1. 23 hour surgery Beth Jackson Senior Clinical Nurse Specialist Breast Unit The Royal Marsden Hospital NHS Foundation Trust

2. April 2010 Jo Marsden and Terri Baxter gave a presentation on their 23 hour surgery model of care at the South West London Cancer Network breast tumour working group meeting.

3. April – August 2010 Two consultant surgeons at the Royal Marsden Hospital interested in this model of care - one based at Sutton and the other at Fulham Road. Both interested in reducing the usage of wound drains routinely post-operatively.

4. August 2010 NHS Improvement workshop introducing the 23 hour model of care attended by a core group from RMH. RMH selected as one of 13 national clinical spread networks to implement this model of care.

5. August – October 2010 Discussions within RMH breast unit and other colleagues regarding implementing the process October 26th 2010 attended second NHS Improvement workshop Target was to reduce unnecessary lengths of stay through implementing 23 hour model of care by March 2011

6. Introducing 23 hour model of care The Royal Marsden Hospital Breast Unit located across two sites Sutton – 650 new patients per year Fulham Road – 350 new patients per year Two separate units but with shared guidelines and goals

7. My role Team leader for Clinical Nurse Specialists – family history, primary breast cancer and secondary disease services across both sites Links within both units Attend both MDTs Project lead for implementing 23 hour surgery model of care (by default!)

8. November 2010 One meeting video linked cross site to introduce project attended by breast unit staff and allied health professional colleagues – physiotherapists, radiographers, nuclear medicine staff, anaesthetist, pharmacist, ward staff. Site specific meetings then held to identify particular issues for each unit.

9. December 2010 Both units very busy so easier to break down introducing 23 hour model of care and refining process for one consultant surgeon each site – only two surgeons to discuss issues with rather than 6! Once process streamlined roll out to other consultants surgeons

10. December – January 2010 Consultant Anaesthetists implemented a shared anaesthetic protocol for 23 hour surgery patients. Pharmacist agreed uniform TTO pack for the wards Physiotherapists have developed a DVD to be given to patients to take home following surgery

11. Historical surgical pathways Day case surgery longstanding at RMH for patients undergoing wide local excision and sentinel lymph node surgery In-patient stay for patients undergoing mastectomy, axillary lymph node dissection, breast reconstruction, breast reduction.

12. New surgical pathway Patients are now scheduled for Day case surgery: wide local excision and sentinel lymph node surgery Day case / 23 hour stay: mastectomy and/or axillary dissection In-patient stay: breast reconstruction and other complex surgery

13. January – February 2010 Written information developed for patients At time of diagnosis advising them of the process At time of pre-admission advice regarding admission and discharge home

14. Currently Process complete Patient information available Introduced both sites by deadline March 2011 Patient evaluation available later this year