Transcript The separation of upper and lower GI surgery

Reconfiguration of GI Surgery in
Edinburgh
Malcolm Dunlop
Academic Coloproctology & Colon Cancer Genetics Group
University of Edinburgh & Western General Hospital
Drivers for change
Better outcomes for patients managed by specialist service
Increasing emergencies and need for specialist cover
Imperative of on-call rotas (training grade and consultant)
Need for intra-specialty cover of complex elective surgery
Requirement for team working
Avoidance of duplication of manpower and hardware resource
Improved training opportunity
Benefits of critical mass
Specialism leads to de-skilling
Aug 2002 - Reconfiguration of surgical services
Coloproctology Unit - WGH
Upper GI and Hepatobiliary Units - RIE
Referral to specialty service
Emergency and elective
Elective
GP’s informed throughout service reconfiguration
Referrals encouraged to be sent to relevant service
Referral protocols established
Inappropriate referrals redirected by OP managers
Emergency
Admission and transfer protocols established
A/E (RIE) and MIU (WGH) triage
City-wide “bed bureau” referral system for GP
Ambulance triage
In-hospital emergencies managed by consultant
communication
Audit of emergency admissions
Source and appropriateness of referrals
Initial versus final diagnosis
Operative procedures undertaken
Impact of transfers
D Elson et al
4 month prospective audit
1831 emergency surgical admissions audited
Prospective data on 1794 admissions (97.9%)
Diagnosis Categories
Upper
RUQ pain/surgical jaundice, PPU, oesophago-gastric
disorders, pancreatitis
Lower
LBO, LIF pain, fresh rectal bleed, perianal abscess
General
Appx, symptomatic hernia/obstruction, NSAP, adhesive SBO
Trauma
Final Diagnosis and Hospital
50%
Percentage of Admissions
RIE
WGH
40%
30%
20%
10%
0%
Upper GI
Lower GI
General
Diagnostic Category
Trauma
Inter-Hospital Transfers
OCT
NOV
DEC
JAN
RIE  WGH
23
24
29
22
WGH  RIE
8
7
5
3
NRIE  WGH
1
2
0
2
TOTAL
32
33
34
27
Final diagnosis of transferred patients
RIE
 WGH
RIE to
WGH
Colon - diverticulitis
Colon - other
Anal - abscess
Anal - other
Abscess - thigh
Appendix
Hernia
Stoma dysfunction
Gynae
Gastric - gastroenteritis
Small bowel obstruction
AAA
Post op problem
NSAP
Total
n
23
24
20
3
1
3
3
1
4
1
3
1
2
9
98
WGH
 RIE
WGH
to RIE
Oesophagus - cancer
Gastric
Pancreatitis
Cholecystitis
Jaundice
Bacterial peritonitis
NSAP
Not Known
Orthopaedic
AAA
n
1
4
5
5
1
1
2
1
1
2
23
Operations performed
140
Numbers
120
100
80
60
40
20
0
RIE
WGH
Refinement of diagnosis
Initial (%) 1st Surgical (%)
Final (%)
RIE
Upper
Lower
General
Trauma
352 (37.8)
25 (2.7)
428 (46.0)
126 (13.5)
354 (38)
43 (4.6)
409 (44)
125 (13.4)
300
47
459
125
WGH
Upper
Lower
General
73 (8.5)
338 (39.2)
452 (52.4)
115 (13.3)
429 (49.7)
319 (37.0)
107 (12.7)
416 (48.2)
340 (39.4)
(32.2)
(5.0)
(49.3)
(13.4)
Conclusion
Reconfiguration of GI surgery on two sites feasible
Iminent provision of pan-Lothian (SE Scotland) CP Service (pop 900K-1.3m)
No major impact on patient transfers
Majority of patients treated by appropriate sub-specialists
Consultant coloproctology rota radically improved
Outcomes improved
Analysis of mortality/morbidity and stoma rate underway