Increasing access or

improving mortality

in endoscopy – the acute

versus elective

debate

Dr Riaz DorConsultant Gastroenterologist

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 handover0915 –1030 6 elective points1030 –1200

Sat SunGIB GIBElective IP InreachTCI 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

What it should look like.

Success

What it really looks like

Thank You

Any questions?