Breast Cancer Surgery Challenging Preconceptions Hamish Brown Consultant Breast and General Surgeon Sandwell and West Birmingham Hospitals NHS Trust

Breast Cancer c46000 new cases per annum Majority will be treated surgically Average LOS nationally = 2.62 days Potential to save at least bed days Must be acceptable to patients

Reducing length of stay in breast cancer surgery Conservative surgery National Screening Program - early detection and small tumours Axillary sampling v clearance Sentinel node biopsy >30% will require mastectomy Axillary clearance if node positive

Length of Stay

Why should mastectomy be an in- patient procedure? Relatively short operation Low post operative pain Early mobilisation No risk of retention/ileus Rare significant post op events

2006 We decided to reduce our standard LOS to 23 hours Process mapping and redesign

In patient activities ‘Pre-operative’ assessment Psychological needs of patients Post operative physiotherapy Temporary prosthesis supply Discharge by doctors Take home medications Wound drain management

Diagnosis Preadmission Admit One Day Pre-op Theatre Post-operative Stay for 4 days Doctor led Discharge after Drain removal Anaesthetic Assessment Surgeon - Consent Discharge Medications Drain Removal Breast Care Nurse Input Foundation Year 1 Pre-operative Assessment Breast care nurse Exercises/wound care Drain management

Pre-operative assessment Standardised multidisciplinary pre-op assessment & discharge planning –Surgical care practitioner –(F1 doctor) –Breast Care Nurse –Developed access to specialist assessment –Post op exercises taught –Self management of drains taught –Day of surgery admission –Reduced cancellations/postponements

Psychological needs Assessment by BCN at pre-ad Psychology assessment very rarely needed Guaranteed telephone access Patient satisfaction survey

Discharge planning Take home analgesia at Pre-ad Follow up appt arranged on admission Temporary prosthesis supply by ward nurses Discharge to protocol by ward nurses Out patient review by BCN at 3 days No Primary care involvement or workload

Historic Pathway Diagnosis Preadmission Admit One Day Pre-op Theatre Post-operative Stay for 4 days Doctor led Discharge after Drain removal FY 1 Anaesthetic Assessment Anaesthetic Assessment Surgeon - Consent TTO BCN input Integrated Care Pathway Diagnosis Preadmission Admit Day of Surgery Theatre Nurse led discharge Same day or 23 hours Day 3 Follow-up by BCN for wound check and drain removal Surgeon – Consent Drain Education, ED Planning (BCN ) SCP /FY1 Anaesthetic Assessment TTO

Pilot Study -Identified problems Patient lack of confidence – drains Over-proscriptive guidelines Nausea and vomiting Bed availability & delays At end of pilot average LOS = 2 days Minor complaints 28 day emergency readmission 1%

Birmingham (NHS)Treatment Centre

Change of Approach Sentinel node biopsy = 50% reduction in traditional IP caseload Treatment Centre admission by preference Review of drain use Default to day case

The results

Conclusions Breast cancer surgery can safely be carried out as 23 hr stay or day case. Wound drains can be managed by patients at home. Wound drains make little difference to seroma rates. Integrated pre-operative assessment is key to reducing length of stay.

British Association of Day Surgery

Spreading the learning Possible to do in other tumour sites? Appropriate length of stay Similar issues How? Who will benefit?