Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress...

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Evolution of Day Surgery & the Vision for ESAC Professor Doug McWhinnie, BADS

Transcript of Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress...

Page 1: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

Evolution of Day

Surgery & the Vision

for ESAC

Professor Doug McWhinnie, BADS

Page 2: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Evolution of Day Surgery in the UK:

A Vision for Surgical AmbulatoryEmergency Care

Doug McWhinniePast-President BADSPresident-Elect IAAS10 April 2019

Consultant General and Vascular SurgeonMilton Keynes University Hospital NHSFT

Page 3: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Historical Timeline

Page 4: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Father of Modern Day Surgery

• 1899-1908 reported on 8988 ops

• performed at the Sick Children’sHospital & Dispensary, Glasgow

BMJ 2:753, 1909

James H. Nicoll(1864–1921)

Page 5: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Page 6: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Ralph Waters

(1883–1979)

1919: The Down-Town Anesthesia

Clinic, Sioux City, USA

Page 7: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

USA: First Hospital Based Day Surgery Units

Opened in

1951: Grand Rapids, Michigan

1952: Los Angeles

Fiscal benefits drove the progress of ambulatory surgery

in the USA and Australia, in 50s, 60s and 70s

Page 8: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Little progress

British Medical Journal in 1948:

“Any surgeon who allows a patient to leave hospital within 14 days of an abdominal

operation (this would include hernia repair) would be in a difficult position

should complications occur”.

Page 9: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Day Case Inguinal Hernia 1955

458 Consecutive Day Case Inguinal Hernia RepairsFarquharson EL, Lancet

1955;ii:517-9Eric L Farquharson

Page 10: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Early UK Day Surgery

Late 1970s – early 1980s

– Pioneering enthusiasts

– Local developments

– No coordinated approach

– Medical & nursing establishment apathetic

Page 11: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Royal College of Surgeons

Published 1985

– revised 1992

Considered 50% elective

surgery as day case

achievable

Page 12: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

1989South MimmsServices

Page 13: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Audit CommissionBasket of Procedures 1990

Inguinal Hernia Repair

Excision Breast Lump

Anal Fissure Excision

Varicose Vein Surgery

Cystoscopy

Circumcision

Excision of Dupuytren’s Contracture

Carpal Tunnel Decompression

Arthroscopy

Excision of Ganglion

Cataract Extraction

Squint Correction

Myringotomy

Sub Mucus Resection

Reduction of Nasal Fractures

Bat Ear Correction

D&C

Laparoscopy+/- Sterilisation

Termination of Pregnancy

Orchidopexy

Page 14: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Audit Commission’s Basket of Procedures 2001

Cataract Extraction

Excision Breast Lump

Carpal Tunnel Decompression

Bat Ears

R/O Metalwork

Bunion Operations

Laparoscopy

Tonsillectomy

TURBT

Squint Correction

Orchidopexy

Anal Fissure

D&C / Hysteroscopy

Nasal Fractures

Myringotomy

Laparoscopic Cholecystectomy

Excision of Ganglion

Hernia Repair

Varicose Veins

Dupuytren’s Contracture

Haemorrhoidectomy

Circumcision

Arthroscopy

SMR

Termination of pregnancy

Page 15: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Government Initiatives

Page 16: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

75% Of Elective Surgery To Be Performed On A Day Case

Basis

White Paper, 2000

Alan Milburn 1999-2003

Page 17: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Why 75%

1967 - 40% Ministry of Health

1985 - 50% Royal College of Surgeons

1994 - 60% NHS Executive

2001 - 75% NHS Plan

Page 18: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Alan MilburnNHS Plan (2002)

Page 19: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Day Surgery Definition

“Day surgery is the admission of selected patients to hospital for a planned surgical procedure, returning home on the same day.

Day Surgery:Operational Guide. DoH,

London,2002

Page 20: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Government Initiatives

NHS Modernisation Agency

– 2002–5

– Clinical Champions

– BADS Collaboration

– Benchmarking exercise with other Trusts

Page 21: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

10 High Impact Changes

NHS Modernisation Agency, 2004

John Reid 2003-5

Page 22: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Service Improvement and Delivery

Top High Impact factor:

Treat day surgery (rather than in-patient surgery) as

the norm for elective surgery

NHS Modernisation

Agency, 2004

Page 23: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

To support improvement in systemic productivity and efficiency

Patricia Hewitt 2005-7

2006

Page 24: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Productivity IndicatorsSeptember 2006

Clinical productivity

Finance

Prescribing

Procurement

Workforce

www.productivity.nhs.uk

Page 25: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

A focus for the greatest productivity and efficiency gains

Reduce avoidable emergency admissionsReduce unnecessary outpatient appointments, follow-

ups & DNA’sAvoid unnecessary proceduresImprove day case performanceReduce wasted bed daysImprove the accuracy of clinical codingReduce variation in length of stayImprove staff productivityActively manage staff and recruitment costs

NHS Institute for Innovation & Improvement, 2006

Page 26: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

“Delivering a fair,

personalised,

effective and safer

NHS”

Lord Darzi , 2007

Alan Johnson 2007-9

Page 27: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

2009

Page 28: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

2009 DoH Enhanced Recovery Programme

Pre OperativeOptimise health Preassessment

Patient information

Patient expectation Discharge Planning

Intra OperativeMinimally invasive Regional anaesthesia

Goal directed fluid therapy

Post OperativePlanned mobilisation Regular analgesia

Avoid opiates Minimal drains

DischargePlanned Patient Information Follow up if required

Andy Burnham 2009-10

Page 29: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Quality Ambulatory Principles

Pre-assessment

Optimised Health

Patient information

Discharge Planning

Minimally invasive

Regional anaesthesia

Goal directed fluid therapy

Planned mobilisation

Regular analgesia

Avoid Opiates

Nurse Led Discharge

Discharge information

Follow up if required

Page 30: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Enhanced Recovery Programme

Page 31: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Payment by ResultsBADS/PbR Steering Group

2009

Inpatient > DC funding

No incentivisation

2010

Same tariff for DC and IP Best Practice tariff for DC laparoscopic cholecystectomy

Page 32: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

The Development of ‘Best Practice’ Tariff

Page 33: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Promoting Quality Day Care

Best Practice Tariff – Laparoscopic Cholecystectomy

2012/13 Daycase

tariff (£)

Elective spell

tariff (£)

GA10D Laparoscopic Cholecystectomy with length of stay 1 day or more without CC - 1,367

GA10E Laparoscopic Cholecystectomy with length of stay 0 days without CC 1,662 1,367

Planned as day caseDischarged day of surgery

Page 34: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery

Impact of Best Practice Tariff

0

10

20

30

40

50

60

70

80

2007 2008 2009

%Lap

Choleas

Day Case

2010

Best practice tariff

Howard, et al. J One-day Surg 21: 4, 2011

Page 35: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Liberating the NHS 2010

Information Revolution

Greater Choice & Control

Health and Social Care Act

Clinical Commissioning Groups

Andrew Lansley 2010-12

Page 36: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

4 hour A&E Wait18 week RTT Cancer Targets

remain….but forhow long?

Page 37: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

•CCG’s

•Failing Trusts

•Hospital Closure

•Trust Amalgamation

•Junior Doctors’ Strikes

•Care Quality CommissionJeremy Hunt 2012-18

Page 38: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Matt Hancock 2018 -

Page 39: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Lessons for Surgical Ambulatory Emergency Care

Page 40: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Is day surgery better than in-patient surgery ?

Not evidence based

re clinical outcomes

but…

Day Surgery is a

process not a

procedure

Page 41: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Day Surgery Definition

“Day surgery is the admission of selected patients to hospital for a planned surgical procedure, returning home on the same day.

Day Surgery:Operational Guide. DoH,

London,2002

Page 42: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Out-Patient Clinic

Selection Criteria

Preassessment

Admission

Operation

Recovery

Day Case Facility

Discharge

Follow-up

Pre-assessment

Pathway

Peri-operative

care

Post-operative

care

Page 43: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

• Unselected

• Unplanned

• Day or Night

Ambulatory Emergency Surgery

Page 44: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Emergency 12 hour post-operative pathwayEmergency Admission

Investigations and diagnosis

Preopassessment by anaesthetist

Discharge plan

Early Operation

No sepsis

Discharge on day of surgery

Page 45: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Ambulatory Emergency Surgery

Definition

“Ambulatory emergency surgery is the management of an emergency patient according to an ambulatory surgical pathway, avoiding overnight stay following their surgical procedure.”

International Association of Ambulatory Surgery May 2018

Page 46: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

Summary

• Long history of day surgery

• Government initiatives

• Ambulatory principles can be applied to emergency surgery

Page 47: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

BADS Booklets

Page 48: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk

BADS Directory 5th Edition (2016)

Page 49: Evolution of Day Surgery & the Vision for ESAC...British Association of Day Surgery Little progress British Medical Journal in 1948: “Any surgeon who allows a patient to leave hospital

British Association of Day Surgery www.bads.co.uk