Business Case for Intra-operative fluid management - NHS ...

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1

TEMPLATE
/
EXAMPLE


INTRAOPERATIVE FLUID

MANAGEMENT TECHNOLOG
Y

BUSINESS CASE

Title of Scheme

Implementation
of I
ntraoperative
Fluid
M
anagement

Technology

Ref :
[INSERT REF]

Board
Approval Date
:

[INSERT DATE]

Division:

Surgery
/Anaesthetics


Lead Clinician
:


Lead Manager
/
Finance
:


Implementation Date
:


Summary Proposal:

This paper outlines a proposal for the implementation
of
intra
-
operative
fluid management to reduce post
operative complications facilitating
shorter recovery times and reductions in hospital stay following major
surgery.


It will outline
both the capital and revenue implications required for
implementation of this technology into routine clinical

practice. I
n
addition, it contains

assumptions about lengths of stay, potential capacity
and associated activity
underpinning the development.

Summary Finance:


The financial calculations
below assume

an average reduction in length of
stay of
[**]

days
for
(list spe
cialities)

releasing
[**]

bed days each year.


EXAMPLE NOT RECOMMENDATION.

T
he case assumes that the trust will
ut
ilise the additional

inpatient bed capacity released through the
reductions in length of stay to undertake an additional
[**]

cases with an
average length of stay of
[**]

days attracting gross additional income of
£
[**]
K. The costs of undertaking this additional activity have been
calculated as £
[**]
K per annum.


Introduction of this technique for intra
-
operative fluid manageme
nt has
been shown to reduce hospital stay for patients undergoing ma
jor
sur
gery. The preferred option requires an investment of £
[**]
K in Y
ear 1
but this investment is fully recovered in year
[**]

from recurrent savings
of £
[**]
K per annum.


2

Capital and Revenue Costs



Intra
-
Operative Fluid Management

2012/13


2013/14


2014/15



Summary

£

£

£

Capital Costs (inc. VAT)








Devices (n) x unit cost




Total Capital Cost


£


£


£


Revenue costs







Staffing

Disposables




Training
Costs




Maintenance costs




Capital Charges




Total Revenue Costs


£


£


£


Other Income Sources


CQUINN

Additional Activity

Endowment Funds





Total Other Income Sources


£


£


£


Total costs ( capital and revenue )


£


£


£



Workforce
Impact:

e.g. Staff / skill mix changes



How will staff structure change?



How many additional/fewer staff will be required to
support the service?

Forecast Activity changes (procedures):


Year 1

Year 2

Year 3

NHS

[**]

[**]

[**]

Private *

[**]

[**]

[**]

Total

[**]

[**]

[**]


Objectives: Links to Trust / Divisional
objectives. Please include division ref.



Improvement in
c
linical
o
utcomes



Reduced
l
ength of
s
tay

(LOS)



Qualifying for CQUIN payments



Management and
r
eduction in
r
isk



Increased c
apacity through release of
b
ed
d
ays


3




Summarise Recommendation























Benefits of the proposal:

To patients, staff etc.




Increased clinician confidence in monitoring high risk
cases



Reduction of post operative complications



Shorter recovery times



Improved patient satisfaction with the service



Improved quality of care



Positive impact on staff satisfaction


Risk:

Impact on organisational risk


Please include Risk Register number



Risk rating (RAG)
[**]




LOS


comparison with national average



Financial effectiveness



Access Targets e.g. cancer waiting times



Health outcomes



Improves quality of life for patients undergoing major
surgery



Reduction in
m
ortality


Patient
/
User experience



Reduced risk of complications following major surgery
will
lead to reduced anxiety for patients and greater
patient satisfaction



Reduction in mortality, fewer complications, reduced
morbidity, shorter recovery times and reduced hospital
stay

Corporate Citizenship

Links to corporate goal



Implementation will impr
ove public and stakeholder
confidence in surgical services as a whole.

4

BUSINESS CASE FOR TH
E IMPLEMENTATION OF

INTRAOPERATIVE FLUID

MANAGEMENT TECHNOLOG
Y


EXECUTIVE SUMMARY


This paper outline
s

the proposal for the

Trust to implement/optimi
s
e the use of Intraoperative
Fluid
Management T
echnolog
ies (IOFMT)

in order to reduce post operative complications
for patients undergoing
major surgery
thus
reducing mortality, length of hospital stay and
fac
ilitating shorter recovery times
.



By demonstrating improved clinical outcomes th
e techniques have also
been shown to reduce unplanned
admissions to ITU/HDU beds
as well as improving management of bed capacity.


This paper also outlines the investment

re
quirements and the activity assumptions made to underpin this
development.




BACKGROUND


The use of an Intra
o
perative Fluid Management Technology (IOFM
T
) enables an anaesthetist to monitor and
manage the patient’s hydration status during major and
high
-
risk surgery. There is a strong body of evidence
which shows that the use of this technology can facilitate improved outcomes for patients.


In March 2011
NICE

published
g
uidance related to one device used for intraoperative fluid management
(Cardio Q
-
ODM)
. Subsequently NICE has said
it recognises that ‘the specific recommendations on individual
technologies are not intended to limit use of other relevant technologies which may offer similar advantages’.


http://publications.nice.org.uk/cardioq
-
odm
-
oesophageal
-
doppler
-
monitor
-
mtg3

.


NICE stated that the available data support a clinical benefit and a cost saving when the CardioQ
-
ODM is used
in patients undergo
ing major or high
-
risk surgery or other surgical patients in whom a clinician would consider
using invasive cardiac monitoring.


In December 2011 the 2012/13 NHS Operating Framework was published. In recognition of the improved
outcomes that can be expecte
d when using these technologies, adoption has been included as a CQUIN pre
-
qualifier from 2013/14. In further recognition of the benefits to be gained, the use of these technologies was
also included as one of the High Impact Changes in Innovation Health
and
Wealth

(IHAW), which was published
by the NHS Chief Executive in early 2012. IHAW reported that ‘Full adoption of this technology across the NHS
is forecast by NICE to benefit over 800,000 patients and generate net financial savings of over £400m’.


Pa
tients undergoing moderate and major surgery can carry a significant risk of mortality and morbidity.
A high
percentage of patients have clinically significant dehydration pre
-
operatively and patients loose varying
amounts of fluid during surgery.



When t
here is not enough fluid in the bloodstream, the volume of blood ejected by the heart during each
heartbeat decreases. This in turn can result in an insufficient blood supply to the tissues and the vital organs
which are consequently starved of oxygen and
nutrients. This can cause complications that, if not dealt with,
can lead to severe compromise, increased hospitalisation or even death.



5

W
hen intravenous fluids are given, the benefits of maintaining optimal circulatory volume and organ perfusion
must be

weighed against the risk of administering excessive fluid which can overload the heart and cause
pulmonary oedema and other complications. Some surgical procedures may also have poorer outcomes if too
much intravenous fluid is given during surgery.


It is

therefore vital for the anaesthetist to assess the patient’s fluid status and to respond with the appropriate
treatment for their individual circumstances. The use of an
Intraoperative

Fluid Management Technology
allows the anaesthetist to monitor the pat
ient closely during surgery and helps them to meet this challenge.



KEY BENEFITS OF THE
TECHNOLOGY



Advice Box

Benefits described will relate to the product selected for implementation



Benefit


Safety


Improved
Processes



Financial

Provides superior

monitoring to conventional
monitoring techniques (Pulse and BP)







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NUMBER OF PATIENTS E
LIGIBLE FOR THIS TEC
HNOLOGY


The Trust has reviewed the number of cases where the evidence suggests that patients will benefit by use of
this technology.


Cumulatively this represents [
**
]

cases

per annum.


Surgery Specialty


Number of
Procedures


Bed Days

PBR Income

















6

OPTIONS APPRAISAL


ILLUSTRATIVE ONLY


Published evidence and NICE Guidance have shown that reductions in length of stay following deployment of
t
hese technologies is achievable.
The current average length of stay for eligible cases at this Trust is
[**]

days
compared to the national average length of stay of
[**]

days for the same case mix.


In order to achieve the Nation CQUIN payments the Trust must achieve and average length of stay of
[**]
days
for patients undergoing colorectal surgery.


This business case
considers
three

options.


Advice Box

A full options appraisal should be undertaken

by the Implementation Team and the business case may also
therefore need to include an evaluation of different products.


The Trust may wish to consider both cash releasing option
s

and opportunities to increase income through
the use of “spare capacity” g
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OPTION 1


DO NOTHING


Doing nothing will lead to non
-
achievement of the CQUIN qualifier and

consequently a large financial impact
upon the Trust of up

to 2.5% of the final contract out
-
turn value.


It also means the benefits of improved
clinical

outcomes, bed reductions/capacity increases and shorter
lengths of stay will be difficult to achieve.



OPTION 2


IMPLEMENT INT
R
AOPERATIVE FLUID MAN
AGEMENT IN COLORECTA
L SURGERY


This option evaluates the impact of
using intra
-
operative fluid management in
[**]

colorectal
surgical cases per
annum to achi
e
ve a reduction in
average
length of stay of
[**]
days. This will release a total of
[**]

surgical bed
days per annum.


Implementation of this option will allow the Trust to achieve pre
-
qualification for CQUIN

and meet NICE
guidance
.




7

Option 2
Colorectal Surgery

2012/13

2013/14

2014/15

Capital costs





Revenue costs





Total Capital and Revenue Costs


£


£


£


Cases per Annum

Current Average Length of Stay





Projected Average Length of Stay





Projected
Bed Days Saved

(
?
cash releasing opportunity
)








Apportioned CQUIN /cash releasing
savings


£


£


£


Total Savings


£


£


£



Option 2 would require an initial investment of £
[**]
K in year 1. This investment is fully recovered in year
[**]

from recurrent overall savings of £
[**]
k per annum.

(
Please note if equipment is purchased
depreciation will need to be calculated

within the cost section
.
)


OPTION 3



IMPLEMENT INTRA
OPERATIVE

FLUID MANAGEMENT IN
A WIDER RANGE OF

SPECIALITIES


Advice Box

This option would be most likely to offer the opportunity f
or additional activity by
utilis
ing released capacity
or alternatively reducing beds. One scenario is given below.


This option evaluates the impact of using intra
-
operative fluid management in
[**]

surgical cases per annum
[list specialties]
to achieve a reduction in average length of stay of
[**]
days.


This will release a total of
[**]

surgical bed days per annum which equates
to [
**]
beds. Alternatively the
“spare” capacity generated by reductions in length of
stay
would enable the trust to undertake an additional
[**]

surgical cases (average LOS
[**]

days) attracting additional gross PBR income of £
[**]
K.





8

Option 3
Wider Range of
Specialties



2012/13


2013/14


2014/15


Capital costs





Revenue costs
(utilizing existing capacity only)

Revenue Costs (additional theatre cases)

See table 5




Total Capital and Revenue Costs


£


£


£


Cases per Annum

Current Average Length of Stay




Projected Average Length of Stay




Projected Additional Activity

Projected Additional PBR Income(case mix sensitive)

£


£


£


Apportioned CQUIN


£


£


£


Total additional income


£


£


£



Additional theatre capacity equating to
[**]

sessions will be required to support the additional
[**]
cases and
the costs of performing this activity have been calculated as £
[**]
K per annum and this is detailed in

the

t
able
below.

(Please note if equipment is purchased depreciation will need to be calculated within the cost section.)



Costs of performi
ng additional activity


2012/13


2013/14


2014/15


[**]
PAs Clinicians (assuming
[**]
cases per session over
[**]

week year)

£


£


£


[**]
Theatre Sessions assuming
[**]
cases per theatre session
over
[**]

week year )

£


£


£


Theatre & Ward Staffing


£


£


£


Additional Consumables


£


£


£


Additional Non Pay


Additional Administration & Audit

£



£



£



Total costs for delivering additional activity


£


£


£



Option 3 would require an initial investment of £
[**]
K in Y
ear 1. This investment is fully recovered in
Y
ear
[**]

from income generated by additional activity of £
[**]
K

per annum.





9

PREFERRED OPTION


The preferred option is Option
[**]

as it supports the investment in new medical technology to improve post
operative clinical outcomes and reduce overall hospital stay. This will enable the Trust to release bed capacity
to
[
realise cost savings
/
undertake additional surgical activity
]

which

will support the Trust to achieve CQUIN
compliance and make
QIPP /
efficiency gains.



PROPOSED

IMPLEMENTATION


It is proposed that this technology is implemented
by
insert date

using a

project plan
agreed with and
supported by
the
surgical and anaesthetics
multidisciplinary team
. As part of this process
the outcomes
achieved should be audited.



MEASURING

THE I
MPACT OF IMPLEMENTAT
ION


In the first instance the data required to demonstrate achievement of CQ
U
IN will be collected
this includes

TBC


1.

Average
l
ength of stay

2.

% of patients undergoing colorectal surgery who receive IOFM

3.

Number of patients undergoing colorectal surgery


Advice Box

Evidence suggests that deployment of Intra
-
operative Fluid Management will also positively
impact upon
mortality, theatre returns and re
-
admission rates. Trusts may wish to measure these in order to
demonstrate impact

/ return on investment. In addition, depending upon the technology selected other
factors may be included e.g. reduction in use

of C
entral Venous
P
ressure

lines.



WORKFORCE

& TRAINING


It is anti
cipated that implementation of I
ntraoperative
F
luid
M
anagement will result in the following changes to
the workforce
.


Advice Box

The option selected may impact upon the existing
staffing establishment, if so the table below may be of
use.




10


Changes in
w
orkforce
following

implementation






Role

Rationale

Duration

Band

WTE

Clinicians

(Additional/
reduced
PAs)








Theatre staff









Ward Staff








Administration &
Audit






Any anticipated training programme and its potential impact upon existing service delivery should be described
here.



RECOMMENDATION


The
Board

is asked to support the purchase and implementation of this technology to realise the benefits
outlined in this business case.


The
Board

is asked to support Option
[**]

investment proposal which
[describe option and benefits]


This is in line with Trust

and National Policy Priorities to

meet NICE
guidance
,

deliver t
he requirements of the
2012/13 O
perational
F
ramework and support implementation of QIPP to
improve patient outcomes,
increase
efficiency and achieve national access targets.


This development

requires an investment in
Y
ear one of £

[**]

K
with an anticipated return on investment
in
Y
ear
[**]

with recurrent savings
/additional income

of £
[**]
K per annum.