Increasing access or
improving mortality
in endoscopy – the acute
versus elective
debate
Dr Riaz Dor
Consultant Gastroenterologist - presentation from seven day services in diagnostics event held on 4 March 2013 #7dayDiagnostics
Increasing access or improving mortality in endoscopy – the acute versus elective debate
1. Increasing access or
improving mortality
in endoscopy – the acute
versus elective
debate
Dr Riaz Dor
Consultant Gastroenterologist
2.
3. Endoscopy Demand
Continues to increase
• Aging population
• Target procedures
• JAG requirements
• Surveillance procedures
• Colonoscopy > UGI Endoscopy
• CRC screening
• Future?
4. Drivers for change
• 18 week pathway
• Waiting list management
• Capacity
• Patient satisfaction
• OOH GIB
5. 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
6. Ironing out the creases - 1
Operational management
• Referral guidelines
• Vetting
• Validation of surveillance
• Scheduling
• Escalation policy
7. Ironing out the creases - 2
Data collection/ Planning
• DNAs
• Share information
8. Ironing out the creases - 3
Managing Capacity/demand
• Proactive vs reactive
• Regular review
• Colonoscopy Preassessment
• Optimise existing capacity/'dropped lists'
• Timings audit
9. Ironing out the creases - 4
Review variation
• Procedures
Patient engagement
• PB vs FB
• DNA reduction
• Satisfaction
10. Drivers for change NMUH
• AMU working
• Consultant weekend working
• WLI expense
• Limited physical space
• ‘The right time’
11. Options
• Optimise current lists
• 8- 9am lists
• Evening lists
• Weekend lists
• More WLI
• More rooms
• More endoscopists
12. WLI
• Efficient
• Throughput
• Popular
• Case selection
• Demand management
• Ad hoc vs continuous
• Costly
14. Benefits
• Safer
• Improve M&M
• Help capacity – inpatient and outpatient
• Commisioners
• ‘GIB Distress Syndrome’
• ? LoS
15. What did we do?
• Job planned
• 5 gastro
• 5: 8 weekends
• Planned working
• Reduction in AMU working
• ACU low risk GIB
16. Weekend plan
0900 –0915 handover
0915 –1030 6 elective points
1030 –1200
Sat Sun
GIB GIB
Elective IP Inreach
TCI elective IP
'
17. Examples
• PEG tubes
• GI bleeds
• Enteral Tube feeding
• Post procedure problems
• ? ERCPs
18. Experience
• Very positive
• Rewarding
• Relief from other teams
• Sunday in reach service v popular
• Not too onerous
• Buy in from colleagues
• ?others
19. 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
20. Challenges
• Nursing Rotas
• Porters
• Planning of lists
• Case selection
• Too popular !
• Remaining 3 weekends
21. Success Success
What it should look like. What it really looks like