Lump in groin/navel (hernia)

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Stephen Allen
5 years ago
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1 Commissioning pathways Lump in groin/navel (hernia) Supplementary information to be read in conjunction with the pathway Reference Supplementary Information 1.2 Incidence & Prevalence 3% adults will require operation for inguinal hernia. Male : Female ratio is 12:1. Elective : Emergency operation 12: UK there were 70,000 inguinal hernia repairs (0.14% of population) M:F 95:5 1.3 Self Assessment & Self Care - Support individuals to undertake and monitor their own healthcare - Provide expert advice 1.3 Self Assessment & Self Care Support for patients in understanding their condition and choices available through NHS Direct and NHS Choices. For more information see the pathway web page. 1.6 Escalation thresholds & decision aids - Receive and direct requests for health care assistance using protocols and guidelines - Prioritise treatment and care for individuals according to their health status and needs - Advise and support others pending the attendance of a healthcare practitioner 1.6 Escalation thresholds & decision aids Support for patients in understanding their condition and choices available through NHS Direct and NHS Choices. 2.0 Primary Assessment - Undertake routine clinical measurements - Determine an individuals state of physical health and fitness - Assess an individual with a suspected health condition Agree the nature and purpose of assessment and investigation into an individuals health status - Plan assessment and investigation into an individuals health status - Plan inter-disciplinary assessment and investigation into an individuals health status - Select assessment and investigative techniques/procedures for use 2.0 Primary Assessment History: Age, male vs female, PMH, pain, description of lump / does anything change the lump (eg lying down / direct pressure) effect on quality of Iife (manual work, hobbies, sexual intercourse, exercise, work). Examination: Observation of lump in groin in standing position, positive cough impulse, palpation reducible / irreducible on

2 manual pressure, does the lump disappear on lying down, extension into scrotum, scars of previous surgery, check for abdominal mass (umbilical) 2.0 Primary Assessment COMMISSIONING AND CONTRACTING Before starting commissioning consider existing primary care medical contracts. Are you already paying for this work? Is it more appropriate to commission this stage of the pathway from primary care contractors? Have your Practice Based Commissioning (PBC) groups considered this pathway for any service redesign? Have you considered the contractual options to commission the pathway at primary care level? Is the current primary care contract fully utilised? Is there capacity to commission additional activity under additional or enhanced service arrangements? 2.2 Diagnostics (Dx) Ultrasound of groin/anterior abdominal wall - If diagnostic uncertainty: If clinical doubt about the nature of the lump, eg to exclude Lymphadenopathy (inguinal), to exclude tumour, abscess (umbilical) Tx Tresholds: Guidelines for direct Listing Services (as at NW London Hopsitals Walk in, Walk out service): Assess whether suitable for Direct Listing Hernia Services: Guidelines for Direct Listing Services - pt willing to have procedure under LA - pt must have responsible adult to take them home and stay with them overnight - reducible direct or indirect inguinal, femoral, umbilical or paraumbilical hernia - pt should be of small to med. build - pt should be able to lie supine for mins. - no known allergy to xylocaine and bupivacaine - pt should not be on warfarin, aspirin, heparin, clopidogrel or any blood thinning medication. If they are, they must be able to be stopped a wk before their appt date - likely to exclude fit elderly with directly reducible hernia where risks of surgery outweigh the benefits 2.2 Diagnostics (Dx) SERVICE IMPROVEMENT A summary of service improvement knowledge for UK Radiologists is available. 2.2 Diagnostics (Dx) COMMISSIONING AND CONTRACTING Commissioning a World Class Imaging Service tool has been developed to support commissioners of imaging services. It aims to bring together a number of valuable resources about diagnostic imaging in one easy and convenient reference tool. For more information see the web page. Generic Patient Reported Outcome Measures exist for this pathway (EQ5D). Currently clinical consensus has not been reached for a condition specific measure. 2.4 Treatments SERVICE IMPROVEMENT The British Association of Day Surgery (BADS) have produced a Directory of Procedures which makes recommendations around whether cases should be day case, 23 hour stay or longer for over 130 procedures. North West London Hospitals introduced a Walk In, Walk Out Hernia Service which resulted in more efficient management of hernia surgery Pre Op Assessment For good practice pre-operative assessment guidance, use the hyperlink above or see the website. 2.4 Treatments Invasive treatment: Direct listing for surgery - See treatment thresholds Where patients do not meet criteria onward referral will be required. 2.4 Treatments - Prescribe pharmaceuticals to achieve specified health goals

3 All aspects of invasive surgery and the wider surgical environment are relevant and this area is still subject to development - Prescribe Pharmaceuticals to achieve specified health goals - Administer medication to individuals 2.5 Rehabilitation & Review WORKFORCE - Evaluate treatment plans with individuals and those involved in their care - Evaluate outcome of intervention Support for patients in understanding their condition and choices available through NHS Direct and NHS Choices. For more information see the pathway web page. Referral Thresholds: Where patients do not meet criteria onward referral will be required COMMISSIONING AND CONTRACTING Can the quality of primary care be improved to help referrals? TECHNOLOGY Oldham Community PAS system for recording waiting time journeys through ICATs or other intermediate services. - Receive and direct requests for health care assistance using protocols and guidelines - Prioritise treatment and care for individuals according to their health status and needs 3.0 Specialist Assessment - Undertake routine clinical measurements - Determine an individuals state of physical health and fitness - Assess an individual with a suspected health condition - Receive requests for health care assistance 3.1 Specialist Diagnostic Thresholds and Decision Aids - Agree the nature and purpose of assessment and investigation into an individuals health status - Plan assessment and investigation into an individuals health status - Plan inter-disciplinary assessment and investigation into an individuals health status - Select assessment and investigative techniques/procedures for use 3.0 Specialist Assessment For support in commissioning successfully and identifying opportunities for service redesign see the No Delays Achiever.

4 3.2 Diagnostics (Dx) Request investigations to provide information on an individuals health status and needs Obtain images [of organs] using ultrasound - Interpret and report on the findings of investigations - Undertake a risk assessment in relation to a defined health need - Assess an individuals needs arising from their health status - Assess an individuals suitability to undergo planned actions - Assess the need for and provision of environmental and social support - Support indiviudals during and after clinical/therapeutic activities - Enable individuals to make health choices and decisions regarding their own health or the health of other 3.2 Diagnostics (Dx) Ultrasound: Ultrasound only indicated after specialist review and where there is clinical doubt about the nature of the palpable lump 3.2 Diagnostics (Dx) SERVICE IMPROVEMENT A summary of service improvement knowledge for UK Radiologists is available. See the hyperlink or website for information. 3.2 Diagnostics (Dx) COMMISSIONING AND CONTRACTING Commissioning a World Class Imaging Service tool has been developed to support commissioners of imaging services. It aims to bring together a number of valuable resources about diagnostic imaging in one easy and convenient reference tool. For more information see the web page. SERVICE IMPROVEMENT For good practice pre-operative assessment guidance, use the hyperlink above or see the website. The British Association of Day Surgery (BADS) have produced a Directory of Procedures which makes recommendations around whether cases should be day case, 23 hour stay or longer for over 130 procedures. Invasive Treatment: Hernia repair: Walk-in, walk out service, day case under LA. NWL Hospitals provide a direct access service for hernia repair where appropriate patients are given an appt. for review by the surgeon and surgery under local anaesthetic on the same visit. BADS recommend: 95% Day case, 5% 23 hour stay for primary repair; 60% Day case, 35% 23 hour stay, 5% 72 hour stay for bilaterals; 70% day case, 30% 23 hour stay for recurrent inguinal hernia. BADS recommend 85% Day case, 15% 23 hour stay for umbilical hernia Reassurance, information, Self- Help - Prescribe pharmaceuticals to achieve specified health goals Pre-operative Assessment -Assess an individuals suitability to undergo planned actions - Assess an individuals needs arising from their health status - Arrange access to resources needed to support planned health care/lifestyle programmes Invasive Treatments - All aspects of invasive surgery and the wider surgical environment are relevant and this area is still subject to development

5 - Provide information and advice to individuals/carers on managing health care needs - Prescribe Pharmaceuticals to achieve specified health goals -Administer medication to individuals 3.5 Rehabilitation, Review & QOL measurement WORKFORCE - Evaluate treatment plans with individuals and those involved in their care - Evaluate outcome of intervention

Indigestion (dyspepsia)

Commissioning pathways Indigestion (dyspepsia) Supplementary information to be read in conjunction with the pathway Reference Supplementary Information 1.1 Symptom Description Annual incidence 40%. Prevalence