1. Reconfiguration of GI Surgery in Edinburgh Malcolm Dunlop Academic Coloproctology & Colon Cancer Genetics Group University of Edinburgh & Western General Hospital

2. Drivers for change Better outcomes for patients managed by specialist service Increasing emergencies and need for specialist cover Imperative of on-call rotas (training grade and consultant) Need for intra-specialty cover of complex elective surgery Requirement for team working Avoidance of duplication of manpower and hardware resource Improved training opportunity Benefits of critical mass Specialism leads to de-skilling Aug 2002 - Reconfiguration of surgical services

3. Coloproctology Unit - WGH

4. Upper GI and Hepatobiliary Units - RIE

5. Referral to specialty service Emergency and elective Elective GP’s informed throughout service reconfiguration Referrals encouraged to be sent to relevant service Referral protocols established Inappropriate referrals redirected by OP managers Emergency Admission and transfer protocols established A/E (RIE) and MIU (WGH) triage City-wide “bed bureau” referral system for GP Ambulance triage In-hospital emergencies managed by consultant communication

6. Audit of emergency admissions Source and appropriateness of referrals Initial versus final diagnosis Operative procedures undertaken Impact of transfers D Elson et al

7. 4 month prospective audit 1831 emergency surgical admissions audited Prospective data on 1794 admissions (97.9%)

8. Diagnosis Categories Upper RUQ pain/surgical jaundice, PPU, oesophago-gastric disorders, pancreatitis Lower LBO, LIF pain, fresh rectal bleed, perianal abscess General Appx, symptomatic hernia/obstruction, NSAP, adhesive SBO Trauma

9. Final Diagnosis and Hospital 0% 10% 20% 30% 40% 50% Upper GILower GIGeneralTrauma Diagnostic Category Percentage of Admissions RIEWGH

10. OCTNOVDECJAN RIE  WGH 23242922 WGH  RIE 8753 NRIE  WGH 1202 TOTAL32333427 Inter-Hospital Transfers

11. RIE  WGHWGH  RIE Final diagnosis of transferred patients

12. Operations performed 0 20 40 60 80 100 120 140 Oesphagus Gastric Duodenum Biliary Tree Colorectal Anus Appendix Superficial abscess Hernia Small Bowel Adhesions Diagnostic Laparoscopy Trauma AAA Other Numbers RIEWGH

13. Initial(%)1 st Surgical (%)Final (%) RIE Upper352 (37.8)354 (38)300 (32.2) Lower25 (2.7)43 (4.6)47 (5.0) General428 (46.0)409 (44)459 (49.3) Trauma126 (13.5)125 (13.4)125 (13.4) WGH Upper73 (8.5)115 (13.3)107 (12.7) Lower338 (39.2)429 (49.7)416 (48.2) General452 (52.4)319 (37.0)340 (39.4) Refinement of diagnosis

14. Conclusion Reconfiguration of GI surgery on two sites feasible Iminent provision of pan-Lothian (SE Scotland) CP Service (pop 900K-1.3m) No major impact on patient transfers Majority of patients treated by appropriate sub-specialists Consultant coloproctology rota radically improved Outcomes improved Analysis of mortality/morbidity and stoma rate underway