Adam Kimble, Consultant Colorectal & General Surgeon, Torbay & South Devon NHS Foundation Trust
Thursday 9th May saw the 2019 joint British Association of Day Surgery (BADS) and Healthcare Conferences UK (HCUK) one-day conference “Developing your Daycase General Surgery Service”. Hosted in the De Vere West One Conference Centre, in central London, it saw delegates and presenters from across the UK from diverse clinical backgrounds relevant to day case and short stay General Surgery for what promised to be a stimulating and informative day.
The meeting was formally opened by Miss Vanessa Cubas, BADS Council Co-opted Association of Surgeons in Training Member, who introduced the first session’s presenters Dr Jane Montgomery, Consultant Anaesthetist from Torbay and BADS Treasurer, who stepped in last minute when BADS President, Dr Mary Stocker was delayed travelling up from Devon. Dr Montgomery gave a comprehensive overview of the day surgery pathway from GP referral to discharge from hospital and recovery at home, including appropriate patient selection. Importance was placed on dedicated facilities separate from inpatient beds to enable expertise to be developed in managing day case patients. Quality improvement, the theme of the day, was introduced as a way of widening the inclusion criteria for day case surgery including those who live alone, the older population, the obese, and more complex surgical procedures. It was also an opportunity to introduce the new Fifth Edition of the BADS Directory of Procedures.
The next part of the first session expanded upon the assertion made by Dr Montgomery that the day case pathway actually starts at (or indeed before) referral from primary care. This part was shared between Professor Gerard Danjoux, Consultant Anaesthetist from South Tees Hospitals NHS Foundation Trust, and Edward Kunonga, the Director of Public Health for Middlesborough Council and was entitled “Prehabilitation and widening thepool for day case surgery”. They talked about the South Tees experience in developing and implementing a cross-sector community-based exercise prehabilitation programme piloted as the PREPWELL study. The premise of which was to improve the fitness of patients in preparation for surgery to improve their outcomes. This has predominantly been in high-risk surgical specialties, but they also outlined the North East’s plans for developing the programme to make it amenable to day case surgery. The key messages were of the effectiveness of collaborative and cross-sector working to achieve system change.
After coffee, Mr Doug Bowley, Head of the West Midlands Paediatric Surgery Network and Consultant Colorectal & General Surgery at the Heart of England NHS Foundation Trust, began the next session with a talk about children and day case general surgery. Mr Bowley explained that for a period of time in the UK there was a push for all paediatric surgery to be carried out by paediatric surgeons in tertiary centres. More recently, however, there has been a recognition that the majority of general paediatric surgery e.g. herniorrhaphy, orchidopexy and circumcision (which can be carried out as day case surgery) can be performed by accredited adult general and urological surgeons. He stressed that these paediatric patients, and their families, should receive high quality care provided locally, with no variation in practice. To underpin this practice requires the development of clinical networks with the appropriate training and education and the provision of child friendly facilities and pathways e.g. “play dates” in the day surgery unit to familiarize the child with what to expect on the day of surgery.
Just before lunch Professor Doug McWhinnie talked about emergency surgery day case pathways. Same Day Emergency Care (SDEC) is a hot topic currently within NHS England. The UK Government and the Royal Colleges have provided impetus to Trusts to improve patient safety and experience, and to improve efficiency for this cohort of patients. Prof McWhinnie defined Ambulatory Emergency Surgery as: “The management of an emergency patient according to an ambulatory pathway, avoiding overnight stay following their surgical procedure”. He showed evidence that by investing in dedicated emergency pathways, patients are seen and treated quicker, wth earlier and more senior input into their management. This enhances the patient experience, and offers hospitals increased efficiency of precious theatre and bed resources, but requires formal recognition and integration of these services to ensure sustainability.
Lunch was followed by a session on Upper GI surgery. Firstly, Mr David Bunting, Consultant Upper GI Surgeon from North Devon Hospital, Barnstaple talked about improving day case laparoscopic cholecystectomy rates and the North Devon experience with the Royal College of Surgeons’ Cholecystectomy Quality Improvement Collaborative (Chole-QuIC) project. Using QI methodology, and empowering teams locally, this initiative highlighted an impressive improvement in the treatment of acute biliary disease requiring surgical intervention. With a shift in North Devon to 71% of patients using an ambulatory care pathway and 47% of patients treated as a day case. This was followed by Mr Paul Super, Consultant Upper GI Surgeon from the Heart of England Foundation Trust in Birmingham talking about day case fundoplication and anti-reflux surgery. Nationally, the day case rate for anti-reflux surgery is about 15%, however the rate at Heartlands is in excess of 80%, with an overwhelmingly positive patient feedback. Mr Super outlined the patient pathway and general principles for day case hiatal surgery that have enabled the unit to achieve these impressive results.
The final session of the day was given by Professor Timothy Rockall, Consultant Colorectal and General Surgeon from the Royal Surrey County Hospital in Guildford. Professor Rockall presented the Guildford experience of 23-hour stay colorectal resection and its acceptability and safety in selected patients undergoing laparoscopic colectomy. Patients followed a modified enhanced recovery program, and of the 10 patients included, all were discharged within 23 hours from the commencement of surgery with no major complications and no readmissions and high patient satisfaction.
Overall the day covered all aspects of day case general surgery and provided all those who attended with food for thought, and no doubt inspiration, to take back to their own Trusts to enable them to improve their own service. A big thank you to all the speakers and all those involved in organizing a successful day conference, and to all the delegates who attended and contributed to the discussion on the day.
Due to excellent feedback from this meeting, it is being held once again in Birmingham on Tuesday 21st January 2020.