Increasing access or improving mortality in endoscopy – the acute versus elective debate
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Transcript of Increasing access or improving mortality in endoscopy – the acute versus elective debate
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Increasing access or
improving mortality
in endoscopy – the acute
versus elective
debate
Dr Riaz DorConsultant Gastroenterologist
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Endoscopy Demand
Continues to increase• Aging population• Target procedures• JAG requirements• Surveillance procedures• Colonoscopy > UGI Endoscopy• CRC screening• Future?
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Drivers for change
• 18 week pathway• Waiting list management• Capacity• Patient satisfaction
• OOH GIB
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OOH GIB
• Current practice• BSG UGIB Audit (2007)• Pt safety• Mortality higher at weekends• denovo presentations vs IP (mortality
almost twice)• Juniors/ Seniors concerns• Ad hoc service at weekend
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Ironing out the creases - 1
Operational management
• Referral guidelines
• Vetting
• Validation of surveillance
• Scheduling
• Escalation policy
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Ironing out the creases - 2
Data collection/ Planning
• DNAs
• Share information
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Ironing out the creases - 3
Managing Capacity/demand
• Proactive vs reactive
• Regular review
• Colonoscopy Preassessment
• Optimise existing capacity/'dropped lists'
• Timings audit
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Ironing out the creases - 4
Review variation• Procedures
Patient engagement• PB vs FB
• DNA reduction
• Satisfaction
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Drivers for change NMUH
• AMU working• Consultant weekend working• WLI expense• Limited physical space• ‘The right time’
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Options
• Optimise current lists• 8- 9am lists• Evening lists• Weekend lists• More WLI• More rooms• More endoscopists
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WLI
• Efficient• Throughput• Popular• Case selection• Demand management• Ad hoc vs continuous• Costly
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Weekend working??!??
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Benefits
• Safer• Improve M&M• Help capacity – inpatient and outpatient• Commisioners• ‘GIB Distress Syndrome’• ? LoS
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What did we do?
• Job planned• 5 gastro• 5: 8 weekends• Planned working• Reduction in AMU working• ACU low risk GIB
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Weekend plan
0900 –0915 handover0915 –1030 6 elective points1030 –1200
Sat SunGIB GIBElective IP InreachTCI elective IP
'
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Examples
• PEG tubes• GI bleeds• Enteral Tube feeding• Post procedure problems• ? ERCPs
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Experience
• Very positive• Rewarding• Relief from other teams• Sunday in reach service v popular• Not too onerous• Buy in from colleagues• ?others
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Has it made any difference ?
• All GIB bleeders scoped within 24 hours• No overnight calls• LoS reduced by 1.8 days• No excess in mortality• Capacity vs WLI• Monday morning calmer • Happier teams
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Challenges
• Nursing Rotas• Porters• Planning of lists• Case selection• Too popular !• Remaining 3 weekends
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Success
What it should look like.
Success
What it really looks like
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Thank You
Any questions?