British Association of Day Surgery www.bads.co.uk British Association of Day Surgery www.bads.co.uk

The challenge of day case surgery

Dr Anna Lipp Lead for Day Surgery, Norfolk and Norwich University Hospital President-elect British Association Day Surgery Mike Davidge Head of Measurement, NHS Institute for Innovation and Improvement Responsible for Better Care, Better Value indicators

British Association of Day Surgery www.bads.co.uk

Outline

• Identifying day surgery challenges locally • Case studies in different surgical

specialties – Orthopaedics – General surgery – Breast surgery

• What you can do • Recommendations

British Association of Day Surgery www.bads.co.uk

Do we have a problem with day surgery rates at NNUH ?

NHS Better Care, Better Value Indicators

British Association of Day Surgery www.bads.co.uk

NNUH rates vs. BADS targets Procedure NNUH day case

rate BADS Target day case rate 2011

Top 5% Hospitals 2011

Lap Chole 9%(2008) 60% 65%

Bunions 45% (2011) 85% 88%

Mastectomy 11% (2011) 30% 14%

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Bunions Consultant % day case

2011 % day case 2012

BADS target %

Top 5%

A 67

B 25

C 33

D 100

E 20

Totals 45% 62% 85% 88%

British Association of Day Surgery www.bads.co.uk

Barriers to Bunions

• Scheduling on afternoon list • Physio gone home by time patients

mobilising • Plaster room shut 5pm- they supply boots

and crutches • Night staff on ward “don’t do discharges”

• “Dinosaur Consultant” • Patient information leaflets out of date

British Association of Day Surgery www.bads.co.uk

Strategies

• Multi-disciplinary bunion team • Updated information leaflets • Boots given out at pre-assessment • Crutches available on ward • Night staff trained in discharge process • Retirement of dinosaur, new, enlightened

consultant appointed!

British Association of Day Surgery www.bads.co.uk

Mastectomy rates

Consultant No. day cases

No. in-patients

% Day case 2011

% Day case 2012

BADS target

Top 5%

A 0 6 0% 15% 30%

B 2 7 29% 27% 30%

C 0 5 0% 33% 30%

D 1 7 11% 29% 30%

Totals 3 25 10% 26% 30% 14%

British Association of Day Surgery www.bads.co.uk

Barriers to mastectomy day case

• Pre conceptions of team • Major, cancer surgery, anxious patients,

thought to prefer to be in hospital • Painful • Drains

• Out of date patient information leaflets • Follow up for Friday discharges

British Association of Day Surgery www.bads.co.uk

Strategies

• Multi-disciplinary team discussion re merits of hospital vs. home

• Surgeons reviewed need for drains • Analgesia actually used on ward reviewed • Pain management at home information

leaflet developed • Ward staff acted as contact point for

Friday discharges

British Association of Day Surgery www.bads.co.uk

Lap cholecystectomy Consultant 2011 Day

case % 2012 Day Case %

BADS Target Top 5%

A 75% (21) 94%

B 25% (2) 100%

C 81% (38) 88%

D 40% (2) 100%

E 50% (2) 100%

F 74% (40) 71%

Totals 71% (105) 81% 60% 65%

British Association of Day Surgery www.bads.co.uk

Day Case lap cholecystectomy rates

0

10

20

30

40

50

60

70

80

2008 2009 2010 2011

Day case rate

Day case rate

British Association of Day Surgery www.bads.co.uk

Barriers to lap chole day cases

• Booking process • Recorded as in-patient if not operated on in

day unit, despite 0 length of stay • Belief that day cases could only be managed

in the “Day Unit”

• Scheduling after major cases, insufficient recovery time

• Inertia

British Association of Day Surgery www.bads.co.uk

Strategies for lap choles

• Importance of intended management day case explained

• Scheduling reviewed- lap–choles go first • Surgeons competitive tendency exploited!

British Association of Day Surgery www.bads.co.uk

Common barriers

• Preconceptions – Doctors, nurses, patients, carers

• Booking issues • Organisational and scheduling issues • Lack of awareness of benefits • Inertia

British Association of Day Surgery www.bads.co.uk

WHAT CAN YOU DO?

British Association of Day Surgery www.bads.co.uk

Day case rates for selected procedures

• Review day case rates for individual procedures

• Use BADS directory to compare rates with targets

British Association of Day Surgery www.bads.co.uk

British Association of Day Surgery www.bads.co.uk

National Dataset

• Data from CHKS • Outcomes for

England 2011 • Top 5%,25% and

50% of hospitals by procedure

British Association of Day Surgery www.bads.co.uk

British Association of Day Surgery www.bads.co.uk

How to access Better Care Better Value indicators

• Web address:

www.productivity.nhs.uk

British Association of Day Surgery www.bads.co.uk

Select your organisation

British Association of Day Surgery www.bads.co.uk

Summary for your organisation Click on indicator to drill down

British Association of Day Surgery www.bads.co.uk

British Association of Day Surgery www.bads.co.uk

British Association of Day Surgery www.bads.co.uk

British Association of Day Surgery www.bads.co.uk

British Association of Day Surgery www.bads.co.uk

Strategies for change

Post operative stay Yes: >1 day Yes: 1 day No

Pre-

oper

ativ

e st

ay

Yes

E Retain as

Inpatient but remove pre-

operative stay

D Convert

proportion to day case but remove all pre-operative

stay

B Easy win to convert to

a day case

No F

Retain as Inpatient

C Convert

proportion to day case

A Effectively

already a day case

British Association of Day Surgery www.bads.co.uk

Specialty level example

62%64%66%68%70%72%74%76%78%80%

ACurrent rate

BA + zero Inpatient

stays

CB + pre-op stays

only

DC + 1 day post-op

stays

Summary Day Case Rates for Urology

2005/06 activity (2482 Elective IP Adms)

Current DC rate Convert zero IP stays

Convert Pre-op only stays Convert 75% 1 day post-op stays

British Association of Day Surgery www.bads.co.uk

Estimate bed days savings

0

500

1000

1500

2000

2500

AConvert Pre-op stays

only

BA + 1 day post-op stays

CB + remove pre-op stays

on all cases

Summary Bed days saved for Urology

2005/06 activity

Convert Pre-op only stays Convert 75% 1 day post-op stays

Remove pre-op stay for longer stays

British Association of Day Surgery www.bads.co.uk

Top Tips for improving day case rates

• Analyse rates by procedure and compare to BADS target and top 5%

• Identify barriers specific for each specialty and procedure

• Exploit surgeons competitiveness! • Keep improving