Focus on: Cholecystectomy

Delivering Quality and Value
Focus on: Cholecystectomy
Introduction
This document aims to help local health communities and organisations
improve the quality and value of care for cholecystectomy patients. It is one
of a series of documents produced by the Delivering Quality and Value team
at the NHS Institute for Innovation and Improvement as part of the high
volume Healthcare Resource Groups (HRG) programme.
Figure 1
Healthcare Resource Groups (HRGs)
Cumulative % FCEs by HRG for England (2003/04)
100
HRGs are groups of
clinically similar
activities for which a
similar quantity of
resources is needed.
They are also the basis
for the NHS Payment
by Results system.
90
80
70
60
% 50
40
30
20
10
0
HRG
Source Hospital Episode Statistics
50 HRGs account for 50% of all bed days. 50 different HRGs (however, there is overlap)
account for 50% of all finished consultant episodes (FCEs). As the graph shows, a relatively
small number of HRGs account for a large proportion of NHS resources.
The programme is based on the
concept that by focusing on a
limited range of high volume
HRGs (or related care groups), the
NHS Institute can help the NHS to
make the maximum impact on
improving the quality and value
of care for NHS patients.
The initial series of HRGs (or
related patient groupings) were
chosen on the basis that they
were high volume, and hence
high resource consumers, and also
represented a range of clinical
areas.
The series of HRGs chosen were:
The document covers:
• acute admissions in adult
mental health
• the Delivering Quality and
Value team’s approach
• acute stroke
• fractured neck of femur
• the key characteristics of
organisations providing high
quality care and value for
money
• cholecystectomy
• measures for improvement
• short stay emergency care
(length of stay two days or less)
• further information.
• Caesarean section
• urinary tract infections (as a
tracker condition for frail
elderly patients)
• primary hip and knee
replacement.
01
The approach
A literature review was
undertaken of the recognised
evidence in delivering optimised
care for cholecystectomy patients.
The ‘Further information’ section
gives further detail of the
documentary evidence.
A thorough data analysis was
done using nationally available
data from Hospital Episode
Statistics (HES) as an indicator to
rank and identify organisations
primarily using day case rates.
The initial statistics were then
adjusted for age and deprivation
levels, mortality rate and
readmission rates.
Verifying the selection of organisations
02
Having identified the local health
and social care communities, we
then approached the
organisations to allow us to visit
them and observe how they
manage this group of patients.
The ‘Acknowledgements’ section
lists the organisations we visited.
The information contained within
this pathway was only possible
because health and social care
communities allowed us to see
their practice.
We then undertook site visits,
ensuring that at least 50% of our
time was spent observing,
watching, listening and looking
at the flow and processes of care.
We also explored the use of
information to aid clinical and
non-clinical decision making. The
remaining time was spent
conducting a series of semistructured interviews with
patients and key members of
staff across the pathway of care
(including surgeons, anaesthetists,
day surgery and theatre
managers, pre-assessment nurses,
ward and theatre nurses,
technical and administrative staff,
information analysts, and middle
and senior managers, including
chief executives). In total we
interviewed or observed over 150
staff and patients for this
pathway.
1 Co-production with the NHS, involving all sites visited and national bodies and experts relevant to the pathway
The knowledge we gained from
these visits and co-production
events1 was then consolidated,
and the optimised pathway of
care illustrated later in the
document was identified.
We worked in partnership with
the NHS throughout this project
to validate the pathway and the
knowledge gained from the site
visits, and to identify measures
for improvement that would be
helpful indicators for evaluating
the impact of change.
03
How to use this document
The content of this document has
been developed with the help of
NHS staff for the benefit of any
organisations and stakeholders
that play any part in the
cholecystectomy pathway.
Key characteristics have been
developed with the expectation
that they will be widely adopted
across the NHS, so that patients
receive a high quality experience
irrespective of where they receive
their care.
The majority of improvements are
applicable and easily transferable
to other surgical procedures, and
implementation will have
numerous benefits for the patient
and health and social care
services.
Included in this document are
case studies and examples from
trusts, including a patient
information leaflet and advice for
surgeons, anaesthetists and
commissioners, to enable units to
rapidly adopt the recommended
pathway.
Cholecystectomy pathway
Context
Using national (England) data
from HES, the following
indicators highlighted wide
variability in cholecystectomy
care.2 There was variability in:
• volume of procedures
• day case rates
• numbers of emergency vs
elective cholecystectomies
• percentage of open and
laparoscopic procedures
• length of stay
04
• readmission rates (within 28
days of surgery).
A total of 49,077 cholecystectomy
procedures took place in England
between 1 April 2005 and
31 March 2006, of which 86%
were performed electively
(42,402) and 14% (6,675) during
an emergency admission. Overall,
84% of cholecystectomies were
undertaken laparoscopically.
There is large variation between
trusts, with high performers
achieving over 90% laparoscopic
rates (includes day case and
inpatients' cholecystectomies)
compared with some low
performers where the rate of
laparoscopic cholecystectomy is
under 50%.3
The national average day case
cholecystectomy rate is only 6.4%.
The highest performing
organisations achieve a day case
rate between 40 and 50% and
feel that the rate of at least 70%
is readily achievable.
Figure 2
Day case rates for laparoscopic cholecystectomy for acute trusts
Day
rates for laparoscopic
cholecystectomy
foror
acute
trusts
from April
2005than
to
Aprilcase
2005–March
2006 (excluding
specialist trusts
those
performing
fewer
March 2006 (excluding specialist trusts or those performing less than 20 cases per annum)
20 cases per annum)
2 Based on HRG codes G13 – Cholecystectomy >69 or with complications and G14 – Cholecystectomy <70 without complications
3 This may include some highly specialised units doing complex surgery, and therefore 50% may be an appropriate rate in this setting
Figure 2
demonstrates the
national variation
in day case rates
for
cholecystectomy,
highlighting that
almost half of
trusts have a day
case rate of less
than 5% and a
third doing no day
cases at all.
Figure 3
Number of laparoscopic cholecystectomies by day cases and inpatients for acute trusts
April 2005–March 2006 (excluding specialist trusts or those performing fewer than 20 cases per annum)
05
Figure 3 highlights the wide variation in overall volumes of laparoscopic cholecystectomies performed
as day case versus inpatient, and demonstrates the potential to increase day case rates.
Figure 4
Average length of stay for elective and emergency cholecystectomy for acute trusts
April 2005–March 2006 (excluding specialist trusts or those performing fewer than
20 cases per annum)
Figure 4 indicates
that the average
length of stay
ranges from 1.1
days to 5.2 days for
an elective
cholecystectomy
and from 5.2 days
to 27 days for an
emergency
cholecystectomy.
Average length of stay for open and laparoscopic cholecystectomy for acute trusts
April 2005–March 2006 (excluding specialist trusts or those performing fewer than
20 cases per annum)
Figure 5 indicates
that the average
length of stay for
open
cholecystectomy is
9.1 days (the range
is from 2.3 days to
21.2 days) and for
laparoscopic
cholecystectomy is
2.6 days (the range
is from 1.2 days to
6 days).
06
Figure 5
Open
Laparoscopic
Figure 6
Readmission rates for elective and emergency cholecystectomy for acute trusts
April 2005–March 2006 (excluding specialist trusts or those performing fewer than
20 cases per annum)
07
Figure 7
Readmission rate %
Readmission rates vs day case rates for elective laparoscopic cholecystectomy for acute trusts
April 2005–March 2006 (excluding specialist trusts or those performing fewer than 20 cases)
08
Figure 7 shows that
there is no
evidence of an
increased
readmission rate in
units that perform
a high number of
day case
laparoscopic
cholecystectomy.
Day case rate %
The average length of stay for laparoscopic
cholecystectomy is 2.6 days (ranging from 1.2 to
6 days). If the average length of stay was
reduced by one day, there would be an annual
saving for the NHS of approximately 35,400 bed
days (£8 million - based on a bed day cost of
£225).
A trust performing 300 elective inpatient
laparoscopic cholecystectomies a year could
expect to save about £100,000 per annum by
performing 40% as day case procedures and
reducing the length of stay of the remainder
by one day (based on a bed day cost
of £225).
The typical and recommended pathways
From our observations and discussions, the following flowcharts highlight the typical and recommended
pathways for the management of patients with gall bladder disease admitted electively or as an
emergency. The pathways illustrate areas where patient satisfaction could be improved and where
considerable cost and time savings could be made for the organisation.
Figure 8
Typical patient pathway for cholecystectomy
Elective process
Emergency process
GP referral with
suspected biliary
disease
Specialist OPA
£225
per day
Repeat investigation
costs £30 for
ultrasound
£10 for LFTs
Acute admission with
suspected biliary
disease
Inpatient investigations
OP
investigations
Are investigations
complete?
NO
Does patient
need surgery on this
admission?
YES
Commissioning contractual
delays of up to five months for
elective treatment
May not universally occur and
lack of pre-operative assessment
can lead to DNAs and on the day
cancellations
Discharged to have
delayed elective
operation
Put on waiting list (WL)
for elective surgery
Pre-operative
assessment
09
NO
Patients have been
known to require three
emergency admissions
for biliary
colic/cholecystitis whilst
on WL for elective
surgery
YES
Admission day or more before
surgery £225 per day
Patients may have unnecessary
investigations done by junior
doctors eg repeat bloods,
chest x-ray
Cost issues at surgery disposable
vs reusable equipment
Routine use of antibiotics £5
£225 per day
Unnecessary repeat
blood tests
Admit for surgery
SURGERY
Post-operative hospital
stay
Each admission (>69 or with complications)
Cholecystitis/biliary colic
= £2,271
as above + cholecystectomy = £4,478
£87 per visit
Outpatient follow-up
Elective cholecystectomy
= £1,875
Figure 9
Recommended patient pathway for cholecystectomy
Start of patient
education process to
prepare them for day
case procedure
Elective GP referral for
suspected biliary disease
Emergency primary care
referral or acute hospital
admission with suspected
acute biliary disease
Investigations completed
prior to OPA ideally by
primary care ie ultrasound
and LFTs
Each day spent in
hospital waiting for tests
or surgery costs £225
Specialist OPA
Rapid diagnostic
assessment (within 24
hours)
Added to waiting list for
surgery at OPA
Date of pre-assessment
and operation offered to
patient
Ideally all three processes
occur at same attendance
10
Lack of effective pre-assessment can lead to
DNAs and on the day cancellations. Patient’s
expectations are also unlikely to have been
properly managed for day case operation
Emergency patients
also go through preassessment process
to ensure consistency
of pre-operative
assessment and
patient information
Pre-assessment clinic
Staggered or semi block arrival
times (patient focus)
Admit on day of surgery
Admission day or more before
surgery costs £225 per day
Emergency patients undergo surgery
on acute admission if appropriate
This avoids commissioning contractual
delays of up to five months for elective
surgery. Patients have been known to
require three emergency admissions for
biliary colic/cholecystitis whilst on
waiting lists for elective surgery
SURGERY
No routine use of antibiotics saves £5
and reduces patient risk
Savings also around standardising disposable
equipment
Same day / 23 hour
discharge
Specialist laparoscopic surgeon
performing >40 laparoscopic
cholecystectomies per annum
reduces rates of conversion to
open surgery
Nurse-led
discharge
Post-operative support via
telephone helpline with
rapid access to surgical
assessment if appropriate.
No routine OP follow-up
Use of standard
post-operative
analgesia
regimes
minimising use
of opiates
Avoiding unnecessary outpatient
follow-up saves £87 per visit
Each admission (>69 or with complications)
Cholecystitis/biliary colic
= £2,271
As above + cholecystectomy = £4,478
Elective cholecystectomy
= £1,875
Fundamental principles for delivering the
recommended cholecystectomy patient pathway
• The pathway is a standardised process which should cover 95% of
laparoscopic cholecystectomy cases, but it does have the flexibility
to allow for exceptions.
• The pathway is applicable to all patients undergoing surgery,
irrespective of whether they are cared for within a day case, 23hour or inpatient environment.
• Day case surgery is the norm rather than the exception in the
majority of elective procedures; this requires the development of a
day case mindset across the organisation.
• Patient expectations are managed consistently across the entire
patient journey, from GP referral to hospital discharge.
• Surgical sub-specialisation reduces patient morbidity, increases
productivity and reduces length of stay. Recent publications
recommend a minimum number of 200 laparoscopic cholecystectomies
per surgeon over five years to minimise morbidity and improve
outcomes (this equates to a minimum of 40 cases per year).4
Conversion rates should be less than 5% for elective laparoscopic
cholecystectomy and less than 10% for emergencies. Conversion
rates should be used in conjunction with complication rates.
• Emergency laparoscopic cholecystectomy is safe in the hands of subspecialised laparoscopic surgeons. Conversion rates are halved (8%
versus 16%) when operating in the acute phase of the disease, as
opposed to allowing the acute episode to settle and the patient
being operated on at a later date.5 Emergency patients have rapid
access to diagnostic investigations (within 48 hours of presentation)
to enable early operative intervention.
4 Hobbs, M.S., Mai, Q., Knuiman, M.W., Fletcher, D.R. and Ridout, C.S. (2006), Surgeon experience and trends in intraoperative complications in laparoscopic
cholecystectomy, British Journal of Surgery, Vol. 93, No. 7, pp. 844–53
5 O’Boyle, C.J., Murphy, C., May, J.C., and Kapadia, C.R. (1999), Immediate versus delayed laparoscopic cholecystectomy for acute cholecystitis, British Journal of Surgery,
Vol. 86, p. 57
11
12
• Redesigning the emergency pathway will reduce costs by preventing
avoidable emergency readmissions, as well as improving the patient
experience.
• An effective, standardised pre-assessment service is essential for
optimising the patient experience. It ensures the patient and carer
are fully informed and prepared for admission, operation and
discharge. Other benefits include reducing cancellations and ‘did not
attends’ (DNAs). Emergency patients would also benefit from the
pre-assessment process.
• Redesigning the pathway reduces:
• unnecessary duplication (eg repeat blood tests)
• emergency readmissions with cholecystitis/biliary colic
• outpatient follow-ups.
It also reduces overall costs, helping to meet or come in under tariff.
• Combining day case facilities with 23-hour/short stay facilities
maximises flexibility of capacity and the use of afternoon theatre
sessions. More complex patients can be accommodated overnight if
required, rather than having to default to an inpatient bed.
The key characteristics of
organisations providing high
quality care and value for
money
The following characteristics
have been found to be the key
features for delivering quality
and value for patients
undergoing cholecystectomy.
These are followed by suggested
measures for improvement. The
suggested measures for
improvement are those that we
judge to be of value to
organisations to enable them to
benchmark their current practice
against the characteristics
described and to further improve
it.
Overarching characteristics
common to the entire pathway
are identified first.
Characteristics are then broken down into the following pathway
steps:
• Referral
• Preoperative assessment
• Admission
• Cholecystectomy operation
• Postoperative care, discharge and follow-up.
13
Overarching characteristics
The wider health community is committed to the
development of high quality and cost-effective elective
day surgery and short stay services.
• Elective day surgery/short stay development is reflected in trusts
annual business plans.
• Day case rates are analysed by procedure, specialty and surgeon to
identify areas for improvement. Commissioners and providers then
discuss an appropriate level of day cases for each procedure. The
British Association of Day Surgery has published a directory of day
surgery procedures6 which recommends performing specific
procedures as either day case, 23-hour or short stay. Trusts can also
examine possible procedure shifts from inpatient to 23-hour stay,
23-hour stay to day case and day case to outpatient or primary care.
• An enthusiastic clinician (with identified sessional commitments)
leads on day surgery/short stay development with a senior manager.
14
• Patients are always defaulted to day case (or 23-hour if day case is
not possible).
• Staff with a day case mindset are developed and recruited.
• Day surgery facilities are designed/redesigned to aid flow
(a combined day surgery and 23-hour facility might provide more
flexibility, but overnight stays should be based on clinical criteria
rather than on the availability of beds). Thought is given to the
flow of patients through the facility, and any non-value-adding
time (such as transferring patients to theatre, and preoperative
and postoperative stays) is reduced by as much as possible.
• There is investment in team training (in-house or other), so that
expertise and specialisation in laparoscopic techniques are
developed. Surgeon sub-specialisation reduces patient morbidity,
increases productivity and reduces length of stay. Recent research
recommends a minimum of 200 laparoscopic cholecystectomies per
surgeon over five years to minimise morbidity and improve outcomes
(this equates to a minimum of 40 cases per year).7 Conversion rates
for laparoscopic cholecystectomy should be less than 5% for electives
and less than 10% for emergencies. Teams can benefit from visiting
high performance organisations and using specialist information
sources (see the ‘Further information’ section). Conversion rates
should be used in conjunction with complication rates.
• There are dedicated training lists, although it is recognised that
these may be less productive. 23-hour stay patients (rather than day
case patients) are considered for use in training.
6 British Association of Day Surgery (2006), BADS Directory of Procedures 2006, BADS, London
(www.daysurgeryuk.org/content/Professionals/BADS-Directory-of-Procedures-2006.asp)
7 Hobbs, M.S., Mai, Q., Knuiman, M.W., Fletcher, D.R. and Ridout, C.S. (2006), Surgeon experience and trends in
intraoperative complications in laparoscopic cholecystectomy, British Journal of Surgery, Vol. 93, No. 7, pp.
844–53
‘It is important to have a champion to take day surgery forward. It
makes all the difference. If our champion was taken out of the
equation, then our outcomes wouldn’t be half as good.’
Consultant anaesthetist
‘Our staff are motivated to shorten the length of stay. We would
do everything as day case if we could, because things run more
smoothly and patients prefer it.’
Theatre sister
‘Two surgeons came up with the idea of developing laparoscopic
work. Management supported the vision and then other surgeons
joined in.’
Consultant surgeon
15
Case study
Royal Surrey County Hospital:
Best practice
16
The default position for the
performance of
cholecystectomy is to perform it
laparoscopically in a day case
setting. Such procedures are
placed first on a morning
theatre list with a view to
discharging the patient from
hospital on the same afternoon.
The limitations of this surgery
relate to co-morbidity and
obesity in the individual
patient, which might preclude
day care on the basis of the
anaesthetic risk. There is a
facility for admitting patients if
they fail to meet the criteria for
discharge, but this is a rare
event. Conversion to open
surgery is also rare in the day
case setting, and patients
deemed to be at high risk of
open conversion are precluded.
The success of day case
laparoscopic cholecystectomy
depends upon good case
selection, high quality surgery
and anaesthetic, and good
postoperative analgesia – both
while in hospital and at home.
Good counselling about what
to expect before, during and
after surgery, and confirmation
of adequate social support once
discharged, are all imperative.
Laparoscopic cases are always
performed with the consultant
in attendance, and are
regarded as good training
opportunities for middle and
senior-grade training surgeons.
Cases are often transmitted live
to our minimal access therapy
training unit (MATTU) during
courses specifically aimed at
training in laparoscopic
cholecystectomy as well as
other generic laparoscopic
courses. The MATTU also allows
for trainees to practise
cholecystectomy techniques
using state-of-the-art
equipment on cadaveric animal
models and using virtual reality
simulators.
The involvement of a
specialised laparoscopic team at
consultant level ensures that,
where possible, surgery is not
prolonged, complications are
minimised and conversions to
open surgery are rare, all of
which results in the delivery of
successful day case surgery for
the majority of patients
undergoing laparoscopic
cholecystectomy.
Professor Tim Rockall,
Consultant Surgeon
www.mattu.org.uk
Multidisciplinary teamwork is key.
• Surgeons, anaesthetists, day surgery managers, nursing staff,
radiology staff, operating department staff, theatre staff, recovery
staff, waiting list managers, diagnostics staff, technical staff,
information analysts and administration staff all work together.
• There is a day case/short stay mindset within the team. Inpatient
care is the exception in the majority of elective procedures, not the
norm.
• There are clear roles and responsibilities, with clearly defined
managerial and clinical leadership.
• The whole team is aware of (and ideally has first-hand experience
of) the entire patient journey, ensuring that a consistent message is
given to patients and carers.
• Multidisciplinary care documents are developed in order to
standardise the process, improve patient safety and facilitate nurseled discharge.
‘It’s everyone’s job to get the list started on time. It requires a team
effort for operating lists to run smoothly.’
Consultant surgeon
17
Case study
Airedale NHS Trust:
Laparoscopic cholecystectomy: default to day
surgery
We wanted to change custom
and practice and challenge
organisational behaviour to
promote best practice in day
surgery.
18
Approach
We arranged a multidisciplinary
working group, with
membership from all aspects of
the patient pathway from
referral to discharge and up to
30 days post surgery.
Laparoscopic cholecystectomy
became the main focus for the
day surgery programme, which
was led by the day care
manager, lead surgeon,
anaesthetist and infection
control clinical nurse specialist.
We developed an audit
questionnaire within the group
which followed the patient
journey from preoperative
assessment through to 30 days
post surgery at home.
Initially the programme
generated opposition from all
areas, but most surprisingly
from the nurses on the day
unit. However, with time,
patience and by demonstrating
the quality benefits and high
levels of patient satisfaction
associated with admitting and
caring for patients as day cases,
staff quickly saw the benefits of
the new approach.
Achievements
1. Improved patient satisfaction.
2. A raised profile for day case
surgery within the Trust and
an agreement to default to
day case for identified
surgical procedures.
3. Increased staff interest in day
case surgery.
4. National recognition,
through presentation at an
international ambulatory care
conference.
5. An increase in overall day
case rates from 59% in 2001
to 83% in 2006.
6. Improved communication
with our partners in the
primary care trust.
7. The release of inpatient beds
and freeing-up of resources.
8. Regular questioning of
traditional medical and
nursing practice, based on
best practice guidelines.
9. Development of a
comprehensive, nurse-led
preoperative assessment
service and nurse-led
discharge using agreed
criteria.
‘Staff satisfaction has improved
because we now do more
complex day case surgery. The
staff do not like doing just local
anaesthetic procedures.’
‘By day 10 I wanted to go back
to work, but the GP did not
want me to. Why?’
Responding to the patient
satisfaction survey, 63 out of 67
people replied that they would
have a similar operation as a
day case again.
Sherie Herpe, Matron for Day
Case and Theatres
Effective use of data and information to enhance
decision making.
• Ensure accurate clinical coding by involving clinicians.
• Data and information are used effectively to enhance decision
making.
• Accurate clinical coding is ensured through the involvement of
clinicians.
• Clinicians are aware of HRG costs and tariffs, including costs of
pathology, drugs and disposables.
• Trusts establish baseline performance, set targets for improvement
based on the top performing organisations and monitor them,
eg they aim to achieve 90% of elective laparoscopic
cholecystectomies as day cases or 23-hour stays.
‘Staff are genuinely interested in how they are performing, and we
audit and feed back regularly.’
Day surgery service manager
19
• Audits take place on a regular basis (eg of conversion rates, length
of stay, reasons for unplanned admissions, infection rates,
cancellations, changes in theatre lists and primary care reattendance rates).
• Benefits of following the recommended pathway for laparoscopic
cholecystectomy are discussed with commissioners to prevent
emergency readmissions during the waiting period and to minimise
the financial implications of operating during acute admission vs
later surgery (see Table 1). See Appendix 5 for further advice for
commissioners.
• Organisations consider developing a rapid emergency surgical
pathway (to allow for surgery during the acute phase) for patients
with acute cholecystitis/biliary colic. This improves the patient
experience and reduces emergency admissions/readmissions.
Table 1
Example of tariff - cholecystectomy older than 69
years
20
Admitted with acute
cholecystitis/biliary colic and
treated conservatively on that
admission
£1,875
Admitted with acute
cholecystitis/biliary colic and
operated on during that
admission
£4,478
Admitted with acute
cholecystitis/biliary colic, treated
conservatively and discharged
then added to waiting list to be
readmitted electively for surgery
£4,146 (£1,875 emergency
admission plus £2,271 for
elective cholecystectomy)
Cost of readmission as an
emergency while waiting for
elective cholecystectomy
£1,875 per admission
Commissioners often impose a
waiting list rule of a minimum of
five months wait for elective
surgery. Patients waiting for
cholecystectomy following an
acute admission for cholecystitis
or biliary colic can be readmitted
up to three times while on the
waiting list for surgery. This is
poor quality care for the patient
and often leads to a more
difficult laparoscopic operation,
increasing operative morbidity
and conversion to open surgery.
Repeat acute admissions prior to
surgery will significantly increase
costs to commissioners and waste
NHS resources.
Case study
Patient interview
Jeremy, a 23-year-old male, was
interviewed, having undergone
a laparoscopic cholecystectomy.
He had returned from theatre
about two hours previously and
was awake and drinking water.
He was being cared for in the
23-hour unit but was hoping to
go home later that evening. His
father and girlfriend were with
him and were also prepared to
take him home.
‘I got acute cholecystitis five
months ago while abroad. I was
hospitalised and investigated
there and then transferred back
to the UK once I was fit to
travel. I was seen in the
outpatient department and told
I would need to have my gall
bladder removed. I tried a lowfat diet to keep the symptoms
at bay. I had several
uncomfortable episodes, as well
as having three episodes of
acute cholecystitis which
required me to be admitted to
hospital. The pain was awful
and you feel so ill. I felt very
well prepared for the operation
today. The pre-assessment was
useful and I have been
prepared to go home this
evening. I am a bit sore, which I
expected, but the pain is not
anything like the acute
cholecystitis pain.
If there was one thing I would
change about my experience it
would be to have had my
operation as soon after
diagnosis as possible. That way I
would have suffered less and I
wouldn’t have needed to be
admitted to hospital several
times or have had to take time
off work.’
21
Measures for improvement
• 70% of elective laparoscopic
cholecystectomies carried out
as day cases (90% including
23-hour short stay).
• Length of stay for
laparoscopic
cholecystectomies.
• Staff satisfaction surveys
(including on multidisciplinary
team working and training
opportunities).
• Consultant data by:
• volume of laparoscopic
cholecystectomy vs volume
of planned open
22
• percentage breakdown of
day case, 23-hour and
inpatient operations
• elective cholecystectomy vs
emergency cholecystectomy
rates
• conversion rates (elective
less than 5% vs emergency
less than 10%) should be
used in conjunction with
complication rates.
• re-admission rates (elective
vs emergency).
• Analysis of costs, including
disposables, drugs,
pathology/radiology, staffing.
• Audit of clinical practices to
identify areas that may not be
accurately reflecting the
procedures performed:
• minimal number of queries
from clinical coder back to
the clinician
• accuracy rate of case notes
for coding.
Referral characteristics
• Consistent information from all healthcare professionals helps to
manage patient and carer expectations throughout the patient
pathway, beginning with the GP consultation. For example, patients
expect to have the operation laparoscopically as a day case (see
Appendix 1 for example).
• A referral pathway is designed collectively with primary care to
include pre-referral investigations and relevant patient details such
as body mass index (BMI), blood pressure and co-morbidity.
• Patients are given a choice of dates and times for their outpatient
appointment, pre-assessment and operation, including preoperative
investigations.
• Emergency patients are diagnosed early, with an ultrasound scan
(USS) and liver function test (LFT) taking place within 24 hours of
presentation.
• An emergency care pathway for cholecystitis/biliary colic patients is
developed with the accident and emergency department, primary
care and the surgical team, including fast track to a specialist
outpatient clinic with results of tests if appropriate.
23
‘We ensure that we give the same message to patients from start
to finish - starting at the GP surgery and reinforced by all staff
throughout the patient journey.’
Preoperative assessment team
‘If I had been an inpatient then I would have had the mentality
that I was ill. The whole outlook of day surgery can really help you
with your recovery. I was able to recover with family and friends, all
in the comfort of my own home. I could return to normality almost
straightaway. It’s a shame more people don’t know about it.’
Day case patient
Measures for improvement
• Percentage of patients with a
confirmed diagnosis of
cholecystitis/biliary colic (rapid
access to USS and LFT within
48 hours for emergency
patients, including inpatients
and outpatients).
• Percentage of GP referrals for
which the results of the USS
and LFT are included in the
GP letter.
Preoperative assessment characteristics
• Dedicated facilities are provided for preoperative assessment, with
the appropriate capacity for pre-assessing all surgical patients.
• Nursing staff are highly trained and have rapid access to
diagnostics, anaesthetic opinions and other multidisciplinary
consultations as appropriate.
• Pre-assessment staff play an important role in obtaining secondstage consent for operations by ensuring that patients have a
thorough understanding of the admission, operation and discharge
process (supported by written information for patients).
• Alternative methods for pre-assessment are explored - telephone,
face-to-face, group pre-assessment, primary care or other.
• Pre-assessment outcomes that could delay surgery are reported to
the appropriate disciplines in a timely manner (including to the
waiting list office to avoid last-minute list changes). The preassessment team has direct access to specialist services if
appropriate.
24
• Inpatients with cholecystitis/biliary colic who are planning to have
surgery on that admission should be assessed by the preoperative
team prior to surgery, where possible. This helps to manage patient
expectations and ensures the standardisation of information.
‘Our pre-assessment staff experience the whole patient pathway,
so they are in a better position to prepare patients for day case
admission and discharge.’
Preoperative assessment sister
‘I had my gall bladder removed as an emergency. When I came
back from theatre I had a tube and a bag coming out of my
tummy. No one warned me that this would happen before my
operation, and for two days I thought I had had a colostomy. If I
had been warned that I would come back with a wound drain, I
wouldn’t have worried about it.’
Inpatient
Measures for improvement
• Percentage of patients given
a choice of date for
preoperative assessment.
• Percentage of DNAs.
• Percentage of cancellations
for medical reasons.
• Percentage of patients being
deferred.
• Patient satisfaction survey on
the pre-assessment
experience.
25
Admission characteristics
• Patients are admitted on the day of surgery.
• Where day case and 23-hour stay patients are on a mixed list, day
case patients are scheduled early in the operating list to facilitate
same-day discharge.
• Patients prefer staggered arrival times to minimise pre-operative
waiting but semi-block arrival times will also facilitate theatre flow.
‘It was really nice to come into hospital only one hour before my
operation. Sitting around would’ve made me more anxious.’
Day case patient
Measures for improvement
26
• Percentage of DNAs and
cancellations for medical and
non-medical reasons (fed
back to the pre-assessment
team).
• Patient waiting time (from
admission to theatre).
Cholecystectomy operation
characteristics
• All-day operation lists are developed (this can entail alterations in
consultant job plans).
• Dedicated lists are used for day surgery and short stay (avoid
mixing them with emergencies and inpatients, if facilities allow).
• Management of pain and postoperative nausea and vomiting
(PONV) is agreed with the team. Use paracetamol and Non
Steroidal Anti-Inflammatory Drugs (NSAID’s) eg diclofenac,
ibuprofen, local anaesthetic infiltration into port sites. Avoid post
operative opiates.
• Day case anaesthetic techniques enable early discharge to take
place.
• There is no routine need for perioperative antibiotics (which cost
approximately £5) in elective laparoscopic cholecystectomies,
minimising drug-related adverse events.
• Less need for DVT Prophylaxis for day cases (which costs
approximately £20 per injection).
27
Case study
Northumbria Healthcare NHS Foundation Trust
28
I was appointed as a specialist
laparoscopic surgeon in 1999,
and the following year I
initiated a day case
laparoscopic cholecystectomy
programme. We had a very
motivated day case unit team,
and with increasing pressure on
inpatient beds, it was an ideal
time to convert to day case
laparoscopic cholecystectomy.
We spent a significant amount
of time in the early days
discussing the care pathway
with our patients, and felt that
patient information, contact
and feedback were very
important. We started by
operating on selected patients,
performing their
cholecystectomy as early in the
morning as possible and
discharging them in the late
afternoon or early evening. We
were conscious that this was
not being done in great
numbers elsewhere, and
arranged to have a district
nurse visit the patient that
evening and also the following
morning if indicated.
We soon decided that selecting
people for this procedure was
the wrong way to do things,
and we changed to a system
where day case cholecystectomy
was the default unless there
were good clinical or social
reasons to admit the patient.
As a result, we have no age
limit and our day case rates
have risen dramatically. Within
two years, our day case rate
was approximately 20%, and it
has now reached over 50%
(and is rising year on year).
Our patient satisfaction rating
is consistently high. Many of
our patients come to the clinic
saying, ‘I will be done as a day
case, won’t I?’ Over the past six
years, we have only had two
patients readmitted having
been discharged as day case
laparoscopic cholecystectomies.
We do occasionally admit
patients postoperatively, mainly
due to the operation being
performed late in the day
rather than due to medical
complications.
Liam Horgan,
Consultant Surgeon
www.nugits.nhs.uk
Measures for improvement
• Conversion rate from
laparoscopic to open
(evidence suggests that less
than 5% is acceptable, but
below 2% is achievable in
experienced hands).
Conversion rates should be
used in conjunction with
complication rates.
• Percentage of late finishes in
theatre, and the reasons for
these.
• Use of perioperative
antibiotics.
• Cost of disposables per
surgeon per procedure.
• Time of operation on list
(surgery performed later in
the day may lead to an
overnight stay, unless facilities
allow late same-day
discharge).
‘It is important to have a well trained, dedicated team; when we
don’t have our normal team it is not as effective. It is all down to
the skills of the laparoscopic surgeon; specialisation is the key. Our
surgeons often do 10 laparoscopic cases on an all-day list.’
Consultant anaesthetist
‘We have identified potential savings of £100,000 through
standardising the use of disposable equipment. I’m sure we could
reduce costs and come in under tariff. Staff are actively
encouraged to suggest ideas for reducing costs.’
Theatre manager
29
Postoperative care, discharge and
follow-up characteristics
• Agreed criteria for discharge (based on patient recovery rather
than minimum postoperative stay) are followed, and discharge is
nurse-led. Refer to Guidance about the discharge process and the
assessment of fitness for discharge (BADS 2002).
• To support later same-day discharge, longer opening hours are
considered as part of the day case facility.
• Ward-dispensed, pre-packed discharge medication is standardised.
• Clear, written patient information regarding discharge care is
provided, containing telephone numbers for postoperative advice.
• 24-hour follow-up advice and support is provided (eg via a
helpline).
• Discharge summaries are sent to GPs in a timely manner.
• There are no routine outpatient postoperative follow-ups.
30
‘I don’t see why we cannot discharge some patients up to 10pm at
night. Patients tell me that they would much prefer to sleep in
their own bed.’
Day ward sister
‘I was discharged later in the day which meant that I could say
“goodnight” to my daughter before she went to bed.’
Day case patient
‘We used to telephone all patients the day after surgery. But we
stopped because patients were either out or we disturbed their
rest. Patients prefer to contact us if there are any problems, rather
than us contacting them. This has saved us a lot of nursing time.’
Day surgery nurse manager
31
Measures for improvement
• Percentage of elective
laparoscopic
cholecystectomies done as
day cases (75% is an
achievable rate), and
percentage done as day cases
including a 23-hour stay (90%
is an achievable rate).
• Percentage of (and reasons
for) unplanned overnight
stays (both medical and nonmedical). The higher the day
case cholecystectomy rate,
the more likely it is that
unplanned overnight stay
rates will increase - this is a
recognised consequence of
trying to maximise day case
cholecystectomy rates.
• Readmission rate (less than
5% is achievable for elective
cholecystectomy).
• Percentage of patients
contacting the 24-hour
follow-up service, and their
reasons.
• Percentage of routine
postoperative follow-up
outpatient appointments (by
consultant).
Benefits of following the
pathway
The length of stay is reduced/the day case rate is
increased.
• Patient flow is improved.
• Variability in the process is reduced. This results in:
• increased activity
• best use of capacity (resources for inpatient operations and
emergency care are freed up)
• patients being treated faster
• shorter waiting times.
Patient expectations are managed and satisfaction is
improved.
32
• Consistent information is provided about the medical condition,
the options for management and what to expect from treatment.
• Patients have choice and certainty over dates for hospital
appointments and over the operation date.
• Access to well designed facilities improves the patient experience.
• Well trained staff provide consistency of care.
• Patients are able to recover in their own homes and return to
normal activities earlier.
• Risks of hospitalisation, eg through hospital-acquired infection, are
reduced.
• Good clinical outcomes improve patient safety.
• Effective pre-assessment and booking processes reduce
cancellations.
There are significant financial benefits.
• Reductions in the length of stay and standardisation of procedures
and equipment all reduce costs.
• Productivity is increased through reducing variations in the process.
• Waste is reduced and resources are freed up, eg fewer last-minute
cancellations free up inpatient beds.
Surgical reputation is enhanced through improvements
in quality.
• Opportunities for marketing are created in the new, competitive
NHS environment.
• Staff and patient satisfaction increase.
• Clinical sub-specialisation is encouraged.
• Recruitment opportunities increase, attracting medical staff.
Team working and the working environment improve.
• The multidisciplinary care pathway achieves a shared vision and
purpose.
• A day case and short stay mindset is developed in staff.
33
Conclusion
34
The contents of this report are
based on the Delivering Quality
and Value team’s observations of
the practices of NHS organisations
that are judged to be delivering
high quality care and value for
money. Although these
observations have been tested
thoroughly, it should be
recognised that they may not be
the only ways of delivering high
quality care and value for money,
but we believe that they will give
valuable guidance and direction
to those seeking this goal.
• Understand how your
organisation performs when
compared against the key
measures and benchmarks
suggested.
Quality and Value team expects
to produce the following to
support the cholecystectomy
pathway:
• Generate a locally owned
change programme for
improvement.
• Guidance for commissioners (to
be published in early December
2006).
• Integrate the local change
management programme
within health community
integrated service improvement
programmes (ISIPs) and local
delivery plans (LDPs).
• Information for GPs and
patients (to be published in
early December 2006).
To improve services, organisations
should follow this guidance and
take the following simple steps:
Further products will be produced
to support implementation of this
guidance and local improvement.
In particular, the Delivering
We would value your
contributions to our future work.
If you would like to be involved,
or have any comments, please
contact the Delivering Quality
and Value team at
[email protected].
Acknowledgements
We wish to thank everyone who has contributed
their time to enable us to carry out this work, and
in particular the staff who took time out from their
busy schedules to show us how they work and for
all the information they shared. This includes the
organisations we visited and their associated PCTs
and local authorities.
We would also like to thank the following for their
contribution:
British Association of Day Surgery
BUPA hospitals
Milton Keynes General NHS Trust
Royal Surrey education laparoscopic centre
The trusts we visited were:
Airedale NHS Trust
Bolton Hospitals NHS Trust
Hereford Hospitals NHS Trust
Northumbria Healthcare NHS Trust
Royal Surrey County Hospital NHS Trust
35
Further information
Published material
Association of Anaesthetists of Great Britain and
Ireland (2005), Day surgery (revised edition 2005),
AAGBI, London
(www.aagbi.org/publications/guidelines/docs/daysur
gery05.pdf).
Aylin, P., Williams, S. and Jarman, B. (2005),
Variation in operation rates by primary care trust,
British Medical Journal, Vol. 331, pp. 539–41
(http://bmj.bmjjournals.com/cgi/reprint/331/7516/539).
British Association of Day Surgery (2002), Guidelines
about the discharge process and the assessment of
fitness for discharge, BADS, London
(www.daysurgeryuk.org/content/files/Handbooks/ba
dsdischargecriteria.pdf).
36
British Association of Day Surgery (2004), Day Case
Laparoscopic Cholecystectomy, BADS, London
(www.daysurgeryuk.org/content/files/Handbooks/La
paroscopicCholecystectomy.pdf).
NHS Modernisation Agency (2004), 10 High Impact
Changes for Service Improvement and Delivery: a
guide for NHS leaders, Department of Health,
London
(www.institute.nhs.uk/NR/rdonlyres/84F6F682-31F14123-BF2CECDB6841DDC5/0/High_Impact_Changes.pdf).
Royal College of Nursing (2004), Day Surgery
Information (sheet 2): Patient information and the
role of the carer, RCN, London
(www.rcn.org.uk/publications/pdf/daysurgery_patien
tinfo.pdf).
Royal College of Nursing (2004), Day Surgery
Information (sheet 4): Discharge planning, RCN,
London
(www.rcn.org.uk/publications/pdf/daysurgery_discha
rge.pdf).
Williams, S., Bottle, A. and Aylin, P. (2005), Length of
hospital stay and subsequent emergency
readmission, British Medical Journal, Vol. 331, p. 371.
Organisations and online resources
British Association of Day Surgery
35–43 Lincoln’s Inn Fields
London WC2A 3PE
Telephone: 020 7973 0308
Fax: 020 7973 0314
Email: [email protected]
Website: www.bads.co.uk
Medline Plus (Patient Education Institute)
Lay person’s interactive guide to the
cholecystectomy procedure:
www.nlm.nih.gov/medlineplus/tutorials/cholecystect
omyopenandlaparoscopic/htm/index.htm
Minimal Access Therapy Training Unit
Royal Surrey County Hospital Postgraduate Medical
School
University of Surrey
Manor Park,
Guildford
Surrey GU2 7WG
Telephone: 01483 688691
Fax: 01483 688633
Email: [email protected]
Website: www.mattu.org.uk
Northumbrian Upper Gastro-Intestinal Team of
Surgeons (NUGITS) Laparoscopic Training Institute
North Tyneside General Hospital
Rake Lane
North Shields
Tyne and Wear
Northumberland NE29 8NH
Website: www.nugits.nhs.uk
Short Stay and minimal access surgical nursing
School of Health Studies
University of Bradford
Unity Building
25 Trinity Road
Bradford BD5 0BB
Website: www.bradford.ac.uk/health
The Preoperative Association
Telephone: 020 7631 8896
Fax: 020 7631 4352
Email: [email protected]
Website: www.pre-op.org
37
Appendix 1
Example of written information given to patients in outpatient
consultation and/or preoperative assessment
Biliary System
right hepatic
duct
left hepatic duct
liver
pancreas
stomach
gallbladder
38
common hepatic
duct
pancreatic duct
cystic duct
common bile duct
duodenum
39
Appendix 2
Overcoming resistance to change - some common myths
Myth
Some doctors and nurses think that patients are
better cared for in hospital after surgery. Patients
cannot have adequate pain control at home.
Patients will be unable to cope. What happens if
something goes wrong during the postoperative
period?
Fact
Laparoscopic cholecystectomy is commonly
performed as a day case procedure already. There
are nationally tested peri- and postoperative
analgesic regimes that enable patients to go
home rapidly after surgery.
40
Myth
Patients expect to stay in hospital to recover for a
couple of days after surgery.
Fact
Adequate information about what to expect on
the day of surgery and in the subsequent
postoperative recovery period is essential. If a
patient expects to be treated as a day case, they
will be prepared for recovering at home. Early
mobilisation post-surgery reduces morbidity.
Patients prefer to recover in their home
environment and to return to independence
quickly, eg familiar surroundings, support from
carers, no sleep deprivation, better food, less risk
of hospital-acquired infections.
Myth
Patients have to stay for a minimum number of
hours postoperatively or demonstrate the ability
to tolerate meals.
Fact
There are well established published discharge
criteria (eg BADS) based on patient recovery.
Myth
Patients cannot be discharged late in the
evening.
Fact
There should be no reason why patients cannot
be discharged later in the evening as long as
discharge criteria are met and social
circumstances allow.
Myth
Elderly patients and patients who live alone are
not suitable for day surgery.
Fact
The pre-assessment process should ensure
patients are not excluded from the option of day
surgery and are helped to organise a
carer/relative to support the early postoperative
period. Exclusion from day surgery on age alone
is inappropriate; it should be based on clinical
criteria. Elderly patients prefer to recover at
home whenever possible.
Myth
All patients need to be seen routinely in the
outpatient clinic after surgery.
Fact
The vast majority of patients do not require
follow-up. However, there should be a system to
enable patients to seek expert advice quickly if
problems occur.
Myth
All patients should be prepared to expect
conversion to open operation.
Fact
Patients should be prepared to expect conversion
only in certain circumstances, eg less than 5%
conversion rate for elective laparoscopic
cholecystectomy and less than 10% for
emergency laparoscopic cholecystectomy.
Myth
If we increase our day case rate, we will increase
our readmission rate.
Fact
There is evidence clearly showing that high day
case rates do not lead to higher readmission rates
and poorer outcomes.
Myth
Hospitals cannot achieve the recommended
cholecystectomy pathway because they don’t
have dedicated day surgery and short stay
facilities.
Fact
It is desirable to have dedicated day case and
short stay facilities. However, this pathway is
designed to enable all patients to have the same
level of care irrespective of bed location. The
mindset of staff is more important rather than
the location of the bed.
41
Appendix 3
Advice for surgeons
• Manage patients' expectations from the first
consultation so they expect a day surgery
procedure.
• If operating on patients from inpatient beds,
schedule early on the theatre list to facilitate
same-day discharge.
• Stagger or semi-block admissions are preferred by
patients and ward staff.
• Develop the staff team to work towards common
objectives.
• Local anaesthetic injection of port sites prior to
insertion of ports reduces postoperative
discomfort.
• Avoid routine use of antibiotics.
42
• Think about the costs vs benefits of laparoscopic
disposables and rationalise use where appropriate.
• Use of a postoperative wound drain does not
prevent same-day discharge (the drain can often
be removed within four hours).
• Lists may run more efficiently and patients are
more likely to be discharged home on the same
day if junior doctor training is confined to
patients who are planned to stay overnight.
• There are well established postoperative analgesic
regimes that avoid opiates and reduce incidence
of postoperative nausea and vomiting (PONV).
This will minimise delayed discharge due to
inadequate pain management and PONV.
• Discharge should be based on agreed criteria for
patient recovery rather than minimum
postoperative stay. This should be nurse-led.
• Avoid routine outpatient follow-up. Rapid access
to follow-up should be in place in the event of
postoperative untoward events following
discharge.
Appendix 4
Advice for anaesthetists
• Manage patients' expectations so they expect a
day surgery procedure.
• Work with the preoperative assessment team to
agree criteria for day case laparoscopic
cholecystectomy and advise on individual cases
where necessary.
• There are well established postoperative and
PONV regimes for laparoscopic cholecystectomy
that minimise the use of opiates and facilitate
early discharge (refer to BADS Day Case
Laparoscopic Cholecystectomy publication).
• Question the routine use of perioperative
antibiotics in elective cases.
• Encourage surgeons to use local anaesthetic
injection of port sites prior to insertion of ports to
reduce postoperative discomfort.
43
Appendix 5
Advice for commissioners
• Identify other high volume surgical procedures
that would benefit from the same approach. Refer
to NHS Institute Delivering quality and value:
Focus on productivity and efficiency for
developing day case surgery.8
• Commissioners should be aware of the quality and
value aspects related to laparoscopic surgery and
encourage local providers to develop sub-specialist
teams (ie recommended minimum number per
surgeon per year/sub-specialisation of surgeon).
• Use the commissioning process to specify, in
discussion with providers, an appropriate day case
rate for procedures.
• The benefits of following the recommended
pathway for laparoscopic cholecystectomy should
be discussed with acute providers, ie to prevent
emergency readmissions during the waiting
period and understand the financial implications
of operating during acute admission vs later
surgery (see Table 1).
• Routine follow-up outpatient appointments after
cholecystectomy are unnecessary. This should be
reflected in your commissioning rules for your
providers.
• GPs should be preparing the patient to expect day
case laparoscopic cholecystectomy and should
start this process prior to referral.
44
Table 1
Example of tariff - cholecystectomy older than 69 years
Admitted with acute
cholecystitis/biliary colic and
treated conservatively on that
admission
£1,875
Admitted with acute
cholecystitis/biliary colic and
operated on during that
admission
£4,478
Admitted with acute
cholecystitis/biliary colic, treated
conservatively and discharged
then added to waiting list to be
readmitted electively for surgery
£4,146 (£1,875 emergency
admission plus £2,271 for
elective cholecystectomy)
Cost of readmission as an
emergency while waiting for
elective cholecystectomy
£1,875 per admission
There is evidence that some commissioners impose a
waiting list rule of a minimum of five months wait
for elective surgery. Patients waiting for elective
cholecystectomy following an acute admission for
cholecystitis or biliary colic can be readmitted up to
three times while on the waiting list for surgery.
This is poor quality care for the patient and often
leads to a more difficult laparoscopic operation,
increasing operative morbidity and conversion to
open surgery. Repeat acute admissions prior to
surgery will significantly increase costs to
commissioners and waste NHS resources.
8 NHS Institute for Innovation and Improvement (2006), Delivering quality and value: Focus on productivity and efficiency, DH, London
(www.institute.nhs.uk/NR/rdonlyres/07F7BB40-B2C3-4C08-8EA5-EC6C8187DF97/0/K6017NHSItoptipsbookmarked.pdf)
To find out more about the NHS Institute Email: [email protected] You can also visit our website www.institute.nhs.uk
NHS Institute for Innovation and Improvement, Coventry House, University of Warwick Campus, Coventry CV4 7AL Tel: 0800 555 550
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