Streamlining the pathway to urgent outpatient cholecystectomy – A quality improvement project

Purpose: It is increasingly recognised that patient outcomes and satisfaction with ‘hot’ cholecystectomy are better than those for delayed surgery for cholecystitis. At Belfast Health and Social Care Trust it has not been possible to manage all eligible patients surgically on their index admission within the allotted resources. In addition, the route to outpatient cholecystectomy was ineffective introducing multiple delays for patients. This project aimed to identify the sources of delay and streamline the pathway. Methods: Using quality improvement methodology 927 consecutive admissions with acute biliary pathology were followed over 16 months and analysed fully mapping the existing pathways, identifying key interfaces and delays on the patients’ journey to surgery. Results: Several barriers were identified including unnecessary clinic visits, redundant pre-assessment of fit patients and missed opportunities to provide procedure information or obtain consent. Collaboration with the anaesthetic team led to development of a pre-assessment screening questionnaire which was included in a resource pack introduced for biliary admissions. This also contained a decision-making tool / pathway flowchart, information leaflets, consent and haemovigilence forms. This increases the potential to maximise decision-making and preparations during the index admission. Unfortunately, due to the impact of COVID-19 on elective operating, few patients (n=35) have completed the journey through the new pathway, but ongoing data collection and analysis is anticipated to show significant benefits. Conclusion: Employing the principles of improvement science has led to a remodelled pathway to urgent cholecystectomy which is hoped to increase efficiency and patient satisfaction.