WHY OFFER SAME DAY DISCHARGE FOR NON-RECONSTRUCTIVE BREAST CANCER SURGERY?

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1 WHY OFFER SAME DAY DISCHARGE FOR NON-RECONSTRUCTIVE BREAST CANCER SURGERY? Jo Marsden, Consultant Breast Surgeon, Kings College Hospital NHS Foundation Trust, London

2 LENGTH OF STAY FOR NON-RECONSTRUCTIVE BREAST CANCER SURGERY Until recently, the standard of care was for in-patient admission All surgeries (breast conservation, mastectomy +/- any axillary surgery including axillary dissection) Same day discharge was the exception rather than the norm Non-reconstructive breast cancer surgery No evidence of an adverse impact of early discharge on physical or psychological recovery compared with in-patient stay

3 LENGTH OF STAY FOR NON-RECONSTRUCTIVE BREAST SURGERY National variation in length of stay In 2007 the mean duration of stay for any non-reconstructive breast cancer surgery was 2 (0 to 4.9) days 27% were day cases MEAN LENGTH OF IN-PATIENT ADMISSION MASTECTOMY (NO RECONSTRUCTION), OTHER EXCISION Duration of admission was dictated by the use of wound drains and a surgical in-patient culture

4 PROMOTING REDUCED LENGTH OF STAY FOR BREAST CANCER SURGERY In 2007 The Cancer Reform and Improving Cancer Outcomes Strategies: Identified development of same day or overnight stay models to be a priority for patient management Improvement the effectiveness, quality and outcomes of care Enhance patient experience Save 1 million bed days Based on experience of change in clinical practice to reduce length of stay at: King s College Hospital, London (same day discharge) The Pan-Birmingham Hospitals Trust (23 hour / overnight stay) The NHS Improvement-Transforming Inpatients Care Programme commenced a national pilot project to support pathway development

5 BREAST SURGERY SAME DAY/23 HOUR MODEL King s College Hospital, London Non-reconstructive surgery on one site (hospital trust) Pan Birmingham Cancer Network Non-reconstructive surgery at 6 hospital trusts DSU (7am-8pm Monday to Friday) Utilise in-patient theatre sessions Aim for same day discharge / 23 hour stay for >90% of patients Aim for standard LOS to be 23 hours for 80% of patients Facilitated by Not using wound drains Patient demand Visited King s and tested replicality Stopped using wound drains and aspirating seromas Commenced March trusts initiated pathway (2006)

6 BREAST SURGERY SAME DAY / OVERNIGHT STAY MODEL KINGS BREAST CARE (KBC) Why did we change practice at King s? Well-women post-operatively on wards (with drains) requiring minimal care Use of wound drains was stopped for non-reconstructive surgery in 2005 Audit: reduced infection, no increase in post-operative complications Patients demanded to go home on day of surgery How was practice change achieved? We mapped the surgical pathway with pro-active stakeholder involvement Simultaneous prospective audit and information about patient experience Was it safe and did patients like it? Yes Change to service was achieved without incurring financial cost

7 THE NHS IMPROVEMENT TRANSFORMING INPATIENT CARE PROGRAMME 2 London Workshops (2010 and 2011) Spread principles of day case and 23 hour models of breast surgical care by 2011 Promote good practice from Transforming In-patient Care Programme Enhanced Recovery Programme Representatives from 13 Cancer Networks debated implementation, developed and audited their own pathways

8 THE NHS IMPROVEMENT TRANSFORMING INPATIENT CARE PROGRAMME Key findings from the pilot programme national audit (2011) Data submitted on 2,087 patients over 6 months 666 had mastectomy 1,421 wide local excision and other procedures (cancer and non-cancer) Use of wound drains There was a move away from the routine use of drains Pain control For most patients, paracetamol alone was sufficient Arm and shoulder exercises Move to education about exercises pre-operatively and not after surgery Delays in discharge Usually due to a failure to follow, or deviation from the agreed surgical pathway

9 THE NHS IMPROVEMENT TRANSFORMING INPATIENT CARE PROGRAMME A pathway template was produced to aid process mapping (endorsed by BADS and available on the BADS website) pathway.png

10 INCENTIVISING SAME DAY DISCHARGE FOR NON-RECONSTRUCTIVE BREAST CANCER SURGERY Promoted by the Department of Health Benchmark for best practice and GP commissioning National Breast Peer Review measure (clinical line of enquiry outcome) Practice (surgeries which are day case or one overnight stay) Outcome (surgical cases readmitted as an emergency within 28 days) Best Practice Tariffs (2012) Expanded to include same day discharge for non-reconstructive surgery BADS Directory of Procedures Recommended procedures for day and short stay surgery National Dataset supplement provides information showing the percentage of procedures successfully carried out on a day case basis

11 REDUCED LENGTH OF STAY FOR BREAST CANCER SURGERY NATIONAL OUTCOMES FRAMEWORK 2013/2014 Reducing length of stay for surgery with the benefits shown meets many of the national outcomes frameworks for cancer care Day surgery

12 QUALITY OF CARE: CLINICAL OUTCOMES LENGTH OF STAY FOR NON-RECONSTRUCTIVE BREAST CANCER SURGERY HES data has shown length of stay has reduced with increased same day discharge This has not been associated with an increased re-admission rate Achieved despite a simultaneous 4% increase in elective breast procedures 10 million reduction in bed costs Indicator 2007/ /2012 Overall mean length of stay for elective breast admissions (day cases and inpatients) 2.0 days 1.0 day Percentage of elective procedures that resulted in day cases 27% 40% Percentage of procedures where patients were admitted on day of surgery overall (day cases and inpatients) Number of bed days overall (day cases and inpatients) 78% 96% 104,888 bed days 53,740 bed days Bed stay costs 20,977,600 10,748,000 Percentage of readmissions within 28 days of episode 3.1% 3.0%

13 WHY IS THIS MEETING BEING HELD? Despite evidence for improved outcomes and experience with same day discharge there is still wide variation in national performance BADS (2012) recommended day case rates National performance of the top 5%, 25% and 50% of hospitals in 2013 (BADS) Top 5% Top 25% 50% (median) Any excision of breast (including wire-guided)* 95% 95% 90% 85% WLE (including wire-guided)* 75% 77% 64% 49% Any excision of breast with sentinel lymph node biopsy or axillary sampling 75% 88% 72% 57% Simple Mastectomy* 30% 38% 9% 2% Sentinel lymph node biopsy, axillary sampling or clearance* 80% 81% 45% 18% Operations on breast ducts 95% 100% 94% 88% Operation on nipple 95% 100% 100% 94% *Procedures identified for best practice tariff remuneration

14 PROPORTION OF MASTECTOMIES, WHICH ARE DAY CASES, BY PROVIDER (London Cancer Alliance; August 2015) Within region there is also considerable variation in practice LCA benchmark set at England average of 57.42% with length of stay 0 or 1 day Data for September 2013 to October 2014