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Reconfiguration of GI Surgery in Edinburgh

Academic Coloproctology & Colon Cancer Genetics Group University of Edinburgh & Western General Hospital. Reconfiguration of GI Surgery in Edinburgh. Malcolm Dunlop. Drivers for change. Better outcomes for patients managed by specialist service

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Reconfiguration of GI Surgery in Edinburgh

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  1. Academic Coloproctology & Colon Cancer Genetics GroupUniversity of Edinburgh & Western General Hospital Reconfiguration of GI Surgery in Edinburgh Malcolm Dunlop

  2. Drivers for change Better outcomes for patients managed by specialist service Increasing emergencies and need for specialist cover Imperative of on-call rotas (training grade and consultant) Need for intra-specialty cover of complex elective surgery Requirement for team working Avoidance of duplication of manpower and hardware resource Improved training opportunity Benefits of critical mass Specialism leads to de-skilling Aug 2002 - Reconfiguration of surgical services

  3. Coloproctology Unit - WGH

  4. Upper GI and Hepatobiliary Units - RIE

  5. Referral to specialty service Emergency and elective Elective GP’s informed throughout service reconfiguration Referrals encouraged to be sent to relevant service Referral protocols established Inappropriate referrals redirected by OP managers Emergency Admission and transfer protocols established A/E (RIE) and MIU (WGH) triage City-wide “bed bureau” referral system for GP Ambulance triage In-hospital emergencies managed by consultant communication

  6. Audit of emergency admissions Source and appropriateness of referrals Initial versus final diagnosis Operative procedures undertaken Impact of transfers D Elson et al

  7. 4 month prospective audit 1831 emergency surgical admissions audited Prospective data on 1794 admissions (97.9%)

  8. Diagnosis Categories Upper RUQ pain/surgical jaundice, PPU, oesophago-gastric disorders, pancreatitis Lower LBO, LIF pain, fresh rectal bleed, perianal abscess General Appx, symptomatic hernia/obstruction, NSAP, adhesive SBO Trauma

  9. RIE WGH Final Diagnosis and Hospital 50% 40% 30% Percentage of Admissions 20% 10% 0% Upper GI Lower GI General Trauma Diagnostic Category

  10. OCT NOV DEC JAN RIE  WGH 23 24 29 22 WGH  RIE 8 7 5 3 NRIE  WGH 1 2 0 2 TOTAL 32 33 34 27 Inter-Hospital Transfers

  11. Final diagnosis of transferred patients RIE  WGH WGH  RIE

  12. Operations performed 140 120 RIE WGH 100 80 Numbers 60 40 20 0 AAA Anus Other Hernia Gastric Trauma Appendix Colorectal Adhesions Duodenum Biliary Tree Oesphagus Small Bowel Superficial abscess Diagnostic Laparoscopy

  13. Refinement of diagnosis Initial (%) 1st Surgical (%) Final (%) RIE Upper 352 (37.8) 354 (38) 300 (32.2) Lower 25 (2.7) 43 (4.6) 47 (5.0) General 428 (46.0) 409 (44) 459 (49.3) Trauma 126 (13.5) 125 (13.4) 125 (13.4) WGH Upper 73 (8.5) 115 (13.3) 107 (12.7) Lower 338 (39.2) 429 (49.7) 416 (48.2) General 452 (52.4) 319 (37.0) 340 (39.4)

  14. Conclusion Reconfiguration of GI surgery on two sites feasible Iminent provision of pan-Lothian (SE Scotland) CP Service (pop 900K-1.3m) No major impact on patient transfers Majority of patients treated by appropriate sub-specialists Consultant coloproctology rota radically improved Outcomes improved Analysis of mortality/morbidity and stoma rate underway

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