Transcript Management of day surgery patients with high BMI

Assessment of obese
patients to facilitate day
case admission
Sister Sue Roberts – Pre-op nurse
practitioner
Dr James Palmer – consultant anaesthetist
Salford Royal Hospitals NHS Trust
Introduction
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Why change practice?
Audit
What could be changed?
Implementation
Effects of new process
Why change?
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Improve patient experience
Manage patients effectively
Meet day surgery targets
Meet 18 week pathway targets
Audit of Gynae Overnight stays
• One year’s data (2004-5)
• 27 ASA1 patients admitted with BMI >35
• 1 required additional analgesia, 1 had
vaginal pack, 2 had no social support.
• 5 went home same day (1 with BMI=46),
• 22 NO nursing/medical intervention required
overnight!
Population Audit of Obesity
• Health survey for England 2000-2002.
• Proportion of population with BMI >30
• National 21.4% (quoted as 21.8%
elsewhere from same source)
• Greater Manchester 21.1%
• Salford 22.1%
Audit figures at Salford Royal
Hospital
• 5.5% of daycases done have BMI ≥37.
• 6% of non daycase elective surgical patients
BMI>37
• Anaesthetic audit showed vast majority
feared:
– postoperative hypoxia in the obese
– OSA
• Some patients might benefit from referral for
sleep studies and possible home CPAP.
What are other NW trusts
doing?
• 2007 telephone/email
audit of all NW day
case units
• Questions:
– Do you have an upper
limit for BMI for day
surgery?
– What is it?
– Why has this figure been
chosen?
Results
45
40
35
30
25
20
15
10
5
0
Max BMI
MRI
UHSM
TGH
Hope
Bolton
Wigan
Bury
Rochdale
Oldham
NMGH
Tameside
Blackburn
S/H
Discussion points
• Choice of max BMI not evidence based
– Pennine acute
• Follow up for high BMI cases
– None declared
• Planned development
– None declared
• Active preassessment
– None declared
How to assess
• Consulted
respiratory team in
trust
• Developed process
for pre-op nurses to
follow
Process
ASA 1 with BMI >37
Baseline sitting SpO2
<95% not fit for DSU
>3% desturation
>95% do 2 minute step test
Refer for PSG
<3% desaturation complete
OSA questionnaire
Negative
ADMIT TO DSU
Improvement with CPAP
Positive PSG – referred for NCPAP training
Pre-op assessment clinic
• Generic clinic
• Qualified nurse
practitioners
• Pre-op support
workers
• Equipment
• In house sleep
studies referral
Implementation
• Step test
• Epworth score
• Sleep studies
how to refer?
?stop clock
Outcome
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Individualised patient process identified
Utilising day surgery more effectively
Increased patient satisfaction
No cancellations/AIRs
Day surgery staff report no problems
Thank you
Questions???