ANNEX 4

SECOND PROTOTYPE DRAFT

STAND-ALONE AMBULATORY CARE CENTRES

KEY ISSUES FOR GLASGOW

1. INTRODUCTION

1.1  This report identifies the findings of a mixed group of clinicians and managers who visited San Diego in California in mid-November, 2000. In three days the group visited one comprehensive ‘Hospital without beds’ (virtually identical in construct to the concept GGNHSB proposes for Stobhill and the Victoria Infirmary) and five Ambulatory Surgery Centres (which concentrate on day surgery and pain relief). We also had a presentation from a hospital which realised it had "missed the boat" in developing an Ambulatory Care Centre and was now proposing to develop one on its main campus.

1.2  Our group comprised:

Brian Bingham

Consultant ENT Surgeon, Victoria Infirmary

Brian Cowan

Medical Director\Consultant Anaesthetist, South Glasgow Trust

John Mackenzie

Consultant Gastroenterologist, Glasgow Royal Infirmary

Professor Jim McKillop

Professor of Medicine, Glasgow University

Andrew McMahon

Consultant General Surgeon, Stobhill Hospital

Ian McMenamin

Consultant Anaesthetist, West Glasgow

Graham Sunderland

Consultant General Surgeon, Southern General Hospital

Yvonne Taylor

GP and Chair of Area Medical Committee

Eleanor Deacon

Nurse Manager, Victoria Infirmary

Margaret Hedivan

ACAD Project Manager, Stobhill Hospital

Maggie Boyle

Chief Executive, North Glasgow Trust

Robert Calderwood

Chief Executive, South Glasgow Trust

Chris Spry

Chief Executive, GGNHSB

1.3 This report reflects the views of the group.

2. BACKGROUND

2.1  GGNHSB’s proposal for Stand-alone Ambulatory Care and Diagnostic Hospitals at the Victoria Infirmary and Stobhill are aimed at providing several key benefits:

a)  rapid diagnostic centres for both GPs and consultant clinics, producing a managed care plan for each patient – often on a one-stop shop basis.

b)  high quality and safe elective day surgery and other treatment services for patients who meet selection criteria – avoiding the need to stay in hospital.

c)  rehabilitation and therapy services provided by physiotherapists, occupational therapists, speech therapists and dieticians.

d) a minor injuries service.

e) all of this on a very locally accessible basis for the population who currently use these hospitals (around 90% of current patient experience of the hospitals).

f) by separating this work from in-patient centres, reducing the conflict between emergency and elective work, to the benefit of both.

2.2  The purpose of our visit to San Diego, in the USA, was to examine American experience to cast further light on the proposed day surgery role for Glasgow’s stand-alone ACADs. San Diego is the seventh largest city in the USA, with a population of 2 million.

2.3  During consultation on the reconfiguration of Glasgow’s acute services critics of GGNHSB’s proposals to provide stand-alone Ambulatory Care Hospitals at the Victoria Infirmary and Stobhill claimed that the day surgery element (only around 5% of their proposed workload) would be unsafe because of the risk of surgical and anaesthetic complications. Others opposed them because they will entail multi-site working for clinicians.

2.4  There is plenty of UK experience of day surgery but few examples as yet of stand-alone day surgery units away from hospital sites. GGNHSB, in responding to the points raised in consultation, quoted data and experience gained at Bexhill in Sussex where there is such a unit 7 miles from Hastings. The Bexhill data indicated that out of 14,000 cases, only 71 (0.5%) had required transfer to an in-patient bed in Hastings. Data produced by Stobhill Hospital regarding its experience of patients transferred to in-patient beds after day surgery was broadly consistent with the Bexhill data.

2.5  Nevertheless, GGNHSB was urged to organise a visit to stand-alone Ambulatory Surgery Centres so that a representative group could see the arrangements and experience at first hand. Since the USA has more of these centres than anywhere else in the world it was felt that a visit there would allow the most concentrated exposure to their experience in the space of a short visit. GGNHSB was under no illusions that the US healthcare system has many flaws and inequities and quite different organisation and incentive systems. However, the focus of the visit was to examine the management of anaesthetic and surgical risk and that has many features which can and should read across into UK experience.

2.6  The destination of San Diego arose from an offer from an American hospital Chief Executive to the GGNHSB Chief Executive to make contact with a firm in California (the Altis Group, LLC) with extensive experience of planning, advising on and commissioning Ambulatory Care Centres.

2.7  Altis is producing a report to supplement our report. Their document will contain more information about the history of Ambulatory Care Centres in the US and their experience and operational arrangements. Our report concentrates on our key observations and the issues which need to be taken on board in Glasgow.

2.8  Annex A describes the centres we visited. Although two of the centres we saw were on the same site as an acute hospital they were not physically connected and had quite separate identities from the adjacent hospital. They organised themselves on the same principles that applied to centres that were further removed from in-patient hospitals. The fact that some of the nearby hospitals were under different ownership added to the sense of the Ambulatory Surgery Centre being a distinct self-contained entity. The largest centre that we saw (Kaiser) was 19 miles away from the Kaiser in-patient hospital to which it would normally transfer patients if necessary (the closest hospital with an Emergency Room was 5 miles away).

3.  SUMMARY OF OUR CONCLUSIONS

In summary our conclusions are that:

a)  stand-alone Ambulatory Surgery Centres can work very well and provide high quality care safely.

b)  in the main they undertake a range of work no less complex than that already undertaken in Day Surgery Units in Glasgow. Indeed in some cases they do more.

c)  any concerns that any of us had about the intrinsic safety of such units have been more than allayed. The number of surgical complications was negligible. The number of anaesthetic-related or pain relief problems requiring unplanned transfer to an in-patient unit was also very low. We describe later inOur full report will this report include a comprehensive set of the data we collected. but what we heard In overall terms it confirmed the validity of the data from Stobhill Hospital and Bexhill which was published by GGNHSB in September.

d)  everyone we met reported high levels of clinician and patient satisfaction and the doctors and nurses we met were very enthusiastic.

e) the incidence of adverse problems requiring home care or re-admission to hospital was minimal.

f)  stand-alone Ambulatory Surgery Centres minimise patients’ exposure to the risks of hospital cross-infection.

g)  the success of the concept requires purposeful organisation and management of clinical policies. High quality leadership is essential if the full potential of the concept is to be realised. Yet we have no doubt that if the NHS in Glasgow exercises these qualities, the patients we would serve in our Ambulatory Care Centres would receive a first class and safe service.

h)  as an aid to forward planning for such a service in Glasgow we recommend that a prospective audit of day surgery outcome in Glasgow should be undertaken. This will help to identify current weaknesses and potential areas for improvement.

4. RANGE OF PROCEDURES UNDERTAKEN

4.1  We saw an almost identical range of procedures undertaken in the stand-alone Ambulatory Surgery Centres (ASCs) as one would see in a typical UK day surgery unit. In one Centre joint replacements and spinal work were being undertaken (sometimes with a 23 hour overnight stay) but this was an exception to normal practice and was linked to selection of patients who were otherwise very fit.

4.2  We were told that, like the UK, the range of procedures had evolved gradually over time.  State licensing regulations did not allow any procedure that involved opening the abdomen, although we were told some centres undertook "mini laparotomies".

4.3  Orthopaedic procedures included arthroscopies, knee joint replacement, shoulders, rotator cusps cuffs, carpal tunnel surgery, anterior cruciate ligament procedures and operations on hands, feet, ankles and elbows.

4.4  In general surgery the procedures undertaken included:

• hernia repair, open and laparoscopic
• haemorrhoids and anal fistula
• laparoscopic cholecystectomy
• simple mastectomy
• varicose veins

General surgical and medical investigations undertaken included:

• upper gastrointestinal endoscopy, with and without sedation
• flexible sigmoidoscopy, with and without sedation, some performed by nurses
• colonoscopy including polypectomy
• bronchoscopy and biopsy
• liver biopsy
• breast biopsy

In addition to these were the minor local anaesthetic procedures commonly performed on an out-patient basis.

4.5  ERCPs (endoscopic retrograde cholangiopancreatography) were not undertaken – mindful of the surgical complications that can arise with this procedure.

4.6  ENT procedures included most nasal surgery, such as septoplasty, rhinoplasty, polypectomy and endoscopic sinus surgery. Ear surgery included grommet insertion, mastoid surgery and stapedectomy. Adenotonsillar surgery, microlaryngoscopy and rigid aerodigestive endoscopy were also undertaken as day cases.

4.7  We did not systematically review the range of procedures being undertaken in gynaecology, urology and ophthalmology but it was apparent that at least as extensive a range of work was being undertaken in stand-alone ASCs as one would find in typical UK day surgery.

4.8  In radiology, the procedures undertaken included:

      • CT scanning
      • MRI scanning
      • Ultrasound
      • Mammography and stereotactic biopsy
      • Fluoroscopy

The injection of contrast media was also undertaken at all the centres we visited but interventional vascular radiology and coronary angiography were not undertaken, although several people we met said that the reason was largely economic rather than clinical.

4.9  As with UK day surgery units, the ASCs avoid undertaking procedures expected to
involve significant bleeding (and hence transfusion).

5. PATIENT SELECTION

5.1  This was emphasised as being crucial to the achievement of good outcomes and the avoidance of complications. ASCs had systematic selection protocols (varying according to the type of procedure undertaken). Factors taken into account included body mass index, respiratory function and relevant co-morbidities such as hypertension and diabetes. In general patients rated ASA1 and 2 were operated on in ASCs and sometimes those on ASA3, although this usually required agreement between surgeon, anaesthetist and the ASC Medical Director.

5.2  Age was not seen as an impediment to surgery in an ASC as long as the patient’sgeneral state of fitness was satisfactory.

5.3  Insulin-dependent diabetes was not normally seen as an impediment to surgery, but was regarded as a factor to be taken into account in the clinical preparation for the procedure.

5.4  Selection also involved ascertaining the suitability of the patient’s home circumstances and the availability of support (family, friends, home nursing) for the relevant period after return home,. including a requirement that the patient was not left alone for the first 24 hours after the procedure and had access to a telephone.

5.5  Glasgow’s day surgery units already exercise very similar selection criteria. systematised In Glasgow’s case, the appraisal of social factors will be more difficult to codify systematise reliably than was the case with San Diego (the US healthcare system effectively streams out many of the most deprived people under 65 years old with difficult social\domestic circumstances). However, it is already the case that the number of people admitted from Glasgow day case surgery units for overnight stay in an in-patient bed is a very small minority of the total day surgery case (see the Stobhill data published by GGNHSB in September). Therefore we would not expect more systematic screening of social circumstances to substantially diminish the role of stand-alone day surgery services in Glasgow.

5.6  We were impressed by the telephone triage arrangements we saw in all the ASCs we visited, usually undertaken by a nurse, 24 to 48 hours prior to attendance at the ASC.  Systematic telephone interview explored whether there had been any material change in the patient’s circumstances or condition and, if any necessary pre-operative tests had not been undertaken, agreed arrangements for them to be undertaken. If any material change is elicited from the interview the nurse refers to the anaesthetist (or surgeon) in order that a clinical judgement can be made as to whether to arrange a further test or clinical consultation or even postpone the operation. This system, which we saw in most of the ASCs we visited, was well regarded by patients, avoiding inconvenient journeys to the ASC prior to the day of operation, reducing "no shows" and yet proving clinically reliable. At Scripps Xi-Med Plaza for instance the percentage of patients screened through their pre-admission telephone triage system ranged from 91% to 95%. The pre-operation cancellation rate was only 0.5%. According to data produced by FASA (the Federated Ambulatory Surgery Association) this is entirely consistent with the US average.

5.7  Clearly the success of telephone triage is dependent on systematic diagnosis, work-up and evaluation of the patient in the period prior to surgery. Since time between the clinician’s consultation with the patient and the operation is so short in the USA there is less likelihood there of the patient’s fundamental condition\fitness altering in the intervening period.

6. THE ROLE OF ANAESTHESIA

6.1  A consistent message from those we spoke to at the ASCs was that the contribution of
anaesthetists to the working of clinical teams was crucial. Achieving the minimisation of dehydration, nausea, vomiting and other post-anaesthetic recovery problems and maximising the success of pain control were seen as key measures of the quality of anaesthesia. The use of local anaesthetic blocks was a significant part of their approach.

6.2  We heard that during most ASC’s development learning curve they had seen significant improvements in anaesthesia. Scripps Xi-med Plaza reported that compared with a US national average of around 30% of cases experiencing some degree of nausea and vomiting, they had over 8 years improved their performance from being about 20% to a rate of less than 12% (in some months often significantly less). They also undertook 24 hour telephone structured follow-up of their patients (conducted by a nurse) and reported post-operative pain at that stage being 1% to 2% and continued post-operative nausea at between 0.5% and 2%.

7. THE MANAGEMENT OF EMERGENCIES

7.1  The ASCs we visited reported that the incidence of intra-operative and post-operative emergencies was extremely low. However, all emphasised that their organisational arrangements were based on the premise that they had to be capable of dealing with the immediate impact of an emergency.

7.2  Thus each ASC was equipped with resuscitation and monitoring equipment and it was a requirement that an anaesthetist was present in the Centre until the last patient had been discharged home. Nurses were provided with ACLS training so that they could competently contribute to the management of emergencies.

7.3  Clearly in the event of an intra-operative emergency the most suitable people – the anaesthetist and the surgeon - were instantly available to deal with it.

7.4  All ASCs had clear agreements with hospitals to receive emergency transfers if necessary. Ambulances would be used to effect these transfers.

7.5  In the event, the clinicians, Medical Directors and nurse managers we met were hard put to recall emergency incidents:

At Scripps Xi-Med Plaza no emergency blood transfusions had been necessary in a period of 9 years and they had had no patient deaths during surgery or within the post-operative 24 hour period. They had experienced one patient who collapsed following allergic reaction to an injection of contrast media but was successfully resuscitated.

None of the other ACS had experienced anything more significant than what was reported to us in detail by Scripps. Kaiser reported that in the 15 months they had been open they had not had to initiate any emergency transfers to an in-patient hospital.

Altis reported that in all their association with many ASCs over many years they were aware of only 1 death occurring within an ASC.

7.6  Clinicians when working in ASCs had no other simultaneous commitments to emergency medical or surgical care at another hospital. The organisation of their working week and its relationship with the total profile of their clinical practice was therefore crucial.

8. POST-PROCEDURE CARE AND FOLLOW-UP

8.1  The provision of immediate post-operative care is almost identical to existing arrangements in Glasgow, with recovery rooms staffed by nurses. We have already described arrangements for dealing with emergencies and reported that an anaesthetist is required to remain in the ASC until the last patient has been discharged.

8.2  The vast majority of patients are discharged within 2 hours of the end of the procedure.  The experience of ASCs with patients not ready for discharge is addressed in the next section of this report.

8.3  All ASCs had well developed arrangements for the post-discharge period which involved permutations of:

a)  careful patient education of what to expect post-discharge and how to deal with it, including clear advice of what to do if anything unexpected occurred.

b)  nurse telephone follow-up 24 hours after discharge.

c)  follow-up clinic with the surgeon (or a member of his\her team) within a specified period (48 hours\72 hours\one week were typical periods quoted by one orthopaedic surgeon).

d)  arranging the attendance of a home care nurse or, in some cases, a physiotherapist at the patient’s home.

e)  accommodation in a patient hotel (helpful if the patient lives at a distance from hospital or has less than satisfactory facilities or support at home).

f)  giving the patient the surgeon’s phone number or alternatively the surgeon calling the patient the evening after discharge.

g)  a patient questionnaire (the main benefit of which is for quality assurance and service improvement purposes).

8.4  The US system usually lacks the GP role which is a key part of the UK system. In developing Ambulatory Care Hospitals in Glasgow we will need to review our own arrangements to make sure they are as reliable and responsive to individuals’ circumstances as they can be. At the same time we must ensure those arrangements
recognise the role of primary care in providing continuity for the patient’s healthcare.

9. DATA ON COMPLICATIONS

9.1  In our visit some of the ASCs had more data immediately to hand to share with us than  others but all had extensive quality assurance systems which are regularly monitored by the Medical Director. None reported any deaths within 24 hours of day surgery. Those we asked commented that the incidence of venous thrombo-embolism was extremely uncommon and if it did occur was unlikely to be manifest in the first 24 hours after surgery anyway.

9.2  We have already commented on the management of nausea and vomiting (see the section on the Role of Anaesthesia) and the efforts made to prevent pain being a significant problem.

9.3  Two of the ASCs reported to us on their data for hospital-acquired infection (recorded by the surgeons at time of post-discharge follow-up). One (Scripps Xi-Med Plaza) reported an infection rate of less than 0.4%. The other (Coast Surgery Centre) said they had 3 or 4 cases in a whole year, which equates to 0.1% of their total workload. This experience confirms one of the major benefits of Ambulatory Care – it minimises a patient’s exposure to the risks of hospital cross-infection.

9.4  The key litmus test for complications is the rate of unplanned transfer to an in-patient hospital. Their data included in this category, patients who had to be admitted to a hospital within 24 hours of discharge from the ASC. The rate for each ASC was as follows:

 

Scripps Xi-Med Plaza
(4,000 total procedures)

Less than 1%. Mostly due to nausea, vomiting and (much less frequently) pain. 90% of surgery in this ASC is done per annum) under general anaesthetic but with extensive use of pain blocks. This ASC deals with a wide range of procedures.

Frost Street
(7,200 total procedures per annum)

0.6%. Mostly due to slow recovery from anaesthesia or  due to pain. During the previous 7 months there had been  no transfers due to surgical complication or bleeding. This ASC deals with a wide range of specialties\procedures.

Kaiser
(3,000 total procedures per annum)

0.2%. Usually due to nausea and vomiting. This Centre has only been open for 15 months and in that period has  not had to organise an emergency transfer. This ASC’s low unplanned transfer rate may be due to case mix\type of anaesthesia or to slow cautious build-up in its activity during its first year of operation.

Sharp Rees Stealy Gastroenterology Suite
(6,700 total procedures per annum)
0.1%. Due to the nature of procedures undertaken, a much lower use of general anaesthetic than other ASCs. Out of  6 cases transferred in a year, 1 was due to anaesthetic  recovery, 4 were because a tumour was found requiring immediate in-patient surgery, and only 1 due to perforation.
Coast Surgery Centre
(3,500 total procedures per annum)

 0.08%. Important to note that pain relief is 50% of the  activity, with orthopaedic surgery being the other 50%.

 

Oasis\Health SouthSurgery Centre
(3,600 total procedures per annum)

 0.03%. This ASC concentrates on orthopaedics but its  patient population is best described as "injured people"  rather than "sick people". Its patient profile is therefore a typical and patient selection rigorously excludes people with a high medical risk.

 

9.5  Our conclusions are that surgical and anaesthetic risk can be minimised by kept to a very acceptable minimum by:

  1. rigorous explicit criteria for patient selection and triage before admission.
  2. maintaining a high level of quality in surgery\endoscopy and anaesthesia.
  3. good recovery facilities with sophisticated monitoring and highly trained staff.
  4. careful patient education for the post-discharge period and ensuring the adequate home support will be in place.
  5. rigorous protocols for managing (the very rare) emergencies.
  6. developing a strong sense of teamwork in the approach adopted by the clinical staff of all disciplines.

9.6  The point was made to us that if an unplanned transfer does become necessary, speed of transfer is not critical. This is because the problem is usually one of nausea, vomiting or pain and those are problems which can be adequately dealt with by recovery room nurses while the arrival of the ambulance is awaited. The incidence of surgical complication, perforation or bleeding was extremely low.

10. THE ROLE OF 23-HOUR BEDS

10.1 Altis advised us that only some 30% of ASCs have overnight beds and that almost  always they were to be used on a pre-planned rather than unplanned basis. Of the six ASCs we saw only 2 had 23-hour beds and even then only between two and four beds used only infrequently, usually for people who had travelled a long distance or who had social\home circumstance reasons or who, on prior assessment, were expected to experience problems with pain relief requiring overnight nursing care. They emphasised that because the beds were only staffed on a pre-planned case by case basis they were not available to deal with unplanned overnight stays – where such needs arose, ambulance transfer to an in-patient hospital was arranged.

10.2  We suggest that in Glasgow the need for "23-hour beds" should be considered only in the context of:

a)  their potential usefulness in extending the range of procedures undertaken on a day surgery basis.

b)  whether the social\home circumstances of the Glasgow population is such that planned provision of such a facility would enable a significant number of people to be treated in an Ambulatory Care Hospital who might otherwise have to be admitted to an in-patient bed in another hospital.

c)  whether there is scope for working our Ambulatory Care Hospital day surgery function for a slightly longer working day (up until around 5 p.m.), in which case the recovery unit would need to be open until no later than, say, 8 9 p.m. at night. This would not however, amount to a 23-hour overnight stay ward and any patient still not fully recovered from anaesthetic would need to be transferred to an in-patient hospital.

10.3  These issues need to be more comprehensively considered during the next stages of planning. However, we counsel careful analysis of the likely numbers of beds that could be used in these ways. Very high levels of surgical activity would need to be taking place to justify more than a handful of beds, which might not be the most cost-effective way of organising a routine surgery service for the Glasgow population.

11.  CLINICIANS’ VIEWS

11.1  The clinicians we met were universally enthusiastic about working in ASCs. They regarded careful patient selection, high quality anaesthesia and thorough early follow-up of the patient as natural features of good clinical practice. They did not regard Ambulatory Surgery as intrinsically ‘risky’; on the contrary it was a part of their clinical practice which combined high levels of certainty with minimum incidence of unexpected disruption. They welcomed the fact that this aspect of their work was protected from the invasion of emergency work.

11.2  The nurses we met were well motivated, enthusiastic and enjoyed the challenge of working in this type of service. The role of nursing staff within ASCs is regarded as integral to the success of ASCs. Recruitment and retention was good since the nurses favoured the teamwork, job satisfaction and organisational style of ASCs.

11.3  In recognising these high levels of clinician satisfaction we were well aware of the differences between the UK and US healthcare systems that influenced these clinicians’ attitudes.

11.4  US clinicians are able to pick and choose what sort of work they will do and which parts of the population they will serve in a way which UK clinicians are far less able to do (although many UK hospital clinicians do shape their work to some extent when they pursue sub-specialisation).

11.5  Secondly US clinicians often work in ‘medical groups’ (similar to a medical version of lawyers’ "chambers") and see many of their patients in their "office" (which combines an examination room and a conventional office, often associated with nearby diagnostic and rehabilitation services support). Sometimes these "offices" are co-located with an Ambulatory Care Centre, sometimes they are located on a hospital campus, sometimes they are free-standing. US clinicians are therefore more familiar with the concept of working in a variety of different settings than many of their UK counterparts. They tend to regard hospitals (and ASCs) as facilities they use as needed rather than as their ‘home base’. Their "office" is their home base.

11.6  Nevertheless, despite these differences, we were impressed by the confidence – and high levels of satisfaction – that the clinicians felt about undertaking day surgery in a free-standing ASC, protected from the distraction of the more complex environment of an in-patient hospital. Indeed a typical comment from a clinician was "This pattern of care is better" (anaesthetist). An orthopaedic surgeon said he had originally been sceptical but now described himself as "an enthusiast". Another orthopaedic surgeon said that working in an ASC was "150% less stressful than working within a hospital". Another said "This is a more ideal setting than a hospital". The Medical Director of the Scripps Xi-Med Plaza said "The efficiency of the ASC allows you to modify your practice – it frees up time for clinicians".

11.7  The different approaches to covering emergency workload offered by the creation of larger clinical teams in Glasgow will reduce the currently turbulent demands made on individual clinicians’ time by emergencies. This, together with the ability to plan schedules of work in Ambulatory Care Centres (confident that they are much less likely to be disrupted by emergency calls), will minimise any adverse impact of multi-site working.

12. PATIENT SATISFACTION

12.1  All the ASCs we visited reported high levels of patient satisfaction. In part this reflects
features of the US healthcare system which are not as comprehensively and systematically replicated throughout the UK (although perhaps they ought to be!):

a)  a strong client relationship between doctor and patient, involving personalised preparation and follow-up to clinical procedures.

b)  considerable attention given to educating the patient about what to expect during the attendance at the ASC and following their return home.

c)  a short period between initial clinical consultation and the performance of surgery.

d)  careful attention to appointment systems and putting much effort into minimising the amount of their own time the patient has to devote to attending for healthcare.

12.2  We were also conscious that we were seeing that part of the system dealing with the insured population, workers’ compensation cases or older people funded by Medicare.

12.3  We were not seeing the uninsured or those people who have to rely on County Hospitals.

12.3  However, the fact remains that the service was designed to achieve a high quality experience for the patient and that should be the standard to which we should aspire for our own universal-access NHS.

13. MANAGEMENT ISSUES

13.1  Typically, ASCs have a Medical Director who exercises leadership and a rigorous approach to developing and maintaining:

a)  a process for approving what procedures can be undertaken within the ASC.  This is done in collaboration with the medical advisory machinery.

b)  clear patient selection criteria and a rigorous approach to pre-admission triage.

c)  systems for the management of emergencies.

d)  systems for post-operative and post-discharge care and follow-up.

e)  thorough clinical audit and patient satisfaction surveys.

f)  staff training and other clinical logistical support.

 

13.2  The Medical Directors we met came from an anaesthetic background.

13.3  It became clear to us that there was an urgent need to identify the medical management arrangements for on-site and stand-alone Ambulatory Care services in Glasgow and to make proleptic appointments so that strong clinical leadership could be exercised through the planning and commissioning processes. Similarly the planning, provision and management of nursing and paramedical services needs to be addressed as early as possible and both Trusts need to review their arrangements to ensure that Project Managers have the best possible support from medical, nursing and PAMs leadership.

13.4  The importance of scheduling was also made very clear to us. The ASCs were using sophisticated software and placed great emphasis on scheduling as the pathway to achieving the best possible productivity. This requirement will be magnified in the more sophisticated ACAD\Ambulatory Care Hospital concept proposed for Glasgow, particularly if more out-patient services are to achieve "one-stop shop" performance.

14.  STAFFING ISSUES

14.1  We have already emphasised the important role of the anaesthetist in maximising the patients’ prospects for a good recovery from anaesthesia and effective pain relief. Likewise, we have commented on the quality of pre-operative assessment and post-operative follow-up in which the surgeon and nurses play a key part. We noted that the surgeons’ ability to provide a rapid follow-up was often assisted by a role that we heard variously described as "physicians’ assistant" or "physician extender". This role entailed a clinician acting on behalf of the surgeon to undertake routine follow-up within policy or practice guidelines determined by the surgeon. It meant that with good scheduling each patient received very prompt, systematic and yet personalised follow-up within a week of the operation.

14.2  In the UK context that role could be undertaken by a staff grade doctor or nurse practitioner. Alternatively a well designed system of liaison between surgeon, GP and\or District Nurse could fulfil a similar function (although involving a larger network of collaborating practitioners makes it intrinsically more difficult to organise in a slick manner). There would also be training opportunities for junior doctors subject to appropriate supervision.

14.3  In the case of nursing great emphasis was placed on ensuring flexibility within the ASC, with individual nurses able to function effectively in pre-operative, operating theatre and recovery areas on an ‘as-required’ basis. This raises issues of training, grades and quality of management that would need to be addressed in the Glasgow context. Since the concept in Glasgow is for two Ambulatory Care Hospitals rather than just Ambulatory Surgery Centres such issues would need to be addressed in a wider functional context. The role of nurses in pre-operative triage and post-operative follow-up has already been noted. In the Sharp Rees Stealy Gastroenterology Suite a nurse practitioner was undertaking flexible sigmoidoscopies (including biopsies but not polypectomies). She worked from 8 a.m. to 12 noon each day and completed one procedure every 20 minutes.

Our overall conclusion is that if we organise day surgery with similar attention to detail within Glasgow Ambulatory Care Services the scope for nurses to play an important and fulfilling role will be significant.

14.4  We referred earlier to the importance of Advanced Cardiac Life Support (ACLS) training for nurses – this is expensive to provide and maintain and careful consideration would need to be given to the number of ACLS-trained nurses needed in Glasgow stand-alone Ambulatory Care Hospitals.

14.5  Effective scheduling is a key role within Ambulatory Care Centres and in Glasgow Trusts would need to ensure that they designed and graded the jobs carefully in order to reflect their importance. Similarly, effective training, good software support and supportive managerial back-up are also ingredients for success which cannot be compromised.

14.6  The profile of working hours reflects staffing requirements and the scheduling of work. In San Diego it was common for the working day to start at 7 a.m. to 7.30 a.m. with the last case leaving theatre by 4 p.m. The time of closure of the ASC then depends on the time needed to assure post-operative recovery – typically it was 7 p.m. to 8 p.m. We have already referred to the role of nurses and anaesthetists in pre-admission triage, the flexibility of nursing roles during the course of the day, the responsibilities of the anaesthetist in monitoring post-operative recovery and the role of the surgeon in post-discharge follow-up. All of this requires careful attention to team work, work scheduling, training and continuing professional development.

15  MEDICAL STUDENTS AND TRAINEES

15.1  None of the ASCs we saw provided service settings in which medical students or trainees were taught. However, we saw nothing intrinsically contrary to what is needed to provide the necessary environment. Consultant presence in the operating theatre is a key feature of both best quality safe care and teaching and that is what is proposed for Glasgow. We did see systems for sound video, observation panels and remote screening which would enhance the capacity to learn – both on site and off-site. The ASC environment will offer students an opportunity to learn about anaesthetic techniques, some practical procedures (e.g. iv cannula insertion, ET intubation), to see common surgical problems which will be uncommon in in-patients and to gain considerable experience in techniques of pain relief and management of nausea. In the ACAD there will be extensive educational opportunities across many clinical specialties, some of which will be mainly ACAD based, such as ophthalmology, ENT, dermatology and many medical specialties. There will have to be appropriate planning to accommodate students and allowance for a certain slowing of throughput resulting from educational activities.

15.2  The ASCs we saw ran at a rate of scheduling theatre time according to the complexity  of cases and the normal pace of individual surgeons. Such flexibility would allow scheduling to reflect the need to spend extra time if there are teaching commitments.  During the visit Professor McKillop established a contact with a Medical School in Chicago using an Ambulatory Surgery Centre and on a forthcoming planned visit to Chicago will ensure that he reviews its functionality in a teaching environment.

CJS\FEB
4.1222.00

ANNEX A

   

Activity

Linkage to in-patient hospital

i)

Kaiser Ambulatory Care Centre

Comprehensive free-standing ACAD virtually identical to what is proposed in Glasgow (including minor injuries service). Around 3,000 day surgery cases per year.

19 miles from Kaiser in-patient hospital. 5 miles away from nearest hospital with an emergency room.

ii)

OASIS\Health South Surgery Centre

A one-stop shop focussed on orthopaedics and rehabilitation. Around 3,600 surgical procedures per annum.

3 miles away from a hospital.

iii)

Coast Surgery Centre

50% of workload is pain relief. 50% is orthopaedic. 3,500 cases per annum.

400 yards away from Sharp Memorial Hospital, separated by multi-lane highway.

iv)

Frost Street Out-patient Surgical Centre

General range of day surgery in a range of specialties plus pain relief (30% of workload). Around 7,200 cases per annum.

Across a busy public road from Sharp Memorial Hospital (a separate institution).

v)

Scripps Xi-Med Plaza

Wide range of day surgery procedures in a range of specialties. 4,000 cases per annum.

Stand-alone block on Scripps Hospital campus. 250 yards from ward block. No link corridor.

Vi)

Sharp Rees Stealy Gastroenterology Suite

Concentrates on upper and lower Gl endoscopies, flexible sigmoidoscopies and liver biopsies. Around 6,700 procedures per year.

Stand-alone block on Sharp Memorial Campus. 250 yards from Sharp Memorial Hospital (a separate institution).

 

Last modified: August 15, 2002

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