Anaesthesia, Perioperative Medicine and Day Case Delivery

Anaesthesia, Perioperative Medicine

and

Day Case Delivery

1

Chris Snowden Freeman Hospital Newcastle

National GIRFT Clinical Lead APOM

North GIRFT Clinical Amabassador

South East Day Case Delivery

13th July 2021

“They (Anaesthetists) must bestir themselves now, go into the

wards, and take their share of preoperative and postoperative

treatment of their patients”

“Having broken the circle confining their art within the narrow

limits of the operating theatre, anaesthetics will take its rightful

place alongside other specialities”

Definitions…..

• Anaesthesia is keeping the patient still (unconscious or pain free) for the surgeon to operate (and other skills)

• Perioperative Medicine is concerned with the patient pathway delivery, from the contemplation of surgery through to recovery and follow up

• Multidisciplinary and Multispecialty

• “Anaesthetists” are key stakeholders

Surgical Recovery Demand

Total England (May 2021)5.3 Million Waiting

336,000 patients (>52 wks)c.60% Surgical Cases

0

10,000

20,000

30,000

40,000

50,000

60,000

Jan-2

0

Feb-

20

Mar

-20

Apr-20

May

-20

Jun-

20

Jul-2

0

Aug-20

Sep-

20

Oct-2

0

Nov-20

Dec-2

0

Jan-2

1

Feb-

21

Mar

-21

Sou

th E

ast

pat

ien

ts w

aiti

ng

Total South East - all incompletes >52 wks

South East England %*

433,557

Balancing Recovery

“Harm Minimisation” vs

Preventing Harm

Case Prioritisation

Independent Sector Use

Health Inequalities and Equity “SMARTER”

RESET

Existing Capacity

New Builds

“Sweat the Assets”

Recovery Fund

Elective Surgical Reset

Principles

• Specialty Driven “Standardisation”

• System Level Approach

• Best Practice Sharing

• Metrics/benchmarking

Higher Volume, Lower Complexity

Specialty Based Procedures

1. How to perform high volume elective surgery safely ?

Speciality Specific procedures

Urology • Bladder outflow obstruction• Bladder tumour resection• Cystoscopy Plus• Minor peno-scrotal surgery• Uteroscopy and stent management

Gynaecology • Diagnostic laparoscopy• Endometrial ablation• Hysteroscopy• Laparoscopic hysterectomy• Vaginal hysterectomy

Spines • Lumbar decompression/discectomy• Cervical spine decompression/fusion• Medical branch/facet joint injections• Lumbar nerve root blocks/therapeutic epidurals• One or 2 level posterior lumbar fusion

Speciality Specific procedures

Orthopaedics • Anterior cruciate ligament reconstruction• Therapeutic shoulder arthroscopy• Total hip replacement• Total Knee replacement• Uni Knee replacement• Bunions

Ophthalmology • Cataract

General Surgery • Laparoscopic cholecystectomy• Inguinal hernia• Paraumbilical hernia

ENT • Tonsillectomy• Nasal Airway Surgery • Myringoplasty• Endoscopic sinus surgery

Cross-Specialty High Volume Procedures

Procedural Standardisation

• “What goes right” (Safety 2)

• Endorsed/Agreed by • Colleges• Clinicians

• Reduces variation

• Scope for Innovation

• Discussion Best Practice

Best Practice Sharing

Information is available for HVLC procedures including:

• GIRFT Gateways (metrics & standards)• GIRFT clinical metrics• RTT waiting times• BADS day case rates• Theatre data

GIRFT is currently developing information to support the specific

HVLC pathways including:

• Monthly Metrics • Rolling (12 month) Trends • Procedure code groups• Pathway metrics• GIRFT standards

Model Hospital System - HVLC

Lower Complexity/Comorbidity Commissioners

• establish prehabilitation services helping them to ‘wait well’ for surgery.

• provide surgery schools to support patients preparing for major surgery

• expand perioperative services to support for patients on waiting lists for surgery

NHS X

• bridge the Primary - secondary care interface access to primary care notes

Primary care providers, surgeons, anaesthetists and multidisciplinary teams

• Shared Decision Making (SDM)• Referrals detailing significant medical comorbidities

Preoperative assessment services • screening and self-assessment health questionnaire• formal preoperative assessment before the day of admission • impact of comorbid conditions on functional capacity, perioperative pathways and outcome • cognitive impairment, psychological distress, malnutrition using validated tools

Surgeons, anaesthetists and perioperative multidisciplinary teams • Objective individualised risk assessment • Avoid surgery for 7 weeks after COVID-19 infection • Advise on improving fitness before surgery including surgery school


Higher Volume, Lower Complexity (and Comorbidity)


DOSA 2. Is there any advantage in admitting a surgical patient into a

hospital bed, pre-operatively

Cancellations


2b. or post-operativelyDay

Case

Day Case Surgery

• 1985 & 92 • RCS: “Provision of Surgical Services”:

• Commission on Day Case Services

• Guidelines for Day Case Surgery: Aim - 50%

• 1989: • British Association of Day Surgery (BADS) founded

2006 2007 2009 2012 2015 2019

Day Case Delivery - Where were we ?

65.0%

66.0%

67.0%

68.0%

69.0%

70.0%

71.0%

72.0%

73.0%

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

FY2014-15 FY2015-16 FY2016-17 FY2017-18 FY2018-19 FY2019-20

% Elective + Daycase Surgical Admissions (selected by Abbott methodology) Recorded as Daycase

DC Admissions EL Admissions % DC

75% 2023/4

% Day case/ Elective Admissions

58.1%

22.8%

19.1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Surgical

Daycase Elective Emergency

In Patient 28 %

Surgical Admissions

DAY CASE 72%

Emergency

Day Case Delivery - Where were we ?

65.0%

66.0%

67.0%

68.0%

69.0%

70.0%

71.0%

72.0%

73.0%

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

FY2014-15 FY2015-16 FY2016-17 FY2017-18 FY2018-19 FY2019-20

% Elective + Daycase Surgical Admissions (selected by Abbott methodology) Recorded as Daycase

DC Admissions EL Admissions % DC

75% 2023/4

% Day case/ Elective Admissions

58.1%

22.8%

19.1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Surgical

Daycase Elective Emergency

In Patient 28 %

Surgical Admissions

DAY CASE 72%

Emergency

Top Decile = 78 %

Median = 72 %

43%

88%

Anterior Cruciate Day Case

Day Case Failure: Pre-COVID

Best Performing

System

Best Performing Systems in

Region

Benchmarking GIRFT Top Decile (5%)

Day Case to IP

ConversionRates

Benchmarking Region Median

(6.5%)

Ham

psh

ire

Surr

ey

Ken

t

Bu

cks

Frim

ley

Suss

ex

COVID Impact on Perioperative Pathways

Elective Care Both 40% reduction Demand Ratio 4:1

COVID Recovery Day Case

Day Case Rates (Change from Pre-COVID Baseline)

20/6/21

Han

ts

Surr

ey

Ken

t

Bu

cks

Frim

ley

Suss

ex

Day Case Re-emergence

- 8%

20/6/21

GIRFT Report: Day Surgery Default

Ensure that day

case surgery is

the default for

all suitable

elective surgical

procedures.

• Ensure patients are made aware in primary care at

time of referral for possible surgery that their

procedure is likely to be conducted as a day case.

• Confirm or establish a dedicated preoperative

assessment and preparation process for the day case

surgery pathway.

• Ensure there is an appropriate trust infrastructure to

deliver effective day case surgery.

• Confirm or appoint an effective trust day case

management team that includes clinical and nursing

leads, an operational manager and a named executive

trust board member responsible for the provision of day

surgery.

• Educate all trust staff in the importance of promoting

day surgery (over inpatient surgery), to ensure

consistent messaging to patients and families.

• Separate day case surgery pathways from inpatient

emergency medical and surgical pathways, to ensure the

continuation of day case surgery during surge

conditions.

• Develop generic and procedure-specific day case

guidelines and pathways, consistent with GIRFT surgical

pathways.

• Develop emergency ambulatory surgical pathways.

BARRIERS

• Infrastructure

• Day Case “Culture”

• Change “Resistance”

Barriers/Facilitators to Day Case Delivery

• Definition of Day Case

• Staffing and Leadership

• Learning from successful units

• Best Practice Sharing

• Day surgery facilities

• Using Digital technology

• Hospital Surge Escalation

• Emergency Ambulatory Surgery

FACILITATORS

Day Case Process

Source: BADS, Centre for Perioperative Care, GIRFT, National Day Surgery Delivery Pack.


Higher Volume, Lower Complexity (and Comorbidity)


DOSA 2a. Is there any advantage in admitting a surgical patient into

a hospital bed, pre-operativelyCancellations

2b. or post-operativelyDay

Case

3. Does hospital admission, outweigh the potential risk of

infection and patient outcome

Elective Pathway Redesign


Hub is responsible

Host is responsible

Patient Selection /

Decision to treat

Patient added to waiting list

Surgery booked

Surgery completed Discharge

Primary care assessment

Referral

Post op follow up

Pre-op assessment

Surgical assessment Admission

3. Generic Standardised PAC & Consistent Cultural

Emphasis for Day Case

2. Consistent WL Prioritisation and

Management

5. StandardisedDischarge and follow up

Recovery

4. Efficient Elective Process

including HVLC & Day Case Process

1. Appropriate & Collaborative ICS

Referral

Perioperative System RedesignHigh Volume, Low

Complexity Specialty Based

Procedures(Including Day

Case)

In-Hospital Cataract Pathway

Pathway

• Referral / Assessment

• Patient Selection / POA

• Booking / Listing

• Admission

• Surgery

• Post-op

• Follow-up / Discharge

Preassessment • No routine blood tests

• BP 180/110 and below is OK. Use community measurements

• If on warfarin check yellow book INR results (preop and on day of surgery)

• BM for blood sugar available. Test if unwell or poor glycaemic control;

• Below 4 mmol/L give a sugary drink

• If high, then seek healthcare team advice to avoid cancellation

Intraoperative • No anaesthetist in theatre and may or may not be

on site

• Cardiac arrest trolley in theatre complex and

checked daily

• ILS or ALS trained theatre team

• Defined pathway for medical advice/patient

transfer to ED

Postoperative

• Nurse led discharge

• Patient discharge information sheet with a

telephone contact

• Discharge summary for GP on the day of surgery

Preoperative • Preassessment (ophthalmology) is primarily nurse and

surgeon led

• Referral pathway for;

• anaesthesia and perioperative medicine advice for hub

patients

• anaesthesia and perioperative medicine review at local

trust for patients not suitable for hub cataract surgery

(and on going cataract surgery plan)

Perioperative Team Input

NHSE/I Pathway Improvement Programs

End to End using Digital transformationCovers all Care settings Inequalities and prevention Capacity and Demand benefits

Initial focus on agreed surgical pathwaysMainly hospital based Better quality, experience and productivity Creates increased capacity

% Day Case

GIRFT Report: Reliable Metrics

Ensure that day

case surgery is

the default for

all suitable

elective surgical

procedures.

• Ensure patients are made aware in primary care at

time of referral for possible surgery that their

procedure is likely to be conducted as a day case.

• Confirm or establish a dedicated preoperative

assessment and preparation process for the day case

surgery pathway.

• Ensure there is an appropriate trust infrastructure to

deliver effective day case surgery.

• Confirm or appoint an effective trust day case

management team that includes clinical and nursing

leads, an operational manager and a named executive

trust board member responsible for the provision of day

surgery.

• Educate all trust staff in the importance of promoting

day surgery (over inpatient surgery), to ensure

consistent messaging to patients and families.

• Separate day case surgery pathways from inpatient

emergency medical and surgical pathways, to ensure the

continuation of day case surgery during surge

conditions.

• Develop generic and procedure-specific day case

guidelines and pathways, consistent with GIRFT surgical

pathways.

• Develop emergency ambulatory surgical pathways.

Ensure that

metrics are

appropriately

recorded and

monitored

using

available tools

to inform

successful day

case delivery.

• Ensure day case surgery is coded as a surgical

procedure

• Record when day case patients have converted to

inpatients and the reason for that conversion.

• Review day case metrics monthly.

• Disseminate data on successful day surgery,

cancellations on the day of surgery and unplanned

admissions to all staff involved in the day surgery

pathway.

• Benchmark day case success rates using British

Association of Day Surgery (BADS) and Model Hospital

metrics. Integrated Care Systems (ICSs) to benchmark

provider trusts as part of a Quality and Efficiency

dashboard.

• Conduct follow-up for all day case patients with a next-

day telephone call to audit postoperative pain, nausea

and vomiting, patient satisfaction and patient feedback.

• Provide all day case surgical patients with a telephone

contact number for postoperative advice.

• Ensure Sustainability and Transformation Partnerships

(STP)/ICS assume a leadership role* where required, to

ensure that day surgery becomes the default option

unless an inpatient stay is unavoidable. (*Trusts to

retain responsibility for the delivery of day-to-day

services.)

Day Case Metrics (BADS)

Presentation title

Benchmarking Success

Speciality Procedures

GIRFT Rates

BADS

Recommends

% Case Deficit

(Opportunity)

Breast All (without reconstruction) 64 (55–72) 95 31ENT Tonsillectomy (Adult) 75 (65–88) 90 15

General Primary inguinal hernia 76 (70–82) 90 14Minor anal operations 94 (92–96) 95 1

Orthopaedic Anterior cruciate repair 61 (33–78) 90 29All arthroscopies 91 (77–98) 95 4

Gynae Anterior/posterior repair 3 (0–13) 60 57Eyes Vitrectomy 97 (92–99) 98 1

Urology TURBT 13 (8–27) 60 47TURP 3 (2–10) 15 12

Endocrine Hemithyroidectomy 4 (0–8) 30 26

Success is based on leadership, engagement, evidence and communication

• Constantly corrected course guided by the evidence (and

anecdote) e.g. hubs.

• Gathering staff and patient feedback is central to our learning;

this has not yet been systematised but would transform

thinking.

• Collecting real-time data on hub activity is very challenging,

yet is critical to decision making.

• Embed within existing information gathering and reporting

mechanisms: more data returns are not the answer

• Recognise the inequalities that our systems inherently

promote. Establishing standard protocols and a single PTL has

helped remove unnecessary variation.

• Agree key principles, “why” and outcomes up front:

constantly remind each-other of your purpose.

• Many concepts are new, or mean different things to different

people. Define these early (e.g. hubs)

• Daily (and then twice weekly) 15-minute video calls with all

32 Leaders to keep them informed and get feedback.

• Ensure everyone (from national teams to front line) is

connected through consistent messaging. In particular, it

must be made crystal clear that we all own the problem and

realise fundamental reform is required.

• Embed a dedicated comms expert part of team, draw on

expertise in CCGs, CSUs, etc.

• Recovery is used to develop our nascent ICSs and redefine

the region’s role.

• Bottom-up engagement needed for the adoption of

pathways. Local clinical and operational managers need

support, guidance and capacity (give them permission to stop

doing other things)

• “Middle” engagement at system level is critical. System

leaders need to let local teams act, but then need to quickly

resolve issues escalated to them. They need to be skilled at

having difficult conversations

• Engagement by regional level is critical. Be clear that you are

in a supportive, not performance management role.

• Clinical leadership is key: start by building on and

strengthening existing clinical networks. Link local clinical

leadership with GIRFT

• Appoint existing senior leaders (e.g. CEOs) who have credibility

and a track record of success. Make it clear that they own the

outcome and then give autonomy.

• Senior Delivery support which links to existing governance.

• Regional leadership should focus on setting up the right team,

defining the purpose / outcome and then clearing away

barriers (e.g. finance).

• Work at pace. Use the symbolism and spirit from what Critical

Care has achieved.

Summary

• Recovery Urgency – 60% Elective Surgery

• Reset – Work Together, Harder and Smarter

• HVLC/Day Case Delivery – Remove ‘Bread and Butter’ Culture

• Standardisation/Innovation of Surgical Procedures

• Integrated into Perioperative System - Culture, PAC, Discharge

• Data-driven Improvements in Outcomes

• Long Term Resilience - through Sustained Improvement Pathways

Anaesthesia, Perioperative Medicine and Day Case Delivery

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