The Cardiff Shine Project: Outpatient operative hysteroscopy with conventional re-useable equipment under local anaesthetic

Transcription

1 The Cardiff Shine Project: Outpatient operative hysteroscopy with conventional re-useable equipment under local anaesthetic Cardiff and Vale University Health Board Gynaecology Dept Richard Penketh Cardiff Shine Team AAGL November 2011

2 The Shine Approach: LA in outpatient clinic Patients Comfortable environment No GA reduced risk of complications Increased convenience Short recovery time More involvement Resource use Release theatre resources No admission costs No cancellations due to list overrun Decreased staffing requirements Staff satisfaction

3 Technical Method Pre-emptive analgesia (diclofenac + paracetemol) 4 amp lignospan cervical block Cervical dilatation (8 or 10 mm) Glycine 1.5% gravity fed Resection of pathology (75W cut 50W coag) Polyp forceps for tissue removal Reinsert scope until complete Patient Experience Arrive 1 hour prior to procedure start (consent and baseline BP/pulse) Walk into procedure room, remove clothing below waist, sheet for modesty, lie on couch Supported by vocal local Pain scores measured during procedure Walk to rest area / cup of tea Follow up assessment at 1 week (Cedar) Notified with histopathology results at 2 weeks (Nurse Practitioner)

4 Cardiff Shine Hysteroscopy Project- Documentation

5 Cardiff Shine Hysteroscopy Project- Drapes

6 Cardiff Shine Hysteroscopy Project- Documentation

7 Cardiff Shine Project: Statistics Mean age = 56.5 (range 35-85) 55% scope, 45% scan Number of patients referred to Shine clinic = not suitable 16 diagnostic scope only Number of attempts = 122 Successful procedures = 110 (90%) 6 women cervix not visualised 3 failed at cervix 3 failed at resectoscope stage Failure of resection = 3/118 (2.5%) No serious procedure complications 1 latex allergy

8 Cardiff Shine Project: Data collection Peri-operative data collection Nursing staff recorded the following information: 7-day follow-up data collection Independent assessment centre carried out phone interviews: Arrival / discharge times Procedure start / end Pain at each stage of procedure Volume of glycine in/out Analgesia Acceptability of environment Preparedness / information Overall pain Concerns / anxieties Recommend procedure?

9 Number of patients Results: Glycine deficit Mean volume of glycine used was 2,475 ml 81% of pts = no glycine deficit 2 patients had >200 ml deficit Glycine deficit at procedure end (mls) Minimal glycine deficit in Shine patients

10 Results: Pathology removed

11 Number of Patients Number of Patients Number of Patients Results: Length of time in Shine clinic >120 Time (minutes) >60 Time (minutes) >=45 Time (minutes) Pre-operative stay Length of procedure Post-operative stay Mean = 79.0 mins Mean = 30.3 mins Mean = 29.1 mins

12 Results: intra-procedure pain scores Pain scores recorded during each stage of procedure by nursing staff (VAS score 1 to 10) Mean pain scores <3 at each stage Overall pain = 3.5 * Many patients were discharged before 30 minutes resulting in low number of patient responses

13 Results: 7-day follow-up Overall pain score (mean 3.6) Was the environment acceptable? Yes 99.1% Did you feel supported by the person sitting with you? Yes 99.1% Did any part of the procedure cause you concern? No 90.6% Would recommend procedure to a friend/relative? Yes 91.5%

14 Cardiff Shine Project: Clinical Summary Cervix dilated to 10 mm under LA in outpatients Pathology resected safely High patient acceptability - low pain scores Procedure times less than GA - less disruption for woman Very low absorption of glycine (max 400ml) Large volumes of tissue removed (up to 7g)

15 Cost analysis: Results Outpatients Reuseable (Shine) Daycase (GA) Daycase (LA) Outpatients (Disposable) Staff and hospital admittance , Single Use Equipment Reusable Equipment Drugs TOTAL (per procedure) Saving offered by Shine (per procedure) $ $ $438 Shine approach is cost saving compared to 3 alternative scenarios

16 Cost analysis: Wider implications If 150 cases moved from GA to outpatients = saving of - 96,000 $154, survey 39,597 procedures 90% done under GA If 25% moved to outpatients = saving of - 6 million $10 million

17 Cardiff Shine Hysteroscopy Project: Main Conclusions Improved patient pathway Release of precious theatre resources Insert Photo of Shine team here Potential to achieve significant savings Motivated, satisfied staff team Now need to spread the message Workshop at BSGE Cardiff 2012

18 The Team and Support Funded by The Health Foundation Shine Award 2010 Gynaecology, Cardiff & Vale UHB Richard Penketh, Consultant Liz Bruen, Gynaecology Nurse Practitioner Sarah Hill, Senior Staff Nurse Asmita Patwardhan, Consultant Mr Peter Lindsay, Consultant Mr Anthony Griffiths, Consultant Sarah Rees, Gynaecology Nurse Practitioner Laura Groves, Clinic Manager Gynaecology Carolyn Alport, Ward Sister Diane Nicholas, Outpatient Sister Kevin Dunster, Medical Records Pat Tamplin Directorate Manager Andrea Aquilina, Directorate Manager Brenda Rees Clinical Governance Joy Whitlock, Quality Improvement Cedar, Cardiff & Vale UHB Dr Grace Carolan-Rees, Cedar Director Dr Judith White, Senior Researcher, Cedar Andrew Cleves, Senior Researcher, Cedar The Health Foundation Mike Firn, Springfield Consultancy Karl Storz UK and Germany