ABSTRACT
Purpose: The COVID-19 pandemic has had a devastating impact on surgical services globally. Due to increasing demands on healthcare and attempts to minimise patients’ exposure to COVID-19, surgical admissions were avoided where possible and early discharge promoted. Specialist HPB practice including the management of necrotising pancreatitis and biliary sepsis, often requires prolonged hospital stay. To facilitate earlier discharge, a consultant-led HPB ambulatory clinic was introduced for a single clinical session per week. This study aims to review the safety and efficacy of this pilot pathway. Methods: A retrospective review of all patients seen at the ambulatory HPB clinic from September to November 2020 inclusively was performed. Patient demographics, clinical investigations, readmission rate and other outcomes were recorded. Results: 57 episodes of patient care were provided, with a mean age of 60.9 years (range 29-93). The mean number of patients requiring review per week was 4.38, and the mean number of visits per patient was 1.46 (range 1-5). Indications for review included drain management (n=28), interval imaging (n=12), early clinical review (n=11) and wound management (n=6). The most common underlying diagnosis was pancreatitis (24.4%), followed by conservatively managed cholecystitis (17.8%) and post-operative complications (22.2%). Other diagnoses included choledocholithiasis, liver abscess and trauma. The readmission rate was 6.66%, with no significant adverse events reported. Conclusion: This retrospective review demonstrates a safe pathway for the ongoing management of these complex patients, providing consultant-led specialist care in a timely fashion and with an acceptable readmission rate.
ABSTRACT
Purpose: It is increasingly recognised that patient outcomes and satisfaction with ‘hot’ cholecystectomy are better than those for delayed surgery for cholecystitis. At Belfast Health and Social Care Trust it has not been possible to manage all eligible patients surgically on their index admission within the allotted resources. In addition, the route to outpatient cholecystectomy was ineffective introducing multiple delays for patients. This project aimed to identify the sources of delay and streamline the pathway. Methods: Using quality improvement methodology 927 consecutive admissions with acute biliary pathology were followed over 16 months and analysed fully mapping the existing pathways, identifying key interfaces and delays on the patients’ journey to surgery. Results: Several barriers were identified including unnecessary clinic visits, redundant pre-assessment of fit patients and missed opportunities to provide procedure information or obtain consent. Collaboration with the anaesthetic team led to development of a pre-assessment screening questionnaire which was included in a resource pack introduced for biliary admissions. This also contained a decision-making tool / pathway flowchart, information leaflets, consent and haemovigilence forms. This increases the potential to maximise decision-making and preparations during the index admission. Unfortunately, due to the impact of COVID-19 on elective operating, few patients (n=35) have completed the journey through the new pathway, but ongoing data collection and analysis is anticipated to show significant benefits. Conclusion: Employing the principles of improvement science has led to a remodelled pathway to urgent cholecystectomy which is hoped to increase efficiency and patient satisfaction.