Delivering Quality and Value Focus on: Cholecystectomy
Introduction This document aims to help local health communities and organisations improve the quality and value of care for cholecystectomy patients. It is one of a series of documents produced by the Delivering Quality and Value team at the NHS Institute for Innovation and Improvement as part of the high volume Healthcare Resource Groups (HRG) programme. Figure 1 Healthcare Resource Groups (HRGs) Cumulative % FCEs by HRG for England (2003/04) 100 90 80 70 60 % 50 40 30 20 10 0 HRG Source Hospital Episode Statistics HRGs are groups of clinically similar activities for which a similar quantity of resources is needed. They are also the basis for the NHS Payment by Results system. 01 50 HRGs account for 50% of all bed days. 50 different HRGs (however, there is overlap) account for 50% of all finished consultant episodes (FCEs). As the graph shows, a relatively small number of HRGs account for a large proportion of NHS resources. The programme is based on the concept that by focusing on a limited range of high volume HRGs (or related care groups), the NHS Institute can help the NHS to make the maximum impact on improving the quality and value of care for NHS patients. The initial series of HRGs (or related patient groupings) were chosen on the basis that they were high volume, and hence high resource consumers, and also represented a range of clinical areas. The series of HRGs chosen were: acute admissions in adult mental health acute stroke Caesarean section fractured neck of femur cholecystectomy short stay emergency care (length of stay two days or less) urinary tract infections (as a tracker condition for frail elderly patients) primary hip and knee replacement. The document covers: the Delivering Quality and Value team s approach the key characteristics of organisations providing high quality care and value for money measures for improvement further information.
The approach A literature review was undertaken of the recognised evidence in delivering optimised care for cholecystectomy patients. The Further information section gives further detail of the documentary evidence. A thorough data analysis was done using nationally available data from Hospital Episode Statistics (HES) as an indicator to rank and identify organisations primarily using day case rates. The initial statistics were then adjusted for age and deprivation levels, mortality rate and readmission rates. Verifying the selection of organisations 02 Having identified the local health and social care communities, we then approached the organisations to allow us to visit them and observe how they manage this group of patients. The Acknowledgements section lists the organisations we visited. The information contained within this pathway was only possible because health and social care communities allowed us to see their practice. We then undertook site visits, ensuring that at least 50% of our time was spent observing, watching, listening and looking at the flow and processes of care. We also explored the use of information to aid clinical and non-clinical decision making. The remaining time was spent conducting a series of semistructured interviews with patients and key members of staff across the pathway of care (including surgeons, anaesthetists, day surgery and theatre managers, pre-assessment nurses, ward and theatre nurses, technical and administrative staff, information analysts, and middle and senior managers, including chief executives). In total we interviewed or observed over 150 staff and patients for this pathway. The knowledge we gained from these visits and co-production events 1 was then consolidated, and the optimised pathway of care illustrated later in the document was identified. We worked in partnership with the NHS throughout this project to validate the pathway and the knowledge gained from the site visits, and to identify measures for improvement that would be helpful indicators for evaluating the impact of change. 1 Co-production with the NHS, involving all sites visited and national bodies and experts relevant to the pathway
03 How to use this document The content of this document has been developed with the help of NHS staff for the benefit of any organisations and stakeholders that play any part in the cholecystectomy pathway. Key characteristics have been developed with the expectation that they will be widely adopted across the NHS, so that patients receive a high quality experience irrespective of where they receive their care. The majority of improvements are applicable and easily transferable to other surgical procedures, and implementation will have numerous benefits for the patient and health and social care services. Included in this document are case studies and examples from trusts, including a patient information leaflet and advice for surgeons, anaesthetists and commissioners, to enable units to rapidly adopt the recommended pathway.
Cholecystectomy pathway Context 04 Using national (England) data from HES, the following indicators highlighted wide variability in cholecystectomy care. 2 There was variability in: volume of procedures day case rates numbers of emergency vs elective cholecystectomies percentage of open and laparoscopic procedures length of stay readmission rates (within 28 days of surgery). A total of 49,077 cholecystectomy procedures took place in England between 1 April 2005 and 31 March 2006, of which 86% were performed electively (42,402) and 14% (6,675) during an emergency admission. Overall, 84% of cholecystectomies were undertaken laparoscopically. There is large variation between trusts, with high performers achieving over 90% laparoscopic rates (includes day case and inpatients' cholecystectomies) compared with some low performers where the rate of laparoscopic cholecystectomy is under 50%. 3 The national average day case cholecystectomy rate is only 6.4%. The highest performing organisations achieve a day case rate between 40 and 50% and feel that the rate of at least 70% is readily achievable. Figure 2 Day case rates for laparoscopic cholecystectomy for acute trusts Day April case 2005 March rates for laparoscopic 2006 (excluding cholecystectomy specialist trusts for or acute those trusts performing from April fewer 2005 than to March 2006 (excluding specialist trusts or those performing less than 20 cases per annum) 20 cases per annum) Figure 2 demonstrates the national variation in day case rates for cholecystectomy, highlighting that almost half of trusts have a day case rate of less than 5% and a third doing no day cases at all. 2 Based on HRG codes G13 Cholecystectomy >69 or with complications and G14 Cholecystectomy <70 without complications 3 This may include some highly specialised units doing complex surgery, and therefore 50% may be an appropriate rate in this setting
Figure 3 Number of laparoscopic cholecystectomies by day cases and inpatients for acute trusts April 2005 March 2006 (excluding specialist trusts or those performing fewer than 20 cases per annum) 05 Figure 3 highlights the wide variation in overall volumes of laparoscopic cholecystectomies performed as day case versus inpatient, and demonstrates the potential to increase day case rates.
Figure 4 Average length of stay for elective and emergency cholecystectomy for acute trusts April 2005 March 2006 (excluding specialist trusts or those performing fewer than 20 cases per annum) Figure 4 indicates that the average length of stay ranges from 1.1 days to 5.2 days for an elective cholecystectomy and from 5.2 days to 27 days for an emergency cholecystectomy. 06 Figure 5 Average length of stay for open and laparoscopic cholecystectomy for acute trusts April 2005 March 2006 (excluding specialist trusts or those performing fewer than 20 cases per annum) Open Laparoscopic Figure 5 indicates that the average length of stay for open cholecystectomy is 9.1 days (the range is from 2.3 days to 21.2 days) and for laparoscopic cholecystectomy is 2.6 days (the range is from 1.2 days to 6 days).
Figure 6 Readmission rates for elective and emergency cholecystectomy for acute trusts April 2005 March 2006 (excluding specialist trusts or those performing fewer than 20 cases per annum) 07
Figure 7 Readmission rates vs day case rates for elective laparoscopic cholecystectomy for acute trusts April 2005 March 2006 (excluding specialist trusts or those performing fewer than 20 cases) Readmission rate % Figure 7 shows that there is no evidence of an increased readmission rate in units that perform a high number of day case laparoscopic cholecystectomy. 08 Day case rate % The average length of stay for laparoscopic cholecystectomy is 2.6 days (ranging from 1.2 to 6 days). If the average length of stay was reduced by one day, there would be an annual saving for the NHS of approximately 35,400 bed days ( 8 million - based on a bed day cost of 225). A trust performing 300 elective inpatient laparoscopic cholecystectomies a year could expect to save about 100,000 per annum by performing 40% as day case procedures and reducing the length of stay of the remainder by one day (based on a bed day cost of 225).
The typical and recommended pathways From our observations and discussions, the following flowcharts highlight the typical and recommended pathways for the management of patients with gall bladder disease admitted electively or as an emergency. The pathways illustrate areas where patient satisfaction could be improved and where considerable cost and time savings could be made for the organisation. Figure 8 Typical patient pathway for cholecystectomy Elective process Emergency process GP referral with suspected biliary disease 225 per day Acute admission with suspected biliary disease Specialist OPA Are investigations complete? Repeat investigation costs 30 for ultrasound 10 for LFTs OP investigations NO Inpatient investigations Does patient need surgery on this admission? YES NO 09 Commissioning contractual delays of up to five months for elective treatment May not universally occur and lack of pre-operative assessment can lead to DNAs and on the day cancellations Put on waiting list (WL) for elective surgery Pre-operative assessment Patients have been known to require three emergency admissions for biliary colic/cholecystitis whilst on WL for elective surgery Discharged to have delayed elective operation Admission day or more before surgery 225 per day YES Patients may have unnecessary investigations done by junior doctors eg repeat bloods, chest x-ray Admit for surgery Cost issues at surgery disposable vs reusable equipment Routine use of antibiotics 5 SURGERY 225 per day Unnecessary repeat blood tests 87 per visit Post-operative hospital stay Outpatient follow-up Each admission (>69 or with complications) Cholecystitis/biliary colic = 2,271 as above + cholecystectomy = 4,478 Elective cholecystectomy = 1,875
Figure 9 Recommended patient pathway for cholecystectomy Elective GP referral for suspected biliary disease Start of patient education process to prepare them for day case procedure Emergency primary care referral or acute hospital admission with suspected acute biliary disease Investigations completed prior to OPA ideally by primary care ie ultrasound and LFTs Each day spent in hospital waiting for tests or surgery costs 225 Specialist OPA 10 Added to waiting list for surgery at OPA Date of pre-assessment and operation offered to patient Lack of effective pre-assessment can lead to DNAs and on the day cancellations. Patient s expectations are also unlikely to have been properly managed for day case operation Ideally all three processes occur at same attendance Pre-assessment clinic Rapid diagnostic assessment (within 24 hours) Emergency patients also go through preassessment process to ensure consistency of pre-operative assessment and patient information Admit on day of surgery SURGERY Same day / 23 hour discharge Staggered or semi block arrival times (patient focus) Admission day or more before surgery costs 225 per day No routine use of antibiotics saves 5 and reduces patient risk Savings also around standardising disposable equipment Emergency patients undergo surgery on acute admission if appropriate This avoids commissioning contractual delays of up to five months for elective surgery. Patients have been known to require three emergency admissions for biliary colic/cholecystitis whilst on waiting lists for elective surgery Specialist laparoscopic surgeon performing >40 laparoscopic cholecystectomies per annum reduces rates of conversion to open surgery Post-operative support via telephone helpline with rapid access to surgical assessment if appropriate. No routine OP follow-up Nurse-led discharge Use of standard post-operative analgesia regimes minimising use of opiates Avoiding unnecessary outpatient follow-up saves 87 per visit Each admission (>69 or with complications) Cholecystitis/biliary colic = 2,271 As above + cholecystectomy = 4,478 Elective cholecystectomy = 1,875
Fundamental principles for delivering the recommended cholecystectomy patient pathway The pathway is a standardised process which should cover 95% of laparoscopic cholecystectomy cases, but it does have the flexibility to allow for exceptions. The pathway is applicable to all patients undergoing surgery, irrespective of whether they are cared for within a day case, 23- hour or inpatient environment. Day case surgery is the norm rather than the exception in the majority of elective procedures; this requires the development of a day case mindset across the organisation. Patient expectations are managed consistently across the entire patient journey, from GP referral to hospital discharge. Surgical sub-specialisation reduces patient morbidity, increases productivity and reduces length of stay. Recent publications recommend a minimum number of 200 laparoscopic cholecystectomies per surgeon over five years to minimise morbidity and improve outcomes (this equates to a minimum of 40 cases per year). 4 Conversion rates should be less than 5% for elective laparoscopic cholecystectomy and less than 10% for emergencies. Conversion rates should be used in conjunction with complication rates. Emergency laparoscopic cholecystectomy is safe in the hands of subspecialised laparoscopic surgeons. Conversion rates are halved (8% versus 16%) when operating in the acute phase of the disease, as opposed to allowing the acute episode to settle and the patient being operated on at a later date. 5 Emergency patients have rapid access to diagnostic investigations (within 48 hours of presentation) to enable early operative intervention. 11 4 Hobbs, M.S., Mai, Q., Knuiman, M.W., Fletcher, D.R. and Ridout, C.S. (2006), Surgeon experience and trends in intraoperative complications in laparoscopic cholecystectomy, British Journal of Surgery, Vol. 93, No. 7, pp. 844 53 5 O Boyle, C.J., Murphy, C., May, J.C., and Kapadia, C.R. (1999), Immediate versus delayed laparoscopic cholecystectomy for acute cholecystitis, British Journal of Surgery, Vol. 86, p. 57
12 Redesigning the emergency pathway will reduce costs by preventing avoidable emergency readmissions, as well as improving the patient experience. An effective, standardised pre-assessment service is essential for optimising the patient experience. It ensures the patient and carer are fully informed and prepared for admission, operation and discharge. Other benefits include reducing cancellations and did not attends (DNAs). Emergency patients would also benefit from the pre-assessment process. Redesigning the pathway reduces: unnecessary duplication (eg repeat blood tests) emergency readmissions with cholecystitis/biliary colic outpatient follow-ups. It also reduces overall costs, helping to meet or come in under tariff. Combining day case facilities with 23-hour/short stay facilities maximises flexibility of capacity and the use of afternoon theatre sessions. More complex patients can be accommodated overnight if required, rather than having to default to an inpatient bed.
The key characteristics of organisations providing high quality care and value for money The following characteristics have been found to be the key features for delivering quality and value for patients undergoing cholecystectomy. These are followed by suggested measures for improvement. The suggested measures for improvement are those that we judge to be of value to organisations to enable them to benchmark their current practice against the characteristics described and to further improve it. Overarching characteristics common to the entire pathway are identified first. 13 Characteristics are then broken down into the following pathway steps: Referral Preoperative assessment Admission Cholecystectomy operation Postoperative care, discharge and follow-up.
Overarching characteristics The wider health community is committed to the development of high quality and cost-effective elective day surgery and short stay services. 14 Elective day surgery/short stay development is reflected in trusts annual business plans. Day case rates are analysed by procedure, specialty and surgeon to identify areas for improvement. Commissioners and providers then discuss an appropriate level of day cases for each procedure. The British Association of Day Surgery has published a directory of day surgery procedures 6 which recommends performing specific procedures as either day case, 23-hour or short stay. Trusts can also examine possible procedure shifts from inpatient to 23-hour stay, 23-hour stay to day case and day case to outpatient or primary care. An enthusiastic clinician (with identified sessional commitments) leads on day surgery/short stay development with a senior manager. Patients are always defaulted to day case (or 23-hour if day case is not possible). Staff with a day case mindset are developed and recruited. Day surgery facilities are designed/redesigned to aid flow (a combined day surgery and 23-hour facility might provide more flexibility, but overnight stays should be based on clinical criteria rather than on the availability of beds). Thought is given to the flow of patients through the facility, and any non-value-adding time (such as transferring patients to theatre, and preoperative and postoperative stays) is reduced by as much as possible. There is investment in team training (in-house or other), so that expertise and specialisation in laparoscopic techniques are developed. Surgeon sub-specialisation reduces patient morbidity, increases productivity and reduces length of stay. Recent research recommends a minimum of 200 laparoscopic cholecystectomies per surgeon over five years to minimise morbidity and improve outcomes (this equates to a minimum of 40 cases per year). 7 Conversion rates for laparoscopic cholecystectomy should be less than 5% for electives and less than 10% for emergencies. Teams can benefit from visiting high performance organisations and using specialist information sources (see the Further information section). Conversion rates should be used in conjunction with complication rates. There are dedicated training lists, although it is recognised that these may be less productive. 23-hour stay patients (rather than day case patients) are considered for use in training. 6 British Association of Day Surgery (2006), BADS Directory of Procedures 2006, BADS, London (www.daysurgeryuk.org/content/professionals/bads-directory-of-procedures-2006.asp) 7 Hobbs, M.S., Mai, Q., Knuiman, M.W., Fletcher, D.R. and Ridout, C.S. (2006), Surgeon experience and trends in intraoperative complications in laparoscopic cholecystectomy, British Journal of Surgery, Vol. 93, No. 7, pp. 844 53
It is important to have a champion to take day surgery forward. It makes all the difference. If our champion was taken out of the equation, then our outcomes wouldn t be half as good. Consultant anaesthetist Our staff are motivated to shorten the length of stay. We would do everything as day case if we could, because things run more smoothly and patients prefer it. Theatre sister Two surgeons came up with the idea of developing laparoscopic work. Management supported the vision and then other surgeons joined in. Consultant surgeon 15
Case study Royal Surrey County Hospital: Best practice 16 The default position for the performance of cholecystectomy is to perform it laparoscopically in a day case setting. Such procedures are placed first on a morning theatre list with a view to discharging the patient from hospital on the same afternoon. The limitations of this surgery relate to co-morbidity and obesity in the individual patient, which might preclude day care on the basis of the anaesthetic risk. There is a facility for admitting patients if they fail to meet the criteria for discharge, but this is a rare event. Conversion to open surgery is also rare in the day case setting, and patients deemed to be at high risk of open conversion are precluded. The success of day case laparoscopic cholecystectomy depends upon good case selection, high quality surgery and anaesthetic, and good postoperative analgesia both while in hospital and at home. Good counselling about what to expect before, during and after surgery, and confirmation of adequate social support once discharged, are all imperative. Laparoscopic cases are always performed with the consultant in attendance, and are regarded as good training opportunities for middle and senior-grade training surgeons. Cases are often transmitted live to our minimal access therapy training unit (MATTU) during courses specifically aimed at training in laparoscopic cholecystectomy as well as other generic laparoscopic courses. The MATTU also allows for trainees to practise cholecystectomy techniques using state-of-the-art equipment on cadaveric animal models and using virtual reality simulators. The involvement of a specialised laparoscopic team at consultant level ensures that, where possible, surgery is not prolonged, complications are minimised and conversions to open surgery are rare, all of which results in the delivery of successful day case surgery for the majority of patients undergoing laparoscopic cholecystectomy. Professor Tim Rockall, Consultant Surgeon www.mattu.org.uk
Multidisciplinary teamwork is key. Surgeons, anaesthetists, day surgery managers, nursing staff, radiology staff, operating department staff, theatre staff, recovery staff, waiting list managers, diagnostics staff, technical staff, information analysts and administration staff all work together. There is a day case/short stay mindset within the team. Inpatient care is the exception in the majority of elective procedures, not the norm. There are clear roles and responsibilities, with clearly defined managerial and clinical leadership. The whole team is aware of (and ideally has first-hand experience of) the entire patient journey, ensuring that a consistent message is given to patients and carers. Multidisciplinary care documents are developed in order to standardise the process, improve patient safety and facilitate nurseled discharge. It s everyone s job to get the list started on time. It requires a team effort for operating lists to run smoothly. Consultant surgeon 17
Case study Airedale NHS Trust: Laparoscopic cholecystectomy: default to day surgery 18 We wanted to change custom and practice and challenge organisational behaviour to promote best practice in day surgery. Approach We arranged a multidisciplinary working group, with membership from all aspects of the patient pathway from referral to discharge and up to 30 days post surgery. Laparoscopic cholecystectomy became the main focus for the day surgery programme, which was led by the day care manager, lead surgeon, anaesthetist and infection control clinical nurse specialist. We developed an audit questionnaire within the group which followed the patient journey from preoperative assessment through to 30 days post surgery at home. Initially the programme generated opposition from all areas, but most surprisingly from the nurses on the day unit. However, with time, patience and by demonstrating the quality benefits and high levels of patient satisfaction associated with admitting and caring for patients as day cases, staff quickly saw the benefits of the new approach. Achievements 1. Improved patient satisfaction. 2. A raised profile for day case surgery within the Trust and an agreement to default to day case for identified surgical procedures. 3. Increased staff interest in day case surgery. 4. National recognition, through presentation at an international ambulatory care conference. 5. An increase in overall day case rates from 59% in 2001 to 83% in 2006. 6. Improved communication with our partners in the primary care trust. 7. The release of inpatient beds and freeing-up of resources. 8. Regular questioning of traditional medical and nursing practice, based on best practice guidelines. 9. Development of a comprehensive, nurse-led preoperative assessment service and nurse-led discharge using agreed criteria. Staff satisfaction has improved because we now do more complex day case surgery. The staff do not like doing just local anaesthetic procedures. By day 10 I wanted to go back to work, but the GP did not want me to. Why? Responding to the patient satisfaction survey, 63 out of 67 people replied that they would have a similar operation as a day case again. Sherie Herpe, Matron for Day Case and Theatres
Effective use of data and information to enhance decision making. Ensure accurate clinical coding by involving clinicians. Data and information are used effectively to enhance decision making. Accurate clinical coding is ensured through the involvement of clinicians. Clinicians are aware of HRG costs and tariffs, including costs of pathology, drugs and disposables. Trusts establish baseline performance, set targets for improvement based on the top performing organisations and monitor them, eg they aim to achieve 90% of elective laparoscopic cholecystectomies as day cases or 23-hour stays. Staff are genuinely interested in how they are performing, and we audit and feed back regularly. Day surgery service manager 19 Audits take place on a regular basis (eg of conversion rates, length of stay, reasons for unplanned admissions, infection rates, cancellations, changes in theatre lists and primary care reattendance rates). Benefits of following the recommended pathway for laparoscopic cholecystectomy are discussed with commissioners to prevent emergency readmissions during the waiting period and to minimise the financial implications of operating during acute admission vs later surgery (see Table 1). See Appendix 5 for further advice for commissioners. Organisations consider developing a rapid emergency surgical pathway (to allow for surgery during the acute phase) for patients with acute cholecystitis/biliary colic. This improves the patient experience and reduces emergency admissions/readmissions.
Table 1 Example of tariff - cholecystectomy older than 69 years 20 Admitted with acute cholecystitis/biliary colic and treated conservatively on that admission Admitted with acute cholecystitis/biliary colic and operated on during that admission Admitted with acute cholecystitis/biliary colic, treated conservatively and discharged then added to waiting list to be readmitted electively for surgery Cost of readmission as an emergency while waiting for elective cholecystectomy Commissioners often impose a waiting list rule of a minimum of five months wait for elective surgery. Patients waiting for cholecystectomy following an acute admission for cholecystitis or biliary colic can be readmitted up to three times while on the waiting list for surgery. This is 1,875 4,478 4,146 ( 1,875 emergency admission plus 2,271 for elective cholecystectomy) 1,875 per admission poor quality care for the patient and often leads to a more difficult laparoscopic operation, increasing operative morbidity and conversion to open surgery. Repeat acute admissions prior to surgery will significantly increase costs to commissioners and waste NHS resources.
Case study Patient interview Jeremy, a 23-year-old male, was interviewed, having undergone a laparoscopic cholecystectomy. He had returned from theatre about two hours previously and was awake and drinking water. He was being cared for in the 23-hour unit but was hoping to go home later that evening. His father and girlfriend were with him and were also prepared to take him home. I got acute cholecystitis five months ago while abroad. I was hospitalised and investigated there and then transferred back to the UK once I was fit to travel. I was seen in the outpatient department and told I would need to have my gall bladder removed. I tried a lowfat diet to keep the symptoms at bay. I had several uncomfortable episodes, as well as having three episodes of acute cholecystitis which required me to be admitted to hospital. The pain was awful and you feel so ill. I felt very well prepared for the operation today. The pre-assessment was useful and I have been prepared to go home this evening. I am a bit sore, which I expected, but the pain is not anything like the acute cholecystitis pain. If there was one thing I would change about my experience it would be to have had my operation as soon after diagnosis as possible. That way I would have suffered less and I wouldn t have needed to be admitted to hospital several times or have had to take time off work. 21
Measures for improvement 22 70% of elective laparoscopic cholecystectomies carried out as day cases (90% including 23-hour short stay). Length of stay for laparoscopic cholecystectomies. Staff satisfaction surveys (including on multidisciplinary team working and training opportunities). Consultant data by: volume of laparoscopic cholecystectomy vs volume of planned open percentage breakdown of day case, 23-hour and inpatient operations elective cholecystectomy vs emergency cholecystectomy rates conversion rates (elective less than 5% vs emergency less than 10%) should be used in conjunction with complication rates. re-admission rates (elective vs emergency). Analysis of costs, including disposables, drugs, pathology/radiology, staffing. Audit of clinical practices to identify areas that may not be accurately reflecting the procedures performed: minimal number of queries from clinical coder back to the clinician accuracy rate of case notes for coding.
Referral characteristics Consistent information from all healthcare professionals helps to manage patient and carer expectations throughout the patient pathway, beginning with the GP consultation. For example, patients expect to have the operation laparoscopically as a day case (see Appendix 1 for example). A referral pathway is designed collectively with primary care to include pre-referral investigations and relevant patient details such as body mass index (BMI), blood pressure and co-morbidity. Patients are given a choice of dates and times for their outpatient appointment, pre-assessment and operation, including preoperative investigations. Emergency patients are diagnosed early, with an ultrasound scan (USS) and liver function test (LFT) taking place within 24 hours of presentation. An emergency care pathway for cholecystitis/biliary colic patients is developed with the accident and emergency department, primary care and the surgical team, including fast track to a specialist outpatient clinic with results of tests if appropriate. 23 We ensure that we give the same message to patients from start to finish - starting at the GP surgery and reinforced by all staff throughout the patient journey. Preoperative assessment team If I had been an inpatient then I would have had the mentality that I was ill. The whole outlook of day surgery can really help you with your recovery. I was able to recover with family and friends, all in the comfort of my own home. I could return to normality almost straightaway. It s a shame more people don t know about it. Day case patient Measures for improvement Percentage of patients with a confirmed diagnosis of cholecystitis/biliary colic (rapid access to USS and LFT within 48 hours for emergency patients, including inpatients and outpatients). Percentage of GP referrals for which the results of the USS and LFT are included in the GP letter.
Preoperative assessment characteristics 24 Dedicated facilities are provided for preoperative assessment, with the appropriate capacity for pre-assessing all surgical patients. Nursing staff are highly trained and have rapid access to diagnostics, anaesthetic opinions and other multidisciplinary consultations as appropriate. Pre-assessment staff play an important role in obtaining secondstage consent for operations by ensuring that patients have a thorough understanding of the admission, operation and discharge process (supported by written information for patients). Alternative methods for pre-assessment are explored - telephone, face-to-face, group pre-assessment, primary care or other. Pre-assessment outcomes that could delay surgery are reported to the appropriate disciplines in a timely manner (including to the waiting list office to avoid last-minute list changes). The preassessment team has direct access to specialist services if appropriate. Inpatients with cholecystitis/biliary colic who are planning to have surgery on that admission should be assessed by the preoperative team prior to surgery, where possible. This helps to manage patient expectations and ensures the standardisation of information.
Our pre-assessment staff experience the whole patient pathway, so they are in a better position to prepare patients for day case admission and discharge. Preoperative assessment sister I had my gall bladder removed as an emergency. When I came back from theatre I had a tube and a bag coming out of my tummy. No one warned me that this would happen before my operation, and for two days I thought I had had a colostomy. If I had been warned that I would come back with a wound drain, I wouldn t have worried about it. Inpatient Measures for improvement Percentage of patients given a choice of date for preoperative assessment. Percentage of DNAs. Percentage of cancellations for medical reasons. Percentage of patients being deferred. Patient satisfaction survey on the pre-assessment experience. 25
Admission characteristics Patients are admitted on the day of surgery. Where day case and 23-hour stay patients are on a mixed list, day case patients are scheduled early in the operating list to facilitate same-day discharge. Patients prefer staggered arrival times to minimise pre-operative waiting but semi-block arrival times will also facilitate theatre flow. It was really nice to come into hospital only one hour before my operation. Sitting around would ve made me more anxious. Day case patient Measures for improvement 26 Percentage of DNAs and cancellations for medical and non-medical reasons (fed back to the pre-assessment team). Patient waiting time (from admission to theatre).
Cholecystectomy operation characteristics All-day operation lists are developed (this can entail alterations in consultant job plans). Dedicated lists are used for day surgery and short stay (avoid mixing them with emergencies and inpatients, if facilities allow). Management of pain and postoperative nausea and vomiting (PONV) is agreed with the team. Use paracetamol and Non Steroidal Anti-Inflammatory Drugs (NSAID s) eg diclofenac, ibuprofen, local anaesthetic infiltration into port sites. Avoid post operative opiates. Day case anaesthetic techniques enable early discharge to take place. There is no routine need for perioperative antibiotics (which cost approximately 5) in elective laparoscopic cholecystectomies, minimising drug-related adverse events. Less need for DVT Prophylaxis for day cases (which costs approximately 20 per injection). 27
Case study Northumbria Healthcare NHS Foundation Trust 28 I was appointed as a specialist laparoscopic surgeon in 1999, and the following year I initiated a day case laparoscopic cholecystectomy programme. We had a very motivated day case unit team, and with increasing pressure on inpatient beds, it was an ideal time to convert to day case laparoscopic cholecystectomy. We spent a significant amount of time in the early days discussing the care pathway with our patients, and felt that patient information, contact and feedback were very important. We started by operating on selected patients, performing their cholecystectomy as early in the morning as possible and discharging them in the late afternoon or early evening. We were conscious that this was not being done in great numbers elsewhere, and arranged to have a district nurse visit the patient that evening and also the following morning if indicated. We soon decided that selecting people for this procedure was the wrong way to do things, and we changed to a system where day case cholecystectomy was the default unless there were good clinical or social reasons to admit the patient. As a result, we have no age limit and our day case rates have risen dramatically. Within two years, our day case rate was approximately 20%, and it has now reached over 50% (and is rising year on year). Our patient satisfaction rating is consistently high. Many of our patients come to the clinic saying, I will be done as a day case, won t I? Over the past six years, we have only had two patients readmitted having been discharged as day case laparoscopic cholecystectomies. We do occasionally admit patients postoperatively, mainly due to the operation being performed late in the day rather than due to medical complications. Liam Horgan, Consultant Surgeon www.nugits.nhs.uk
Measures for improvement Conversion rate from laparoscopic to open (evidence suggests that less than 5% is acceptable, but below 2% is achievable in experienced hands). Conversion rates should be used in conjunction with complication rates. Time of operation on list (surgery performed later in the day may lead to an overnight stay, unless facilities allow late same-day discharge). Percentage of late finishes in theatre, and the reasons for these. Use of perioperative antibiotics. Cost of disposables per surgeon per procedure. It is important to have a well trained, dedicated team; when we don t have our normal team it is not as effective. It is all down to the skills of the laparoscopic surgeon; specialisation is the key. Our surgeons often do 10 laparoscopic cases on an all-day list. Consultant anaesthetist 29 We have identified potential savings of 100,000 through standardising the use of disposable equipment. I m sure we could reduce costs and come in under tariff. Staff are actively encouraged to suggest ideas for reducing costs. Theatre manager
Postoperative care, discharge and follow-up characteristics Agreed criteria for discharge (based on patient recovery rather than minimum postoperative stay) are followed, and discharge is nurse-led. Refer to Guidance about the discharge process and the assessment of fitness for discharge (BADS 2002). To support later same-day discharge, longer opening hours are considered as part of the day case facility. Ward-dispensed, pre-packed discharge medication is standardised. Clear, written patient information regarding discharge care is provided, containing telephone numbers for postoperative advice. 24-hour follow-up advice and support is provided (eg via a helpline). Discharge summaries are sent to GPs in a timely manner. There are no routine outpatient postoperative follow-ups. 30 I don t see why we cannot discharge some patients up to 10pm at night. Patients tell me that they would much prefer to sleep in their own bed. Day ward sister I was discharged later in the day which meant that I could say goodnight to my daughter before she went to bed. Day case patient We used to telephone all patients the day after surgery. But we stopped because patients were either out or we disturbed their rest. Patients prefer to contact us if there are any problems, rather than us contacting them. This has saved us a lot of nursing time. Day surgery nurse manager
31 Measures for improvement Percentage of elective laparoscopic cholecystectomies done as day cases (75% is an achievable rate), and percentage done as day cases including a 23-hour stay (90% is an achievable rate). Percentage of (and reasons for) unplanned overnight stays (both medical and nonmedical). The higher the day case cholecystectomy rate, the more likely it is that unplanned overnight stay rates will increase - this is a recognised consequence of trying to maximise day case cholecystectomy rates. Readmission rate (less than 5% is achievable for elective cholecystectomy). Percentage of patients contacting the 24-hour follow-up service, and their reasons. Percentage of routine postoperative follow-up outpatient appointments (by consultant).
Benefits of following the pathway The length of stay is reduced/the day case rate is increased. Patient flow is improved. Variability in the process is reduced. This results in: increased activity best use of capacity (resources for inpatient operations and emergency care are freed up) patients being treated faster shorter waiting times. Patient expectations are managed and satisfaction is improved. 32 Consistent information is provided about the medical condition, the options for management and what to expect from treatment. Patients have choice and certainty over dates for hospital appointments and over the operation date. Access to well designed facilities improves the patient experience. Well trained staff provide consistency of care. Patients are able to recover in their own homes and return to normal activities earlier. Risks of hospitalisation, eg through hospital-acquired infection, are reduced. Good clinical outcomes improve patient safety. Effective pre-assessment and booking processes reduce cancellations.
There are significant financial benefits. Reductions in the length of stay and standardisation of procedures and equipment all reduce costs. Productivity is increased through reducing variations in the process. Waste is reduced and resources are freed up, eg fewer last-minute cancellations free up inpatient beds. Surgical reputation is enhanced through improvements in quality. Opportunities for marketing are created in the new, competitive NHS environment. Staff and patient satisfaction increase. Clinical sub-specialisation is encouraged. Recruitment opportunities increase, attracting medical staff. Team working and the working environment improve. 33 The multidisciplinary care pathway achieves a shared vision and purpose. A day case and short stay mindset is developed in staff.
Conclusion 34 The contents of this report are based on the Delivering Quality and Value team s observations of the practices of NHS organisations that are judged to be delivering high quality care and value for money. Although these observations have been tested thoroughly, it should be recognised that they may not be the only ways of delivering high quality care and value for money, but we believe that they will give valuable guidance and direction to those seeking this goal. To improve services, organisations should follow this guidance and take the following simple steps: Understand how your organisation performs when compared against the key measures and benchmarks suggested. Generate a locally owned change programme for improvement. Integrate the local change management programme within health community integrated service improvement programmes (ISIPs) and local delivery plans (LDPs). Further products will be produced to support implementation of this guidance and local improvement. In particular, the Delivering Quality and Value team expects to produce the following to support the cholecystectomy pathway: Guidance for commissioners (to be published in early December 2006). Information for GPs and patients (to be published in early December 2006). We would value your contributions to our future work. If you would like to be involved, or have any comments, please contact the Delivering Quality and Value team at HRG@institute.nhs.uk.
Acknowledgements We wish to thank everyone who has contributed their time to enable us to carry out this work, and in particular the staff who took time out from their busy schedules to show us how they work and for all the information they shared. This includes the organisations we visited and their associated PCTs and local authorities. The trusts we visited were: We would also like to thank the following for their contribution: British Association of Day Surgery BUPA hospitals Milton Keynes General NHS Trust Royal Surrey education laparoscopic centre Airedale NHS Trust Bolton Hospitals NHS Trust Hereford Hospitals NHS Trust Northumbria Healthcare NHS Trust Royal Surrey County Hospital NHS Trust 35
36 Further information Published material Association of Anaesthetists of Great Britain and Ireland (2005), Day surgery (revised edition 2005), AAGBI, London (www.aagbi.org/publications/guidelines/docs/daysur gery05.pdf). Aylin, P., Williams, S. and Jarman, B. (2005), Variation in operation rates by primary care trust, British Medical Journal, Vol. 331, pp. 539 41 (http://bmj.bmjjournals.com/cgi/reprint/331/7516/539). British Association of Day Surgery (2002), Guidelines about the discharge process and the assessment of fitness for discharge, BADS, London (www.daysurgeryuk.org/content/files/handbooks/ba dsdischargecriteria.pdf). British Association of Day Surgery (2004), Day Case Laparoscopic Cholecystectomy, BADS, London (www.daysurgeryuk.org/content/files/handbooks/la paroscopiccholecystectomy.pdf). NHS Modernisation Agency (2004), 10 High Impact Changes for Service Improvement and Delivery: a guide for NHS leaders, Department of Health, London (www.institute.nhs.uk/nr/rdonlyres/84f6f682-31f1-4123-bf2c- ECDB6841DDC5/0/High_Impact_Changes.pdf). Royal College of Nursing (2004), Day Surgery Information (sheet 2): Patient information and the role of the carer, RCN, London (www.rcn.org.uk/publications/pdf/daysurgery_patien tinfo.pdf). Royal College of Nursing (2004), Day Surgery Information (sheet 4): Discharge planning, RCN, London (www.rcn.org.uk/publications/pdf/daysurgery_discha rge.pdf). Williams, S., Bottle, A. and Aylin, P. (2005), Length of hospital stay and subsequent emergency readmission, British Medical Journal, Vol. 331, p. 371.
Organisations and online resources British Association of Day Surgery 35 43 Lincoln s Inn Fields London WC2A 3PE Telephone: 020 7973 0308 Fax: 020 7973 0314 Email: bads@bads.co.uk Website: www.bads.co.uk Medline Plus (Patient Education Institute) Lay person s interactive guide to the cholecystectomy procedure: www.nlm.nih.gov/medlineplus/tutorials/cholecystect omyopenandlaparoscopic/htm/index.htm Minimal Access Therapy Training Unit Royal Surrey County Hospital Postgraduate Medical School University of Surrey Manor Park, Guildford Surrey GU2 7WG Telephone: 01483 688691 Fax: 01483 688633 Email: alisons@mattu.org.uk Website: www.mattu.org.uk Northumbrian Upper Gastro-Intestinal Team of Surgeons (NUGITS) Laparoscopic Training Institute North Tyneside General Hospital Rake Lane North Shields Tyne and Wear Northumberland NE29 8NH Website: www.nugits.nhs.uk Short Stay and minimal access surgical nursing School of Health Studies University of Bradford Unity Building 25 Trinity Road Bradford BD5 0BB Website: www.bradford.ac.uk/health The Preoperative Association Telephone: 020 7631 8896 Fax: 020 7631 4352 Email: info@pre-op.org Website: www.pre-op.org 37
Appendix 1 Example of written information given to patients in outpatient consultation and/or preoperative assessment right hepatic duct liver Biliary System left hepatic duct pancreas 38 gallbladder cystic duct common bile duct duodenum stomach common hepatic duct pancreatic duct
39
Appendix 2 Overcoming resistance to change - some common myths 40 Myth Some doctors and nurses think that patients are better cared for in hospital after surgery. Patients cannot have adequate pain control at home. Patients will be unable to cope. What happens if something goes wrong during the postoperative period? Fact Laparoscopic cholecystectomy is commonly performed as a day case procedure already. There are nationally tested peri- and postoperative analgesic regimes that enable patients to go home rapidly after surgery. Myth Patients expect to stay in hospital to recover for a couple of days after surgery. Fact Adequate information about what to expect on the day of surgery and in the subsequent postoperative recovery period is essential. If a patient expects to be treated as a day case, they will be prepared for recovering at home. Early mobilisation post-surgery reduces morbidity. Patients prefer to recover in their home environment and to return to independence quickly, eg familiar surroundings, support from carers, no sleep deprivation, better food, less risk of hospital-acquired infections. Myth Patients have to stay for a minimum number of hours postoperatively or demonstrate the ability to tolerate meals. Fact There are well established published discharge criteria (eg BADS) based on patient recovery. Myth Patients cannot be discharged late in the evening. Fact There should be no reason why patients cannot be discharged later in the evening as long as discharge criteria are met and social circumstances allow. Myth Elderly patients and patients who live alone are not suitable for day surgery. Fact The pre-assessment process should ensure patients are not excluded from the option of day surgery and are helped to organise a carer/relative to support the early postoperative period. Exclusion from day surgery on age alone is inappropriate; it should be based on clinical criteria. Elderly patients prefer to recover at home whenever possible. Myth All patients need to be seen routinely in the outpatient clinic after surgery. Fact The vast majority of patients do not require follow-up. However, there should be a system to enable patients to seek expert advice quickly if problems occur.
Myth All patients should be prepared to expect conversion to open operation. Fact Patients should be prepared to expect conversion only in certain circumstances, eg less than 5% conversion rate for elective laparoscopic cholecystectomy and less than 10% for emergency laparoscopic cholecystectomy. Myth If we increase our day case rate, we will increase our readmission rate. Myth Hospitals cannot achieve the recommended cholecystectomy pathway because they don t have dedicated day surgery and short stay facilities. Fact It is desirable to have dedicated day case and short stay facilities. However, this pathway is designed to enable all patients to have the same level of care irrespective of bed location. The mindset of staff is more important rather than the location of the bed. Fact There is evidence clearly showing that high day case rates do not lead to higher readmission rates and poorer outcomes. 41
Appendix 3 Advice for surgeons 42 Manage patients' expectations from the first consultation so they expect a day surgery procedure. If operating on patients from inpatient beds, schedule early on the theatre list to facilitate same-day discharge. Stagger or semi-block admissions are preferred by patients and ward staff. Develop the staff team to work towards common objectives. Local anaesthetic injection of port sites prior to insertion of ports reduces postoperative discomfort. Avoid routine use of antibiotics. Think about the costs vs benefits of laparoscopic disposables and rationalise use where appropriate. Use of a postoperative wound drain does not prevent same-day discharge (the drain can often be removed within four hours). Lists may run more efficiently and patients are more likely to be discharged home on the same day if junior doctor training is confined to patients who are planned to stay overnight. There are well established postoperative analgesic regimes that avoid opiates and reduce incidence of postoperative nausea and vomiting (PONV). This will minimise delayed discharge due to inadequate pain management and PONV. Discharge should be based on agreed criteria for patient recovery rather than minimum postoperative stay. This should be nurse-led. Avoid routine outpatient follow-up. Rapid access to follow-up should be in place in the event of postoperative untoward events following discharge.
Appendix 4 Advice for anaesthetists Manage patients' expectations so they expect a day surgery procedure. Work with the preoperative assessment team to agree criteria for day case laparoscopic cholecystectomy and advise on individual cases where necessary. There are well established postoperative and PONV regimes for laparoscopic cholecystectomy that minimise the use of opiates and facilitate early discharge (refer to BADS Day Case Laparoscopic Cholecystectomy publication). Question the routine use of perioperative antibiotics in elective cases. Encourage surgeons to use local anaesthetic injection of port sites prior to insertion of ports to reduce postoperative discomfort. 43
Appendix 5 Advice for commissioners Identify other high volume surgical procedures that would benefit from the same approach. Refer to NHS Institute Delivering quality and value: Focus on productivity and efficiency for developing day case surgery. 8 Use the commissioning process to specify, in discussion with providers, an appropriate day case rate for procedures. Routine follow-up outpatient appointments after cholecystectomy are unnecessary. This should be reflected in your commissioning rules for your providers. GPs should be preparing the patient to expect day case laparoscopic cholecystectomy and should start this process prior to referral. Commissioners should be aware of the quality and value aspects related to laparoscopic surgery and encourage local providers to develop sub-specialist teams (ie recommended minimum number per surgeon per year/sub-specialisation of surgeon). The benefits of following the recommended pathway for laparoscopic cholecystectomy should be discussed with acute providers, ie to prevent emergency readmissions during the waiting period and understand the financial implications of operating during acute admission vs later surgery (see Table 1). 44 Table 1 Example of tariff - cholecystectomy older than 69 years Admitted with acute cholecystitis/biliary colic and treated conservatively on that admission Admitted with acute cholecystitis/biliary colic and operated on during that admission Admitted with acute cholecystitis/biliary colic, treated conservatively and discharged then added to waiting list to be readmitted electively for surgery Cost of readmission as an emergency while waiting for elective cholecystectomy 1,875 4,478 4,146 ( 1,875 emergency admission plus 2,271 for elective cholecystectomy) 1,875 per admission There is evidence that some commissioners impose a waiting list rule of a minimum of five months wait for elective surgery. Patients waiting for elective cholecystectomy following an acute admission for cholecystitis or biliary colic can be readmitted up to three times while on the waiting list for surgery. This is poor quality care for the patient and often leads to a more difficult laparoscopic operation, increasing operative morbidity and conversion to open surgery. Repeat acute admissions prior to surgery will significantly increase costs to commissioners and waste NHS resources. 8 NHS Institute for Innovation and Improvement (2006), Delivering quality and value: Focus on productivity and efficiency, DH, London (www.institute.nhs.uk/nr/rdonlyres/07f7bb40-b2c3-4c08-8ea5-ec6c8187df97/0/k6017nhsitoptipsbookmarked.pdf)
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