Campbelltown Hospital is located within South Western Sydney Local Health District (SWSLHD), covering an area of 6,243 km2. It continues to be one of the fastest growing regions in NSW, with a culturally and linguistically diverse population group. Campbelltown Hospital piloted a criteria-led protocol for laparoscopic cholecystectomy with Enhanced Recovery after Surgery (ERAS) components from 2019– 2020.
In NSW public hospitals between 2018-2019, laparoscopic cholecystectomy was performed as a day-only procedure in 4% of cases. SWSLHD's baseline data exceeded the NSW average length of stay (ALOS) and Relative Stay Index (RSI) benchmarks. Winter bed demand challenged surgical access. In May 2019, the Surgical Management Committee reviewed Performance Unit data, noting an increase in same-day surgery cancellations and hospital-related cancellations, primarily due to post-operative bed access. Local data indicated that the ALOS for laparoscopic cholecystectomy was 2.8 days, costing $8,785 per patient and $3,873 per day.
A deeper dive revealed that delays in surgical discharges were caused by stringent protocols, with over 70% of patients discharged after midday, affecting patient flow. In May 2019, the hospital adapted criteria-led discharge and care pathways for surgical procedures, establishing the Surgical Clinical Pathways Working Group under the District Surgical Management Committee.
Reducing length of stay and increasing inpatient capacity
The Surgical Clinical Pathways Working Group aimed to:
- reduce surgical procedure length of stay
- increase inpatient capacity for emergency department accessible beds
- lower procedure cancellations
- reduce expenditure by 30% on inpatient LOS for laparoscopic cholecystectomy between 2019-2020.
The working group reviewed existing processes for laparoscopic cholecystectomy and agreed to use an ‘opt out’ approach to manage most elective procedures as day surgery. The Laparoscopic Cholecystectomy Criteria-Led Discharge (LCCLD) model and flyers were implemented concurrently from 1 October 2019 as a pilot, along with a local laparoscopic cholecystectomy guideline which was in the form of a clinical pathway from admission to discharge. The ‘opt-out’ model included strict patient selection and exclusion criteria for same-day procedures.
Same-day discharge model
The working group used Accelerated Implementation Methodology to implement change, establishing a default same-day model that required documented clinical reasons for planned overnight stays. To enable same-day discharge, patients were ideally booked for morning surgical lists or as the first afternoon patient. A monthly day-only laparoscopic cholecystectomy and hernia session was also established.
Clinical management was crucial to the success of the same-day pathway. Multimodal analgesia and strategies to minimise postoperative nausea and vomiting contributed significantly. The criteria-led discharge was clear and easy to follow, while follow-up calls addressed procedure-specific concerns that could lead to hospital return.
Implementation enablers:
- The Surgical Clinical Pathways Group included the Gastroenterology Stream Manager, a surgeon, perioperative nurse, and anaesthetist.
- Effective staff and consumer engagement in the pathway design ensured acceptance and successful implementation, enhancing the outcome through open dialogue and inclusivity.
- External incentives including benchmarking reports on the length of stay.
- Clinical champions supported a criteria-led discharge approach, incorporating insights from NICE UK NG45 Routine preoperative tests for elective surgery into preadmission assessments.
Implementation barriers:
- Surgeons feeling the team wasn't fully involved in protocol development.
- Integrating clinical models required departmental consultation to agree on standardisation of care.
- Registrar oversight was needed until consultants were confident with the discharge pathway.
Savings of 1.5 bed days on average
Data from 2021-2022 shows that SWSLHD now has the highest rate of laparoscopic cholecystectomy performed as same day procedures in the state. As of October 2023, Campbelltown Hospital is reported as having the highest rate of same day laparoscopic cholecystectomy in the state, at 58.2%. SWSLHD has published the Surgical and Procedural Services Plan in 2021-2022, recommending district-wide clinical pathways that included processes to ensure surgical procedures are undertaken according to best practice and current evidence (where available). The plan recommends, building in discharge planning with criteria led discharge in the pathway and identifying relevant same day surgical procedures.
From 2022-2023, Campbelltown Hospital performed 295 planned laparoscopic cholecystectomies, with 88% booked on the same day, and 67% (199 patients) discharged the same day. In 2018-2019, 248 procedures were done, with only 9% same-day bookings and just 2% (6 patients) discharged on the same day. Bed days dropped from 364 in 2018-2019 to 157 in 2022-2023, saving 1.5 bed days per patient on average, highlighting improved efficiency.
Campbelltown Hospital is expanding its day-only incision and drainage pathway for complex abscesses, in addition to the existing 24-hour discharge and return protocol. This allows for incising specific abscesses in the emergency department without general anaesthetic or an operating theatre visit. Building on local success, a working group was established to support same-day elective joint replacement surgery using redesign methodology, as same-day laparoscopic cholecystectomy procedures eased bed pressures.
Moving forward, SWSLHD is using the success from this project to launch further same day clinical pathways building on the lessons learnt from this project.
