SAME DAY / 23 HOUR AMBULATORY SURGERY BREAST CARE MODEL IS IT FEASIBLE? Jo Marsden, Terri Baxter...

SAME DAY / 23 HOUR AMBULATORY SURGERY BREAST CARE MODEL

IS IT FEASIBLE?

Jo Marsden, Terri BaxterKing’s Breast Care,

Kings College HospitalFoundation Trust, London

BREAST SURGERY SAME DAY/23 HOUR MODEL

• Why did we change practice at King’s College Hospital?– Patient demand

• How did we change practice?– We examined the patient pathway and patient experience

• Is it safe and do patients like it?– Yes

• What are we doing now to improve service?– Ensuring continual patient feedback


Non-reconstructive breast cancer surgery• Breast conservation• Mastectomy• +/- sentinel node biopsy /

axillary dissection

• No evidence of adverse physical / psychological recovery compared with in-patient stay

• Nationally variation in length of stay– Day surgery rates in London

range from 20% to > 80%– Average LOS for breast

surgery UK 4.8 days

MEAN LENGTH OF IN-PATIENT ADMISSIONMASTECTOMY (NO RECONSTRUCTION),

OTHER EXCISION 2008-2009

SAME DAY DISCHARGE FOR BREAST CANCER SURGERY AT KING’S BREAST CARE (KBC)

Ambulatory surgery has been offered at KBC since March 2006

• Same day discharge / 23 hour stay• All non-reconstructive breast cancer surgery

– Breast conservation +/- sentinel node biopsy / axillary dissection

– Mastectomy +/- sentinel node biopsy / axillary dissection

The service was introduced in direct response to patient demand

following a change in surgical practice• Cessation of routine use of wound drains (April 2005)

removing the need for in-patient admission

MAPPING THE PATIENT PATHWAY (before and during admission)

Historic Pathway

Diagnosis

Pre-admission

In-patient admission day 1 pre-op

Theatre

Post-op in-patient stay 2-4 days

Doctor-led ward discharge after drain removal

Same day / 23 hour stay

Diagnosis

Pre-assessment clinic 1-2 weeks before surgery

Pre-admission clinic the day before surgery

DSU admission on the day of surgery

Nurse-led same day or 23 hour discharge

Nurse-led pre-assessment

Surgeon consent Anaesthetic

review

Breast CNS Wound + drain

care Arm exercises

TTO’s Drain removal

Pre- assessmentDSU nurse

Breast CNS Discharge planning

Physiotherapist Pre-admission

Consultant (consent)Breast CNS

ENSURING PATIENT SAFETY FOLLOWING DISCHARGE

Results clinic, date for pre-assessment and surgery

Nurse-led pre-admission clinic. Decision for same day / 23 hr

discharge based on DSU medical and social criteria

Pre-admission clinic day 1 pre-op (consent, CNS review)

Admit to DSU for surgery Same day: CNS-led

discharge 23 hour stay CNS-led discharge

Post-discharge support. CNS (9am-5pm Mon to

Fri) DSU senior nurse (5pm-9am) 24/7 bleep holder

Community nurse home visit for social assessment.

Documentation faxed to KBC

Day 1 post-op Community nurse

telephone follow-up or home visit (patient

choice)

Initial care pathway developed with

community nurse PCT leads

KING’S BREAST CARE POST DISCHARGE QUESTIONNAIRE

DEVELOPING THE AMBULATORY PATHWAY

• There have been 3 phases in service development

• At all times KBC co-ordinated continuity of care

March ’06 Same day discharge introduced • Initially one half day list on alternate weeks

• 6 month audit• 44% women used service• Reasons for not using service

• Lack of DSU list (26%) • Lack of overnight-stay facility (17%)

• No re-admissions for complications• Women deferred surgery until DSU available

Nov ’06 - March ‘07

Commenced weekly all day list in DSU Introduction of 23 hour stay

July ’07 – Jan ‘08 Qualitative focus group research with Breast Cancer Care to assess patient and carer needs

KING’S BREAST CARE: DEVELOPMENT OF PATHWAY FEEDBACK FROM FOCUS GROUP DISCUSSIONS

Results clinic, date for pre-assessment and surgery

Nurse-led pre-admission clinic. Decision for same day / 23 hr

discharge based on DSU medical and social criteria


Admit to DSU for surgery Same day: CNS-led

discharge 23 hour stay CNS-led discharge

Post-discharge support. CNS (9am-5pm Mon to

Fri) DSU senior nurse (5pm-9am) 24/7 bleep holder

Community nurse pre-operative home visit

Day 1 post-op community nurse

telephone follow-up / home visit

• More explicit post-operative information wanted

• Dislike of community nurse input - confusion about who to contact with post-op problems

Patient focus group

discussions

POST-DISCHARGE SUPPORT CHANGED FOLLOWING FOCUS GROUP FEEDBACK

Initial Care Pathway (March 2006)

Breast CNS Monday to Friday (9 to 5)

DSU senior nurse Out of hours (5pm to 9am)

24/7 bleep holder

Community nurse Day 1 post-op: standardised post-operative questionnaire (telephone or home visit - patient choice)

Current Care PathwayPatient emphasis on

Breast CNS support

Breast CNS Monday to Friday (9 to 5)

Day 1 post-op: standardised post-operative questionnaire (telephone or home visit - patient choice)

DSU senior nurseOut of hours (5pm to 9am)

24/7 bleep holder

Telephone follow-up by Breast CNS

Breast CNS revised patient post-operative

information

KING’S BREAST CARE: REVISED PATHWAY

Results clinic, date for pre-assessment and surgery, Breast CNS

present

Nurse-led pre-admission clinic Decision for same day / 23 hr discharge based on DSU medical

and social criteria


Admit to DSU for surgery Same day: CNS-led discharge

23 hour stay CNS-led discharge

Post-discharge support. CNS (9am-5pm Mon to Fri) and

telephone questionnaire day 1 post-op DSU nurse (5pm-9am) 24/7 bleep holder

The default position is that all non-reconstructive

breast surgery can be done in DSU

Any change to this for medical or social reasons is

made at the pre-assessment clinic

The only definitive contra-indication is the surgical

procedure

FAQs ABOUT SAME DAY / 23 HOUR STAY AT KING’S BREAST CARE

• ‘Your patients are different’– No they’re not

• ‘It’s not safe to send patients home early’– Yes it is

• ‘Patients need to be on a ward to bond with each other’– ?????? Where’s the evidence

AMBULATORY SURGERY: ALL OPERABLE PATIENTS ARE POTENTIALLY ELIGIBLE

EPG GPG MPG1 MPG2 PPG

3.7

13.4

29.3

19.5

34.1

14.2

26.224.4

18.616.6

NPI for symptomatic invasive breast cancer (% all ages KBC vs BCCOM)

All (KBC) All (BCCOM)

Worse prognosisBetter prognosis

SAME DAY / 23 HOUR BREAST SURGERY MODEL: OUTCOMES AT KBC

King’s Breast Care• All non-reconstructive surgery

is now performed in DSU

• Re-admission rates (March 06 – end June ‘10)– 1251 procedures– 3.4% (N=43) patients

required re-admission for complications

• 2.8% (N=35) managed via DSU and discharged the same day

• 0.6% (N=8) in-patient admission [median stay 3 (range 1-9) days]

same day overnight > overnight

57.4

6.4

36.2

93.1

5.1 1.8

Duration of stay: % patients

March 06 to March 07 Mean age 58 (24-85) yrsJan 09 to June 10 Mean age 58 (30-91) yrs

IS A SAME DAY/23 HOUR SURGERY MODEL FEASIBLE?

Yes• With adequate patient and carer preparation• If all stakeholders are involved• Frees up hospital in-patient resource• Can be done with or without wound drains

Key points• DSU should be the default position for surgery

– In-patient admission should be the exception– Discharge planning starts at pre-assessment

• Patient selection is based on medical co-morbidity and social support

• Clear, reliable anaesthetic / pre-assessment process pathway

Process / pathway mapping• Must be patient focused• Reduces variation in patient care and outcomes• Get patient feedback

REDUCING LENGTH OF STAY FOR BREAST CANCER SURGERY IS NOW A NATIONAL PRIORITY

The Cancer Reform Strategy (2007, 2010)

• Reducing length of stay for breast surgery is a priority – Improve quality of care– Cost savings– Will be an indicator /

benchmark for patients– Promoted as best practice by

GP commissioning

• National implementation supported by the NHS Transforming In-patient Care Programme– Piloted in 13 cancer networks

PATIENT EXPERIENCE OF AMBULATORY BREAST CANCER

SURGERY

Terri Baxter, Breast CNS,

Kings College HospitalFoundation Trust, London

PATIENT EXPERIENCE OF DAY SURGERY

• Reducing length of stay for breast cancer surgery has improved continuity of care

• Having a pre-defined surgical pathway; – Equity of access to all levels of support available for

patients – Identifies patients requiring specific input

• Enhances individualising patient care

• In-patient admission does not provide superior patient psychological support

SAME DAY / 23 HOUR SURGERY HAS FOCUSED SERVICE ON PATIENTS

Patient at centre of activity

Pre-admission clinic (KBC)Day 1 pre-op

Consultant, Breast CNSPhysiotherapist

DSU

Admit 7.30am OR 12.30pm on day of surgery

Anaesthetist

Same nurses admit / recovery

Breast CNS-led dischargeTelephone follow-up

Day 1 post-discharge

Breast CNS

Can arrange for wound check

Results clinic

1 week post-op

Wound check

Discuss further treatment

Physiotherapy review

Pre-assessment clinic (KBC)1 -2 weeks pre-op

Breast CNSPre-assessment nurse

WHAT DO PATIENTS AND CARERS THINK?FOCUS GROUP FINDINGS

Patient support for day surgery was unanimous

• All same day discharge patients said they would have it again

• DSU provided an early psychological boost

• Early discharge implies that surgery is ‘minor’ but at odds with the ‘serious’ diagnosis of breast cancer

In-patient care was not deemed to be superior

Unsuccessful at recruiting carers for focus group discussions

• Telephone interviews with 2 carers

• Information about what to expect after surgery important

WHAT DO PATIENTS AND CARERS THINK?FOCUS GROUP FINDINGS

Care Delivery - Day Surgery

• Infection risk perceived to be less

• Continuity of DSU nursing staff valued highly

• Important for carers to be at home on the day of discharge and for a few days afterwards

• Dislike of community nurse input – preference for breast care team

Care Delivery – In-patient admission• Dissatisfaction with;

• Hospital environment• Lack of continuity of nursing

care and specialist nursing care

Information Needs

• Knowing what to expect after discharge important in reducing patient and carer anxiety

Wound management

• Seroma• Size, appearance, aspiration

unnecessary• Wound drains

• Relief at not having a drain• In-patients who had drains

found them inconvenient and uncomfortable

NATIONAL CANCER PATIENT EXPERIENCE SURVEY PROGRAMME DECEMBER 2010 - BREAST

Operations

Admission date not changed Staff gave complete explanation of what would be

done

Patient given written information about the

operation

Staff explained how operation had gone in understandable way

KCH National KCH National KCH National KCH National

96% 94% 83% 86% 82% 77% 69% 72%

Information given to you before you left hospital and home support

Given clear written information about what

should / should not do post discharge

Staff told patient who to contact if worried post

discharge

Family definitely given all information needed to help

care at home

Patient definitely given enough care from health or

social services


90% 88% 94% 95% 60% 57% - -

Ward nurses

Got understandable answers to important questions

all/most of the time

Patient had confidence and trust in all ward nurses

Nurses did not talk in front of patient as if they were not

there

Always/nearly always enough nurses on duty


59% 74% 45% 66% 67% 86% 63% 62%

PREPARATION FOR SURGERY

In-patient admission

• Need to confirm bed / ward on day of admission

• Discharge planning starts when admitted

• Support during admission• Ad hoc - is patient on

ward when CNS visits?• Peer support?

Same day / 23 hour discharge

• No need for patient / relatives to confirm bed / ward

• Discharge planning starts at the pre-assessment clinic

• Patients still supported• ‘Protected’ time pre

and postoperatively to see CNS

WHAT TO EXPECT IN HOSPITAL


• Potential for changes to ward during admission

• Lack of continuity of nursing staff / doctors (shifts)• Potential for conflicting

medical information and inappropriate medical care

• Hospital environment not conducive to rest


• Patient remains on the same ward per and post op

• Continuity of nursing staff and doctors• Experienced team

managing care for duration of admission

• In home environment patient has control

PLANNING RECOVERY


• Uncertainty over discharge• Drains• When is the ward

round?• When will TTO’s be

prescribed?

• May adopt sick role• Increased analgesia

uptake due to drug rounds


• Control over discharge• No drains simplifies

management• Breast CNS-led• Pre-prescribed TTOs

• Routine maintained• Important for vulnerable

pts• Nuture not make

dependent

PATIENT EXPERIENCE OF DAY SURGERY

• Reliability of service– What you say happens will happen

• Problems are pre-empted – Patient trust in staff increases– Enhances relationships with patients

• CNS time management is improved – Plan when to see patients– Privacy and dignity of patients maintained

• Meet in the breast unit at mutually agreed times• Patient, carers and CNS not waiting for each other on wards

HOW CARE CAN BE INDIVIDUALISED FURTHER

Patient at centre of activity

Pre-admission clinic (KBC)Day 1 pre-op

Consultant, Breast CNSPhysiotherapist

DSU

Admit 7.30am OR 12.30pm on day of surgery

Anaesthetist

Same nurses admit / recovery

Breast CNS-led discharge Telephone follow-up

Day 1 post-discharge

Breast CNS

Can arrange for wound check

Results clinic

1 week post-op

Wound check

Discuss further treatment

Physiotherapy review

Pre-assessment clinic (KBC)1 -2 weeks pre-op

Breast CNSPre-assessment nurse

Wound assessment chartPost-op PROM

●Information needs and DSU experience

Pre-op PROM ● Information

needs

Baseline assessment● Social (FACE tool)

● Psychological

KING’S BREAST CAREBREAST SURGERY SAME DAY/23 HOUR MODEL

When it works well• Good communication

– Pre-assessment staff– DSU– Anaesthetics – Breast care team– Patient / carers

• Patients with dementia and learning difficulties– No problems with, during

or following admission

When it doesn’t• Poor communication

• Cancellation on the day of surgery due to deviation from normal pre-assessment pathway– No cohesive review of

patient assessment

RED = Not Started AMBER = Work in Progress GREEN = Implemented BLUE = N/A

Primary Care - Optimising Pre Op Health

0

5

10

15

20

25

30

35

40

Blood pressure BMI, diabetes etc Lifestyle advice Patient Choice Patient Information

Pathway

Rec

eive

d P

athw

ay R

etur

ns

PROMOTING REDUCED LENGTH OF STAY FOR BREAST CANCER SURGERY

Cancer Reform Strategy (CRS, 2007)– Identified breast cancer surgery same day / 23 hour stay to be a

priority– Aim to improve:

• Effectiveness by reducing unnecessary length of stay• Clinical outcomes• Quality of care for patients - ensure experience of care is

positive

The NHS Improvement Transforming Inpatient Care Programme– Support the CRS implementation of same day / 23 hour surgery

model – Promote good clinical practice from:

• Transforming Inpatient Care Programme• Enhanced Recovery Programme

BREAST SAME DAY/23 HOUR MODELTHE ROLE OF THE NHS CANCER IMPROVEMENT TEAM

Transforming in-patient careCancer and QIPP priority (Quality, Innovation, Productivity, Prevention) Save 1 million bed daysEvidence, testing, spread

Enhanced recovery programmeOptimise;Pre-operative assessmentPeri / post-operative managementPost-operative rehabilitation

King’s College Hospital - emphasis on same day dischargePan Birmingham Network - aim for 23 hour LOS


King’s College Hospital

• Non-reconstructive surgery on one site (hospital trust)

• DSU (7am-8pm Monday - Friday)

• Aim for same day discharge / 23 hour stay for >90% of non-reconstructive surgery

• Facilitated by • Not using wound drains• Seromas not aspirated• Patient demand

• Commenced March 2006

Pan Birmingham Cancer Network

• Non-reconstructive surgery at 6 hospital trusts

• Utilise in-patient theatre sessions

• Aim for standard LOS to be 23 hours for 80% of non-reconstructive surgery

• Visited King’s• Test replicality• No routine use of drains or

routine seroma aspiration

• 2 trusts initiated pathway (2006)


Different resourcesBoth achieved their

aimProcess mapping at both sites enabled

service development

King’s Breast CareEmphasis on same

day discharge

Pan-Birmingham Trust

Emphasis on 23 hour stay

BREAST CANCER AT KING’S

Screen-detected cancers• Screening uptake in

Camberwell is the lowest in the UK

• (62% vs 72%)• Social deprivation

• Tumour characteristics similar to that expected from the national BASO screening audit– 25% node positive– Mean grade– Mean size

Symptomatic cancers• 70% of cancers nationally

present symptomatically• At KBC ~ 85%

• ~25% of women are

inoperable at presentation– Co-morbidity– Locally advanced /

metastatic disease

• If patients have operable disease, selection for ambulatory surgery should be based on comorbidity and social criteria

Pre-operative surgical assessment (as soon as surgery is decided on)• Full clinical and risk assessment• Default booking as day case – overnight booking as

the exception not the rule• Specialist advice… anaesthetic/co-morbidity

management• Obtain patient informed surgical consent• Inform patient of admission time, length of

stay & discharge date• Patient education: self management e.g. arm

mobility exercises - physiotherapist/nurse/ DVD• Prosthesis advice/fitting• Prescribe TTO’s• Plan theatre scheduling and timing

Intra-operative• Drains the exception not

the norm • Anaesthetics: short acting/

local anaesthetic• Analgesia: non

steroidal/non opiate • Minimal intra operative

fluids• *Sentinel node Biopsy

Post-operative• Analgesia: avoid PCA/opiates• Provide nutrition• Nurse led discharge: • Information: Patient discharge

summary with 24/7 contact information and wound care

• GP discharge summary• Drain management information

(if required)• Fitting permanent prosthesis• TTO’s

Surgical follow-up options• Patient activated

e.g. telephone call• Nurse follow up call• Outpatients appointment• GP follow-up• Open Access: seromas/drain

management and complications• Joint clinic: e.g. further treatment options: chemotherapy/radiotherapy

*Intra-operative -Sentinel Node Biopsy: In centres where adequate training has been provided. Extra theatre time e.g. 40mins is required for this procedure

Primary care – optimising pre- operative health• Blood pressure • BMI, diabetes etc.• Lifestyle advice• Patient choice • Patient

information

Diagnosis (Triple Assessment Clinic) • Full clinical assessment• Mammogram/ultrasound/ +/-MRI +Chest X-ray • Core/fine needle biopsy • Bloods• Discuss informed consent• Pathology reportingOutcomes• Discuss results• Involve patient in choice of

treatments/trials/reconstruction• Confirm treatment/surgery date• Provide patient information prescription, hand held

record/care plan/patient diary• Inform patient of next steps…pre-operative assessment• Inform GP positive results within 24 hours/negative

within 10 working days

Admission ( Day Unit, Treatment Centre, Surgical Ward)• Admit day of surgery • Starvation – the ‘2 and 6’ rule fasting time 6 hours for food and clear fluids 2 hours prior to surgery (consider carbohydrate drink)• No pre med• Pre-op analgesia (paracetamol/ non steroidals)

‘Patient involvement & Choice Guarantee’ ‘Professional & Patient Outcome Audits’

Continuing care for cancer patients• Continuing cancer

care assessment care plan (including referral as appropriate to AHPs)

• Education – self care management programme

Enhanced Recovery Programme - Day Case/23 Hour Breast Pathway

Patient informed decision making

AMBULATORY SURGERY: ALL OPERABLE PATIENTS ARE POTENTIALLY ELIGIBLE

EPG GPG MPG1 MPG2 PPG

13

7

11

14

2

8

17

5

14

3

11

24

16

28

NPI - symptomatic invasive breast cancer at KBC

PreMP PostMP All


The NHS Improvement-Transforming Inpatients Care Programme Workshops

• Where next?– Template for breast same day / 23 hour model agreed

(based on Enhanced Recovery Programme)– Prospective audit to monitor implementation at test sites

(November 2010 to March 2011)

The Cancer Reform Strategy (2007, 2010)• Reducing length of stay for breast surgery is a priority

– Has been recognised as offering potential for cost savings– May become one of the published indicators / benchmarks for

patients– May be promoted as best practice by GP commissioning

BREAST SURGERY SAME DAY/23 HOUR MODELWHERE NEXT?

NHS Improvement-Transforming Inpatients Care Programme

WorkshopsAgreed template for model

Enhanced Recovery Programme)

Prospective audit to monitor implementation at test sites

(November 2010 to March 2011)

The Cancer Reform Strategy – Refresh

Length of stay for breast surgeryRecognised as offering cost savings May become a benchmark of care May be

promoted as best practice by GP commissioning

Reduced length of stay will happenDevelop a pathway that works for

for patients

SAME DAY / 23 HOUR AMBULATORY SURGERY BREAST CARE MODEL IS IT FEASIBLE? Jo Marsden, Terri Baxter...

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