Learning from practice

All routine children’s ENT surgery is offered at Epsom General Hospital on a day case basis. The day case rate of 95 per cent is one of the highest in England for the same operations.

Nevertheless, complication rates for tonsillectomy are comparable to national rates measured by the recent National Prospective Tonsillectomy Audit. When this service was developed over five years ago, there was a follow-up home visit the next day by the paediatric community nursing team as part of a pilot project. This soon proved unnecessary and the team now offer a nurse-led telephone follow-up in the 36 hours after surgery.

There is an ‘open door’ policy to the children’s day surgery ward during the two-week convalescent period, addressing initial concerns from primary care colleagues that the post-operative burden would shift to them.

Day surgery was introduced gradually over a period of months to ensure that all parties - from patients and their carers to surgeons, anaesthetists, nurses and GPs - were fully confident in the safety and feasibility of this model. A small, unused ward was converted into a dedicated 12-bed children’s day surgery ward and rooms with TV/DVD and en-suite facilities address the privacy that adolescents prefer away from the smaller children.

The ward is also used for children’s private surgery, generating income for the Trust and offering a safe, high-quality children-based private service. The clinical team has a protocol for managing the children in terms of anaesthesia and post-operative analgesia, which they believe are key to the success of its paediatric day surgery service.

A number of colleagues have already visited from the UK and abroad both informally and on organised courses to pick up hints on adapting and developing their own day surgery service. Says Peter Robb, consultant ENT surgeon and current President of the British Association for Paediatric Otorhinolaryngology; “There is capital investment required to set up the day surgery service, but issues of cross infection and specialised surgical nursing mean that it is not possible to effectively incorporate this service on a busy acute children’s ward or adult day surgery unit.

In areas where investment in facilities is supported and day surgery criteria are met, day surgery for routine procedures is good for children and good for their parents.” In the outpatient setting, parents of small children with hearing loss, typically less than four years of age, have been shuttled between hospital-based ENT clinics and community-based paediatric audiology clinics.

However, at Epsom, the children’s ENT clinic now offers a joint paediatric ENT and audiology service, giving children and their parents or carers the benefit of a one-stop hearing and ENT assessment. Continues Peter; ‘As it’s generally not possible to perform routine audiology for children under four years of age, patients have historically been referred to second tier community audiology clinics to have a hearing assessment and then to the ENT clinic for a surgical opinion.

This has meant parents and small children have had to travel to and from community and hospital clinics.” “In order to minimise this, I integrated my children’s ENT clinic with one of the community audiology clinics on a fortnightly basis to offer a one-stop assessment clinic for these younger children.

This has brought a community service into the hospital clinic but is actually more convenient for parents as it avoids multiple visits to different clinics. It was also cost-neutral as we reduced some of the demand for the community-based service. There is also a network of community-based outpatient clinics in a number of local community hospitals, taking ENT consultant clinics closer to patients’ homes.

No formal studies have yet been undertaken, but patients anecdotally report high levels of satisfaction with the community hospital clinics as they are geographically convenient and the parking is invariably free. Concludes Peter;

“From a PCT perspective, initial capital investment is usually required to produce a high-quality service, with appropriate facilities and staff. This can produce savings on increasing day surgery rates. However, with small children and surgery involving the airway, this type of surgery is not suitable for stand-alone units and should be under the umbrella of a dedicated paediatric, surgical, anaesthetic and nursing service and facility.”

The Care Closer to Home Demonstration Project has been set up to consider how care can be shifted and delivered in innovative ways to make it more convenient for patients. The project is evaluating care pathways and models of care in six specialities - dermatology, orthopaedics, gynaecology, urology, ENT and general surgery. DH web page gives more details at http://digbig.com/4nken