Download Breast Cancer Surgery Default to Day Case

Breast Cancer Surgery
Challenging Preconceptions
Hamish Brown
Consultant Breast and General Surgeon
Sandwell and West Birmingham Hospitals NHS Trust
[email protected]
Breast Cancer
• c46000 new cases per annum
• Majority will be treated surgically
• Average LOS nationally = 2.62 days
• Potential to save at least 65000 bed days
• Must be acceptable to patients
Reducing length of stay in breast
cancer surgery
• Conservative surgery
• National Screening Program - early
detection and small tumours
• Axillary sampling v clearance
• Sentinel node biopsy
• >30% will require mastectomy
• Axillary clearance if node positive
Length of Stay
Distribution of elective lengths of stay, 2009-10 prov Total excision of breast
3,000
2,500
Total LOS
Post-op LOS
No. cases
2,000
1,500
1,000
500
-
0
2
4
6
8
10
12
14
16
18
Length of stay (days)
20
22
24
26
28
30+
Why should mastectomy be an inpatient procedure?
•
•
•
•
•
Relatively short operation
Low post operative pain
Early mobilisation
No risk of retention/ileus
Rare significant post op events
2006
• We decided to reduce our standard LOS
to 23 hours
• Process mapping and redesign
In patient activities
•
•
•
•
•
•
•
‘Pre-operative’ assessment
Psychological needs of patients
Post operative physiotherapy
Temporary prosthesis supply
Discharge by doctors
Take home medications
Wound drain management
Diagnosis
Foundation Year 1
Pre-operative
Assessment
Preadmission
Surgeon - Consent
Admit One
Day Pre-op
Anaesthetic
Assessment
Theatre
Breast care nurse
Exercises/wound care
Drain management
Post-operative
Stay for 4 days
Doctor led
Discharge after
Drain removal
Discharge Medications
Drain Removal
Breast Care Nurse
Input
Pre-operative assessment
• Standardised multidisciplinary pre-op
assessment & discharge planning
–
–
–
–
–
–
–
–
Surgical care practitioner
(F1 doctor)
Breast Care Nurse
Developed access to specialist assessment
Post op exercises taught
Self management of drains taught
Day of surgery admission
Reduced cancellations/postponements
Psychological needs
• Assessment by BCN at pre-ad
• Psychology assessment very rarely
needed
• Guaranteed telephone access
• Patient satisfaction survey
Discharge planning
• Take home analgesia at Pre-ad
• Follow up appt arranged on admission
• Temporary prosthesis supply by ward
nurses
• Discharge to protocol by ward nurses
• Out patient review by BCN at 3 days
• No Primary care involvement or workload
Historic Pathway
Integrated Care Pathway
Diagnosis
Diagnosis
Preadmission
Admit One
Day Pre-op
FY 1
Anaesthetic
Assessment
Anaesthetic
Assessment
Surgeon - Consent
Theatre
Post-operative
Stay for 4 days
Doctor led
Discharge after
Drain removal
SCP /FY1
Anaesthetic Assessment
TTO
Preadmission
Drain Education,
ED Planning (BCN)
Surgeon – Consent
Admit Day of Surgery
Theatre
TTO
BCN input
Nurse led discharge
Same day or 23 hours
Day 3 Follow-up by BCN for
wound check and drain removal
Pilot Study -Identified problems
•
•
•
•
Patient lack of confidence – drains
Over-proscriptive guidelines
Nausea and vomiting
Bed availability & delays
• At end of pilot average LOS = 2 days
• Minor complaints
• 28 day emergency readmission 1%
Birmingham (NHS)Treatment Centre
Change of Approach
• Sentinel node biopsy = 50% reduction in
traditional IP caseload
• Treatment Centre admission by
preference
• Review of drain use
• Default to day case
The results
Numbers (MX, WLE & ANC, ANC
120
100
80
60
40
20
0
2006-7
2007-8
2008-9
Progressive Move to Day Case
90
80
70
60
50
%BTC
40
30
20
10
0
%DC
2006-7
2007-8
2008-9
Changes to In-Patient LOS
2.5
2
1.5
Cons A & B
Cons C
1
0.5
0
2006-7
2007-8
Days
2008-9
Conclusions
• Breast cancer surgery can safely be
carried out as 23 hr stay or day case.
• Wound drains can be managed by
patients at home.
• Wound drains make little difference to
seroma rates.
• Integrated pre-operative assessment is
key to reducing length of stay.
British Association of Day Surgery
Spreading the learning
•
•
•
•
•
Possible to do in other tumour sites?
Appropriate length of stay
Similar issues
How?
Who will benefit?