SP3.1.9 Building the ‘LIEGS’ way – The development and delivery of ambulatory surgical services in the busiest acute surgical unit in the UK

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Adam Peckham-Cooper ◽  
Andrea Giorga ◽  
Nasira Amtul ◽  
Aman Ahmad ◽  
Giles Toogood ◽  
...  
Keyword(s):  
Primary Care ◽  
Decision Making ◽  
Surgical Care ◽  
Day Case ◽  
Emergency General Surgery ◽  
Alternative Pathways ◽  
Rapid Access ◽  
Acute Surgery ◽  
Patient Pathways ◽  
The Uk

Abstract Background Managing unplanned surgical care presents enormous challenges to trusts and continues to be resource intensive. Significant patient numbers can be managed in novel ways preventing admission with effective triage to alternative flow streams using outpatient/ambulatory models. Leeds Institute of Emergency General Surgery (LIEGS) reports its early experience. Methods Patients requiring assessment or admission from primary care are triaged directly by a consultant. GP’s are offered advice or patients are directed to appropriate assessment/triage pathways. A number of alternative pathways exist depending on pathology and patient demographics. Prospective data for all patients referred are captured and retrospective analysis of outcomes collected. We report our experience from October-November 2020. Results Consultant triage and early senior decision-making has streamlined patient pathways and flow. 51%(237) of all GP referrals(465) were assessed primarily in ASC, 8%(36) required advice only and 10%(44) were directed to other specialities. 30%(139) were seen on the Surgical Assessment Unit ward representing a reduction of 70% compared to the previous year. Outcomes from those patients seen in ASC were discharge after imaging (87,18.7%), discharge without imaging (74,15.9%), hospital admission (65,14%), acute operation (63,13.5%), referral to other specialty (64,13.8%) and Rapid Access Theatre for day case operation (32,6.9%). Conclusion 71.7% of all acute surgery primary care referrals were managed on in an ambulatory fashion providing an invaluable resource. Early senior decision making, a one-stop clinic for investigations and day case Rapid Access Theatre (RAT) lists can significantly improve the patient pathways and experience.

scholarly journals UK Health Care Workers' Experiences of Major System Change in Elective Surgery during the COVID-19 Pandemic: Reflections on Rapid Service Adaptation

2021 ◽  
Author(s):  
Georgina Singleton ◽  
Anna Dowrick ◽  
Louisa Manby ◽  
Harrison Fillmore ◽  
Aron Syversen ◽  
...  
Keyword(s):  
Decision Making ◽  
Elective Surgery ◽  
Rapid Change ◽  
Surgical Care ◽  
Systems Change ◽  
System Level ◽  
Framework Analysis ◽  
Surgical Services ◽  
The Uk ◽  
Service Adaptation

Background The COVID-19 pandemic disrupted the delivery of elective surgery in the UK. The majority of planned surgery was cancelled or postponed in March 2020 for the duration of the first wave of the pandemic. We investigated the experiences of staff responsible for delivering rapid changes to surgical services during the first wave of the pandemic in the UK, with the aim of developing lessons for future major systems change. Methods Using a rapid qualitative study design, we conducted 25 interviews with frontline surgical staff during the first wave of the pandemic. We also carried out a policy review of the guidance developed for those delivering surgical services in pandemic conditions. We used framework analysis to organise and interpret findings. Results Staff discussed positive and negative experiences of rapid service organisation. Clinician-led decision making, the flexibility of individual staff and teams, and the opportunity to innovate service design were all seen as positive contributors to success in service adaptation. The negative aspects of rapid change were inconsistent guidance from national government and medical bodies, top-down decisions about when to cancel and restart surgery, the challenges of delivering emergency surgical care safely and the complexity of prioritising surgical cases when services re-started. Conclusion Success in the rapid reorganisation of elective surgical services can be attributed to the flexibility and adaptability of staff. However, there was an absence of involvement of staff in wider system-level pandemic decision-making and competing guidance from national bodies. Involving staff in decisions about the organisation and delivery of major systems change is essential for the sustainability of change processes.

scholarly journals Introduction of a Day-Case Laparoscopic Cholecystectomy Service in the UK: A Critical Analysis of Factors Influencing Same-Day Discharge and Contact with Primary Care Providers

2009 ◽  
Vol 91 (7) ◽  
pp. 583-590 ◽  
Author(s):  
CD Briggs ◽  
GB Irving ◽  
CD Mann ◽  
A Cresswell ◽  
L Englert ◽  
...  
Keyword(s):  
Primary Care ◽  
Laparoscopic Cholecystectomy ◽  
Healthcare Providers ◽  
Operation Time ◽  
Primary Care Providers ◽  
Care Providers ◽  
Day Case ◽  
Factors Influencing ◽  
Same Day Discharge ◽  
The Uk

INTRODUCTION The objective of this study was to determine the safety and acceptability of the implementation of a day-case laparoscopic cholecystectomy (LC) service in a large UK teaching hospital, and analyse factors influencing contact with primary care providers. Wide-spread introduction of day-case LC in the UK is a major target of healthcare providers. However, few centres have reported their experience. In the US, out-patient surgery for LC has been reported, though many groups have utilised 24-h observation units to facilitate discharge. Concerns remain amongst surgeons regarding the feasibility and acceptability of the introduction of day-case LC in the UK. PATIENTS AND METHODS Comprehensive care and operative data were prospectively collected on the first 106 consecutive day-case procedures in our hospital. Postoperative recovery was monitored by telephone questionnaire on days 2, 5 and 14, including complications, satisfaction and general practitioner consultation. RESULTS A total of 106 patients were admitted for day-case LC, of whom 84% were discharged on the day of surgery. Patient satisfaction rate was 94% in both the successful day-case and the admitted patients. Mean operation time was 62 min, with an average total stay on the day-care unit of 426 min. Training-grade surgeons performed 31% of operations. Both the re-admission rate after surgery and rate of conversion to open surgery were 2%. Advice from primary healthcare providers was sought by 33% of patients within the first 14 postoperative days. CONCLUSIONS Introduction of day-case LC in the UK is feasible and acceptable to patients. The potential burden to primary care providers needs further study.

scholarly journals EP.FRI.472Building the ‘LIEGS’ way – Establishing an ambulatory Rapid Access Theatre Service for those patients with acute surgical pathology requiring operative management

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Nasira Amtul ◽  
Aman Ahmad ◽  
Lindsay Mutyavaviri ◽  
Adam Peckham-Cooper ◽  
Giles Toogood ◽  
...  
Keyword(s):  
Wait Time ◽  
Database Systems ◽  
Operative Management ◽  
Day Case ◽  
Rapid Access ◽  
Early Results ◽  
Patient Database ◽  
Biliary Pathology ◽  
Operating List ◽  
The Uk

Abstract Aim LTHT is the largest acute surgical unit in the UK and has seen an annual 11% increase in attendances with often 90 patients assessed daily. 40% patients present with acute biliary pathology but despite this there has been no dedicated operating list for this cohort of patients. Rapid Access Theatre (RAT) lists were created to manage these patients. We report our early results. Method In October 2020 the trust appointed four EGS Consultants forming a dedicated acute general surgical service. Emphasis was placed on creating ambulatory pathways and those patients safe to be managed at home but requiring surgical intervention are placed on a day case RAT list. COVID-19 has restricted the broad use of this service for all emergency admissions but biliary pathology continues to be amenable to these pathways. Data was collected retrospectively using in-house coding and electronic patient database systems.   Results 34 day case laparoscopic cholecystectomies were performed in the first 10 weeks. Mean age was 44(17-67) with a male:female ratio of 1:1. Mean wait time from clinical review to theatre was 11(3-23) days. 1 patient required overnight admission but there were no readmissions and no reported complications at 30 days.   Conclusion Despite isolation restrictions resulting from COVID-19, the service has allowed patients to be assessed and treated in a timely, safe fashion. The new service has resulted in significant reductions in bed stays and improved patient experiences. Financial savings have been clearly delineated and as such expansion of the model is underway.

scholarly journals Clinical decision making in a high-risk primary care environment: a qualitative study in the UK

BMJ Open ◽  
2012 ◽  
Vol 2 (1) ◽  
pp. e000414 ◽  
Author(s):  
John Balla ◽  
Carl Heneghan ◽  
Matthew Thompson ◽  
Margaret Balla
Keyword(s):  
Primary Care ◽  
Decision Making ◽  
High Risk ◽  
Qualitative Study ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Care Environment ◽  
The Uk

scholarly journals P-EGS09 The Introduction of an Ambulatory Surgical Pathway

2021 ◽  
Vol 108 (Supplement_9) ◽  
Author(s):  
Joshua Wall ◽  
Katie Boag ◽  
Mikolaj Kowal ◽  
Tobias Plotkin ◽  
Rachel Maguire ◽  
...  
Keyword(s):  
Primary Care ◽  
General Surgery ◽  
Similar Proportion ◽  
Control Group ◽  
Emergency General Surgery ◽  
Telephone Advice ◽  
Assessment Unit ◽  
The Uk ◽  
Surgical Pathway ◽  
Hospital Acquired

Abstract Background Since the publication of the Emergency General Surgery Commissioning Guide by ASGBI in 2014, there has been a drive to develop ambulatory pathways for acute surgical patients, saving inpatient stays and reducing the risk of hospital-acquired infections. Many units, like ours, had a large workload increased by seeing next day returns as well as acute presentations. In October 2020 an Institute of Emergency General Surgery was formed who developed an ambulatory pathway to ameliorate some of these issues and provide a point of contact for primary care referrals, for one the busiest emergency general surgical takes in the UK. Methods A retrospective analysis was undertaken to identify all acute referrals to general surgery over a 14-day period in February 2019 prior to (Pre-ASC) and 2021 after (Post-ASC) the introduction of an Ambulatory Surgical Clinic (ASC). All patient episodes were reviewed, and descriptive statistics on overall attendance to the surgical assessment unit (SAU), admissions to inpatient wards and referrals to ASC were analysed. Patients presenting to the acute urology take were used as a control to compare the number patients attending the surgical assessment unit both before and during the COVID-19 pandemic. Results 830 patients presented over the 28-day study period (426 pre-ACS vs 404 post-ACS; 5% reduction), totalling 992 patient encounters including planned returns (525 vs 467; 11% reduction). After the introduction of the ASC total attendance to SAU was reduced by 42% (525 vs 306); next day return attendances were reduced by 87% (99 vs 13) and attendances from primary care were reduced by 68% (208 vs 67). The proportion of patients admitted was similar (46% vs 50%). 146 patients attended the ASC, and 15 patients received telephone advice alone. The control group saw attendance increase by 25% (178 vs 223). Conclusions The results clearly show that the introduction of the ASC has decreased attendance to SAU, freeing clinicians to dedicate more time to those acutely unwell. The similar proportion of admissions after the introduction of the ASC suggests that the ambulatory pathway correctly identifies those who are well enough to be managed as outpatients. The increased attendance in the control group suggests that the data were not the results of a decrease in referrals due to COVID-19. The results shared here should encourage other large units to consider developing ambulatory pathways.

Bilateral varicose vein surgery in the UK

2006 ◽  
Vol 21 (1) ◽  
pp. 12-15 ◽  
Author(s):  
K Overbeck ◽  
D Zubrzycka ◽  
G Stansby
Keyword(s):  
Decision Making ◽  
Health Economic ◽  
Great Britain ◽  
Varicose Veins ◽  
Postal Questionnaire ◽  
Day Case ◽  
Varicose Vein Surgery ◽  
Economic Implications ◽  
The Uk ◽  
Significant Health

Objective: To assess the views of surgeons in the UK concerning the surgical management of patients with bilateral varicose veins (BVV) requiring surgery. Methods: A postal questionnaire was sent to members of the Vascular Society of Great Britain and Ireland. Questions concerned the use of BVV surgery in general, its use on day-case patients and which factors influenced decision-making in this area. Results: In all, 63% of surgeons never or only occasionally performed BVV surgery as a day case, whereas only 27% never or only occasionally performed BVV surgery on inpatients. The majority (70.2%) were not influenced by patient age or occupation (81.9%). The patient's general health was, however, a factor in decision-making for the majority (60.1%), as was the extent of the varicosities (52.8%). Other important factors were the availability of a second surgeon and a perception that there was likely to be increased morbidity with BVV surgery. Conclusions: There appears to be considerable variation between individual surgeons in the UK with regard to BVV surgery. This is manifested mainly as a reluctance to perform BVV as a day case by a significant number of surgeons. As there is no randomized trial(s) in this area, no firm guidance can be given. The issue is worthy of further study and may have significant health economic implications.

scholarly journals TP9.2.25No beds! Developing ambulatory surgical care in a District General Hospital

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Rola Salem ◽  
Richard Hayes ◽  
Kirk Bowling ◽  
Helen Whitmore ◽  
Cait Bleakley ◽  
...  
Keyword(s):  
Decision Making ◽  
Patient Experience ◽  
Average Length ◽  
Initial Period ◽  
Surgical Care ◽  
District General Hospital ◽  
Emergency Team ◽  
Acute Surgery ◽  
Number Of Patients ◽  
The Impact

Abstract Aims Referrals to acute surgery are increasing by 10% a year with no increase in inpatient bed numbers. Our aims are to improve the patient experience with early review and provide early decision making preventing admission to hospital. In August 2019 we launched our ambulatory surgical service, in order to measure the impact we have reviewed every patient that has come through the service from its inception. Methods The service is manned by two dedicated surgical fellows based in an ambulatory unit with dedicated early morning USS slots available. To compare old with new we collated presentations into categories, for example ‘Right upper quadrant pain’ and compared the number of patients ‘ambulated’ to the average length of stay for patients with these presentations before ambulatory care. Results From August to October a total of 180 patients were ambulated via the new service. Using the comparison described this equated to approximately 423.05 ‘bed days’ saved the three-month initial period. Discharge times were spread throughout the day rather than ‘peaking’ with emergency team handover indicating an improved experience this has been backed up by qualitative reports from patients and families. Conclusion The introduction of the ambulatory service has improved the general surgical on-call experience at our hospital both for patients and clinicians alike, whilst decreasing surgical bed occupation. Utilising existing resources we have improved the patient experience, enabled quicker decision making and taken pressure away from the on-call.

How multidisciplinary are multidisciplinary case reviews in cancer care? Feasibility analysis of a theory-driven team decision-making fidelity framework

2019 ◽  
Author(s):  
Tayana Soukup ◽  
Ged Murtagh ◽  
Ben W Lamb ◽  
James Green ◽  
Nick Sevdalis
Keyword(s):  
Decision Making ◽  
Cancer Care ◽  
Recent Decade ◽  
Individual Case ◽  
Multidisciplinary Teams ◽  
Final Decision ◽  
Political Climate ◽  
Implementation Framework ◽  
Feasibility Evaluation ◽  
The Uk

Background Multidisciplinary teams (MDTs) are a standard cancer care policy in many countries worldwide. Despite an increase in research in a recent decade on MDTs and their care planning meetings, the implementation of MDT-driven decision-making (fidelity) remains unstudied. We report a feasibility evaluation of a novel method for assessing cancer MDT decision-making fidelity. We used an observational protocol to assess (1) the degree to which MDTs adhere to the stages of group decision-making as per the ‘Orientation-Discussion-Decision-Implementation’ framework, and (2) the degree of multidisciplinarity underpinning individual case reviews in the meetings. MethodsThis is a prospective observational study. Breast, colorectal and gynaecological cancer MDTs in the Greater London and Derbyshire (United Kingdom) areas were video recorded over 12-weekly meetings encompassing 822 case reviews. Data were coded and analysed using frequency counts.Results Eight interaction formats during case reviews were identified. case reviews were not always multi-disciplinary: only 8% of overall reviews involved all five clinical disciplines present, and 38% included four of five. The majority of case reviews (i.e. 54%) took place between two (25%) or three (29%) disciplines only. Surgeons (83%) and oncologists (8%) most consistently engaged in all stages of decision-making. While all patients put forward for MDT review were actually reviewed, a small percentage of them (4%) either bypassed the orientation (case presentation) and went straight into discussing the patient, or they did not articulate the final decision to the entire team (8%). Conclusions Assessing fidelity of MDT decision-making at the point of their weekly meetings is feasible. We found that despite being a set policy, case reviews are not entirely MDT-driven. We discuss implications in relation to the current eco-political climate, and the quality and safety of care. Our findings are in line with the current national initiatives in the UK on streamlining MDT meetings, and could help decide how to re-organise them to be most efficient.

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