1. 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

2. 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

3. 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

4. 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

5. 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

6. 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 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

7. KING’S BREAST CARE POST DISCHARGE QUESTIONNAIRE

8. 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

9. 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 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

10. 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) /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) /7 bleep holder
Telephone follow-up by Breast CNS

11. 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 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

12. 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

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

14. 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]

15. 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

16. 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

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

18. 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

19. 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

20. 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

21. 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

22. Information given to you before you left hospital and home support
NATIONAL CANCER PATIENT EXPERIENCE SURVEY PROGRAMME DECEMBER 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%

23. 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

24. 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

25. 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

26. 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

27. 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

28. FACE ASSESSMENT TOOL

29. 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

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

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

32. 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

33. 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

34. 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

35. 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

37. 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)

38. 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

39. 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

41. 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 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

42. AMBULATORY SURGERY: ALL OPERABLE PATIENTS ARE POTENTIALLY ELIGIBLE

43. 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

44. 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