principles of day case emergency general surgery · 2020-01-16 · - axillary, groin, neck,...
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Principles of Day Case Emergency General Surgery
Douglas McWhinniePresident IAAS
Past-President BADS
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Reorganise Emergency Surgery
• Consultant-Led
• Prioritise Emergency care over Elective care
• Timely input of senior decision-makers
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Admissions and Beds
Increasing PopulationLack of Social Care
Failure of Primary Care
Minimally Invasive Surgery Shorter Length of Stay
Day Surgery
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Traditional Model For Emergency Admissions
Discharge
Day 2 Day 3 +
Treatment
Minimum 2-night stay
Admission
Day 1
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Can we apply ambulatory principles to the emergency pathway?
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James H. Nicoll(1864–1921)
Father of Modern Day Surgery
British Medical Journal 1909;2:753.
8988 day case operations performed Sick Childrens’Hospital and Dispensary, Glasgow
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Day Surgery Definition
“Day surgery is the admission of selected patients to hospital for a plannedsurgical procedure, returning home on the same day.
Day Surgery:Operational Guide. DoH, London,2002
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Unselected
Unplanned
Day or Night
Ambulatory Emergency Surgery
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Selection Criteria
Preassessment
Admission
Operation
Day Unit
Same-Day Discharge
Pre-assessment
Pathway
Peri-operative
Care
Post-operative
Care
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Modern Timeline
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100 consecutive patients referred with superficial abscesses
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Day case group 33/46 (70%) Successfully treated as day cases
Day case group 19 nightsIn-patient group 86 nights
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• 48 patients with abscesses
• Unplanned overnight admission rate 5.5%
• Traditional pathway 5.7 times longer than day case
pathway
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Lessons from the Abscess Pathway
Personcentric
Prioritise first on list to allow same day discharge
Send patient home to be re-admitted electively
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Lessons from the Abscess Pathway
Personcentric
Prioritise first on list to allow same day discharge
Send patient home to be re-admitted electively
Can we utilise this management model to treat other acute surgical conditions?
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Hotchen AJ, Coleman G, O’Callaghan JM, McWhinnie D.British Journal of Hospital Medicine 2016; 77(3):180-183
Before After
Initial review (Mins) 29 18
Senior review (Mins) 85 55
Length of stay (Days) 5.2 2.9
Abscesses, Appendicectomies,Irreducible Herniae
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Lessons Learned
The management model can be extended to other procedures
BUT…….
A sustainable pathway requires :-
Senior decision-makers
Integration into the emergency pathway
Admission Avoidance
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Urgency of Surgery
Elective – Intervention planned or booked in advance of routine admission (planned)
Immediate – Immediate life, limb or organ-saving intervention (within minutes)
Urgent – Intervention for acute onset or deterioration of potential life-threatening conditions (within hours)
Expedited – Patient requiring early treatment where the condition is not an immediate threat to life (within days)
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Expedited ProceduresGeneral Surgery Trauma & Orthopaedics
Incision & Drainage of Abscess
- axillary, groin, neck, perianal, pilonidal
Laparoscopic Appendicectomy
Laparoscopic Cholecystectomy
Irreducible Herniae
- Inguinal, femoral, paraumbilical
Biopsy
- lymph node, temporal artery
Arthroscopy
Tendon Repair
K – wiring (finger or wrist)
Reduction & Internal Fixation
Evacuation RPC
Lap Ovarian Cystectomy
Gynaecology
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Triage Outcome
Four Month Pilot with Senior Decision-Maker
1028 Referrals with 377 (37%) on ESAC Pathway
266 of 377(69%) Avoided Admission
Royal Derby Hospital
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IntroducedThe Virtual ward
Miss Sarah RichardsNational Clinical Lead NHS Elect
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SAEC : Adopted by 33 Hospitals in UK
Cohort 1• Aintree University Hospital NHS FT• Barts Health NHS Trust• Royal Bournemouth and Christchurch
Hospitals NHS FT• Central Manchester NHS FT• Frimley Health NHS FT• Kingston Hospital NHS FT• Mid Cheshire Hospitals NHS FT• Norfolk and Norwich University Hospitals
NHS FT• St Helens and Knowsley Teaching Hospitals
NHS Trust• City Hospitals Sunderland NHS FT• Whittington Health NHS Trust• Wirral University Hospital NHS FT
Cohort 2• University Hospitals Coventry &
Warwickshire NHS Trust• Southern Health and Social Care Trust HSCNI• Dorset County Hospital NHS FT• King’s College Hospital NHS FT• University Hospitals of Leicester NHS Trust• West Suffolk Hospital NHS FT
Cohort 3• Bradford Teaching Hospitals NHS FT• East Kent University Hospitals NHS FT• Hampshire Hospitals NHS FT• Imperial College Healthcare NHS Trust• North Bristol NHS Trust• University Hospitals Bristol NHS FT
Cohort 4• Leeds Teaching Hospitals NHS Trust• Lewisham and Greenwich NHS Trust• Maidstone and Tunbridge Wells NHS Trust• Princess Alexandra Hospitals NHS Trust• Royal Surrey County Hospital NHS FT• Shrewsbury and Telford NHS Trust• South Tees Hospitals NHS FT• Southport and Ormskirk Hospital NHS Trust• The Royal Wolverhampton NHS Trust
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Reducing emergency admissions and length of stay by introducing emergency surgical ambulatory serviceKazem MA, Hopley C, Corless D.Ann Med Surg (Lond)2019 Jul; 43: 17–24
Leighton Hospital, Crewe
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Beware of Data
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Emergency General Surgery : Length of Stay
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Percentage of emergencies staying overnight
Number of occupied surgical beds at 01.00 hours
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Surgical Same-DayEmergency Care Pathway
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Traditional Model For Emergency Admissions
Discharge
Day 2 Day 3 +
Treatment
Minimum 2-night stay
Admission
Day 1
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Emergency Pathway Re-Design
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Emergency Pathway Re-DesignAdmissions/Assessment
+
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Default to Day Surgery
Can this emergency surgical patient be treated as a day case ?
Is there any reason this emergency surgical patient cannot be treated as a day case ?
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Admission Avoidance
Virtual Ward Concept
- patients wait at home, not in hospital
- called in when anoperating slot available
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Emergency Assessment
by Senior Decision-
Maker
Decision Operation
Complex Inpatient
Expedited Planned AS
Virtual Ward
Dedicated Diagnostics
Operative AmbulatoryEmergency Pathway
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Planned Ambulatory Emergency SurgeryExpedited Procedures
Exclude :
< 18 years
Systemic sepsis before temporary discharge
Patients with diabetes
Patients with major co-morbidities
Ensure adequate oral analgesia / antibiotics
Proposed surgery is suitable for day case
Patient Selection
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Planned Ambulatory Emergency PathwayExpedited emergency procedure required
Pre-operative assessment by clinical team
Temporary discharge to home
Admitted to ‘Virtual Ward’
Coordinator contacts patient regarding
fasting and time/place of admission
Expedited emergency procedure performed as
scheduled
Patient discharged on day of surgery
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Where are the Ambulatory Emergency Theatre Slots ?
CEPOD list
- First on list (‘Golden Patient’)
- Between major cases
Ambulatory list
- First on list
Look for cancellations
- Lists
- Individual patients
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Ambulatory Appendicectomyin Adults
International Journal of Surgery 12 (2014) 640-644
13 Studies : 8 Retrospective, 2 Prospective, 1 case-controlled1152 patients
Discharged within :12 hours – 27%24 hours – 53%72 hours – 20%
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Acute Cholecystectomy
The ‘Golden 72 hours’
Gutt CN et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial. Ann Surg. 2013 Sep;258(3):385-93
Cao AM, Eslick GD, Cox MR. Early laparoscopic cholecystectomy is superior to delayed acute cholecystitis: a meta-analysis of case-control studies. Surg Endoscopy 2016;30(3):1172-82.
Complication RateBile Duct InjuryOperation TimeHospital Stay
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Emergency Assessment
by Senior Decision-
Maker
Decision Hot Clinic
Treat & Discharge
Virtual Ward
Dedicated Diagnostics
Non-Operative Ambulatory
Emergency Pathway Operation
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Ambulatory Hot Clinic Conditions
Watch and Wait
Early discharge (‘safety net’)
Wound problems
Postoperative complications
Stable PR bleed
Painful jaundice
and so on………….
Patient Selection
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Selection Criteria
Preassessment
Admission
Operation
Day Unit
Same-Day Discharge
Pre-assessment
Pathway
Peri-operative
Care
Post-operative
Care
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