Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

And so we're just setting that up a very brief. Thank you. I think, sorry. There's just a lot of pressure on time now. I suspect, isn't it consulting a resurgent if you'd like to know anymore about? I am available in the bar afterwards because we were together. So thank you. Hopefully we get the first slide. Uh So you might wonder why I'm talking about this subject today. This is something that I developed in my consultant time in the early years in Southampton. So it feels a bit bit like old news now, but it still may be an ongoing story. But the reason I chose to talk about this today was essentially this work was totally inspired by my time at French, which was an incredibly happy time between 1996 and 2004. And the reason it was inspired by that work was one of the things we haven't heard much about today that, that I did experience as a registrar was day case microdiscectomy might sound like a simple and obvious thing to do. But the fact was there weren't many places if any other places doing it at the time and actually interestingly, not many places have really university adopted this ever since. Um, so shortly after and, you know, I was a bit blown away by this. To be honest, I've done neurosurgery and spine surgery elsewhere. Patient's came in the night before, spent three days in hospital, then went home after an uncomplicated recovery and I saw this daycare surgery and I thought, wow, this is amazing. It just goes to show what you can do with some good planning and some good logical thinking. So I guess that stuck with me shortly after I arrived in Southampton, we went to one of these uh consultant away days as you do, we talked about transformation in neurosurgery, which is a another subject that goes round and round, doesn't it? Every few years? And one of the things we talked about was how we could get more work done with the resources we had available. We didn't have enough beds, we didn't have enough theater time. We had lots to many patient's. So I offered to the group. I said, well, I, I've got a great idea. Something I've seen in Bristol was deck a surgery. Let me go away and do some more research on that. I'll come back and present to you my findings. Now, I felt I was kind of on safe ground because actually I was a cranial NeuroOncology surgeon. I thought I would come back and just tell all my spine colleagues you need to do all these operations as day cases and it wouldn't have any impact on me. But being a moderately responsible person, I thought I'd better first in preparing this uh work, better have a look through the literature just to make sure there wasn't anyone crazy enough anywhere in the world to have done Dake a surgery for brain tumors. And somewhat to my surprise, I found that there was so I then sort of slightly with my tail between my legs, went back to my colleagues. And yes, I presented work on day case microdiscectomy, but also presented my thoughts on day case, a biopsy and craniotomy for brain tumors. And that's what this is all about. And I'll try and rattle through it a bit more quickly than maybe the slides will allow. But the next slide, please. So I could never read off this screen. Even with these glasses on, I'll have to look at this screen. I'm sorry. Um length of stay is very variable, but it is one of those things that we get met that gets measured very easily, doesn't it? And were often it's often used as a surrogate marker for quality and safety in that patient's who have poor outcomes may likely spend more time in hospital, but it's not just that it's also a marker of efficiency too. Um In this talk, I will use two terms day case, which I mean patient's discharged home on the same day of surgery usually six hours later and short stay, which is an overnight, less than 24 hours stay in our unit. And I guess it's our work on day case surgery that prompted us to think, um, how we might use short stay surgery more widely. Next slide, please. There are many benefits. I might say that this is a sort of triple win in a sense, there are benefits for patient's for providers and the NHS as a whole, you got happier patient's with less cancellations, shorter waiting lists, then you'll have happier doctors as well as happier patient's happier hospitals and more efficient and cost effective care. So in this situation, everyone is a winner. Next slide, please. But why has it taken so long? Like I've been banging on about this for 17 years now. And why is this not widespread practice in this country or even in many countries? Well, I think one of the most significant fears is that patient's will suffer a, a complication soon after surgery that requires immediate resuscitation and return to theater. And of course, that won't be possible if the patient is sat in the comforts of their own home. So this really comes down to fear about I CH. But in order to be somewhat more logical about your thinking, you need to consider what's the incidents and timing of postoperative I CH. And in fact, 1998 the year I was appointed as a registrar in Bristol um, there was a publication of a large series of patient's almost 2.5 1000. You'll see that they found about a 2% incidence of hemorrhage. But you'll also note that the vast majority of those occur in the first few hours after surgery. And that won't come as a surprise to anyone who practices neurosurgery, but some of them do occur in a delayed manner. Hence, is there a risk? Well, why do the delayed presentations occur? And often these patient's who deteriorate two or three days after their surgery? Two possible explanations. One is, and, and, and many of you, I suppose we'll have seen this on, on rare occasions. A hematoma forms in a, for example, a tumor resection cavity and that hematoma and the patient is stable for a few days is either some further bleeding or this some swelling. And that patient then deteriorates and requires a return to theater. So how can you minimize that risk or simply by taking out a post operative scan in the early POSTOP period to rule out the presence of an occult hemorrhage? Next slide please. Does secondary hemorrhage happen? So, is that a completely safe thing to do? Um, the fact of the matter is and we all got talk this when we were doing our FRCS exams, that secondary hemorrhage is a real phenomenon, you'll notice it tends to occur 10 to 14 days after surgery. Um Thankfully, in the, in the context of brain surgery. Whilst it does happen, it's very rare, it's very rarely catastrophic and it's often treated conservatively. Now importantly, the timing there would mean that if you were to protect yourself from this consequence, you would need to keep all of your patient's in hospital for significantly longer than 14 days. And no one does that there is therefore very little logic in the thought process behind keeping people in for 34567 days as is often the practice next slide, please. The pathway I may not talk through this in detail, but there really isn't anything very clever about any of this. I'm sort of embarrassed to admit, I suppose the pathway you see described here is a typical pathway for any patient coming through our our units now. And in a neuro-oncology service, we try and move as many patients as possible into an urgent elective pathway. Um We have a one stop clinic where we image patient's. We see and assess patients'. They have pre assessment clinic. I heard that mentioned earlier, really important to make sure patient's are optimized and well informed before they come in for surgery. Um standard principles of enhanced recovery, avoiding prolonged starvation and lack of fluids and so forth. Walkie patient's to theater and hopefully they'll be walking out later the same day. Um But on the right hand side in red, although it doesn't look very red from here, that one of the things we learned very early on in this was we struggled with this a bit of first and this was due to the lack of consistency of our messaging. By which I mean, if I saw the patient in the clinic and told them you're going home after one day and they've just been to the nursing pre assessment clinic and they told them you're staying in for a week already. The patient's thinking, hey, you know, and the nurses on the ward are all set up for five days. So one of the things we got built in very early on is that consistent messaging from pre assessment clinic, nursing staff on the wards to the message from us and lo and behold and excuse the pun honestly. The most important thing here, it's all in the head. This is a psychological thing. If you believe it and tell your patient's, it's going to happen. I can promise you it will happen. Next slide, please. We we we heard about navigation and that has very much influence my, my career from the early days with David Sanderman here in Bristol. But we we now for our biopsies and our awakes actually do them frameless and pin lis using AM navigation means you can use local anesthetic techniques, get people up and recovered very rapidly after surgery as you can see here. Next slide, please. So just administrations of the of the biopsy kit that can be used with with trajectory guide attached to the to the skull in this situation. Next slide, please await cranial to me. Again, we heard about this before. Minimal access surgery using neuronavigation is all that's required to remove tumours from any part of the brain, including eloquent parts of the brain. And again, you'll find that using these principles, patient's recover rapidly from surgery, we do full awake technique were conscious sedation and no anesthetic stages. I'm afraid I'm too impatient to wait for the patient to wake up. And I think there's a risk involved in that and patient's recover really rapidly and tolerate this procedure incredibly well, next slide, please. Um, so short stay surgery. So one of our biggest constraints in this is we have a day case unit that closes about six o'clock and having a day case unit is great because all the beds are empty in the morning, but consequently, they close at nighttime. And that means for a six hour period of observation, you need to finish your surgery by about midday one o'clock, maybe if we're pushing it. So realistically, that means we can only get the first if it's a craniotomy, the first case through a day case unit. If they're biopsies, you can get more than one case through. Um, but thinking of the principles we designed around day Kay surgery, what would you do with the patient operated in the afternoon? Well, logic will tell you, yes, you might need to keep them in hospital overnight, but you can move them through a rapid pathway and discharge them the next morning. And indeed, that is what we now do. Who do we do this for? Well, in our NeuroOncology practice, essentially pretty much all of our patient's primary tumor's gliomas metastases, supratentorial cases, post foster cases. I guess the only cases I wouldn't try this for our those sort of fourth ventricular brain brain stem tumor is where you might think a period in intensive care will be worried about Bulba function. For example, POSTOP. Now you won't achieve this for every single case. But I can promise you, you will achieve it for the vast majority using these principles and you'll probably get about 80% of people out the next day. Next slide, please. Um You'll notice the dates on this almost feel historic now because this is work I started about a year after I started in Southampton. Um We collected data up till about 2013 and studied and published this data. We haven't studied, published it in the same way subsequently, but we are obviously got a much larger series of patient's just now. But you'll see here with uh what was 211 patient's the biopsy series, the Craniotomy series. At first, we were relatively conservative. So there was a small hematoma on the postop scan in a well patient, we'd probably keep them in and you can see of the biopsy cases that was about 5% craniotomy, about eight or 9%. Um In actual fact, we kept those patient's in for a day or two. None of them subsequently deteriorated, but definitely better to be safe than sorry in this context. Next slide, please. Um Did we have any complications where we did have some later complications and interestingly to complications, significant complications that occurred, both occurred at 11 days. Um One was a patient who died suddenly after a biopsy or be unrelated to the biopsy. He'd already been back for his follow up, had his results, had his clips out, been to see the oncologist had a plan for treatment and collapsed at home. I probably from a major seizure and we had a patient come in with the secondary I CH again at 11 days. Um small hematoma in the cavity, a little bit of blood in the ventricle presented with a sudden onset headache, kept him for a day or two discharge. No, no treatment. Um So importantly, and this stands to this date, you know, 10, 10 years on from this, we still haven't had uh any significant um complications as a result of the early discharge of patient's from hospital. Next slide, please. Thanks to Rick and that provided us with lots of data in the past. And thanks to the program from Gerst, we've had lots of data to allow us to compare ourselves with our peers. Next slide, please. The end up data some years ago now showed this that the length of stay after craniotomy for intrinsic tumor in Southampton is one day compared with the national median of six for meningioma. And that's all comers. So that includes my skull based colleagues as well. It's a bit longer four days. But next slide, please. Um uh for some reason, girth data produce the main, not the median. Um but you'll notice that we have the shortest length of stay for either intrinsic tumor's primary tumor, secondary tumor's and then in Germans in the country. So this this pathway really, really can work and is effective. Next slide, please. So that's us on the right hand side, I won't leave this up for too long, not wanting to name and shame anyone. But you, you can see if you've got very good eyesight, all of the names of the units at the bottom there. But this, I would argue opportunities for improvement in in many units across the country. Next slide, please. Next slide, please. So all of these graphs of funnel plots. Next slide, please showing the readmission rate from the left. And one of the things I had imagined was if we're sending patient's home really very much earlier than than usual, we would probably have to accept there'd be a higher readmission rate. In fact, that does not prove to be the case. So we have the blue dot on all of those graphs, the lilac colored line is the is the median. And you can see our readmission rate in in primary tumor, secondary tumors and million Germans is an average level across the country. Just reassuring. Thank you. Next slide please. I was told before that patient's would hate this. So we lo and behold, we have to go out and ask them and we've done and presented and published some studies on this. And this is one piece of data from that. We asked our patient's how happy they were with their discharge time going home at six hours, post surgery. The vast majority, you can see when we surveyed them, we're happy. Um Interestingly, just as many patient's reported that they felt they felt they went home too late as too soon. And you might think. Well, that sounds a bit ridiculous. But you, if you set up in the mind of your patient, you're going home at six hours and then your ttos don't arrive for another two hours, guess what? They're not happy. They complain. They've been in hospital for too long. Next slide, please. 15 minutes. He would've thought. So here you go, day case and short stay surgery really is a safe and feasible thing to do. Um The huge advantages for everyone patients' providers and the NHS as a whole. And I'm honestly incredibly grateful for everyone who trained me and taught me in Bristol, uh, and my early experiences which has allowed us to develop this work as time has gone by. Thank you very much. Thanks Paul, another fantastic talk.