76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:05 Page 2              WINNER                                               N...
76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:05 Page 3                                                                    ...
76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:05 Page 4                                                         Delivering ...
76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:05 Page 5        4      Delivering major breast surgery safely as a day case ...
76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:05 Page 6                                                                    ...
76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:05 Page 7        6                          Delivering major breast surgery s...
76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:05 Page 8                                                                   D...
76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:05 Page 9        8       Delivering major breast surgery safely as a day case...
76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:05 Page 10                                                                   ...
76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 11        10       Delivering major breast surgery safely as a day ca...
76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 12                                                                 De...
76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 13        12     Delivering major breast surgery safely as a day case...
76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 14                                                           Deliveri...
76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 15        14     Delivering major breast surgery safely as a day case...
76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 16                                                                   ...
76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 17        16     Delivering major breast surgery safely as a day case...
76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 18                                                                   ...
76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 19        18     Delivering major breast surgery safely as a day case...
76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 20                                                            Deliver...
76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 21        20     Delivering major breast surgery safely as a day case...
76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 22                                                                 De...
Delivering major breast surgery safely as a day case or one night stay (excluding reconstruction)
Delivering major breast surgery safely as a day case or one night stay (excluding reconstruction)
Delivering major breast surgery safely as a day case or one night stay (excluding reconstruction)
Delivering major breast surgery safely as a day case or one night stay (excluding reconstruction)
Delivering major breast surgery safely as a day case or one night stay (excluding reconstruction)
Delivering major breast surgery safely as a day case or one night stay (excluding reconstruction)
Delivering major breast surgery safely as a day case or one night stay (excluding reconstruction)
Delivering major breast surgery safely as a day case or one night stay (excluding reconstruction)
Delivering major breast surgery safely as a day case or one night stay (excluding reconstruction)
Delivering major breast surgery safely as a day case or one night stay (excluding reconstruction)
Delivering major breast surgery safely as a day case or one night stay (excluding reconstruction)
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Delivering major breast surgery safely as a day case or one night stay (excluding reconstruction)

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Delivering major breast surgery safely as a day case or one night stay (excluding reconstruction)
"Streamlining of the breast surgical pathway could reduce length of stay by 50% and release 25% of unnecessary bed days for 80% of major breast surgery (excl reconstruction)"

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Delivering major breast surgery safely as a day case or one night stay (excluding reconstruction)

  1. 1. 76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:05 Page 2 WINNER NHS NHS Improvement Delivering major breast surgery safely as a day case or one night stay (excluding reconstruction)
  2. 2. 76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:05 Page 3 NHS ASSOCIATION OF NHS Improvement BREAST SURGERY Day case or one night stay breast surgical pathway (excluding reconstruction) Primary care Pre-operative assessment Anaesthetics/surgery Post surgery follow-up options optimising pre- • Overnight booking the exception not the rule • Anaesthetics: short • No follow up required operative health • Full clinical and risk assessment eg venous thromboembolism acting, use local • Patient activated e.g. telephone • Blood pressure prophylaxis anaesthetic call/questionnaire • BMI, diabetes etc. • Anaesthetic/co-morbidity management seek prompt specialist • Analgesia: non • Pro-active follow up call • Lifestyle advice advice steroidal/non opiate • Outpatients appointment • Patient choice • Patient education: e.g. mobility - physiotherapist/nurse/DVD • Minimal intra operative • GP follow-up • Patient information • Prosthesis advice fluids • Open access: seromas/drain • Prescribe TTO’s • Sentinel Node Biopsy* management and complications • Check patient informed surgical consent • Drains the exception not • Joint clinic: e.g. further treatment • Inform patient of admission time, length of stay and discharge the norm options; chemotherapy/radiotherapy date and time • Palliative care • Plan theatre scheduling and timing General Diagnosis & Continuing Practitioner Assessment care for cancer (80% of referrals) (Same day one stop MDT /two visit system) Admission Post-operative patients Referral (2 week Routine wait) screening and Pre-operative Intra-operative Surgical MDT assessment Follow-up (20% of referrals) Diagnosis Admission (Day Unit, Treatment Centre, Post-operative Continuing care for • Full clinical assessment Surgical Ward) • Analgesia: avoid PCA/opiates cancer patients • Imaging: Mammogram/ultrasound/ +/-MRI +Chest X-ray • Admit day of surgery • Provide nutrition and mobilise • Continuing cancer care • Pathology: Core/fine needle biopsy • Starvation – the ‘2 and 6’ rule fasting • Nurse led discharge assessment care plan • Bloods time 6 hours for food and clear fluids 2 • Patient and GP discharge summary with 24 (including referral as • Discuss informed consent hours prior to surgery hour contacts and wound care advise appropriate to AHPs) • Pathology reporting • Consider carbohydrate drink) • GP discharge summary • Education – self Outcomes • No pre med • Drain management information (if required) care management • Discuss results • Pre-op analgesia (paracetamol/non • Fit prosthesis programme • Involve patient in choice of treatments/trials/reconstruction steroidals) • Dispense TTO’s • Palliative care • Obtain patient informed surgical consent • Confirm treatment/surgery date ** Pre-operative assessment • Provide patient information prescription, hand held *Intra-operative - Sentinel Node Biopsy Analysis: This is an emerging technique and needs to be evaluated. record/care plan/patient diary • Inform patient of next steps • Inform GP positive results within 24 hours/negative within 10 working days Patient informed decision making Acknowledgements NHS Improvement would like to thank the thirteen clinical spread networks, the British Association of Day Surgery, the Association of Breast Surgery, Breakthrough Breast Cancer, clinical advisors and patients for their support.
  3. 3. 76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:05 Page 4 Delivering major breast surgery safely as a day case or one night stay 3 Contents Foreword 4 Why should major breast surgery be an inpatient procedure? 5 From testing to spread... the approach 7 Keep improvement simple 8 Influences, innovation and incentives for spread 9 Transforming Inpatients Framework for Spread application in practice: 1. Collaboration, partnerships and team working 11 2. Learning and unlearning 12 3. Continuous monitoring: Measuring spread and adoption 15 4. Patient centred 19 5. Spread simple principles and messages 21 6. Alignment with opportunities and levers 23 7. Leadership, engagement and accountability 26 Summary 27 References 28 www.improvement.nhs.uk/cancer
  4. 4. 76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:05 Page 5 4 Delivering major breast surgery safely as a day case or one night stay Foreword Twenty five years ago, I am delighted to have the when I was first a opportunity to introduce consultant medical this work that oncologist specialising in demonstrates the breast cancer, patients effectiveness of providing undergoing breast surgery major breast surgery as a (mastectomy or breast day case or one night stay conserving surgery) typically procedure. stayed in hospital for 10 days. Within a few years This programme is a very this had fallen to five days, successful demonstration of but that then became the norm. developing and spreading a new way of working that meets patients’ expectations and reduces the demand on Much more recently a second revolution in surgical care in-patient beds at the same time in a safe and effective has taken place. It is now recognised that the vast manner. majority of operations for breast cancer (excluding operations for breast construction) can be safely Many patients who need breast surgery are undertaken as a day case procedure or with a single understandably anxious about their diagnosis, and this overnight stay. has often been compounded historically by the need to spend several nights in hospital, away from their families. NHS Improvement has been working with clinical teams This NHS Improvement work has been able to change across England to transform the way in which breast the way in which such patients are managed, and reduce surgery is delivered. This work has been supported by the ‘medicalisation’ of their care, so that many feel that the British Association of Day Surgery, the Association of they are able to retain their autonomy and get through Breast Surgery and by patients. All the partners have the process of health care more easily. recognised that the transformation is good for patients and good for the NHS. Patients do not need to be It is a clear advantage, in the current extremely tight admitted to hospital the night before surgery. Equally economic environment, that this change benefits they want to return to normal life as quickly as possible. patients, is also to the benefit of those managing the healthcare budget since it reduces the demand for in- The original hypothesis underlying this work was that patient beds for a large cohort of patients and thus saves streamlining could reduce length of stay by 50% and money for trusts. release 25% of unnecessary bed days for 80% of major breast surgery (excluding reconstruction). This goal has The day case and one night stay breast surgery been exceeded. Mean length of stay has reduced form programme was started in a small area and has spread, 2.35 days to 1.35 days overall. The number of patients via NHS Improvement methodology, to hospitals across with length of stay greater than one day has been the country. It has now been taken up by others beyond reduced markedly. Overall bed days have been reduced the programme as well, resulting in a significant shift in by more than 40%. national figures for length of stay for patients having breast surgery. Although improvements have been observed in most NHS Trusts, significant reductions in lengths of stay could This is a quality improvement that helps patients and still be achieved in some areas. I urge them to read this healthcare organisations; its very pleasing to think that report and to take action. Meanwhile I would like to many patients who have to have breast surgery will be thank all those who have delivered both quality and going “Home for Tea”! productivity – a remarkable example of ‘QIPP’ in action. Professor Sir Mike Richards Celia Ingham Clark National Clinical Director for Cancer National Clinical Lead for and End of Life Care Transforming Inpatient Care www.improvement.nhs.uk
  5. 5. 76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:05 Page 6 Delivering major breast surgery safely as a day case or one night stay 5 Why should major breast surgery be an inpatient procedure? • It’s a relatively short operation • Low post operative pain Figure 1: The increasing shift to day case and one night stay has been gradual • Patients can mobilise, eat and Breast Surgery Patients - Elective Procedures drink early 60,000 • Rare post operative events • Patients want to return to 50,000 normal life as quickly as Number of Procedures possible. 40,000 In 2007, NHS Improvement 30,000 Transforming Inpatient Care 20,000 Programme as part of the Cancer Reform Strategy (2007) and recently 10,000 the Improving Cancer Outcomes Strategy (2011) redesigned the breast 0 care surgical pathway (excluding Year Year Year Year Year 06/07 07/08 08/09 09/10 10/11 V13 reconstruction) with the working No. of inpatient No. of inpatient No. of day cases hypothesis that: admissions LoS >1 admissions LoS = 0,1 “Streamlining of the breast surgical pathway • There has been a gradual shift in the • A further 30% have LOS of one could reduce length of overall length of stay for patients night only, (2010/11 HES (Figure 1). The traditional inpatient provisional) stay by 50% and release pathway had a range of length of • The overall mean LOS has reduced 25% of unnecessary bed stay from 0-7 days (2007, Hospital by 56%, exceeding the original Episode Statistics (HES) working hypothesis (Figure 2). days for 80% of major • Currently (2011) around 42% of breast surgery (excluding breast surgical procedures have length of stay (LOS) = 0 days and a reconstruction).” ‘day case’ ranging from 6 to 12 hours Good progress has been made • 72% of breast surgery patients across England now benefit from the pathway, this number Figure 2: Breast surgery patients - Elective mean length of stay continues to increase indicating 3.5 that 85% is achievable, 3.15 exceeding the original 3.0 2.78 hypothesis. 2.57 Mean Length of Stay 2.5 2.33 2.35 2.04 2.03 2.0 1.61 1.81 1.5 1.33 1.0 0.5 Figures 1, 2 and 3 source: Transforming Inpatient Care – HES Breast Surgery Patients, 0 a paper for the National Transforming Year Year Year Year Year 06/07 07/08 08/09 09/10 10/11 V13 Inpatient Care Committee, Sep 2011, based on HES extraction by NATCANSAT, and Mean LoS - Inpatients only Mean LoS - Overall analysis by DH. Further details on the HES extraction are provided in appendix 1. www.improvement.nhs.uk
  6. 6. 76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:05 Page 7 6 Delivering major breast surgery safely as a day case or one night stay The continued spread, and Figure 3: Breast surgery bed days reduced by 41%, exceeding sustainability of the breast surgical the working hypothesis pathway across England is an Breast Surgery Patients - Elective Bed Days important contribution to the whole 140,000 cancer programme and as Professor Sir Mike Richards states: 120,000 “Over the next 15 years Number of Bed Days 100,000 80,000 the incidence of cancer 60,000 is likely to increase by 40,000 around 24% (based on 20,000 current trends). Putting 0 pressure on inpatients’ Year 06/07 Year 07/08 Year 08/09 Year 09/10 Year 10/11 V13 cancer services; hence in Bed days for inpatient admissions LoS >1 Bed days for inpatient admissions LoS = 0,1 order to keep inpatients costs at the same level the average length of stay must fall by one quarter.” • Bed days for breast cancer have • Patient feedback of their experience reduced from the baseline by 50,329 of the pathway is extremely positive Professor Sir Mike Richards (2011) (41%) with most of the reduction • Strong clinical engagement is National Clinical Director for Cancer due to shorter lengths of stay for evident in leading the improvements and End of Life Care episodes longer than a day; • Variation in practice still remains although the increase of short stays with 28% of breast surgical (zero or one day) has contributed procedures staying in hospital longer If all patients with a length of (Figure 3) than two days stay of more than one night • The proportion of patients not being • Lengths of stay of more than one were converted to the day admitted the day before surgery has night increases with age although case/one night stay model, increased from 69.6% (2006/7) to variation exists across Trusts potentially 40,000 bed days 94.6% • Variation in clinical practice could be saved. • Professional endorsement of the surrounding the use of wound pathway has been achieved drains, draining of, seromas, the • A Best Practice Tariff (BPT) is administration of anaesthetics and proposed for 2012/13 to incentivise pain control continues. day case surgery www.improvement.nhs.uk
  7. 7. 76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:05 Page 8 Delivering major breast surgery safely as a day case or one night stay 7 From testing to spread... the approach Throughout the service improvement phases (Figure 4) NHS Improvement shared the learning across the NHS to encourage local spread, adoption and adaption. Figure 4: Service improvement stages Phase Year Service Improvement stages NHS coverage Spreading the learning 1 2007 • Baseline the current situation • Review clinical procedures • Listen to all views and perspectives • Understand the culture, context and content of Trusts, clinical teams and pathways • Identify best practice and challenges 2 2008 • Testing out the idea: Proof of 7 NHS hospital sites The Winning Principles: Principle – What could be Transforming Inpatient Care achieved. The Winning (July 2008) Principles (2008) Meeting the Challenge Together (October 2008) 3 2009 • Prototype testing the 25 NHS hospital sites Spreading the Winning Principles transferability, confidence and and Good Practice (July 2009) competence of the improvement Consolidation Report (2009) From Testing to Spread 4 2010-11 • Spread, adoption and adaption 13 clinical spread Spreading the Winning Principles networks (72 hospital case studies (July 2010) sites) 41% coverage across England Breast day case/one night stay case studies www.improvement.nhs.uk Service improvement literature has, highlighted the multiplicity and complexity of service improvement, redesign the challenges of spread and the time it takes…. it’s like a marathon not a sprint, however, it’s a race worth doing. Pettigrew et al 1992, Senge 1999, Plesk 2000, Fraser 2002, McNulty et al 2002, Ovretveit et al 2002, Williamson 2007, Driver 2008). www.improvement.nhs.uk
  8. 8. 76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:05 Page 9 8 Delivering major breast surgery safely as a day case or one night stay Keep improvement simple Figure 5: A consistent systematic approach was applied to capture the impact and learning Testing Cycles Is it the Analysis Identify the Visioning Test out the ideas/ right solution Baseline from real root of the What are you innovations to address the different perspectives problem trying to achieve? Test confidence real problem and competence NO YES Evaluate and Case for change Agree the Evaluation Implementation Plan the implementation redesign and Evaluate the benefits check Implement the of the test idea implentation of the What is the sustainability idea Build the case for change improvements difference? Clinical Spread Spread/Adoption Networks Strategy Winning Principles Capture the impact and learning The redesign and streamlining of the breast surgical pathway took a simple systematic approach involving a multitude of reiterative service improvement cycles (plan do study act) and building the evidence for continuous improvement (Figure 5). www.improvement.nhs.uk
  9. 9. 76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:05 Page 10 Delivering major breast surgery safely as a day case or one night stay 9 Influences, innovation and incentives for spread Over the four years common themes and practices have emerged that supported the spread of the breast pathway. The themes have been collated and applied to the Transforming Inpatient Framework for Spread (Figure 6). The spread framework identifies the common components found to influence the rate of spread. Figure 6: Transforming Inpatient Framework for Spread - Common themes and practices Spreading new ideas and good practice Understanding what good practice looks like Active dissemination Prove what works and the benefits Passive diffusion Involve those who need to be actively ‘One size fits no one problem’ involved at the start A Vision for Quality Improvement Systematic Spread Receptive to the improvement Improvement Strategy Adaption to the context Approach Policies and procedures A degree of flexibility Linked Organisational Strategic and Culture Operational and Fit Change Continuous Spread Spread Information Communication Monitoring Simple Shared comparative Progress and Making the Principles and Use of opinion leaders data Connections Finding the right focus Impact Messages for quality and efficiency Collaboration Leadership Partnerships Engagement and Team Accountability Working Clinical and managerial Stakeholders Alignment Responsibility for delivery Ownership and a Learning with Executive leadership distribution of & Unlearning Opportunities responsibilities Patient and Levers networking Centred Knowledge required Local quality indicators and priorities Coaching Commissioning agreement and healthy Changing practice and behaviour competition Patients involved in testing Training Accepted or rejected the improvement The framework reflects the work of Pettigrew (1992) Receptive Contexts for Change and Rodgers (2003) Theory on the Diffusions of Innovations. www.improvement.nhs.uk
  10. 10. 76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 11 10 Delivering major breast surgery safely as a day case or one night stay All the components of the framework were relevant and applied. Seven components (Figure 7) appeared to be more influential in enhancing spread within clinical teams. This was evident from local interactions, case studies and reported site feedback involving clinical leadership, multidisciplinary teams and patients. Figure 7: The seven influential components A Vision for Quality Improvement Systematic Spread Improvement Strategy Approach Linked Organisational Strategic and Culture Operational and Fit Change Continuous Spread Spread Monitoring Simple Progress and Making the Principles and Impact Connections Messages Collaboration Leadership Partnerships Engagement and Team Accountability Working Alignment Learning with & Unlearning Opportunities Patient and Levers Centred www.improvement.nhs.uk
  11. 11. 76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 12 Delivering major breast surgery safely as a day case or one night stay 11 Learning from the 13 national clinical spread networks on the seven dominate components - Transforming Inpatients Framework for Spread application in practice: 1. Collaboration, partnerships and team working Getting teams “Its been very gratifying to have been able to share our together was extremely experiences with so many teams from around the Collboration, partnership beneficial. country. I have been impressed with the interest and Rodgers and team (2003), enthusiasm of teams and the quality of the discussions, working highlights which have helped us to further examine our practice the importance of and the perceptions around enhanced recovery after the nature of the breast surgery.” social system in which innovations are diffused. The clinical spread networks Hamish Brown, Consultant Breast and General Surgeon, Sandwell and West Birmingham were brought together as a Hospitals NHS Foundation Trust community for spread involving organisations, clinical and managerial teams, patients and carers. Their contribution to spread was Figure 8: National Clinical invaluable through enhancing the Spread Networks debate and sharing learning with peers. They provided a succinctness gaining consensus on the breast pathway. The sites shared personal experiences, perceptions and concerns. They could be described as the “early Lancashire and South Cumbria Humber and majority” of adopters, forming a Yorkshire localised network for spread, Greater communication and an important link Manchester in the spread process with their Merseyside deliberate willingness to adopt. and Cheshire Anglia East Midlands Pan Birmingham Arden North Three Counties West Avon, Somerset London and Wiltshire South West London Thames Valley www.improvement.nhs.uk
  12. 12. 76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 13 12 Delivering major breast surgery safely as a day case or one night stay Transforming Inpatients Framework for Spread application in practice 2. Learning and unlearning Many lessons have been Supporting spread: Key learning from learned over the clinical spread networks: the four Learning and years. The knowledge of 13 unlearning Some of the learning was new, reiterative and Take a systematic Understand the national challenging. approach to service and local context and It was evident across the sites that there improvement. This takes coherence with local was variation in service improvement values and priorities. understanding and application. Also, builds up a time but This should not be the time required for redesign was a challenge for many organisations. This good evidence underestimated and is can make the continuous spread of base and gets to the real needed to gain improvement difficult. commitment to deliver in root of the problem. challenging times. Give the right messages Engagement with key in the right language to people leading change is the different audiences and to not enough, support spread the knowledge them to manage, for persuasion and organise and mobilise decisions. the change. Clinicians don’t like targets, managers do, and patients are more concerned with getting better. Build relationships across professions and Patient experience and organisational feedback is a key factor in boundaries. accelerating the pace of spread. There is a need to create the common purpose. www.improvement.nhs.uk
  13. 13. 76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 14 Delivering major breast surgery safely as a day case or one night stay 13 Keep things simple, Clinicians focus on Identifying key realistic and flexible. research, gathering principles that can be more evidence and adapted to benefit all It’s ok to get it audit. patients develops a wrong. common purpose. They are often uncomfortable with the service improvement approach – but once they understand its Understand the value there is no The breast pathway is stopping them. common sense, simple measurement of and comprehensible. impact and success and Those that do not be clear what you want understand are in the to achieve, but remember minority but can be time- one persons new idea is consuming. Go with the another person’s normal majority – the others will practice. catch on later. The importance of Build the evidence base Professional boundaries and traditional roles can be communication, from the begining of the improvement work to barriers to spread. co-operation, and collaboration in strengthen, spread We found the doctors working partnerships is and sustain and to win accepted the pathway vital and so is over the sceptics. quicker than the nurses, but commitment. once the nurses came on board it flew. www.improvement.nhs.uk
  14. 14. 76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 15 14 Delivering major breast surgery safely as a day case or one night stay Some of the learning focused on ”There was a misconception that the proportion of dealing with uncertainties, assumptions and perceptions. Peer to women who would be suitable for early discharge in peer support helped to build parts of the country with greatest concentration of confidence levels in the new pathway and the changes in clinical practice. elderly or socially deprived patients would be difficult. The results have shown this not to be the case with Four specific aspects were commonly achievements from Birmingham (the fourth most highlighted: deprived area in the country outside London) and Kings 1. Changing clinical practice College Hospital NHS Foundation Trust who has 20% of relating to the use of wound drains, drainage of seromas and patients who are asylum seekers and a high number of pain control. patients with complex psychological support needs, 2. Assumptions that patients with many from a socially deprived background. Day would not want to go home surgery has been beneficial for sorting this out earlier. smoothly.” 3. Perceptions that the redesign was a cost cutting exercise. Jo Marsden, Consultant Breast Surgeon, Kings College Hospital NHS Foundation Trust 4. Preconceptions “We do this anyway” and “this will increase Many of these uncertainties had been re-admissions.” tested by the early adopters (see Figure 4 - Spreading the Learning). “One must learn by doing The spread networks included some of the thing, for though you the early adopter sites. Bringing these together helped to decrease the think you know it, you uncertainty and provide an evidence have no certainty until base in which to build the new knowledge and challenge the old. you try.” The spread networks could be Sophocles, 400BC described as the early majority adopters (Rodgers, 2003). www.improvement.nhs.uk
  15. 15. 76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 16 Delivering major breast surgery safely as a day case or one night stay 15 Transforming Inpatients Framework for Spread application in practice 3. Continuous monitoring: Measuring spread and adoption Measuring the Spread survey Relative advantage, complexity spread and and trial: A four month national audit adoption of NHS Improvement conducted a wider (November 2010 to March 2011); Continuous completed by 61% of spread sites the breast spread survey (2010): This identified monitoring: pathway that there was an increasing uptake of provided important insights. Data was Measuring spread cannot be NHS Trusts applying Winning Principle collected on 2,087 patients, 666 and adoption over 2 (NHS Improvement Transforming mastectomy patients, and 1,421 wide simplified. Inpatient Winning principles 2009) local excision and other breast It is ever- particularly associated with the breast procedures (cancer and non cancer). changing and surgery pathway. many measurement indicators only The purpose of the audit was provide part of the story. Rodgers threefold; to measure progress (2003) recommends that four towards compliance against the attributes should be measured, but elements of the pathway, identify the these rely on individual’s perceptions changes in practice and to capture the as a measure of spread. views of patients who had Winning Principle 2 experienced the new pathway. Rodgers attributes include: All patients should be on defined • Rate of adoption The audit incorporated areas identified inpatient pathways based on their • Complexity in the National Mastectomy Audit tumour type and reasons for • Relative advantage report 2010 and the national admission. • Trial. inpatient survey (2010). These are well researched factors and Complexity: Local baseline of Breast pathway audit results taken into account as part of the compliance with the elements of the spread stage. breast surgical pathway were captured Wound drains by the spread sites carrying out a The audit showed there continues to Are these attributes a measure of pathway analysis reviewing their be clinical variation in the usage of spread and adoption? current practice. wound drains and identified that It was found that certainly the patient’s with wound drains required attributes added to knowledge, 21% (Figure 9) more aspirations than learning and communication but the patients without drains. spread and adoption is “a marathon, not a sprint”, as the breast improvement work illustrates. It has Figure 9: Patients who had drains required 21% more aspirations taken four years to reach this stage, working with the majority of early 100 adopters. Although other Trusts 11.2% 90 outside of the spread networks have 32.2% 80 adopted the new pathway the Percentage of Patients 70 evidence of this is based on HES length of stay data. 60 50 88.8% Application of Rodgers Attributes 40 67.8% Influence Spread and Adoption 30 Rate of adoption: National HES data 20 provided the national picture and 10 benchmarking of progress, related to 0 No Drains Drains the shift in length of stay, potential number of bed days released and the No Aspiration Aspiration trends. www.improvement.nhs.uk
  16. 16. 76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 17 16 Delivering major breast surgery safely as a day case or one night stay The audit indicated a shift in practice: • There was an increase in the number Figure 10: Length of stay increased for sixteen patients as a result of having a drain of patients not having wound drains • Patients are now having drains 9 removed prior to discharge 8 • Patients are now being discharged 7 home on the day of surgery with Number of Days their drains in situ. 6 5 Traditionally, patients would have 4 remained in hospital until the drain 3 was removed. Results showed that the 2 impact on primary care of patients 1 going home with drains in situ has been minimal. 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Number of Patients The audit showed that only 31 patients were reluctant to go home with drains in situ. Sixteen patients stayed in hospital between three days to eight days until their drains had been Figure 11: 30% of patients said they did not require any analgesia removed (Figure 10). Although the 450 numbers are small the impact on bed days is significant. 400 Usage Number Recorded from Network Analysis 350 Clinical teams are continuing to 300 conduct local audits associated with 250 wound drains, particularly looking at 200 the cosmetic effects when using drains 150 compared to no drains. 100 Pain control 50 • Pain control was a key feature of the 0 Paracetamol Ibuprofen Diclofenac Paracetamol, audit. Concerns had been raised by Paracetamol Paracetamol Tramadol patients and clinicians that reducing Codeine Cocodamol Dihydrocodeine Codeine, Paracetamol Paracetamol Diclofenac, length of stay relies on the patient Paracetamol receiving adequate pain control. The Analgesia Drugs and Drug Combinations audit found the majority of patients pain was controlled with paracetamol • 30% of patients reported that “The centres that have successfully implemented 100% although they had only been in hospital as a day case or one night day case or one night stay mastectomy have combined stay they had not needed to take either oral or intravenous paracetamol, often any analgesia at home (Figure 11) • The audit found that analgesia for commenced preoperatively, with one or more local mastectomy should be multimodal. anaesthetic technique i.e. local infiltration, installation Various combinations of paracetamol plus one or more local anaesthetic of local anaesthetic into the wound and/or peripheral technique are able to provide nerve blockade.” effective analgesia. Martin Kuper, Consultant in Anaesthesia and Intensive Care Medicine, The Whittington Hospital NHS Trust and NHS Improvement Enhanced Recovery National Clinical Lead www.improvement.nhs.uk
  17. 17. 76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 18 Delivering major breast surgery safely as a day case or one night stay 17 Arm and shoulder exercises • The redesigned pathway introduced Figure 12: Patients who performed shoulder exercises arm exercises prior to surgery in 600 contrast to traditionally YES NO post-operatively. Patients pre- 500 operatively received information and Number of Patients were shown exercises. The audit 400 found that 30% of patients reported that they did not do any 300 arm exercises post discharge (Figure 12). 200 100 0 Partial Excision Re-excision of Wire Guided Mastectomy of Breast Breast Margins Partial Excision of Breast Re-admission rates There was an assumption that reducing the length of stay would increase re-admissions. The audit showed a 2% re-admission rate, which is below the national average 3.2% (HES 2010), The main cause for re-admissions requiring therapeutic intervention are shown in Figure 13. Figure 13: Main causes for re-admission Haematoma Mastectomy Haematoma Other Wound Dehiscence Mastectomy Complication Type Wound Dehiscence Other Skin Necrosis Mastectomy Skin Necrosis Other Systemic Complications Mastectomy Systemic Complications Other 0 1 2 3 4 5 6 Percentage of Patients www.improvement.nhs.uk
  18. 18. 76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 19 18 Delivering major breast surgery safely as a day case or one night stay Length of stay - from days to hours Figure 14: Shift from traditional inpatient to day case or one night stay The audit established the length of Actual Length of Stay by Procedure Type stay in hours, highlighting a shift in November 2010 - March 2011 practice as length of stay is 120 traditionally recorded in days. (Figure Other Breast Procedures 14) Importantly, this provided the 100 Number of Patients evidence that the original definition Total Excision of Breast - Total Mastectomy NEC 80 of 23 hours was not accurate. Variation in admission times and 60 theatre scheduling across the spread networks needed to be taken into 40 consideration leading to the revised definition, breast day case or one 20 night stay pathway. 0 0 8 15 23 30 37 46 53 60 70 77 84 101 108 124 132 149 174 195 271 529 8817 Delays in discharge Length of Stay (Hours) The audit highlighted that 10.5% of patients had a delayed discharge, the reasons recorded were: • Patients did not want to go home with a drain in situ • No local drain policy re discharge home with drains in situ • No one at home and delayed social care package, not noted pre-operatively • Changes in the initial extent of surgery: Immediate reconstruction, bilateral mastectomy • Nausea • Awaiting medical decision • Other medical problems • Booked as an inpatient! www.improvement.nhs.uk
  19. 19. 76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 20 Delivering major breast surgery safely as a day case or one night stay 19 Transforming Inpatients Framework for Spread application in practice 4. Patient centred One of the Patients have evaluated the new “Highly recommended - strongest breast pathway positively influences The patients’ experience has been day surgery is better.” for spread captured in various ways: Patient is the centred Patients challenged professional ‘patient’s Patients have been recorded on film assumptions voice.’ sharing their experiences: Nurses and doctors at Kings College www.improvement.nhs.uk Hospital NHS Foundation Trust found Patients patients were asking to go home. were involved “I was in at 7am, sitting Raising the question why are we in the redesign of the pathway and keeping patients in? Patients also told us: up with tea and biscuits at asked to go home at Northampton 11am, home for tea by General Hospital NHS Trust, George “Being diagnosed with 3pm and out dancing at a Eliot Hospital NHS Trust and Derby Hospitals NHS Foundation Trust. breast cancer can be a party on Saturday night.” difficult transition to Frequently concerns were raised by professionals particularly nurses that make, one day you are a “Just because you are reducing the length of stay could lead healthy person, the next older does not mean you to patients not receiving adequate you are a patient with communication, information and have to stay in hospital support. The audit of over 2,000 cancer.” longer.” patients (2010) who experienced the new pathway indicated this not to be Patients talked about how: the case (Figure 15). The results are comparable with the National Patient “Unnecessary waits, Survey (2010). procedures and sitting around in beds increased Figure 15: Audit of 2,000 patients who experienced the new pathway anxiety.” (Four questions taken from the National Patient Survey, 2010) Patient survey question Response Patients stressed: Q1 Were you involved as much as 92% Yes definitely “We want to get back to you wanted to be in decisions (mastectomy and other normal as soon as about your care and treatment? procedures) possible.” Q2 How much information about 93% Right amount your condition or treatment was (mastectomy) “The new pathway should given to you? 94% Right amount (other procedures) value our time.” Q3 Did you feel you were involved in 77% Yes definitely decisions about your discharge (mastectomy) “Treat me as a person not from hospital? a cancer patient.” Q4 Did hospital staff tell you who 83% yes definitely (other to contact if you were worried procedures) about your condition or 94% Yes (mastectomy & other treatment after you left procedures) hospital? www.improvement.nhs.uk
  20. 20. 76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 21 20 Delivering major breast surgery safely as a day case or one night stay Independent patient evaluation Different patients views are a key factor to spread Different strategies for patient engagement and involvelment were used Patient focus groups were held as part across the spread networks (Figure 16). as an independent qualitative study of experiences of the pathway (Health Experiences Research Group University Figure 16: Patient engagement strategies of Oxford 2011). The 13 national clinical networks were invited to Ask questions Patient voices participate in the study by inviting their patients to take part. Knowing patient Charities expectations What is informed Spread the message choice? What ideas should we test? Get feedback Pre and post operative focus groups Post operative Story boards and story telling Telephone calls Patient questionnaires Audit change Patient videos Patient diaries Independent evaluation findings: “Patients were often surprised that they could be treated on a day case or one night basis. Some patients and their friends and family, were initially suspicious about whether the service was driven by a desire to cut costs. Experiences in hospital (waiting for surgery, communication and information, quality of care, emotional support and discharge) were described positively and acted to reassure patients that their care would not suffer, despite short stays. This positive experience was slightly undermined if hospital staff appeared critical of short stay.“ (Barlow et al 2011) www.improvement.nhs.uk
  21. 21. 76837_NHS_BOOKLET_Home for Tea 08/12/2011 09:06 Page 22 Delivering major breast surgery safely as a day case or one night stay 21 Transforming Inpatients Framework for Spread application in practice 5. Spread simple principles and messages Patients traditionally stayed in hospital “More challenging was for as long as six days, now the majority are home the same day or convincing some of the Spread simple The after one night. Patient’s challenged hospital staff that the day principles and concept of professional beliefs of not wanting to spread be in hospital. There was: case or one night stay messages networks as ambulatory care was a forum of “Reluctance on the part achievable for patients communication has been key of some staff to discharge having mastectomy and to spread messages and make patients sooner and with axillary node clearance. interpersonal links to influence others. a drain.” However, confidence in The success of the approach relates the process has grown to its affiliation with the common Burton Hospital and Kings Mill Hospital purpose; and a overcame the issue by holding substantially with “group of knower’s.” education events for ward nurses and implementation and feeding back patients positive (Driver A, 2011) comments. successful outcomes.” Concerns were raised about the Yeovil District Hospital (2011) Interestingly, it was found that although the spread networks were reduction in the length of stay being detrimental to patients psychological/ Across the clinical spread networks, geographically located, the informal physical well being. The recent audit coversations about patient experience networks across geographical areas of patients (80% response) indicates and satisfaction highlighted that the were often stronger, particularly with that there has been no adverse effect, pathway was received positively. clinicians. but the foundation for this lies with Through using simple messages which good pre-operative assessment and “Patient feedback has informing patients that they will be relayed information, principles and going home on the day of surgery or been extremely positive, sharing practices on the ground knowledge was enhanced and the following day right from the patients reported they discussions and conversations beginning. (Clinical Networks 2010). were involved in their were stimulated. “Changes in clinical care, treatment and “First of all we had to practice have had a discharge and received overcome our own positive effect with other sufficient information.” preconceptions of procedures, for example Southport and Ormskirk Hospital patient’s opinion about a patients having a NHS Trust (2011) shorter stay in hospital. therapeutic mammoplasty, We thought patients now also only have a would find the shorter stay single night’s stay.” unacceptable and patient Geraldine Mitchell, Consultant Breast anxiety levels would Surgeon, Royal Liverpool and Broadgreen increase; but, we did not University Hospitals NHS Trust find this to be the case.” Royal Bolton NHS Foundation Trust (2011) www.improvement.nhs.uk

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