1. Improving Patient Flow: Making the most of Day Case Surgery Dr Samantha Walker, Dr Tom Pike, Miss A. Kausar East Lancashire Hospital Trust samantha.j.walker@doctors.org.uk 1. Identify Problem or Issue: Why is this important ?  Day case surgery is an ongoing and evolving issue, often featuring in most NHS hospital trust’s annual business plans.  A major push to promote day surgery both in the UK and worldwide is being implemented, aiming on benefitting both patients and hospitals (1).  Early mobilisation and short hospital reduce the risk of hospital acquired infections and venous thromboembolisms (2,3).  Improvement in the quality of the services equates to an efficient cost effective outcome, a fundamental principle in modern NHS ethos.  In laparoscopic cholecystectomy, an average day bed cost totals £225. A reduction of length of stay by just one day, could lead to an annual saving of £8million (1). 2. Set Criteria and Standards: Aims  This audit highlights the reasons for prolonged length of stay for patients undergoing laparoscopic cholecystectomy and investigate service improvement.  Guidance and standards were taken from the NHS Institute for Innovation and Improvement, focus on: Cholecystectomy (updated 2011) which have set standards for day case rates at 70% (1).  We sought to improve the services at the day case unit, thereby improving patient flow, service delivery and overall patient care. 3. Observe Practice: Methods  A combined electronic and manual search was carried out identifying all patients having undergone both elective and emergency laparoscopic cholecystectomy during August – October 2011.  Variables assessed included Sex, Age, Listing Criteria, Surgery Start Time, Length of Anaesthetic Time, Duration of Operation and Post-Operative Complications.  The initial changes of practice in 2011 was re- audited in August – October 2012 with specific attention to the above aims. 6. Sustaining Improvements: Where do we go from here?  Currently we are performing 55% of operations as a day case, with targets set at 70% there is still plenty of scope for improvement.  The next steps involves increased educational promotion for all involved: patients, surgeons, anaesthetists, day case staff, booking office staff and those working with the quality care commission.  A standardised anaesthetic and post-operative analgesia protocol will aide in facilitating early discharge.  The length of stay for 30% of patients was between 24 – 36 hours, it is this group where emphasis can be made for earlier discharge.  The next audit cycle will include staff and patient satisfaction surveys and a further re-audit to assess progress. Figure 1: comparison of day case rates from 2011- 2012 5. Implementing Change: What did we do?  A multi-disciplinary workgroup was set up to establish:- Patients undergoing laparoscopic cholecystectomy listed for day case procedure as default Extended day case unit opening hours (until 22:00 from 19:00) Liaise with waiting list coordinators Working towards a universal anaesthetic protocol Improving patient education via leaflets in the outpatients department 4. Compare Performance: Results  The audit revealed that only 29% of the total number of patients in 2011 had their elective laparoscopic cholecystectomy performed as a day case procedure. The significant factor on influencing length of stay was the listing criteria, i.e. day case listing leads to earlier operating times and shorter length of stay.  On the basis of these results all patients undergoing laparoscopic cholecystectomy subsequently were automatically defaulted to a day case procedure.  The closing times of the day case unit were extended to 22:00 to accommodate for late starting surgery.  Results of the re-audit from the same time period in 2012 revealed a total of 55% of patients now admitted for elective day case laparoscopic cholecystectomy are performed as a day case procedure (figure 1). References : 1.NHS Institute for Innovation and Improvement. Focus On: Cholecystectomy. Coventry: NHS Institute for Innovation and Improvement, 2006.Anaesthesia. GUIDELINES: Day case and short stay surgery: 2. London: Association of Anaesthetists of Great Britain and Ireland, British Association of Day Surgery, 2011. 2.British Association of Day Surgery. Day Case Laparoscopic Cholecystectomy. London, British Association of Day Surgery, 2004. 3.Association of Anaesthetists of Great Britain and Ireland. Day surgery (revised edition 2005). London: Association of Anaesthetists of Great Britain and Ireland, 2005 85