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AUGIB services:
The South West
Perspective
David Parker
Gastroenterologist
BSG Regional Representative
for South West England
Geography
 Gloucestershire, Wiltshire, Bristol, Somerset,
Devon, Cornwall

 The M4/M5/A30 corridor
 A361, A303, A353
Dr David Parker - acute upper GI bleed services SW England
Severn Deanery Trusts
 Swindon
 Gloucestershire
 Cheltenham
 Gloucester

 North Bristol
 Southmead
 Frenchay






University Hospitals Bristol (BRI)
Weston-super-Mare
Taunton
Yeovil
Peninsula Deanery Trusts
 North Devon (Barnstaple)
 Exeter

 Torbay (Torquay)
 Plymouth (Derriford)
 Royal Cornwall (Treliske, Truro)
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)
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?
A problem: measuring workload

 Non-responders
 Out of hours workload or all cases?
 When does OOH start?

 Daily bleed lists/slots
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?
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
Three Case studies

 Split site
 Example of networking

 Small trust
 Needs to network?

 Isolated trust
 50+ miles / 1 hour 15 minutes from nearest
neighbour
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
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
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.
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
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
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
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
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?

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Dr David Parker - acute upper GI bleed services SW England

  • 1. AUGIB services: The South West Perspective David Parker Gastroenterologist BSG Regional Representative for South West England
  • 2. Geography  Gloucestershire, Wiltshire, Bristol, Somerset, Devon, Cornwall  The M4/M5/A30 corridor  A361, A303, A353
  • 4. Severn Deanery Trusts  Swindon  Gloucestershire  Cheltenham  Gloucester  North Bristol  Southmead  Frenchay     University Hospitals Bristol (BRI) Weston-super-Mare Taunton Yeovil
  • 5. Peninsula Deanery Trusts  North Devon (Barnstaple)  Exeter  Torbay (Torquay)  Plymouth (Derriford)  Royal Cornwall (Treliske, Truro)
  • 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?