Pre-clinic information for patients Google search “Bristol thoracic surgery”

Videolinked pre-operative assessment in thoracic surgery: an update Alistair Johnstone, Eveline Internullo, Gianluca Casali, Claire Dowse, Doug West University Hospitals Bristol NHS Trust

Why? principles Increasingly fewer, larger units Patient demand for care close to home To streamline our care pathways to improve referral to treatment times To improve the patients experience of care Reduce waste Maintain standardisation Why? principles

~900 thoracic patients per year, 400 lung resections, 278 for primary lung cancer, 80% thoracoscopic (2014-15) 100% reviewed by anaesthetists pre operatively Standardised pre-operative assessment and optimisation programme Purpose built £2.4m pre operative department opened 2015 Routine DOSA Lung cancer LOS 5 days About us

Where do our patients come from? 254 Patients with “non Bristol” postcodes Nov – April 2014 Source: UH Bristol Data / Medway

How long does it take patients to get to the BRI? N=157 patients Unselected, April14

“35 mins to get to Bristol then another 45 minutes driving round trying to find somewhere to park” “waited ages for the hospital bus” “does not include time waiting for transport” “had to leave really early with transport” “Approx 1 hour then 40 mins finding a parking space near enough to walk to hospital” It’s not always easy! N=157 patients Unselected, April14

Round trip mileage to BRI Gloucester Royal 80 miles Yeovil 86 miles Bath RUH 25 miles Musgrove Park 94 miles Weston 46 miles Round trip mileage to BRI

Video Pre-Op Assessment

Traditional Pathway 2-5 Days 2-3 Days 11 - 22 Days 7-14 Days MDT decision to refer to surgery Wednesday Day 0 2-5 Days Traditional Pathway Referral letter Typed Thursday Day 1 Arrive Friday Day 2 (best case scenario) 2-3 Days 11 - 22 Days Triage/Booking clinic appointment Monday Day 5 7-14 Days Clinic appointment at BRI Surgical clinic + Preop clinic Wednesday Day 7 (Best case scenario) Friday Day 9 (Most likely scenario) Tuesday Day 13 (Occasionally) Wednesday Day 14 (Occasionally) ? High risk Complex case review meeting Second line tests + review Surgery

new pathway 1 Days 7 Days 6 Days MDT decision to refer to surgery Wednesday Day 0 new pathway 1 Days Fast Referral/Triage Booking clinic appointment 7 Days 6 Days Clinic appointment at remote site Surgical clinic + VIDEO Preop clinic Wednesday Day 7 (Routinely) Second line tests + high risk MDT Surgery

ONE STOP CLINIC IN THE PERIPHERY SOUTHMEAD MODEL WHO DOES WHAT BY WHEN DOCUMENT MDT decision to refer to surgery Output Effective handover of information to the surgical team Achieved with one of the two followin options Fast referral Referral Letter WEEK 0 Day 0: Wednesday Clinic Appointment VIDEO POAC VIDEO CNS Output Patient ready for surgery Achieved with Completed Pathway (Surgeon + POAC nurse) Signed Consent Education (Surgical CNS + POAC + Surgeon) ECG, Bloods WEEK 1 Day 7: Wednesday Surgery WEEK 1 + X DAYS Surgery Advanced tests Specialist assessments WEEK 1 + X DAYS

MDT decision to refer to surgery Output Effective handover of information to the surgical team Achieved with one of the two followin options Fast referral Referral Letter WEEK 0 Day 0: Wednesday FAST REFERRAL Who Surgeon and Resp Physician does what fill the fast referral form by when by the end of the MDT Who Surgeon does what brings the fast referral form to the BRI by when by Day 0 + 1 Who Secretary does what Create T number by when by Day 0 + 1 does what fills in the ICE form by when by Day 0 + 1 Who CNS does what ensures that patient is booked in clinic by when by Day 0 + 1 does what ensures that BRI knows about booking in Southmead To avoid double booking by when by Day 0 + 1 does what organises Bloods, ECG, other missing tests by when by Day 0 + 1

Reducing delays: North Bristol data TIME REFERRAL TO CLINIC (DAYS) REMOTE + VIDEO CONTROL MEDIAN (RANGE) 6 (0-15) 10 (0-30) MEAN 5.4 11.6   TIME REFERRAL TO READY FOR SURGERY (DAYS) 10 (2-43) 24 (2-87) 12.9 25.8 TIME CLINIC TO READY (DAYS) 5 (1-30) 13 (0-78) 7.5 14.9 TIME REFERRAL TO OPERATION (DAYS) 12 (7-61) 43 (16-119) 22.8 44.6 CLINIC TO OPERATION (DAYS) 6 (4-61) 29 (6-119) 17.5 Reducing delays: North Bristol data Referral Clinic POAC Ready Operation

Median times: NBT

What do our patients think? I think it is a very good idea to do the video interviews as it saves extra visits to the hospital Overall the service is great….. I was very pleased to be part of the video pre op assessment. Everything worked well and I saved a great deal of time. I hope that it becomes a regular routine What do our patients think? I enjoyed taking part…. found it very friendly….it saved a long journey to the BRI…. When I actually went for my op I felt I knew everybody already… I thought it was very good…it saved me time going to the BRI and time trying to find parking. It was very straight forward and the nurse and anaesthetist were very nice.

Why have we been successful? Multi disciplinary working, lead by clinicians who could identify problems and implement solutions Stepwise changes, decided by not imposed on clinicians Reducing administrative delays whilst continuing to deliver high quality, patient focused care Integrating existing technology into care pathways to improve patient experience Why have we been successful? Cancer Specialist Nurses Pre Op Nurses Lung Cancer MDT Lead Administrators Surgeons Anaesthetists IT departments Clinical Operations Managers Outpatient Nurses

Starting: lessons so far Two sites Southmead Gloucester Royal 2016 Easier second time! Led by CNS and nursing teams on both sites POAC slots owned by local team Technology issues surmountable Weekly clinic essential Fast referral proforma helpful Patients like it! Starting: lessons so far

Challenges and the future Advanced testing – CPEX Trial recruitment Consent documentation Staffing in POAC Tariff reimbursement Roll out to all weekly peripheral clinics More optimisation in 2WW- smoking / COPD Video trials consent ?video follow up Recording discussions and sharing with patients Challenges and the future