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Increasing access or improving mortality in endoscopy – the acute versus elective debate

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NHS Improvement
NHS Improvement

Increasing access or improving mortality in endoscopy – the acute versus elective debate Dr Riaz Dor Consultant Gastroenterologist - presentation from seven day services in diagnostics event held on 4 March 2013 #7dayDiagnostics

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Increasing access or improving mortality in endoscopy – the acute versus elective debate Dr Riaz Dor Consultant Gastroenterologist
Increasing access or improving mortality in endoscopy – the acute versus elective debate
Endoscopy Demand Continues to increase • Aging population • Target procedures • JAG requirements • Surveillance procedures • Colonoscopy > UGI Endoscopy • CRC screening • Future?
Drivers for change • 18 week pathway • Waiting list management • Capacity • Patient satisfaction • OOH GIB
OOH GIB • Current practice • BSG UGIB Audit (2007) • Pt safety • Mortality higher at weekends • denovo presentations vs IP (mortality almost twice) • Juniors/ Seniors concerns • Ad hoc service at weekend
Ironing out the creases - 1 Operational management • Referral guidelines • Vetting • Validation of surveillance • Scheduling • Escalation policy
Ironing out the creases - 2 Data collection/ Planning • DNAs • Share information
Ironing out the creases - 3 Managing Capacity/demand • Proactive vs reactive • Regular review • Colonoscopy Preassessment • Optimise existing capacity/'dropped lists' • Timings audit
Ironing out the creases - 4 Review variation • Procedures Patient engagement • PB vs FB • DNA reduction • Satisfaction
Drivers for change NMUH • AMU working • Consultant weekend working • WLI expense • Limited physical space • ‘The right time’
Options • Optimise current lists • 8- 9am lists • Evening lists • Weekend lists • More WLI • More rooms • More endoscopists
WLI • Efficient • Throughput • Popular • Case selection • Demand management • Ad hoc vs continuous • Costly
Weekend working??!??
Benefits • Safer • Improve M&M • Help capacity – inpatient and outpatient • Commisioners • ‘GIB Distress Syndrome’ • ? LoS
What did we do? • Job planned • 5 gastro • 5: 8 weekends • Planned working • Reduction in AMU working • ACU low risk GIB
Weekend plan 0900 –0915 handover 0915 –1030 6 elective points 1030 –1200 Sat Sun GIB GIB Elective IP Inreach TCI elective IP '
Examples • PEG tubes • GI bleeds • Enteral Tube feeding • Post procedure problems • ? ERCPs
Experience • Very positive • Rewarding • Relief from other teams • Sunday in reach service v popular • Not too onerous • Buy in from colleagues • ?others
Has it made any difference ? • All GIB bleeders scoped within 24 hours • No overnight calls • LoS reduced by 1.8 days • No excess in mortality • Capacity vs WLI • Monday morning calmer • Happier teams
Challenges • Nursing Rotas • Porters • Planning of lists • Case selection • Too popular ! • Remaining 3 weekends
Success Success What it should look like. What it really looks like
Thank You Any questions?

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Increasing access or improving mortality in endoscopy – the acute versus elective debate

  • 1. Increasing access or improving mortality in endoscopy – the acute versus elective debate Dr Riaz Dor Consultant Gastroenterologist
  • 3. Endoscopy Demand Continues to increase • Aging population • Target procedures • JAG requirements • Surveillance procedures • Colonoscopy > UGI Endoscopy • CRC screening • Future?
  • 4. Drivers for change • 18 week pathway • Waiting list management • Capacity • Patient satisfaction • OOH GIB
  • 5. OOH GIB • Current practice • BSG UGIB Audit (2007) • Pt safety • Mortality higher at weekends • denovo presentations vs IP (mortality almost twice) • Juniors/ Seniors concerns • Ad hoc service at weekend
  • 6. Ironing out the creases - 1 Operational management • Referral guidelines • Vetting • Validation of surveillance • Scheduling • Escalation policy
  • 7. Ironing out the creases - 2 Data collection/ Planning • DNAs • Share information
  • 8. Ironing out the creases - 3 Managing Capacity/demand • Proactive vs reactive • Regular review • Colonoscopy Preassessment • Optimise existing capacity/'dropped lists' • Timings audit
  • 9. Ironing out the creases - 4 Review variation • Procedures Patient engagement • PB vs FB • DNA reduction • Satisfaction
  • 10. Drivers for change NMUH • AMU working • Consultant weekend working • WLI expense • Limited physical space • ‘The right time’
  • 11. Options • Optimise current lists • 8- 9am lists • Evening lists • Weekend lists • More WLI • More rooms • More endoscopists
  • 12. WLI • Efficient • Throughput • Popular • Case selection • Demand management • Ad hoc vs continuous • Costly
  • 14. Benefits • Safer • Improve M&M • Help capacity – inpatient and outpatient • Commisioners • ‘GIB Distress Syndrome’ • ? LoS
  • 15. What did we do? • Job planned • 5 gastro • 5: 8 weekends • Planned working • Reduction in AMU working • ACU low risk GIB
  • 16. Weekend plan 0900 –0915 handover 0915 –1030 6 elective points 1030 –1200 Sat Sun GIB GIB Elective IP Inreach TCI elective IP '
  • 17. Examples • PEG tubes • GI bleeds • Enteral Tube feeding • Post procedure problems • ? ERCPs
  • 18. Experience • Very positive • Rewarding • Relief from other teams • Sunday in reach service v popular • Not too onerous • Buy in from colleagues • ?others
  • 19. Has it made any difference ? • All GIB bleeders scoped within 24 hours • No overnight calls • LoS reduced by 1.8 days • No excess in mortality • Capacity vs WLI • Monday morning calmer • Happier teams
  • 20. Challenges • Nursing Rotas • Porters • Planning of lists • Case selection • Too popular ! • Remaining 3 weekends
  • 21. Success Success What it should look like. What it really looks like