Principles of Day Case Emergency General Surgery

Douglas McWhinniePresident IAAS

Past-President BADS

Reorganise Emergency Surgery

• Consultant-Led

• Prioritise Emergency care over Elective care

• Timely input of senior decision-makers

Admissions and Beds

Increasing PopulationLack of Social Care

Failure of Primary Care

Minimally Invasive Surgery Shorter Length of Stay

Day Surgery

Traditional Model For Emergency Admissions

Discharge

Day 2 Day 3 +

Treatment

Minimum 2-night stay

Admission

Day 1

Can we apply ambulatory principles to the emergency pathway?

James H. Nicoll(1864–1921)

Father of Modern Day Surgery

British Medical Journal 1909;2:753.

8988 day case operations performed Sick Childrens’Hospital and Dispensary, Glasgow

Day Surgery Definition

“Day surgery is the admission of selected patients to hospital for a plannedsurgical procedure, returning home on the same day.

Day Surgery:Operational Guide. DoH, London,2002

Unselected

Unplanned

Day or Night

Ambulatory Emergency Surgery

Selection Criteria

Preassessment

Admission

Operation

Day Unit

Same-Day Discharge

Pre-assessment

Pathway

Peri-operative

Care

Post-operative

Care

Modern Timeline

100 consecutive patients referred with superficial abscesses

Day case group 33/46 (70%) Successfully treated as day cases

Day case group 19 nightsIn-patient group 86 nights

• 48 patients with abscesses

• Unplanned overnight admission rate 5.5%

• Traditional pathway 5.7 times longer than day case

pathway

Lessons from the Abscess Pathway

Personcentric

Prioritise first on list to allow same day discharge

Send patient home to be re-admitted electively

Lessons from the Abscess Pathway

Personcentric

Prioritise first on list to allow same day discharge

Send patient home to be re-admitted electively

Can we utilise this management model to treat other acute surgical conditions?

Hotchen AJ, Coleman G, O’Callaghan JM, McWhinnie D.British Journal of Hospital Medicine 2016; 77(3):180-183

Before After

Initial review (Mins) 29 18

Senior review (Mins) 85 55

Length of stay (Days) 5.2 2.9

Abscesses, Appendicectomies,Irreducible Herniae

Lessons Learned

The management model can be extended to other procedures

BUT…….

A sustainable pathway requires :-

Senior decision-makers

Integration into the emergency pathway

Admission Avoidance

Urgency of Surgery

Elective – Intervention planned or booked in advance of routine admission (planned)

Immediate – Immediate life, limb or organ-saving intervention (within minutes)

Urgent – Intervention for acute onset or deterioration of potential life-threatening conditions (within hours)

Expedited – Patient requiring early treatment where the condition is not an immediate threat to life (within days)

Expedited ProceduresGeneral Surgery Trauma & Orthopaedics

Incision & Drainage of Abscess

- axillary, groin, neck, perianal, pilonidal

Laparoscopic Appendicectomy

Laparoscopic Cholecystectomy

Irreducible Herniae

- Inguinal, femoral, paraumbilical

Biopsy

- lymph node, temporal artery

Arthroscopy

Tendon Repair

K – wiring (finger or wrist)

Reduction & Internal Fixation

Evacuation RPC

Lap Ovarian Cystectomy

Gynaecology

Triage Outcome

Four Month Pilot with Senior Decision-Maker

1028 Referrals with 377 (37%) on ESAC Pathway

266 of 377(69%) Avoided Admission

Royal Derby Hospital

IntroducedThe Virtual ward

Miss Sarah RichardsNational Clinical Lead NHS Elect

SAEC : Adopted by 33 Hospitals in UK

Cohort 1• Aintree University Hospital NHS FT• Barts Health NHS Trust• Royal Bournemouth and Christchurch

Hospitals NHS FT• Central Manchester NHS FT• Frimley Health NHS FT• Kingston Hospital NHS FT• Mid Cheshire Hospitals NHS FT• Norfolk and Norwich University Hospitals

NHS FT• St Helens and Knowsley Teaching Hospitals

NHS Trust• City Hospitals Sunderland NHS FT• Whittington Health NHS Trust• Wirral University Hospital NHS FT

Cohort 2• University Hospitals Coventry &

Warwickshire NHS Trust• Southern Health and Social Care Trust HSCNI• Dorset County Hospital NHS FT• King’s College Hospital NHS FT• University Hospitals of Leicester NHS Trust• West Suffolk Hospital NHS FT

Cohort 3• Bradford Teaching Hospitals NHS FT• East Kent University Hospitals NHS FT• Hampshire Hospitals NHS FT• Imperial College Healthcare NHS Trust• North Bristol NHS Trust• University Hospitals Bristol NHS FT

Cohort 4• Leeds Teaching Hospitals NHS Trust• Lewisham and Greenwich NHS Trust• Maidstone and Tunbridge Wells NHS Trust• Princess Alexandra Hospitals NHS Trust• Royal Surrey County Hospital NHS FT• Shrewsbury and Telford NHS Trust• South Tees Hospitals NHS FT• Southport and Ormskirk Hospital NHS Trust• The Royal Wolverhampton NHS Trust

Reducing emergency admissions and length of stay by introducing emergency surgical ambulatory serviceKazem MA, Hopley C, Corless D.Ann Med Surg (Lond)2019 Jul; 43: 17–24

Leighton Hospital, Crewe

Beware of Data

Emergency General Surgery : Length of Stay

Percentage of emergencies staying overnight

Number of occupied surgical beds at 01.00 hours

Surgical Same-DayEmergency Care Pathway

Traditional Model For Emergency Admissions

Discharge

Day 2 Day 3 +

Treatment

Minimum 2-night stay

Admission

Day 1

Emergency Pathway Re-Design

Emergency Pathway Re-DesignAdmissions/Assessment

+

Default to Day Surgery

Can this emergency surgical patient be treated as a day case ?

Is there any reason this emergency surgical patient cannot be treated as a day case ?

Admission Avoidance

Virtual Ward Concept

- patients wait at home, not in hospital

- called in when anoperating slot available

Emergency Assessment

by Senior Decision-

Maker

Decision Operation

Complex Inpatient

Expedited Planned AS

Virtual Ward

Dedicated Diagnostics

Operative AmbulatoryEmergency Pathway

Planned Ambulatory Emergency SurgeryExpedited Procedures

Exclude :

< 18 years

Systemic sepsis before temporary discharge

Patients with diabetes

Patients with major co-morbidities

Ensure adequate oral analgesia / antibiotics

Proposed surgery is suitable for day case

Patient Selection

Planned Ambulatory Emergency PathwayExpedited emergency procedure required

Pre-operative assessment by clinical team

Temporary discharge to home

Admitted to ‘Virtual Ward’

Coordinator contacts patient regarding

fasting and time/place of admission

Expedited emergency procedure performed as

scheduled

Patient discharged on day of surgery

Where are the Ambulatory Emergency Theatre Slots ?

CEPOD list

- First on list (‘Golden Patient’)

- Between major cases

Ambulatory list

- First on list

Look for cancellations

- Lists

- Individual patients

Ambulatory Appendicectomyin Adults

International Journal of Surgery 12 (2014) 640-644

13 Studies : 8 Retrospective, 2 Prospective, 1 case-controlled1152 patients

Discharged within :12 hours – 27%24 hours – 53%72 hours – 20%

Acute Cholecystectomy

The ‘Golden 72 hours’

Gutt CN et al. Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial. Ann Surg. 2013 Sep;258(3):385-93

Cao AM, Eslick GD, Cox MR. Early laparoscopic cholecystectomy is superior to delayed acute cholecystitis: a meta-analysis of case-control studies. Surg Endoscopy 2016;30(3):1172-82.

Complication RateBile Duct InjuryOperation TimeHospital Stay

Emergency Assessment

by Senior Decision-

Maker

Decision Hot Clinic

Treat & Discharge

Virtual Ward

Dedicated Diagnostics

Non-Operative Ambulatory

Emergency Pathway Operation

Ambulatory Hot Clinic Conditions

Watch and Wait

Early discharge (‘safety net’)

Wound problems

Postoperative complications

Stable PR bleed

Painful jaundice

and so on………….

Patient Selection

Selection Criteria

Preassessment

Admission

Operation

Day Unit

Same-Day Discharge

Pre-assessment

Pathway

Peri-operative

Care

Post-operative

Care