Dr David Parker - acute upper GI bleed services SW England

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Dr David Parker gives an overview of the acute upper GI bleed services in South West England

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Dr David Parker - acute upper GI bleed services SW England

  1. 1. AUGIB services: The South West Perspective David Parker Gastroenterologist BSG Regional Representative for South West England
  2. 2. Geography  Gloucestershire, Wiltshire, Bristol, Somerset, Devon, Cornwall  The M4/M5/A30 corridor  A361, A303, A353
  3. 3. Severn Deanery Trusts  Swindon  Gloucestershire  Cheltenham  Gloucester  North Bristol  Southmead  Frenchay     University Hospitals Bristol (BRI) Weston-super-Mare Taunton Yeovil
  4. 4. Peninsula Deanery Trusts  North Devon (Barnstaple)  Exeter  Torbay (Torquay)  Plymouth (Derriford)  Royal Cornwall (Treliske, Truro)
  5. 5. Some Golden Standards of Care  Underpinned by NICE, SIGN, BSG     24/7 rota staffed by suitably skilled people If not available in-house, a formal network Suitably qualified/experienced nurses on call All forms of therapy available 24/7  Banding, dual (triple?) therapy, glue  All high risk patients endoscoped within 24h  All unstable patients endoscoped within 2 h of adequate resuscitation  (All acute GI bleeds endoscoped within 24h)
  6. 6. A problem: definitions  NCEPOD audit confusion  “GI bleeding” codes  Lower GI bleeds are included in data searches  How do you define “acute UGI bleed”?  High risk bleeds or all bleeds?  Therapeutic cases only?  Coffee ground vomits?  Scoring systems  Out of hours workload or all cases?  When does OOH start?
  7. 7. A problem: measuring workload  Non-responders  Out of hours workload or all cases?  When does OOH start?  Daily bleed lists/slots
  8. 8. What we know  6 trusts have 24/7 rota staffed by Gastroenterologists  1 has regular Sat AM list  3 trusts 24/7 rota shared with Surgeons  1 trust has regular Sunday AM list  1 trust 24/7 rota shared between gastro and surgery but gaps  Reliant upon goodwill?  2 trusts have ad hoc arrangements shared with Surgery  both 5/7, but one has timetabled Sunday AM bleed list  Planning formal 24/7 rotas  Reliant upon goodwill?
  9. 9. Comments  Various solutions  Large trusts OK (heavy workload; 500 pa)  1 “network”  Various problems  Still some gaps in 24/7 cover  Surgeons still need to help  Level of therapeutic experience?  Isolated trusts  Small trusts
  10. 10. Three Case studies  Split site  Example of networking  Small trust  Needs to network?  Isolated trust  50+ miles / 1 hour 15 minutes from nearest neighbour
  11. 11. Case 1: split site (1)  One trust  2 DGH hospitals: 600k population  Both take acute unselected admissions  One rota covers both sites  Bleeds done on both sites  Rota 24/7: Gastroenterologists  Weekday bleed lists 0800/1230  100 out of hours bleeds pa  In-pat and new pat scoped <24h
  12. 12. Case study 1: Split site (2)  Problems:  Access to theatres  Sometimes have to wait for a gap between surgical/orthopaedic cases  No instances of having to be in two places at once (yet)  Lack of familiarity with unit/kit not an issue  Hospitals 8 miles/20 minutes apart
  13. 13. Case study 2: Small trust (1)  Population 180k  1 site  Rota 1 in 8 (3 gastro, 5 surgeons)  2 AM slots daily Mon-Fri for in-patients  OOH cases usually done in theatre  Endoscopy Nurse on call  ~140 cases pa but most scoped in hours  All high risk cases scoped <24h  ~45 therapeutic interventions pa.
  14. 14. Case study 2: small trust (2)  Problems:  None of the surgeons want to do it  Some of the surgeons do low numbers of diagnostic OGD  Not all on the rota can/willing to band/glue  Other physicians do 1 in 11. No extra pay for the gastroenterologists.  Some rota gaps: dependent on goodwill (Gaps are paid for)  Once in past year management had to ask neighbouring trust to cover  Prospect of networking not popular  Significant workload if have to participate in cover at larger trust  Risk of in-comers lack of familiarity with kit/unit
  15. 15. Case study 3: Isolated trust (1)  1 site  160k population  1 in 8 rota  3 gastro, 5 surgeons  Other physicians do 1 in 11  Gastro gets extra 0.125 PA extra  Endoscopy nurse on call
  16. 16. Case study 3: Isolated trust (1)  Potential Problems:  Isolation  50 miles from nearest neighbour  A roads  1 hour 15 minutes in winter; longer in summer months  Network not practical  No issues yet  Rota in infancy
  17. 17. Summary & conclusions (1)  10 trusts have a formal rota  Large trusts Gastroenterology  Small trusts shared with surgery  Others working towards rotas  Surgeons seem disinclined to participate  Skill set not always complete  Low numbers of routine OGDs  Networks challenging  Distance  Potential “two places at once”  Participation in onerous rotas not popular
  18. 18. Summary & conclusions (2)  Where do we go from here:  Support training of consultants on rotas  JAG accredited courses are costly  Limited Study leave  Press for Gastroenterology to come off medical take?  Unlikely in smaller trusts  Other ideas?

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