CLINICAL FEATURE KEYWORDS Surgical care practitioner / Outpatient service / Elective surgery / Service management / Elective cholecystectomy / Telephone follow Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication October 2012.
The general surgical care practitioner improves surgical outpatient streamlining and the delivery of elective surgical care by Rohan Kumar, Lisa DeBono, Paritosh Sharma and Sanjoy Basu Correspondence address: Rohan Kumar, Specialty Registrar in General Surgery, William Harvey Hospital, Ashford, TN24 0FW. Email: [email protected]
The feasibility of implementing a surgical care practitioner (SCP) role for the delivery of secondary care within the general surgery department of a district general hospital was evaluated. Streamlining patients into an SCP-led ‘one-stop’ gallbladder clinic for symptomatic uncomplicated cholelithiasis led to a reduction in follow-up clinic workload for major elective laparoscopic work and more appropriate triaging of primary care referrals. Each of these improvements contributed to an efficient service model. Introduction The National Health Service (NHS) is currently facing challenging times, with increasing demands to provide and maintain satisfactory patient outcomes and to deliver both community and hospitalbased healthcare efficiently, simultaneously, and in a timely and financially economic fashion. General surgery departments across NHS hospitals throughout the country are no exception. We piloted a prospective observational study in order to evaluate the feasibility of implementing a surgical care practitioner (SCP) role to assist in the delivery of a secondary care service within the general surgery department of a NHS district general hospital.. An existing, experienced general surgical theatre nursing sister was appointed to the role of general surgical SCP on an upper gastrointestinal (UGI) consultant surgeon’s team. By implementing SCP-delivered triage, our aim was to reduce the misdirection of outpatient referrals that had been made to our department by local GPs. Additionally, we assessed whether new referrals could 138
be directly managed by an experienced SCP. Finally, we assessed whether all elective, benign, major UGI laparoscopic surgery cases could be followed up by a telephone conversation post-operatively, instead of at a face to face outpatient clinic appointment. This article discusses our data and proposes that NHS general surgery departments may benefit from a designated, appropriately trained SCP, undertaking a locally-implemented, specific departmental role to improve the surgical throughput of patients and the efficiency of operative elective general surgical secondary care services.
Methodology Firstly we audited the current service provision to identify areas where an SCP may be beneficial within our department. The results of this evaluation of service audit identified three main areas for the role of the SCP to address. We then analysed the prospectively-collected database of all non ‘choose and book’ referrals to the general surgery department..
The role of the SCP was to assess prospectively all the new (non-‘choose and book’) outpatient referrals made to our department by the local GPs. Assessing only the clinical information given in written form, the SCP was to triage the patient to an appropriate sub-specialty general surgeon or, if appropriate, to redirect the patient to an entirely different specialty all together. The SCP’s second role was to assess and manage all new patients who met selection criteria, and who had been referred for symptomatic uncomplicated cholelithiasis by their GP. This became a SCP-led, general surgical one-stop gallbladder outpatient clinic. Finally, the question of whether a SCP could successfully follow up major elective operations was assessed. All patients undergoing elective, benign, major UGI laparoscopic surgery were followed up by a telephone conversation between the SCP and the patient eight weeks postoperatively. This was instead of routinely reviewing these patients face to face in an outpatient clinic.
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The local GPs in the primary care trust were provided with strict inclusion criteria for appropriate referral and for avoidance of unnecessary delay in the pathway to secondary care for patients with cholelithiasis
The SCP in this study had twenty years experience as a senior operating theatre sister, and in 2009 had been directly attached to an UGI surgeon’s firm in order to gain the necessary training and experience for the role of SCP in 2011. Additionally our SCP completed a part-time degree at the University of Greenwich, London between 2010 and 2012. The SCP was employed for 37.5 hours a week. The timetable would typically include a single session of the one-stop gallbladder clinic and a postoperative telephone follow up, two sessions of triage of new referrals and five sessions for elective theatres. The SCP clinic ran alongside the consultant and specialty registrar’s clinic, so that supervision and immediate clinical decisions were possible, rather than having to recall the patient back to another clinic appointment. The local GPs in the primary care trust were provided with strict inclusion criteria for appropriate referral and for avoidance of unnecessary delay in the pathway to secondary care for patients with cholelithiasis. A total of 1448 new patient referrals to the general surgical department were triaged over 12 months from March 2011 to February 2012. Fifty two of these were patients with symptomatic, uncomplicated cholelithiasis. These patients subsequently underwent a clinical review and were assessed by the SCP nurse-led outpatient clinic for suitability for laparoscopic cholecystectomy. One hundred and ten patients were followed up with a telephone conversation eight weeks after their elective major laparoscopic surgery.
per rectal bleeding with sinister symptoms, which had initially been referred to an upper gastrointestinal surgeon, was triaged to a colorectal subspecialty general surgeon; a patient with symptoms of acid-reflux, who was initially referred to a breast and thyroid (endocrine) surgeon was more appropriately diverted to a UGI surgeon. In total, during the study, inappropriate referrals of 175 new patients were prevented. This approximated to 12.0% of the total general surgical outpatient work load, saving an average of approximately 35 new outpatient appointments per month.
Follow up Following strict inclusion criteria formulated by a UGI surgeon, 52 patients of the 1448 new referrals met the criteria for symptomatic uncomplicated cholelithiasis, and were deemed suitable for streamlining and further management by the SCPled one-stop gallbladder clinic. All these patients had their entire episode of clinical and surgical care successfully managed by the SCP, from the initial assessment in the outpatient clinic, through to reaching a clinical diagnosis by further organising biochemical, radiological investigations, as well as assessment of suitability for a day-case operation. Fifty one of the 52 patients were subsequently enlisted for a laparoscopic cholecystectomy by the SCP on a designated operating day-case list. Informed, written consent was gained by the operating surgeon on the day of operation. Fifty two patients were reviewed in the SCP one-stop clinic. There was a male to female ratio of 7:45, a mean age of 42
Results A total of 1448 new patient referrals were triaged by the SCP (a mean average value of 288 patients per month). Of these, 103 patients were rejected on basis of being a low priority procedure, and 40 patients were diverted to a more appropriate specialty (e.g. orthopaedics, gynaecology, paediatrics, urology, cardiology, otolaryngology and vascular). Furthermore, 32 patients of the 1448 were diverted to a more appropriate sub-specialty general surgeon. For example, a clearly colorectal case referral for new
(range 19-66) years and a mean body mass index (BMI) of 29 (range 20-44). One (2%) patient was re-referred to the UGI surgeon’s clinic, 1 (2%) patient required further imaging (magnetic resonance cholangio-pancreaticography) and 1 (2%) patient declined surgery. Thirty-two (65%) patients have had their laparoscopic cholecystectomy; there was a male to female ratio of 5:27, a mean age of 39 (range 19-66) years and a mean BMI of 29 (range 20-42). The mean length of postoperative stay was 0.2 days and none of our patients required readmission.
Finally, 110 elective, major laparoscopic surgery patients were successfully followed up by the SCP with a telephone conversation after eight weeks to review their post operative convalescence (see Table 1). The SCP was initially trained regarding the surgeon’s specific requirements (follow up proforma) pertaining to the follow up of these patients, as would have been the case had they been seen directly in a clinic appointment by the surgeon. Of the 110 patients seen by the SCP at follow up, 103 were satisfied with this process. Only seven patients expressed a wish or were required, on clinical criteria, to attend a face to face outpatient appointment with their surgeon. This equated to a mean average saving of approximately 15 follow-up outpatient clinic appointments per month. During the period of the study a total of 1558 outpatient appointments occurred,
Major benign elective operation
Number of telephone follow ups
Laparoscopic anti-reflux surgery
Laparoscopic cholecystectomy, cholangiogram and bile duct exploration
Endoscopic (totally extra-peritoneal) inguinal herniae repair
Laparoscopic incisional herniae mesh repair
Elective laparoscopic spenectomy
Removal of gastric band
TOTAL 110 Table 1 The variety of major general surgical cases that were followed up by telephone
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The general surgical care practitioner improves surgical outpatient streamlining and the delivery of elective surgical care Continued
increase in successful outpatient service delivery by physiotherapists working beyond their normal scope of duties, the so-called extended scope practitioner. This is reported to have led to more efficient deployment of orthopaedic consultant programmed appointment time and resources (Hattam 2001).
OPD clinic appointments OPD clinics reduced from consultant surgeon’s workload New
SCP gallbladder clinic
SCP elective major laparoscopic surgery follow up 103
Table 2 Outpatient clinic appointments that were appropriately streamlined or managed by the SCP
330 of which were managed by the SCP using the one-stop gallbladder clinic and telephone follow up. The SCP therefore saved approximately 21% of outpatient appointments by more appropriate triaging and redirecting of referrals for major benign elective cases (See Table 2).
Discussion The Royal College of Surgeons highlights that SCPs are non-medical practitioners such as senior nurses, operating department practitioners and physiotherapists, and that, by extending the scope of their standard daily work and with appropriate training, they are able to work as effective members of a surgical team (DH 2006). SCPs may provide care by direct participation in surgical interventions and by assessments of both pre and postoperative care, under the supervision of a consultant. SCPs are required to complete a two year part-time clinical course at a higher education institute to gain the relevant competencies (Martin et al 2007). Over the last decade there has been a drive to reduce waiting times from diagnosis to initiation of treatment, and this has led to an increased outpatient service workload. Additionally patients tend to have a shorter hospital stay. Increased patient turnover (Car & Sheikh 2003) and the continuous pressure to cut costs have meant that some elective procedures, like laparoscopic cholecystectomy or herniae repairs, are now routinely discharged without any formal follow up outpatient appointment. However some elective major operations, like laparoscopic anti-reflux surgery, do warrant further follow up. But for carefully selected cases where the anticipated risks of postoperative complication are low, a telephone 140
conversation may suffice and may help to reduce routine outpatient appointments (Cox & Wilson 2003). Nurse-led clinic follow up and, by extension, the advent of telephone conversation follow up have been shown to reduce outpatient workload in a variety of surgical procedures (McVay et al 2008) and in colorectal cancer nurse led follow up (Macfarlane et al 2012). Additionally, telephone follow up has been shown to work well for monitoring of disease progression or surveillance for recurrence of cancers, e.g. nurse-led prostate specific antigen (PSA) telephone follow up for prostate cancer. A telephone follow up reduces patient anxiety associated with waiting in a busy, over-run clinic, only to be reassured that the PSA level is within normal limits (Faithful et al 2001, Anderson 2010). The misdirection of referrals to the secondary care, hospital-based service leads to inefficiency in service provision, unnecessary delays in patient care and has the potential to adversely affect the overall quality of care delivered. Orthopaedic and rheumatology are specialties which have been reported in the literature, where referrals to the musculoskeletal service have the potential to be misdirected to an orthopaedic surgeon when a non-surgical, rheumatological assessment would have been a more appropriate initial line of management (Speed & Crisp 2005). It has been estimated that, in orthopaedic secondary care service provision, between 34 and 43 percent of GP referrals do not necessarily need to be managed by a surgeon (Elwyn & Stott 1994, Roland et al 1991). In orthopaedics there has been an
In our NHS trust a new referral outpatient clinic appointment is 20 minutes. Taking new (non-choose and book) referrals alone, during our study, 175 patients were more appropriately diverted to the correct specialty or subspecialty, saving approximately 58 hours of clinic time. This equates to 14 full outpatient sessions during our study alone, on the basis that our outpatient clinics are four hours in length. Furthermore, our trust receives £209 per new patient referral from the primary care trust, which equates to £36,575 that was more appropriately utilised during this period. Our study demonstrates that, on average, approximately 21% of general surgical outpatient clinic appointments can be saved by appropriate SCP management. We have shown three ways to help reduce outpatient work load: n introduction of a SCP-led one-stop gallbladder clinic for symptomatic uncomplicated cholelithiasis n using telephone conversations instead of routine follow-up clinic appointments for major elective laparoscopic work n appropriate triaging of primary care referrals. These savings have benefits to all concerned. Advantages to the patients are that they are able to carry on with their daily activities without having to organise transport to hospital, out-going expenses (e.g. fuel and car parking) and organising time off from employment. Additionally, by appropriate triage of patient clinic appointments, patients may be dealt with more efficiently and this assists in their movement through the NHS secondary care referral and treatment model (Fallis & Scurrah 2001, Gray et al 2010). From the consultant’s perspective, the savings in clinic time approximated to one
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The Trust usually pays an increased salary to the SCP but this is offset by the financial savings gained by unnecessary or inappropriate clinic appointments
and a half clinic sessions per month, per surgeon, in our trust. This session has been more effectively utilised by the consultant to direct their service, to increase their availability for an extra theatre session which further helps to reduce waiting lists, to participate in training the trainees at Deanery teaching sessions, and to undertake assigned educational supervisor work as outlined in the Intercollegiate Surgical Curriculum Project. From the SCP’s perspective, there may be increased self worth, and better career progression pathways, prospects for future employability and increased salary. The Trust usually pays an increased salary to the SCP but this is offset by the financial savings gained by unnecessary or inappropriate clinic appointments. We demonstrate, for the first time, that a SCP can make an invaluable contribution to the service provision of a general surgery department in a district general hospital. In our department, we demonstrate improved appropriateness and a reduction in misdirection of referrals when patients were assessed by SCP-delivered triage. Additionally, we show that a SCP may manage new referrals for uncomplicated symptomatic cholelithiasis and that this is feasible in an NHS setting. Finally, we show that the majority of major, benign, elective operations in our department were followed up by an SCP-led telephone conversation alone. We propose that the implementation of a SCP role should be considered in general surgery departments, following an evaluation of service audit to identify specific, local roles to address. This will help to increase the throughput of patients in an overburdened specialty and will enhance the delivery of operative surgical care.
References Anderson B 2010 Benefits to nurse-led telephone follow-up for prostate cancer British Journal of Nursing 19 1085-90
About the authors Rohan Kumar MRCS (Eng), MBBS (Hons), BSc (Hons)
Car J, Sheikh A 2003 Telephone consultations British Medical Journal 326 966-9
Specialty Registrar in General Surgery, William Harvey Hospital, Ashford
Cox K, Wilson E 2003 Follow-up for people with cancer: Nurse-led services and telephone interventions Journal of Advanced Nursing 43 51-61
Lisa DeBono RGN, Dip Theatre Practice, BSc (Hons) Clinical Practice
Department of Health 2006 The curriculum framework for the surgical care practitioner London, DH Available from: www.rcseng.ac.uk/ surgeons/training/docs/curriculum_framework_ SCPs.pdf [Accessed November 2012] Elwyn G, Stott N 1994 Avoidable referrals? Analysis of 170 consecutive referrals to secondary care British Medical Journal 309 567-8
Surgical Care Practitioner in General Surgery, William Harvey Hospital, Ashford Paritosh Sharma MBBS, MRCS StR in General Surgery, William Harvey Hospital, Ashford Sanjoy Basu MS, FRCS
Faithful S, Corner J, Meyer L et al 2001 Evaluation of nurse-led follow-up for patients undergoing pelvic radiotherapy British Journal of Cancer 85 1854-64
Consultant Upper GI and General Surgeon, William Harvey Hospital, Ashford
Fallis WM, Scurrah D 2001 Outpatient laparoscopic cholecystectomy: Home visits versus telephone follow-up Canadian Journal of Surgery 44 39-44
No competing interests declared
Gray RT, Sut MK, Badger SA et al 2010 Postoperative telephone review is cost effective and acceptable to patients Ulster Med Journal 79 76-9 Hattam P 2001 The effectiveness of orthopaedic triage by extended scope physiotherapists Clinical Governance International Journal 9 244-52
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Macfarlane K, Dixon L, Wakeman CJ et al 2012 The process and outcomes of a nurse led colorectal cancer follow up clinic Colorectal Disease 14 245-9 Martin S, Purkayastha S, Massey R et al 2007 The surgical care practitioner: A feasible alternative. Results of a prospective 4-year audit at St Mary’s Hospital Trust, London Annals of Royal College of Surgeons of England 89 30-5 McVay MR, Kelley KR, Matthews DL et al 2008 Postoperative follow-up: is a phone call enough? Journal of Pediatriatric Surgery 43 88-96 Roland M, Porter R, Matthews J et al 1991 Improving care: a study of orthopaedic outpatient referrals British Medical Journal 302 1124-8 Speed CA, Crisp AJ 2005 Referrals to hospital-based rheumatology and orthopaedic services: seeking direction Rheumatology 44 469-71
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