BADS / CO-OPERATION AND WORKING TOGETHER ......Dr Cathy Armstrong F.F.A.R.C.S.I. Anaesthetic Lead...
Transcript of BADS / CO-OPERATION AND WORKING TOGETHER ......Dr Cathy Armstrong F.F.A.R.C.S.I. Anaesthetic Lead...
Dr Cathy Armstrong F.F.A.R.C.S.I.
Anaesthetic Lead CAWT DS Project
Member BADS (IRE)
Consultant Anaesthetist
BADS / CO-OPERATION AND WORKING TOGETHER
(CAWT)
IMPROVING DAY SURGERY IN BORDER REGION
HISTORY- DAY SURGERY
Over last decade in UK
elective surgical procedures performed as day cases have
increased from 55% to over 70%
Short stay surgery has also gained momentum
Drivers for change
Government /NHS planning
Public demand
Facilitators of successful change
Multidisciplinary approach
BRITISH ASSOCIATION OF DAY SURGERY
UK , day surgery defined as
Admission of patient to hospital that is planned as a day case procedure and patient successfully returns home on the
SAME CALANDER DAY
Typical stay is 6-8hrs
Extended opening times 12 -14hrs (8am-9)
THE BEGINNING-1ST
James Henderson Nicoll ,Glasgow
1898-1908 -- 9000- day of surgery discharge/children
½cases under 3yo
1st published BMJ 1909 ‘Surgery of Infancy’ 50y
? Motivation---radical practice
shortfall beds
high levels cross infection
financial considerations over 100yrs ago
??Sounds familiar??
HX
During 1900 s slow to embrace—UK
1916 USA 1st Day case clinic in Iowa
1940s early mobilisation post surgery
1955 Eric Farquharson ,Edinburgh
Lancet , series 458 consecutive hernia repairs performed on a day
case basis
1969 First free-standing Ambulatory Surgical Centre
opens in Arizona
PRE-BADS
• 1969 Prof. James Calnan, Hammersmith,London
converted army hut and installed it in car park of
Hammersmith hospital
10,000 pts treatred in first 10 years
• 1969 First dedicated day unit opened UK 10y
DAY SURGERY UK
By 1970/80 there were sufficient numbers of proactive
units with good results to encourage the RCS to publish a
report
‘Guidelines for Day Case Surgery’ in 1985
PERI-BADS 1985 RCS suggest
50% target for elective surgical procedures to be performed as day cases.(national aver 15%)
1989 British Association of Day Surgery formed-like minded
Dr. Paul Jarrett Prof Day Surgery, Kingston Hospital, London
1991 Audit commission publish ‘Basket of 25’
1995 BADS joined IAAS International
Association
Ambulatory
Surgery
11 countries promoting Day Surgery Worldwide
ASM 2 DAY CONFERENCE
BADS 24 YRS DRIVING CHANGE PUBLICATIONS
*Journal of One Day Surgery—published every Quarter
*Web site for patients, managers, clinicians.
Plus a discussion room for members.
BADS
2006 First Directory of Procedures published
??? Offers indicative percentages for length of stay for over 200
individual surgical procedures for day, 23 hr or short stay (up to 72 hrs)
2012 Forth edition Directory of Procedures published
2012 e-directory of Procedures
• Electronic assessment tool
to enable units to assess
and record performance
against those procedure
rates in BADS directory
E DIRECTORY
DIRECTORY OF PROCEDURES
ACHIEVABLE ASPIRATIONAL RATES
RESOURCES BOOKLETS *A number of Guideline booklets covering all aspects of
Day/short stay procedures. From, operational
management, pre-operative assessment through to Nurse
Led Discharge
COLLABORATIVE WORKS
RESOURCES-TEXTBOOK 2012
BADS TEXTBOOK
ADVISORY ROLE
Has been involved with government and
D of H (UK) advisory role and as experts in driving enhanced
recovery in UK.
Instrumental in incorporating day surgery into surgical/anaesthesia curriculum.
Day case principle is the ultimate in enhanced recovery
MAIN RESOURCE---MEMBERS
Regular Guest Speakers at
AAGBI WSM
ESA AGM
ASA WSM
IAAS AGM
BADS
Goal: Promotion of health and
wellbeing of all members of the E U
EUROPEAN HEALTH CARE
STRATEGY
EUROPEAN HEALTH CARE STRATEGY
EU COMMISSION
E U Health Strategy, ratified by Maastricht treaty 1991
Interregional funding * secured *
Special subdivision , cross border division
Main goal is to ‘deliver universal health care through EU to all EU citizens.
in any border region , between any member states, to guarantee
equal access to quality care
CAWT –ROLE AND REMIT
The Cross border health and social care BODY is CAWT
Established 1992- Ballyconnell Agreement
CAWT structures: Management Board,
Secretariat,
Project Boards
Strategy Groups,
Development Centre
CAWT PARTNERS
• Northern Ireland
– Southern Health and Social Care Trust
– Western Health and Social Care Trust
– Health and Social Care Board
– Public Health Agency
–
• Republic of Ireland
– Health Service Executive West - border counties
– Health Service Executive Dublin North East - border counties
EU FUNDING
CAWT(CAWT- CROSS BORDER HEALTH AND SOCIAL CARE PARTNERSHIP)
CAWT --- Co-operation and working together
1996-2000 Eu Special Support programme for
peace and reconciliation
2002-2008 EU interreg111A -£6.74 million
Peace11 £ 1.08million
2009-2014 EU interreg1Va (12) £90 million
£2.7billn ewide
2014--2020 EU interreg £100 million
‘Putting Patients, Clients and Families First’
THE CAWT PARTNERSHIP
• Co-operation and Working Together
• Over 50 cross border projects implemented with EU funding to date
• EU INTERREG IVA funding
• 12 large scale projects to be
completed by 2013
• ‘Putting Patients, Clients
and Families First’
EUROPEAN HEALTH STRATEGY
• Since 1993, Ireland, EU members have had access to
• Peace fund 188million euro
• Intereg (IV) 256 million euro Health/CAWT in this section
Population of 1.6 million
Accounts for about 25%
Of total area of Island of Ireland
Similar
demographics ,age,health,illness
Infrastructures, dist to specl centres
CAWT TERRITORY OF IRELAND
CAWT REGION IRELAND
RATIONALE FOR CAWT
1.6 million residents sharing
Common demographic
Similar health status
Work/across two jurisdictions:
Goal Maximise value for money
Reduce duplication of scarce resources
equipment/people
Funding for procedures for Public Patients
DAY SURGERY AND CAWT
Using BADS Support and resource's,
enabled me to approach the
CAWT partnership ,
with
Day Surgery project idea.
CAPACITY
Available? Theatre Capacity (vacant)
Could Erne accommodate a pilot?
??? MATH: 15%(3w)--42.5%/month(9w) unused o r sesn/week £££££££
£10/min-£2,400 session
£600/hr x 24hrs = £14,400/day
£7,200--£21,600/week! Av loss £14,000/m
ACUTE SERVICES-ERNE
This Day Surgery pilot project encompassed 3 strands:
--- Using Local Surgical Skills—
Ear, Nose and Throat
Urology (including Uro-gynae)
Vascular
project worth €9 million in EU funding
EU INTERREG IVA PROJECTS (2009 – 2014)
‘PUTTING PATIENTS, CLIENTS & FAMILIES FIRST’
Acute Hospital Services - £5,874,164
Sexual Health Services / GUM clinics - £1,742,141
Development of Eating Disorder Services - £2,582,540 ‘Time IVA Change’ – Border Region Alcohol Project - £1,632,341 ‘Turning the Curve’ – Autism Support Project - £1,332,554 Improving Outcomes for Children and Families - £670,794
Support for Older People - £1,899,453
‘UP4IT!’ - Preventing and Managing Obesity - £971,852
‘Citizenship’ - Support for People with a Disability - £2,259,258 Tackling Social Exclusion and Health Inequalities - £1,904,662
Tackling Diabetes in High Risk Clients - £2,313,575 Cross border Workforce Mobility - £816,665
ORGANISATIONAL ISSUES
‘Variation is enemy of quality’
Used BADS guidance
TEAM WORK
Patient Focused process
To make patient journey as easy and as
un-disruptive as possible.
Lead surgeon Lead anaesthetist
Lead manager -DSU ,WL staff
Secretarial, Nursing staff,
Local Ownership – will to succeed!
PROCESS -PATIENT JOURNEY
Selection to After Care-3 STOPS First Surgical Appointment sent with
pre-op assessment questionnaire. (www.bads.co.uk)
1.Combined surgical (+consent/scans.)
+-pre-operative assessment clinics, (+investig) in DPU
Consultant run, all patients seen and walk around unit to familiarize for admission --------------- op date set
2.Admission,procedure, discharge.
3.Follow up surgical appointment date-- on discharge.
PRE-OPERATIVE ASSESSMENT-START Information two way process
Patient is informed to understand their role
In day surgery process
Hospital informed to treat the patient efficiently
• Patient Preparation
• Fully informed of their role AND what
to expect post op(wc)
• Fasting
• PONV
• Anxiolysis(p/c)
• Carer o/n
• escort home/phone
• Hospital Preparation
• Medical info,
• Co morbidities optimisation
• prescribed drug -
• Referrals—specialist/gp(cvs)
• Investigations
• Airway assessment
PRE-OPERATIVE ASSESSMENT 2 WAY
PROCESS TO GAIN INFORMATION
WHO SUITABLE?
Inclusion criteria----Expanding!
Physiological functional status+ proposed surgery
Setting of unit , stand alone(default) or acute hosp site
**Exclusion criteria-- -no transport
---no carer
---no phone
---high risk/unstable
PRE-OPERATIVE ASSESSMENT
Time for Optimisation, or exclusion
Protocol Driven-
co-morbidities stabilised (referral to specialist or GP)
Formation of ‘short notice, patients list for cancellations
VTE prophylaxis, VTE ,Reducing the risk NICE Jan 2010
Diabetic patient HbA1C<8%
MRSA decolonisation,
antibiotic cover, PPI
Anti-platelet medication, omits am of surgery
Priority on list schedule
Pregnancy test am of surgery
BENEFITS OF PRE ASSESSMENT • Reduction of cancellations on D of S
• Reduction in DNA on D of S
• Reduction in unplanned admissions
• Increase in theatre time utilisation-reduce delays
• Increased patient satisfaction
• Reduction in patient/carer anxiety with admission, treatment, after
care
• Empowers patient> confidence in care
D ‘S
Distance NO LIMIT - 5MINS-2 HRS top Donegal
<1mile—100 miles
Duration of surgery No Limit 40mins—160 mins
INTRA OPERATIVE-ANAESTHESIA
• Anaesthetic agents (S/D-TIVA)
• Anti-emetics (www.bads.co.uk)
• Analgesia NSAIDS+ (pre-emtive NSAID)
• Hydration
• Antibiotics
• VTE prophylaxis NICE 2010 VTE: reducing the risk
• O2/AIR
normothermia(T=>36C) NICE 2008 Perioperative Hypothermia
L.A. use
Minimal morphine ( 3xponv)
‘ Variation is the enemy of quality’
PONV *** RISK FACTORS ***
PATIENT RISK FACTORS SURGICAL
Female Laparoscopic surgery
Non smoker Oral or ENT surgery
Hx Motion sickness or PONV Squint surgery
Peri-operative opioids
LOW RISK INTERMEDIATE RISK HIGH RISK
0 or 1 risk factor 2or3 risk factors >3 risk factors
General measures Gen Measures + Gen Measures+
Fluids (20ml/kg) 5HT3 antagonist 5HT3 antagonist
pre-emtive
non-opioid or and
analgesics Dexamethasone(4-8mg) Dexamethasone(4-8mg)
www.bads.co.uk
PONV
Persistent PONV
cyclizine 50 mgs +/-
Prochlorperazine12.5mgs
+20mls/kg i.v. over 30 mins NaCl 0.9% to correct Hypovolaemia
Self limiting-------admission if risk of dehydration,
distance v long
RECOVERY
• PONV-- UNPLANNED ADMISSIONS
********* PERI-OP OPIATES *********
• Stage one Recovery
I.V. Fentanyl (25ug bolus) q 2mins up to max 100ug
> anaesthetist
York Health Service ,I Jackson, 2006
www.bads.co.uk
POST OPERATIVE
• TTA PARACETAMOL
co-ccodamol 8/500-+laxative (senna)
ibuprofen 800 or diclofenac 50,ppi
odansetron 4mg sl
AFTER CARE
• LOCAL CONTACT NOS -Emerg - local hospital CAWT
• OUR CONTACT NOS - anytime- anaesthetist on call
• DAY 1 follow up phone call---- case anaesthetist
• POST OP CLINIC DATE on discharge
DISCHARGE
Nurse led
CAPITAL EQUIPMENT INVESTMENT
Letterkenny 600,000 euro—urology
Sligo 160,000 euro--urology
Enniskillen 110,000 euro—vascular
Craigavon 160,000 euro—ENT
€1,030,000 until 2011
NEW STAFF EMPLOYED
LETTERKENNY- 1C,3 nchd,1 nurse (U)
ENNISKILLEN- 4 nurse, 2s.local C
CRAIGAVON- 2 C, 4 nurse 3nchd
MONAGHAN- 2 C , local staff
• Vascular
• Urology
(incl urogynae)
• ENT
Opthalmology
• PROJECTED TOTAL
COMPLETED TOTAL
634 patients treated
2116
10,620
1036
6700 patients
14,417 patients
(216%)
SO FAR…
First All Ireland Day Surgery Conference
Farmleigh, Dublin 2010
CONFERENCE DAY SURGERY (FUNDED)
SUMMARY
• Day and short stay surgery –Priority North+South
Efficiency***saving
Financial***saving
incorporating best practice advancements in anaesthetic/surgical techniques
Change in practice, outside ‘comfort zone’
Team approach vital
•
FUTURE
Developed strong networks for overcoming challenges of service delivery
cross border
.
• Broaden case mix DS
• Secured funding for:
• Nurse preop assessment training course
• Dr. AE Bourke
• Day Surgery Conference October 2013
FUTURE
Exciting opportunity for everyone
in health care provision
Next round interreg funding to include recruitment and retention
Especially now, $$ tight
FUTURE
Day surgery, better care, safer care
RAF
‘ Knowledge eliminates fear’
‘If you live in the past,
while in the present,
you have no future’
CO-OPERATION AND WORKING TOGETHER
(CAWT):
INFO
British Association of Day Surgery
35-43 Lincoln’s Inn Fields, London,WC2A3PE
www.bads.co.uk
CAWT
CAWT Development Centre,
Riverview House,Abercorn Road,Londonderry, BT486SB