AMBULATORY BREAST CANCER SURGERY AT KING S BREAST CARE (KBC) Jo Marsden, Terri Baxter, Uli Fountain Kings College Hospital Foundation Trust London
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1 AMBULATORY BREAST CANCER SURGERY AT KING S BREAST CARE (KBC) Jo Marsden, Terri Baxter, Uli Fountain Kings College Hospital Foundation Trust London
2 AMBULATORY BREAST CANCER SURGERY AT KING S BREAST CARE (KBC) Ambulatory Surgery Same day discharge or 23 hour (overnight) admission Axillary dissection, mastectomy commonplace in USA Unusual in European practice Ambulatory surgery / early discharge (+/- drains in situ) Compared with longer in-patient stay Improved patient mobility / recovery No adverse impact on patient psychology or carers Ambulatory surgery has been offered at KBC since March 2006
3 AMBULATORY BREAST CANCER SURGERY AT KING S BREAST CARE (KBC) Why was the service started? Change in surgical practice management simplified Routine use of wound drains was stopped in April 2005 Removed the need for in-patient admission Out-patient seroma not routinely aspirated Align patient expectations Patient demand for early discharge Community nurses involved with service planning Approached independently by Southwark PCT community nurses to extend their role
4 DEVELOPMENT OF AMBULATORY SURGERY AT KBC At all times KBC has co-ordinated continuity of care Initial care pathway developed between KBC and community nurses Service refined / developed following; Audit Patient involvement research with Breast Cancer Care There have been three phases in service development to date March 2006 Nov 2006 March 2007 July 2007 to present Service commenced - same day discharge Introduction of 23 hour stay Identification of issues relevant to patients / carers (Breast Cancer Care focus group research)
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6 HOW HAS OUR SERVICE DEVELOPED? Audits Initial 6 month DSU activity (March to October 2006) Increase in number of DSU lists due to patient demand (from alternate week to weekly list) Reduction in post-operative infection No re-admission for early post-operative complications In-patient duration of stay Over one year only 4 in-patients required more than O/N stay (range 2-7 days) Introduction of 23 hour stay facilities Comparing drains vs no drains following surgery No difference in infection rates, seroma incidence, wound dehsicence
7 HOW HAS OUR SERVICE DEVELOPED? Focus group research in collaboration with Breast Cancer Care Day surgery patients In-patients Findings Patient support for day surgery unanimous In-patient care was not deemed to be superior Issues surrounding information needs and care delivery Women did not want community nurse input
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9 POST-OPERATIVE SUPPORT Initial care pathway for same day discharge patients (March 2006) Breast CNS Monday to Friday (9 to 5) DSU senior nurse Out of hours (5pm to 9am) 24/7 bleep holder Community nurse Day 1 post-op standardised post-operative questionnaire Telephone or home visit (patient choice) Current care pathway applies to all patients admitted to DSU Breast CNS Monday to Friday (9 to 5) Day 1 post-op standardised post-operative questionnaire DSU senior nurse Out of hours (5pm to 9am) 24/7 bleep holder
10 KING S DAY SURGERY UNIT (DSU)
11 ARRANGING ADMISSION
12 PREASSESSMENT Safe preparation of the individual Physically Socially Psychologically Carer s Role
13 DAY OF SURGERY
14 REPORTING IN AT RECEPTION
15 ARRIVAL ON WARD
16 ADMISSION PROCESS
17 PRE-OPERATIVE CHECKS
18 GOING TO THEATRE
19 1 ST STAGE RECOVERY
20 BACK ON THE WARD
21 RESUME NORMAL ACTIVITIES
22 DISCHARGE CRITERIA Escort On the telephone Transport Home Carer for 1st 24 hours Extended support Take Home medication
23 PREPARING FOR DISCHARGE
24 GOING HOME
25 SUPPORT FROM DSU AT HOME 24/ 7 pager advice service Advertised in our literature Carried by senior clinical team
26 AMBULATORY BREAST SURGERY Advantages vs disadvantages Can you see ambulatory surgery being implemented at your workplace? If yes, why? If no, why not?
27 AMBULATORY BREAST SURGERY AT KBC Quality improvement Reduced length of stay Improvement in immediate pre and post-operative nursing care Less exposure to infection Trust Benefits Patient choice, meeting targets ~ 250,000 per year can be released to other areas PCT benefits Cost neutral Unanticipated benefits Improved resource utilisation DSU flexibility
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