SAME DAY / 23 HOUR AMBULATORY SURGERY BREAST CARE MODEL IS IT FEASIBLE? Jo Marsden, Terri Baxter King’s Breast Care, Kings College Hospital Foundation Trust, London 1

BREAST SURGERY SAME DAY/23 HOUR MODEL Why did we change practice at King’s College Hospital? Patient demand How did we change practice? We examined the patient pathway and patient experience Is it safe and do patients like it? Yes What are we doing now to improve service? Ensuring continual patient feedback

BREAST SURGERY SAME DAY/23 HOUR MODEL Non-reconstructive breast cancer surgery Breast conservation Mastectomy +/- sentinel node biopsy / axillary dissection No evidence of adverse physical / psychological recovery compared with in-patient stay Nationally variation in length of stay Day surgery rates in London range from 20% to > 80% Average LOS for breast surgery UK 4.8 days MEAN LENGTH OF IN-PATIENT ADMISSION MASTECTOMY (NO RECONSTRUCTION), OTHER EXCISION 2008-2009

SAME DAY DISCHARGE FOR BREAST CANCER SURGERY AT KING’S BREAST CARE (KBC) Ambulatory surgery has been offered at KBC since March 2006 Same day discharge / 23 hour stay All non-reconstructive breast cancer surgery Breast conservation +/- sentinel node biopsy / axillary dissection Mastectomy +/- sentinel node biopsy / axillary dissection The service was introduced in direct response to patient demand following a change in surgical practice Cessation of routine use of wound drains (April 2005) removing the need for in-patient admission

MAPPING THE PATIENT PATHWAY (before and during admission) Historic Pathway Same day / 23 hour stay Diagnosis Pre-admission In-patient admission day 1 pre-op Theatre Post-op in-patient stay 2-4 days Doctor-led ward discharge after drain removal Diagnosis Pre-assessment clinic 1-2 weeks before surgery Pre-admission clinic the day before surgery DSU admission on the day of surgery Nurse-led same day or 23 hour discharge Nurse-led pre-assessment Surgeon consent Anaesthetic review Breast CNS Wound + drain care Arm exercises TTO’s Drain removal Pre- assessment DSU nurse Breast CNS Discharge planning Physiotherapist Pre-admission Consultant (consent) Breast CNS

ENSURING PATIENT SAFETY FOLLOWING DISCHARGE Results clinic, date for pre-assessment and surgery Nurse-led pre-admission clinic. Decision for same day / 23 hr discharge based on DSU medical and social criteria Pre-admission clinic day 1 pre-op (consent, CNS review) Admit to DSU for surgery Same day: CNS-led discharge 23 hour stay CNS-led discharge Post-discharge support. CNS (9am-5pm Mon to Fri) DSU senior nurse (5pm-9am) 24/7 bleep holder Community nurse home visit for social assessment. Documentation faxed to KBC Day 1 post-op Community nurse telephone follow-up or home visit (patient choice) Initial care pathway developed with community nurse PCT leads

KING’S BREAST CARE POST DISCHARGE QUESTIONNAIRE

DEVELOPING THE AMBULATORY PATHWAY There have been 3 phases in service development At all times KBC co-ordinated continuity of care March ’06 Same day discharge introduced Initially one half day list on alternate weeks 6 month audit 44% women used service Reasons for not using service Lack of DSU list (26%) Lack of overnight-stay facility (17%) No re-admissions for complications Women deferred surgery until DSU available Nov ’06 - March ‘07 Commenced weekly all day list in DSU Introduction of 23 hour stay July ’07 – Jan ‘08 Qualitative focus group research with Breast Cancer Care to assess patient and carer needs

KING’S BREAST CARE: DEVELOPMENT OF PATHWAY FEEDBACK FROM FOCUS GROUP DISCUSSIONS Results clinic, date for pre-assessment and surgery Nurse-led pre-admission clinic. Decision for same day / 23 hr discharge based on DSU medical and social criteria Pre-admission clinic day 1 pre-op (consent, CNS review) Admit to DSU for surgery Same day: CNS-led discharge 23 hour stay CNS-led discharge Post-discharge support. CNS (9am-5pm Mon to Fri) DSU senior nurse (5pm-9am) 24/7 bleep holder Community nurse pre-operative home visit Day 1 post-op community nurse telephone follow-up / home visit More explicit post-operative information wanted Dislike of community nurse input - confusion about who to contact with post-op problems Patient focus group discussions

POST-DISCHARGE SUPPORT CHANGED FOLLOWING FOCUS GROUP FEEDBACK Initial Care Pathway (March 2006) Breast CNS Monday to Friday (9 to 5) DSU senior nurse Out of hours (5pm to 9am) 24/7 bleep holder Community nurse Day 1 post-op: standardised post-operative questionnaire (telephone or home visit - patient choice) Breast CNS revised patient post-operative information Current Care Pathway Patient emphasis on Breast CNS support Breast CNS Monday to Friday (9 to 5) Day 1 post-op: standardised post-operative questionnaire (telephone or home visit - patient choice) DSU senior nurse Out of hours (5pm to 9am) 24/7 bleep holder Telephone follow-up by Breast CNS

KING’S BREAST CARE: REVISED PATHWAY Results clinic, date for pre-assessment and surgery, Breast CNS present Nurse-led pre-admission clinic Decision for same day / 23 hr discharge based on DSU medical and social criteria Pre-admission clinic day 1 pre-op (consent, CNS review) Admit to DSU for surgery Same day: CNS-led discharge 23 hour stay CNS-led discharge Post-discharge support. CNS (9am-5pm Mon to Fri) and telephone questionnaire day 1 post-op DSU nurse (5pm-9am) 24/7 bleep holder The default position is that all non-reconstructive breast surgery can be done in DSU Any change to this for medical or social reasons is made at the pre-assessment clinic The only definitive contra-indication is the surgical procedure

FAQs ABOUT SAME DAY / 23 HOUR STAY AT KING’S BREAST CARE ‘Your patients are different’ No they’re not ‘It’s not safe to send patients home early’ Yes it is ‘Patients need to be on a ward to bond with each other’ ?????? Where’s the evidence

AMBULATORY SURGERY: ALL OPERABLE PATIENTS ARE POTENTIALLY ELIGIBLE Worse prognosis Better prognosis

SAME DAY / 23 HOUR BREAST SURGERY MODEL: OUTCOMES AT KBC King’s Breast Care All non-reconstructive surgery is now performed in DSU Re-admission rates (March 06 – end June ‘10) 1251 procedures 3.4% (N=43) patients required re-admission for complications 2.8% (N=35) managed via DSU and discharged the same day 0.6% (N=8) in-patient admission [median stay 3 (range 1-9) days]

IS A SAME DAY/23 HOUR SURGERY MODEL FEASIBLE? Yes With adequate patient and carer preparation If all stakeholders are involved Frees up hospital in-patient resource Can be done with or without wound drains Key points DSU should be the default position for surgery In-patient admission should be the exception Discharge planning starts at pre-assessment Patient selection is based on medical co-morbidity and social support Clear, reliable anaesthetic / pre-assessment process pathway Process / pathway mapping Must be patient focused Reduces variation in patient care and outcomes Get patient feedback 15

REDUCING LENGTH OF STAY FOR BREAST CANCER SURGERY IS NOW A NATIONAL PRIORITY The Cancer Reform Strategy (2007, 2010) Reducing length of stay for breast surgery is a priority Improve quality of care Cost savings Will be an indicator / benchmark for patients Promoted as best practice by GP commissioning National implementation supported by the NHS Transforming In-patient Care Programme Piloted in 13 cancer networks

PATIENT EXPERIENCE OF AMBULATORY BREAST CANCER SURGERY Terri Baxter, Breast CNS, Kings College Hospital Foundation Trust, London 17

Patient experience of day surgery Reducing length of stay for breast cancer surgery has improved continuity of care Having a pre-defined surgical pathway; Equity of access to all levels of support available for patients Identifies patients requiring specific input Enhances individualising patient care In-patient admission does not provide superior patient psychological support

SAME DAY / 23 HOUR SURGERY HAS FOCUSED SERVICE ON PATIENTS Patient at centre of activity Pre-admission clinic (KBC) Day 1 pre-op Consultant, Breast CNS Physiotherapist DSU Admit 7.30am OR 12.30pm on day of surgery Anaesthetist Same nurses admit / recovery Breast CNS-led discharge Telephone follow-up Day 1 post-discharge Breast CNS Can arrange for wound check Results clinic 1 week post-op Wound check Discuss further treatment Physiotherapy review Pre-assessment clinic (KBC) 1 -2 weeks pre-op Pre-assessment nurse

WHAT DO PATIENTS AND CARERS THINK? FOCUS GROUP FINDINGS Patient support for day surgery was unanimous All same day discharge patients said they would have it again DSU provided an early psychological boost Early discharge implies that surgery is ‘minor’ but at odds with the ‘serious’ diagnosis of breast cancer In-patient care was not deemed to be superior Unsuccessful at recruiting carers for focus group discussions Telephone interviews with 2 carers Information about what to expect after surgery important

WHAT DO PATIENTS AND CARERS THINK? FOCUS GROUP FINDINGS Information Needs Knowing what to expect after discharge important in reducing patient and carer anxiety Wound management Seroma Size, appearance, aspiration unnecessary Wound drains Relief at not having a drain In-patients who had drains found them inconvenient and uncomfortable Care Delivery - Day Surgery Infection risk perceived to be less Continuity of DSU nursing staff valued highly Important for carers to be at home on the day of discharge and for a few days afterwards Dislike of community nurse input – preference for breast care team Care Delivery – In-patient admission Dissatisfaction with; Hospital environment Lack of continuity of nursing care and specialist nursing care

Information given to you before you left hospital and home support NATIONAL CANCER PATIENT EXPERIENCE SURVEY PROGRAMME DECEMBER 2010 - BREAST Operations Admission date not changed Staff gave complete explanation of what would be done Patient given written information about the operation Staff explained how operation had gone in understandable way KCH National 96% 94% 83% 86% 82% 77% 69% 72% Information given to you before you left hospital and home support Given clear written information about what should / should not do post discharge Staff told patient who to contact if worried post discharge Family definitely given all information needed to help care at home Patient definitely given enough care from health or social services 90% 88% 95% 60% 57% - Ward nurses Got understandable answers to important questions all/most of the time Patient had confidence and trust in all ward nurses Nurses did not talk in front of patient as if they were not there Always/nearly always enough nurses on duty 59% 74% 45% 66% 67% 63% 62%

PREPARATION FOR SURGERY In-patient admission Need to confirm bed / ward on day of admission Discharge planning starts when admitted Support during admission Ad hoc - is patient on ward when CNS visits? Peer support? Same day / 23 hour discharge No need for patient / relatives to confirm bed / ward Discharge planning starts at the pre-assessment clinic Patients still supported ‘Protected’ time pre and postoperatively to see CNS

WHAT TO EXPECT IN HOSPITAL In-patient admission Potential for changes to ward during admission Lack of continuity of nursing staff / doctors (shifts) Potential for conflicting medical information and inappropriate medical care Hospital environment not conducive to rest Same day / 23 hour discharge Patient remains on the same ward per and post op Continuity of nursing staff and doctors Experienced team managing care for duration of admission In home environment patient has control

Same day / 23 hour discharge PLANNING RECOVERY In-patient admission Uncertainty over discharge Drains When is the ward round? When will TTO’s be prescribed? May adopt sick role Increased analgesia uptake due to drug rounds Same day / 23 hour discharge Control over discharge No drains simplifies management Breast CNS-led Pre-prescribed TTOs Routine maintained Important for vulnerable pts Nuture not make dependent

Patient experience of day surgery Reliability of service What you say happens will happen Problems are pre-empted Patient trust in staff increases Enhances relationships with patients CNS time management is improved Plan when to see patients Privacy and dignity of patients maintained Meet in the breast unit at mutually agreed times Patient, carers and CNS not waiting for each other on wards

HOW CARE CAN BE INDIVIDUALISED FURTHER Wound assessment chart Post-op PROM ●Information needs and DSU experience Pre-op PROM ● Information needs Baseline assessment ● Social (FACE tool) ● Psychological Patient at centre of activity Pre-admission clinic (KBC) Day 1 pre-op Consultant, Breast CNS Physiotherapist DSU Admit 7.30am OR 12.30pm on day of surgery Anaesthetist Same nurses admit / recovery Breast CNS-led discharge Telephone follow-up Day 1 post-discharge Breast CNS Can arrange for wound check Results clinic 1 week post-op Wound check Discuss further treatment Physiotherapy review Pre-assessment clinic (KBC) 1 -2 weeks pre-op Pre-assessment nurse

FACE ASSESSMENT TOOL

SYMPTOMATIC INVASIVE BREAST CANCERS: KBC 2006 Median age 54 (32-98) yrs Premenopausal Postmenopausal Median age / yrs (range) Number of cancers (%) ER +ve (%) Grade I (%) Grade II (%) Grade III (%) Median size (range) mm LN + ve (%) LN – ve (%) LN x (%) Median NPI 43 (32-49) 47 (40%) 57.4 4 49 47 26 (13-209) 57.5 36.2 6.4 5.68 66 (50-98) 73 (60%) 75.3 11 53 36 32 (3-99) 37 31.5 5.92

SYMPTOMATIC INVASIVE BREAST CANCER AT KBC (2006) COMPARISON WITH BCCOM Lymph node status ER status

SYMPTOMATIC INVASIVE BREAST CANCER AT KBC (2006) COMPARISON WITH BCCOM Tumour grade Tumour size in mm

KING’S BREAST CARE BREAST SURGERY SAME DAY/23 HOUR MODEL When it works well Good communication Pre-assessment staff DSU Anaesthetics Breast care team Patient / carers Patients with dementia and learning difficulties No problems with, during or following admission When it doesn’t Poor communication Cancellation on the day of surgery due to deviation from normal pre-assessment pathway No cohesive review of patient assessment

have started analyzing the Gap analysis from the pathways that I have received from the sites. The results regarding Optimizing pre operative Health with GP’s has shown that this has either been implemented (need to check with sites what has actually been done) or not applicable The general view seems to be questioning the role of GP’s regarding Breast patients as they are otherwise well, there is little scope to improve or speed up the pathway before diagnosis in terms of optimizing health although patient information and patient choice seems to be the important areas. Also the importance of informing GP’s of change in practice re the model e.g LOS to help with patients expectations (this has been mentioned on calls ) but the focus seems to be at pre op assessment Would you agree with this from your perspective? RED = Not Started AMBER = Work in Progress GREEN = Implemented BLUE = N/A

PROMOTING REDUCED LENGTH OF STAY FOR BREAST CANCER SURGERY Cancer Reform Strategy (CRS, 2007) Identified breast cancer surgery same day / 23 hour stay to be a priority Aim to improve: Effectiveness by reducing unnecessary length of stay Clinical outcomes Quality of care for patients - ensure experience of care is positive The NHS Improvement Transforming Inpatient Care Programme Support the CRS implementation of same day / 23 hour surgery model Promote good clinical practice from: Transforming Inpatient Care Programme Enhanced Recovery Programme

BREAST SAME DAY/23 HOUR MODEL THE ROLE OF THE NHS CANCER IMPROVEMENT TEAM Transforming in-patient care Cancer and QIPP priority (Quality, Innovation, Productivity, Prevention) Save 1 million bed days Evidence, testing, spread Enhanced recovery programme Optimise; Pre-operative assessment Peri / post-operative management Post-operative rehabilitation King’s College Hospital - emphasis on same day discharge Pan Birmingham Network - aim for 23 hour LOS

BREAST SURGERY SAME DAY/23 HOUR MODEL King’s College Hospital Non-reconstructive surgery on one site (hospital trust) DSU (7am-8pm Monday - Friday) Aim for same day discharge / 23 hour stay for >90% of non-reconstructive surgery Facilitated by Not using wound drains Seromas not aspirated Patient demand Commenced March 2006 Pan Birmingham Cancer Network Non-reconstructive surgery at 6 hospital trusts Utilise in-patient theatre sessions Aim for standard LOS to be 23 hours for 80% of non-reconstructive surgery Visited King’s Test replicality No routine use of drains or routine seroma aspiration 2 trusts initiated pathway (2006)

BREAST SURGERY SAME DAY/23 HOUR MODEL Different resources Both achieved their aim Process mapping at both sites enabled service development King’s Breast Care Emphasis on same day discharge Pan-Birmingham Trust Emphasis on 23 hour stay

BREAST CANCER AT KING’S Screen-detected cancers Screening uptake in Camberwell is the lowest in the UK (62% vs 72%) Social deprivation Tumour characteristics similar to that expected from the national BASO screening audit 25% node positive Mean grade Mean size Symptomatic cancers 70% of cancers nationally present symptomatically At KBC ~ 85% ~25% of women are inoperable at presentation Co-morbidity Locally advanced / metastatic disease If patients have operable disease, selection for ambulatory surgery should be based on comorbidity and social criteria

Enhanced Recovery Programme - Day Case/23 Hour Breast Pathway Primary care – optimising pre- operative health Blood pressure BMI, diabetes etc. Lifestyle advice Patient choice Patient information Pre-operative surgical assessment (as soon as surgery is decided on) Full clinical and risk assessment Default booking as day case – overnight booking as the exception not the rule Specialist advice… anaesthetic/co-morbidity management Obtain patient informed surgical consent Inform patient of admission time, length of stay & discharge date Patient education: self management e.g. arm mobility exercises - physiotherapist/nurse/ DVD Prosthesis advice/fitting Prescribe TTO’s Plan theatre scheduling and timing Intra-operative Drains the exception not the norm Anaesthetics: short acting/ local anaesthetic Analgesia: non steroidal/non opiate Minimal intra operative fluids *Sentinel node Biopsy Surgical follow-up options Patient activated e.g. telephone call Nurse follow up call Outpatients appointment GP follow-up Open Access: seromas/drain management and complications Joint clinic: e.g. further treatment options: chemotherapy/radiotherapy Diagnosis (Triple Assessment Clinic) Full clinical assessment Mammogram/ultrasound/ +/-MRI +Chest X-ray Core/fine needle biopsy Bloods Discuss informed consent Pathology reporting Outcomes Discuss results Involve patient in choice of treatments/trials/reconstruction Confirm treatment/surgery date Provide patient information prescription, hand held record/care plan/patient diary Inform patient of next steps…pre-operative assessment Inform GP positive results within 24 hours/negative within 10 working days Admission ( Day Unit, Treatment Centre, Surgical Ward) Admit day of surgery Starvation – the ‘2 and 6’ rule  fasting time 6 hours for food and clear fluids 2 hours prior to surgery (consider carbohydrate drink) No pre med Pre-op analgesia (paracetamol/ non steroidals) Post-operative Analgesia: avoid PCA/opiates Provide nutrition Nurse led discharge: Information: Patient discharge summary with 24/7 contact information and wound care GP discharge summary Drain management information (if required) Fitting permanent prosthesis TTO’s Continuing care for cancer patients Continuing cancer care assessment care plan (including referral as appropriate to AHPs) Education – self care management programme *Intra-operative -Sentinel Node Biopsy: In centres where adequate training has been provided. Extra theatre time e.g. 40mins is required for this procedure ‘Patient involvement & Choice Guarantee’ ‘Professional & Patient Outcome Audits’  Patient informed decision making

AMBULATORY SURGERY: ALL OPERABLE PATIENTS ARE POTENTIALLY ELIGIBLE

BREAST SURGERY SAME DAY/23 HOUR MODEL The NHS Improvement-Transforming Inpatients Care Programme Workshops Where next? Template for breast same day / 23 hour model agreed (based on Enhanced Recovery Programme) Prospective audit to monitor implementation at test sites (November 2010 to March 2011) The Cancer Reform Strategy (2007, 2010) Reducing length of stay for breast surgery is a priority Has been recognised as offering potential for cost savings May become one of the published indicators / benchmarks for patients May be promoted as best practice by GP commissioning

BREAST SURGERY SAME DAY/23 HOUR MODEL WHERE NEXT? NHS Improvement-Transforming Inpatients Care Programme Workshops Agreed template for model Enhanced Recovery Programme) Prospective audit to monitor implementation at test sites (November 2010 to March 2011) The Cancer Reform Strategy – Refresh Length of stay for breast surgery Recognised as offering cost savings May become a benchmark of care May be promoted as best practice by GP commissioning Reduced length of stay will happen Develop a pathway that works for for patients