6. Some Golden Standards of Care
Underpinned by NICE, SIGN, BSG
24/7 rota staffed by suitably skilled people
If not available in-house, a formal network
Suitably qualified/experienced nurses on call
All forms of therapy available 24/7
Banding, dual (triple?) therapy, glue
All high risk patients endoscoped within 24h
All unstable patients endoscoped within 2 h of
adequate resuscitation
(All acute GI bleeds endoscoped within 24h)
7. A problem: definitions
NCEPOD audit confusion
“GI bleeding” codes
Lower GI bleeds are included in data searches
How do you define “acute UGI bleed”?
High risk bleeds or all bleeds?
Therapeutic cases only?
Coffee ground vomits?
Scoring systems
Out of hours workload or all cases?
When does OOH start?
8. A problem: measuring workload
Non-responders
Out of hours workload or all cases?
When does OOH start?
Daily bleed lists/slots
9. What we know
6 trusts have 24/7 rota staffed by Gastroenterologists
1 has regular Sat AM list
3 trusts 24/7 rota shared with Surgeons
1 trust has regular Sunday AM list
1 trust 24/7 rota shared between gastro and surgery but
gaps
Reliant upon goodwill?
2 trusts have ad hoc arrangements shared with Surgery
both 5/7, but one has timetabled Sunday AM bleed list
Planning formal 24/7 rotas
Reliant upon goodwill?
10. Comments
Various solutions
Large trusts OK (heavy workload; 500 pa)
1 “network”
Various problems
Still some gaps in 24/7 cover
Surgeons still need to help
Level of therapeutic experience?
Isolated trusts
Small trusts
11. Three Case studies
Split site
Example of networking
Small trust
Needs to network?
Isolated trust
50+ miles / 1 hour 15 minutes from nearest
neighbour
12. Case 1: split site (1)
One trust
2 DGH hospitals: 600k population
Both take acute unselected admissions
One rota covers both sites
Bleeds done on both sites
Rota 24/7: Gastroenterologists
Weekday bleed lists 0800/1230
100 out of hours bleeds pa
In-pat and new pat scoped <24h
13. Case study 1: Split site (2)
Problems:
Access to theatres
Sometimes have to wait for a gap between
surgical/orthopaedic cases
No instances of having to be in two places at
once (yet)
Lack of familiarity with unit/kit not an issue
Hospitals 8 miles/20 minutes apart
14. Case study 2: Small trust (1)
Population 180k
1 site
Rota 1 in 8 (3 gastro, 5 surgeons)
2 AM slots daily Mon-Fri for in-patients
OOH cases usually done in theatre
Endoscopy Nurse on call
~140 cases pa but most scoped in hours
All high risk cases scoped <24h
~45 therapeutic interventions pa.
15. Case study 2: small trust (2)
Problems:
None of the surgeons want to do it
Some of the surgeons do low numbers of diagnostic
OGD
Not all on the rota can/willing to band/glue
Other physicians do 1 in 11. No extra pay for the
gastroenterologists.
Some rota gaps: dependent on goodwill (Gaps are
paid for)
Once in past year management had to ask neighbouring trust
to cover
Prospect of networking not popular
Significant workload if have to participate in cover at larger
trust
Risk of in-comers lack of familiarity with kit/unit
16. Case study 3: Isolated trust (1)
1 site
160k population
1 in 8 rota
3 gastro, 5 surgeons
Other physicians do 1 in 11
Gastro gets extra 0.125 PA extra
Endoscopy nurse on call
17. Case study 3: Isolated trust (1)
Potential Problems:
Isolation
50 miles from nearest neighbour
A roads
1 hour 15 minutes in winter; longer in summer
months
Network not practical
No issues yet
Rota in infancy
18. Summary & conclusions (1)
10 trusts have a formal rota
Large trusts Gastroenterology
Small trusts shared with surgery
Others working towards rotas
Surgeons seem disinclined to participate
Skill set not always complete
Low numbers of routine OGDs
Networks challenging
Distance
Potential “two places at once”
Participation in onerous rotas not popular
19. Summary & conclusions (2)
Where do we go from here:
Support training of consultants on rotas
JAG accredited courses are costly
Limited Study leave
Press for Gastroenterology to come off
medical take?
Unlikely in smaller trusts
Other ideas?