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Assessment of obese patients to facilitate day case admission Sister Sue Roberts – Pre-op nurse practitioner Dr James Palmer – consultant anaesthetist Salford Royal Hospitals NHS Trust Introduction • • • • • Why change practice? Audit What could be changed? Implementation Effects of new process Why change? • • • • Improve patient experience Manage patients effectively Meet day surgery targets Meet 18 week pathway targets Audit of Gynae Overnight stays • One year’s data (2004-5) • 27 ASA1 patients admitted with BMI >35 • 1 required additional analgesia, 1 had vaginal pack, 2 had no social support. • 5 went home same day (1 with BMI=46), • 22 NO nursing/medical intervention required overnight! Population Audit of Obesity • Health survey for England 2000-2002. • Proportion of population with BMI >30 • National 21.4% (quoted as 21.8% elsewhere from same source) • Greater Manchester 21.1% • Salford 22.1% Audit figures at Salford Royal Hospital • 5.5% of daycases done have BMI ≥37. • 6% of non daycase elective surgical patients BMI>37 • Anaesthetic audit showed vast majority feared: – postoperative hypoxia in the obese – OSA • Some patients might benefit from referral for sleep studies and possible home CPAP. What are other NW trusts doing? • 2007 telephone/email audit of all NW day case units • Questions: – Do you have an upper limit for BMI for day surgery? – What is it? – Why has this figure been chosen? Results 45 40 35 30 25 20 15 10 5 0 Max BMI MRI UHSM TGH Hope Bolton Wigan Bury Rochdale Oldham NMGH Tameside Blackburn S/H Discussion points • Choice of max BMI not evidence based – Pennine acute • Follow up for high BMI cases – None declared • Planned development – None declared • Active preassessment – None declared How to assess • Consulted respiratory team in trust • Developed process for pre-op nurses to follow Process ASA 1 with BMI >37 Baseline sitting SpO2 <95% not fit for DSU >3% desturation >95% do 2 minute step test Refer for PSG <3% desaturation complete OSA questionnaire Negative ADMIT TO DSU Improvement with CPAP Positive PSG – referred for NCPAP training Pre-op assessment clinic • Generic clinic • Qualified nurse practitioners • Pre-op support workers • Equipment • In house sleep studies referral Implementation • Step test • Epworth score • Sleep studies how to refer? ?stop clock Outcome • • • • • Individualised patient process identified Utilising day surgery more effectively Increased patient satisfaction No cancellations/AIRs Day surgery staff report no problems Thank you Questions???