London Patient Choice Project

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London Patient Choice Project
London Patient Choice Project Urogynaecology
Care Pathway (TVT) 4/9/2003
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Urogynaecology ( Clinical ) Pathway (TVT)
Principles and Standards Evidence Base
Patient Identification
Pre - Operative

• Operative Assessment Visit
• Requirement for patient records
• Patient notes urodynamic study results (if
  these results are not available/adequate, they
  may need to be repeated).
• Personnel required
• Surgeon -Consultant or equivalent level of
  experience.
• Nurse - trained to carry out anaesthetic
  assessment if anaesthetist not present.
• Tests - B/P, Urinalysis, Height, Weight, FBC
  Hb, Coagulation screen, Sickle Cell(if
  appropriate),Group Save, ECG for pts over 40
  years old CXR as required.
• Consent - taking note of the advice given in the
  guidelines quoted.
• Patient information about procedure and what to
  expect.
• Anaesthetic Assessment / Suitability for daycase
  treatment (Procedure can be performed under
  local, regional or general anaesthesia)

• All patients who have been on the waiting list
  for the agreed procedure for 5 months and are
  registered with a London GP (PCT) are eligible to
  be offered Choice EXCEPT patients in the
  following groups
• Known MRSA
• Active Tb
• MI or cardiac surgery within last 6 months.
• Taking warfarin/anticoagulants (if known)
• Current complex renal treatment/dialysis.

• Principles
• Clear responsibility for ongoing treatment in the
  best interests of the patient
• Need for Trusts to work together to provide a
  high quality experience for the patients.
• Minimal reasons for excluding patients from being
  offered Choice - No cherry picking by the
  Receiving Trust.

• Best Practice Guidelines Standards
• Good Practice in Consent Implementation guide -
  DOH, March 2001
• Royal College of Anaesthetists ASA Guidelines
  - including guidelines for Pre-Admission - 2002
• Day Surgery - Operational Guide. DOH. Aug 2002.
• RCOG Clinical Standards - advice on planning the
  service in Obstetrics Gynaecology. July 2002.
• Good practice in continence services. DOH. 2002
• Guidance on the use of tension-free vaginal tape
  for stress incontinence. NICE. Feb 2003

• Procedures
• TVT
• (Use of tension-free vaginal tape for stress
  incontinence - generally for women with
  uncomplicated urodynamic stress incontinence in
  whom conservative management has failed.)
• NB This procedure may be performed in
  conjunction with other gynaecological procedures
  - see major pelvic surgery pathway.

• There are a number of possible outcomes from this
  visit - local arrangements to accommodate track
  these outcomes MUST be in place.
• Patient fit for surgery, wishes to proceed (at
  RT) date of operation agreed with patient.
• Patient fit for surgery but wishes to have
  surgery at OT.
• Patient decides not to proceed with
  surgery/Chooses another treatment option.
• Patient is temporarily unfit for surgery -
  requires treatment by GP or OT prior to returning
  to RT for operation.
• Patient not suitable for surgery at any time.
• A clear record must be kept of the clinical
  reasons which prevent patients progressing to
  surgery - these outcomes will be audited by the
  LPCP team. The RT consultant must also write to
  the OT consultant with the clinical findings.

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Gynaecology ( Clinical ) Pathway (TVT)
Planning for Discharge
Peri-Operative
Post Operative
Follow up

• Surgeon
• Accredited consultant
• Has attained certificate of completion of
  surgical training.
• Has received appropriate training in this
  technique and who regularly carries out surgery
  for stress incontinence in women.
• Anaesthetist
• Accredited consultant
• Has attained certificate of completion of
  anaesthetic training
• Operating Department
• In line with current recommendations on GMP,
  workforce, working practices, record keeping etc.

• Any emergencies should be treated at the nearest
  facility and then referral arrangements made as
  appropriate.
• In general terms, conditions directly relating to
  the surgery should be returned to the RT and
  other conditions treated at the OT.
• Patients should have a follow up appointment at
  the RT 6 weeks after surgery.
• Urodynamic studies should be repeated 6 months
  after surgery

• This procedure will generally be carried out as a
  daycase.
• Surgeon Anaesthetist must see patient prior to
  discharge.
• Clear written discharge information discussed
  with and given to patient by nurse and/or medical
  staff - this should include what to expect.
  following the procedure and any dos and donts
  that the patient needs to know to maintain
  recovery at home.
• Patients must be given 24 hour emergency contact
  telephone number at the RT on discharge.

It is not anticipated that complex discharge
planning will be required for this group of
patients. However, if a patient does present
with more complex needs then there must be
liaison between RT and OT and a treatment plan
agreed.
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Patient Choice System PCA Process
Principles Standards
Pre Operative
Patient Identification
Patient Choice System
IT System Development - See separate documents
on system development and reporting process
(Guidelines, Closing the Loop etc)
RTs need to provide specific information about
Operative Assessment Operating schedules - day,
date, time, surgeon etc. Arrangements need to be
made so that women can have the option to be
treated by a female surgeon. It is likely that
more slots will be required for Operative
Assessment than for operation to allow for
patients not proceeding to surgery.
Information about RTs for patients being offered
Choice - PCA files

• Operations should take place within a maximum of
  4 weeks following the Operative Assessment.
• The outcome of the Operative Assessment,
  including the guaranteed date for surgery etc
  MUST be reported as per the Patient Choice
  Guidelines (See Appendix re Closing the Loop)
• The date for surgery MUST be arranged with the
  patient at the Operative Assessment or through
  the PCA - the patient MUST NOT just be sent an
  appointment by letter at a later date.
• RTs are recommended to use Integrated Care
  Pathway type documentation (which should commence
  at the Operative Assessment) to facilitate both
  accurate contained record keeping at the RT and
  comprehensive return of clinical information to
  the Originating Trust for inclusion in the
  patients notes.

• OT will need to identify appropriate (named)
  personnel to identify patients qualifying for
  Choice from PAS systems and patient notes.
• The OT will need to arrange for provision of
  patient notes and test results as specified.
• RT will need to provide robust system for
  transferring the above - named person
  responsible. The notes will stay at the RT until
  the episode is completed - specific arrangements
  should be agreed between OTs and RTs if notes are
  required elsewhere.
• OT will need to log patients excluded from Choice
  and the reason why against the exclusion criteria.

Rigorous quality assurance process prior to Go
Live to ensure operational capacity of
participatingTrusts - see separate documents.
PCA Process
Stage 1 Outpatients Stage 2 Pt. Waiting Stage 3
Choice Offered Stage 4 Choice Accepted
Stage 5 Pre-Operative Assessment, Surgery
Discharge
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Patient Choice System PCA Process
Planning for Discharge
Peri-Operative
Post Operative
Follow up
Patient Choice System

• PCA Evaluation
• Learning
• Patient Tracking /
• Reporting Cycle

• Copy of RT notes/Integrated Care pathway t be
  returned to OT with any original scans etc.
• Outcomes of the completed episode must be
  reported via the Choice system to OT PCA team.
• Discharge letter must be sent from the RT to the
  patients GP.
• Patient outcomes should be audited and results
  documented.

PCA Process
Stage 5
Stage 5
Stage 5
Stage 6