DAY CASE SURGERY
away from their GPs due to the pandemic and they are likely to start being referred, potentially leading to another surge. In London, Prof. Briggs was asked to be the clinical lead of the high volume, low complexity elective day case surgery pathways, to oversee the clinical scope of the Getting it Right First Time (GIRFT) programme. The aim was to drive equity of access, excellent clinical outcomes and productivity through the standardisation of pathways and adoption of best practice. Standardised procedure level day case pathways were agreed across all providers in London, supported by expert advisory panels and professional societies. The programme included expectations on productivity, such as 10 cataract operations per half-day list, or four joint replacements on a full day list. The theatre principle was day case by default, for 85% of all procedures.
“Clinicians stepped up to the plate and pathways were developed in just seven weeks. This would have been unthinkable before COVID,” said Prof. Briggs. Twenty-nine pathways, which were mostly day case by default, were signed off by the London Clinical Advisory Group and supported by specialist societies and Royal Colleges. Suitable locations for fast-track surgery hubs across London have been identified, based on analysis of the waiting list and its growth trajectory, alongside a review of theatre and perioperative care capacity. “These have been working very well,” he commented. “So why is there a need to achieve 85% day case rates for elective surgery? It is safer for patients, it ensures resilience if you have surges of infection such as COVID, the top decile of outcome is better for patients, and it will allow us to maintain elective care.” He added that this requires leadership, support from the GIRFT programme, data (via the Model Hospital initiative), anaesthetic support (i.e. topical, local anaesthetic, regional blocks), as well as operational support. So, what are the potential opportunities in the London region for top decile performance in orthopaedics and fracture neck of femur?
“If we reach the top decile for one-year readmissions, 30-day readmissions, day case rates and length of stay, we can free up 83 beds, allowing us to perform an extra 7,279 THR/TKR procedures, improving productivity and efficiency,” he commented. “Similarly, for ophthalmology, if you aim for the top decile, extra capacity could total an extra 33% cataracts per year (or around 4,000 cataract procedures), while also yielding 9,000 outpatient slots. Day case surgery is an important part of this and can transform services.” London now has the lowest number of ophthalmology patients waiting more than 52 weeks for treatment. For orthopaedics,
Current national day case rates will need to improve to tackle the backlog, but Trusts will also need to improve productivity. There is significant variation in terms of late starts, early finishes and inter-case downtime at Trusts, which need to be addressed.
the waiting list has also grown significantly slower than the national picture. Prof. Briggs commented that there is a huge opportunity to reduce unwarranted variation across Trusts in terms of the rates of day case surgery. With the collection of data, it is now possible to challenge Trusts, while they can also learn from the best performing providers. Current national day case rates will need to improve to tackle the backlog, but Trusts will also need to improve productivity. There is significant variation in terms of late starts, early finishes and inter- case downtime at Trusts, which need to be addressed. “Recovery in the future will mean that we have to do something different. It is urgent; it is not an option. We need to use the GIRFT methodology to deliver clinical transformation, use the surgical pathways to standardise care and outcomes, and we need top decile performance to become the ‘new normal’. Maximising day case rates is absolutely imperative to success,” Prof. Briggs continued. He emphasised that theatre principles need to maximise efficiency and productivity – the hub site model, in London, not only ensures this, but also resilience. He asserted that the health service will need to maximise elective capacity at 130%-150%, in order to put elective surgery back on the path to recovery. “We cannot default to pre-COVID
behaviour. We will need to have some difficult conversations with colleagues, systems and hospitals, using granular data,” he concluded.
References 1 El‐Boghdadly, K, & Cook T.M et al, SARS‐CoV‐2 infection, COVID‐19 and timing of elective surgery; A multidisciplinary consensus statement on behalf of the Association of Anaesthetists, the Centre for Peri‐operative Care, the Federation of Surgical Specialty Associations, the Royal College of Anaesthetists and the Royal College of Surgeons of England, Anaesthesia, 18 March 2021, https://doi. org/10.1111/anae.15464
2 The Herald, Coronavirus in Scotland: Surgeon warns fifth of hip fracture patients ‘caught virus in hospital’, 9 June 2020, accessed at: www.
heraldscotland.com/news/
18504171.coronavirus- scotland-surgeon-warns-fifth-hip-fracture-patients- caught-virus-hospital/
3 Price, J., Sheraton, T., Self, R., Cook, T.M, 64 l
WWW.CLINICALSERVICESJOURNAL.COM AUGUST 2021
Towards safe, stable and sustainable resumption of planned surgery after COVID-19. Supported by the Royal College of Anaesthetists, Association of Anaesthetists and The Faculty of Intensive Care Medicine, Anaesthesia, February 2021. https://static1.squarespace. com/static/5e6613a1dc75b87df82b78e1/t/60 549d43cae34a3e18ea0572/1616158019933/ Restarting+surgery_guideline+version+160321.pdf
4 Kotecha, S, COVID: Many NHS staff ‘traumatised’ by first wave of virus, study shows, BBC,
www.bbc.
co.uk/news/health-55630157, 13 January 2021.
5 Greenberg, N., ‘Going for Growth: An outline NHS staff recovery plan post-COVID19 (outbreak 1), Royal College of Psychiatrists, 7 May 2020, www.
rcpsych.ac.uk/docs/default-source/about-us/ covid-19/going-for-growth-version-3-05-05-20. pdf?sfvrsn=7cf71c97_4
The British Association of
CSJ
Day Surgery The British Association of Day Surgery (BADS) is a multidisciplinary organisation, promoting excellence and enhancing education in the delivery of day surgery. The BADS annual virtual conference was held 18 March 2021 and featured a variety of topical presentations from leading experts, poster presentations, and a virtual exhibition. To view the full programme on demand, visit:
https://bads.co.uk/ conference/virtual-conference-2021/ To support the delivery of day surgery, BADS has also published a ‘National Day Surgery Delivery Pack’, developed in collaboration with GIRFT and The Centre for Perioperative Care, Royal College of Anaesthetists, which outlines the key principles and best practice. To access this resource, visit:
www.gettingitrightfirsttime.
co.uk/wp-content/uploads/2020/10/ National-Day-Surgery-Delivery-Pack_ Sept2020_final.pdf To access the BADS Directory of Procedures 6th Edition, visit:
https://publications.bads.co.uk/ bads-directory-of-procedures-6th-
edition-1-p.asp
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