consent, CNS review)
Admit to DSU for surgery
Same day: CNS-led discharge
23 hour stay CNS-led discharge
Post-discharge support.
CNS (9am-5pm Mon to Fri)
DSU senior nurse (5pm-9am) 24/7
bleep holder
Community nurse
pre-operative home
visit
Patient focus
group
discussions
• More explicit postoperative information
wanted
• Dislike of community
nurse input - confusion
about who to contact with
post-op problems
Day 1 post-op
community nurse
telephone follow-up
/ home visit
POST-DISCHARGE SUPPORT CHANGED FOLLOWING FOCUS
GROUP FEEDBACK
Initial Care Pathway (March 2006)
Breast CNS
Monday to Friday (9 to 5)
Breast CNS
revised patient
post-operative
information
DSU senior nurse
Out of hours (5pm to 9am)
24/7 bleep holder
Community nurse
Day 1 post-op: standardised postoperative questionnaire (telephone
or home visit - patient choice)
Telephone
follow-up by
Breast CNS
Current Care Pathway
Patient emphasis on
Breast CNS support
Breast CNS
Monday to Friday (9 to 5)
Day 1 post-op: standardised postoperative questionnaire (telephone
or home visit - patient choice)
DSU senior nurse
Out of hours (5pm to 9am)
24/7 bleep holder
KING’S BREAST CARE: REVISED PATHWAY
The default position is that all
non-reconstructive breast
surgery can be done in DSU
Any change to this for medical
or social reasons is made at
the pre-assessment clinic
The only definitive contraindication is the surgical
procedure
Results clinic, date for pre-assessment
and surgery, Breast CNS present
Nurse-led pre-admission clinic
Decision for same day / 23 hr discharge
based on DSU medical and social criteria
Pre-admission clinic day 1 pre-op
(consent, CNS review)
Admit to DSU for surgery
Same day: CNS-led discharge
23 hour stay CNS-led discharge
Post-discharge support.
CNS (9am-5pm Mon to Fri) and
telephone questionnaire day 1 post-op
DSU nurse (5pm-9am) 24/7 bleep holder
FAQs ABOUT SAME DAY / 23 HOUR STAY AT KING’S
BREAST CARE
• ‘Your patients are different’
– No they’re not
• ‘It’s not safe to send patients home early’
– Yes it is
• ‘Patients need to be on a ward to bond with each other’
– ?????? Where’s the evidence
AMBULATORY SURGERY: ALL OPERABLE PATIENTS
ARE POTENTIALLY ELIGIBLE
NPI for symptomatic invasive breast cancer (% all ages KBC vs BCCOM)
All (KBC)
All (BCCOM)
34.1
29.3
26.2
24.4
19.5
14.2
18.6
16.6
13.4
3.7
EPG
GPG
Better prognosis
MPG1
MPG2
Worse prognosis
PPG
SAME DAY / 23 HOUR BREAST SURGERY MODEL:
OUTCOMES AT KBC
King’s Breast Care
• All non-reconstructive surgery is
now performed in DSU
•
Re-admission rates (March 06 –
end June ‘10)
– 1251 procedures
– 3.4% (N=43) patients required
re-admission for complications
• 2.8% (N=35) managed via
DSU and discharged the
same day
• 0.6% (N=8) in-patient
admission [median stay 3
(range 1-9) days]
Duration of stay: % patients
March 06 to March 07 Mean age 58 (2485) yrs
Jan 09 to June 10 Mean age 58 (30-91)
yrs
93.1
57.4
36.2
6.4 5.1
same day
overnight
1.8
> overnight
IS A SAME DAY/23 HOUR SURGERY MODEL FEASIBLE?
Yes
• With adequate patient and carer preparation
• If all stakeholders are involved
• Frees up hospital in-patient resource
• Can be done with or without wound drains
Key points
• DSU should be the default position for surgery
– In-patient admission should be the exception
– Discharge planning starts at pre-assessment
• Patient selection is based on medical co-morbidity and social support
• Clear, reliable anaesthetic / pre-assessment process pathway
Process / pathway mapping
• Must be patient focused
• Reduces variation in patient care and outcomes
• Get patient feedback
REDUCING LENGTH OF STAY FOR BREAST CANCER
SURGERY IS NOW A NATIONAL PRIORITY
The Cancer Reform Strategy (2007, 2010)
• Reducing length of stay for breast
surgery is a priority
– Improve quality of care
– Cost savings
– Will be an indicator / benchmark for
patients
– Promoted as best practice by GP
commissioning
•
National implementation supported by
the NHS Transforming In-patient Care
Programme
– Piloted in 13 cancer networks
PATIENT EXPERIENCE OF
AMBULATORY BREAST CANCER
SURGERY
Terri Baxter,
Breast CNS,
Kings College Hospital
Foundation Trust, London
PATIENT EXPERIENCE OF DAY SURGERY
• Reducing length of stay for breast cancer surgery has improved
continuity of care
• Having a pre-defined surgical pathway;
– Equity of access to all levels of support available for patients
– Identifies patients requiring specific input
• Enhances individualising patient care
• In-patient admission does not provide superior patient psychological
support
SAME DAY / 23 HOUR SURGERY HAS FOCUSED
SERVICE ON PATIENTS
Pre-admission clinic
(KBC)
Day 1 pre-op
Consultant, Breast CNS
Physiotherapist
DSU
Admit 7.30am OR 12.30pm on
day of surgery
Anaesthetist
Same nurses admit / recovery
Breast CNS-led discharge
Telephone follow-up
Day 1 post-discharge
Breast CNS
Can arrange for wound
check
Patient at
centre of
activity
Pre-assessment clinic
(KBC)
1 -2 weeks pre-op
Breast CNS
Pre-assessment nurse
Results clinic
1 week post-op
Wound check
Discuss further treatment
Physiotherapy review
WHAT DO PATIENTS AND CARERS THINK?
FOCUS GROUP FINDINGS
Patient support for day surgery
was unanimous
• All same day discharge patients
said they would have it again
• DSU provided an early
psychological boost
• Early discharge implies that
surgery is ‘minor’ but at odds with
the ‘serious’ diagnosis of breast
cancer
In-patient care was not deemed
to be superior
Unsuccessful at recruiting carers
for focus group discussions
• Telephone interviews with 2 carers
• Information about what to expect
after surgery important
WHAT DO PATIENTS AND CARERS THINK?
FOCUS GROUP FINDINGS
Information Needs
Care Delivery - Day Surgery
• Knowing what to expect after
discharge important in reducing
patient and carer anxiety
• Infection risk perceived to be less
• Continuity of DSU nursing staff
valued highly
• Important for carers to be at home
on the day of discharge and for a
few days afterwards
• Dislike of community nurse input –
preference for breast care team
Wound management
• Seroma
• Size, appearance, aspiration
unnecessary
• Wound drains
• Relief at not having a drain
• In-patients who had drains found
them inconvenient and
uncomfortable
Care Delivery – In-patient
admission
• Dissatisfaction with;
• Hospital environment
• Lack of continuity of nursing care
and specialist nursing care
NATIONAL CANCER PATIENT EXPERIENCE SURVEY PROGRAMME
DECEMBER 2010 - BREAST
Operations
Admission date not changed
Staff gave complete
explanation of what would be
done
Patient given written
information about the
operation
Staff explained how
operation had gone in
understandable way
KCH
National
KCH
National
KCH
National
KCH
National
96%
94%
83%
86%
82%
77%
69%
72%
Information given to you before you left hospital and home support
Given clear written
information about what
should / should not do post
discharge
Staff told patient who to
contact if worried post
discharge
Family definitely given all
information needed to help
care at home
Patient definitely given
enough care from health or
social services
KCH
National
KCH
National
KCH
National
KCH
National
90%
88%
94%
95%
60%
57%
-
-
Ward nurses
Got understandable answers
to important questions
all/most of the time
Patient had confidence and
trust in all ward nurses
Nurses did not talk in front of
patient as if they were not
there
Always/nearly always
enough nurses on duty
KCH
National
KCH
National
KCH
National
KCH
National
59%
74%
45%
66%
67%
86%
63%
62%
PREPARATION FOR SURGERY
In-patient admission
Same day / 23 hour discharge
• Need to confirm bed / ward
on day of admission
• No need for patient / relatives
to confirm bed / ward
• Discharge planning starts
when admitted
• Discharge planning starts at
the pre-assessment clinic
• Support during admission
• Ad hoc - is patient on ward
when CNS visits?
• Peer support?
• Patients still supported
• ‘Protected’ time pre and
postoperatively to see CNS
WHAT TO EXPECT IN HOSPITAL
In-patient admission
Same day / 23 hour discharge
• Potential for changes to ward
during admission
• Patient remains on the same
ward per and post op
• Lack of continuity of nursing
staff / doctors (shifts)
• Potential for conflicting
medical information and
inappropriate medical care
• Continuity of nursing staff and
doctors
• Experienced team
managing care for duration
of admission
• Hospital environment not
conducive to rest
• In home environment patient
has control
PLANNING RECOVERY
In-patient admission
Same day / 23 hour discharge
• Uncertainty over discharge
• Drains
• When is the ward round?
• When will TTO’s be
prescribed?
• Control over discharge
• No drains simplifies
management
• Breast CNS-led
• Pre-prescribed TTOs
• May adopt sick role
• Increased analgesia uptake
due to drug rounds
• Routine maintained
• Important for vulnerable pts
• Nuture not make
dependent
PATIENT EXPERIENCE OF DAY SURGERY
•
Reliability of service
– What you say happens will happen
•
Problems are pre-empted
– Patient trust in staff increases
– Enhances relationships with patients
•
CNS time management is improved
– Plan when to see patients
– Privacy and dignity of patients maintained
• Meet in the breast unit at mutually agreed times
• Patient, carers and CNS not waiting for each other on wards
HOW CARE CAN BE INDIVIDUALISED FURTHER
Pre-admission clinic
(KBC)
Day 1 pre-op
Consultant, Breast CNS
Physiotherapist
Pre-op PROM
● Information needs
DSU
Admit 7.30am OR 12.30pm on
day of surgery
Anaesthetist
Same nurses admit / recovery
Breast CNS-led discharge
Pre-assessment clinic
(KBC)
1 -2 weeks pre-op
Breast CNS
Pre-assessment nurse
Baseline assessment
● Social (FACE tool)
● Psychological
Patient at
centre of
activity
Telephone follow-up
Day 1 post-discharge
Breast CNS
Can arrange for wound
check
Results clinic
1 week post-op
Wound check
Discuss further treatment
Physiotherapy review
Wound assessment chart
Post-op PROM
●Information needs and
DSU experience
KING’S BREAST CARE
BREAST SURGERY SAME DAY/23 HOUR MODEL
When it works well
• Good communication
– Pre-assessment staff
– DSU
– Anaesthetics
– Breast care team
– Patient / carers
•
Patients with dementia and
learning difficulties
– No problems with, during or
following admission
When it doesn’t
• Poor communication
•
Cancellation on the day of surgery
due to deviation from normal preassessment pathway
– No cohesive review of patient
assessment
Received Pathway Returns
Primary Care - Optimising Pre Op Health
40
35
30
25
20
15
10
5
0
Blood pressure
BMI, diabetes etc
Lifestyle advice
Patient Choice
Patient Information
Pathway
RED = Not Started
AMBER = Work in Progress
GREEN = Implemented
BLUE = N/A
PROMOTING REDUCED LENGTH OF STAY FOR
BREAST CANCER SURGERY
Cancer Reform Strategy (CRS, 2007)
– Identified breast cancer surgery same day / 23 hour stay to be a priority
– Aim to improve:
• Effectiveness by reducing unnecessary length of stay
• Clinical outcomes
• Quality of care for patients - ensure experience of care is positive
The NHS Improvement Transforming Inpatient Care Programme
– Support the CRS implementation of same day / 23 hour surgery model
– Promote good clinical practice from:
• Transforming Inpatient Care Programme
• Enhanced Recovery Programme
BREAST SAME DAY/23 HOUR MODEL
THE ROLE OF THE NHS CANCER IMPROVEMENT TEAM
Transforming in-patient care
Cancer and QIPP priority (Quality,
Innovation, Productivity, Prevention)
Save 1 million bed days
Evidence, testing, spread
Enhanced recovery programme
Optimise;
Pre-operative assessment
Peri / post-operative management
Post-operative rehabilitation
King’s College Hospital - emphasis on same day discharge
Pan Birmingham Network - aim for 23 hour LOS
BREAST SURGERY SAME DAY/23 HOUR MODEL
King’s College Hospital
Pan Birmingham Cancer Network
• Non-reconstructive surgery on
one site (hospital trust)
• Non-reconstructive surgery at 6
hospital trusts
• DSU (7am-8pm Monday - Friday)
• Utilise in-patient theatre sessions
• Aim for same day discharge / 23
hour stay for >90% of nonreconstructive surgery
• Aim for standard LOS to be 23
hours for 80% of nonreconstructive surgery
• Facilitated by
• Not using wound drains
• Seromas not aspirated
• Patient demand
• Visited King’s
• Test replicality
• No routine use of drains or
routine seroma aspiration
• Commenced March 2006
• 2 trusts initiated pathway (2006)
BREAST SURGERY SAME DAY/23 HOUR MODEL
King’s Breast Care
Emphasis on same
day discharge
Pan-Birmingham Trust
Emphasis on 23 hour
stay
Different
resources
Both achieved
their aim
Process mapping
at both sites
enabled service
development
BREAST CANCER AT KING’S
Screen-detected cancers
• Screening uptake in Camberwell
is the lowest in the UK
• (62% vs 72%)
• Social deprivation
•
Tumour characteristics similar to
that expected from the national
BASO screening audit
– 25% node positive
– Mean grade
– Mean size
Symptomatic cancers
• 70% of cancers nationally present
symptomatically
• At KBC ~ 85%
•
~25% of women are inoperable at
presentation
– Co-morbidity
– Locally advanced / metastatic
disease
•
If patients have operable disease,
selection for ambulatory surgery
should be based on comorbidity
and social criteria
Enhanced Recovery Programme - Day Case/23 Hour Breast Pathway
Primary care –
optimising preoperative health
• Blood pressure
• BMI, diabetes etc.
• Lifestyle advice
• Patient choice
• Patient information
Pre-operative surgical assessment
(as soon as surgery is decided on)
• Full clinical and risk assessment
• Default booking as day case – overnight booking as
the exception not the rule
• Specialist advice… anaesthetic/co-morbidity management
• Obtain patient informed surgical consent
• Inform patient of admission time, length of
stay & discharge date
• Patient education: self management e.g. arm
mobility exercises - physiotherapist/nurse/ DVD
• Prosthesis advice/fitting
• Prescribe TTO’s
• Plan theatre scheduling and timing
Diagnosis (Triple Assessment Clinic)
• Full clinical assessment
• Mammogram/ultrasound/ +/-MRI +Chest X-ray
• Core/fine needle biopsy
• Bloods
• Discuss informed consent
• Pathology reporting
Outcomes
• Discuss results
• Involve patient in choice of treatments/trials/reconstruction
• Confirm treatment/surgery date
• Provide patient information prescription, hand held
record/care plan/patient diary
• Inform patient of next steps…pre-operative assessment
• Inform GP positive results within 24 hours/negative within
10 working days
Intra-operative
Surgical follow-up options
• Drains the exception not
the norm
• Anaesthetics: short acting/
local anaesthetic
• Analgesia: non
steroidal/non opiate
• Minimal intra operative
fluids
• *Sentinel node Biopsy
• Patient activated
e.g. telephone call
• Nurse follow up call
• Outpatients appointment
• GP follow-up
• Open Access: seromas/drain
management and complications
• Joint clinic: e.g.
further treatment options:
chemotherapy/radiotherapy
Admission ( Day Unit,
Treatment Centre, Surgical Ward)
• Admit day of surgery
• Starvation – the ‘2 and 6’ rule
fasting time 6 hours for food and
clear fluids 2 hours prior to surgery
(consider carbohydrate drink)
• No pre med
• Pre-op analgesia (paracetamol/
non steroidals)
‘Patient involvement & Choice Guarantee’
Post-operative
• Analgesia: avoid PCA/opiates
• Provide nutrition
• Nurse led discharge:
• Information: Patient discharge
summary with 24/7 contact
information and wound care
• GP discharge summary
• Drain management information
(if required)
• Fitting permanent prosthesis
• TTO’s
Continuing care for
cancer patients
• Continuing cancer
care assessment
care plan (including
referral as appropriate
to AHPs)
• Education – self
care management
programme
*Intra-operative -Sentinel Node Biopsy: In centres where adequate training has been
provided. Extra theatre time e.g. 40mins is required for this procedure
‘Professional & Patient Outcome Audits’
Patient informed decision making
AMBULATORY SURGERY: ALL OPERABLE PATIENTS
ARE POTENTIALLY ELIGIBLE
NPI - symptomatic invasive breast cancer at KBC
PreMP
PostMP
All
28
24
17
16
14
11
8
14
11
7
5
1
2
EPG
3
3
GPG
MPG1
MPG2
PPG
BREAST SURGERY SAME DAY/23 HOUR MODEL
The NHS Improvement-Transforming Inpatients Care Programme Workshops
• Where next?
– Template for breast same day / 23 hour model agreed
(based on Enhanced Recovery Programme)
– Prospective audit to monitor implementation at test sites (November
2010 to March 2011)
The Cancer Reform Strategy (2007, 2010)
• Reducing length of stay for breast surgery is a priority
– Has been recognised as offering potential for cost savings
– May become one of the published indicators / benchmarks for patients
– May be promoted as best practice by GP commissioning
BREAST SURGERY SAME DAY/23 HOUR MODEL
WHERE NEXT?
NHS Improvement-Transforming
Inpatients Care Programme
Workshops
Agreed template for model
Enhanced Recovery Programme)
Prospective audit to monitor
implementation at test sites
(November 2010 to March 2011)
The Cancer Reform Strategy –
Refresh
Length of stay for breast surgery
Recognised as offering cost savings
May become a benchmark of care
May be promoted as best practice by
GP commissioning
Reduced length of stay will happen
Develop a pathway that works for
for patients