SHINE Final Report

Outpatient operative hysteroscopy with conventional re-useable equipment: a cost

effective alternative to day case theatre. Assessment of effectiveness, patient

acceptability and comparative health economics.

Richard Penketh

Page 2 of 37

Summary

1.1 Project Title:

Outpatient operative hysteroscopy with conventional re-useable equipment: a cost effective alternative to

day case theatre. Assessment of effectiveness; patient acceptability and comparative health economics

1.2 Lead organisation:

Department of Gynaecology, Cardiff and Vale University Health Board

1.3 Partner organisations:

Cedar, Directorate of Radiology, Medical Physics and Clinical Engineering, Cardiff and Vale University

Health Board (UHB).

Cedar’s primary role is as an external assessment centre for the National Institute for Health and Clinical

Excellence (NICE) as part of the Medical Technologies Evaluation Programme (MTEP). We specialise in

clinical and economic evidence gathering and evaluation. During the course of the SHINE project Cedar

has acted as an independent centre to assess patient acceptability by carrying out follow-up phone

interviews with patients. Cedar has been responsible for analysing patient satisfaction data and has also

led the economic evaluation element of the SHINE project.

1.4 Provide a brief summary of your project

Some causes of bleeding after the menopause require removal of abnormal tissue such as polyps or

fibroids, from within the lining of the womb. Traditionally such procedures require a general anaesthetic

and the tissue is removed using a 10 mm diameter telescope which is inserted through the cervix after

dilatation; the tissue being cut away with an electric loop. The fluid glycine is used to distend the uterus

during the procedure and if too much is absorbed into the patient’s circulation it can cause electrolyte

imbalance which requires monitoring and occasionally treatment.

The equipment is re-useable and not expensive. There is a perception amongst gynaecologists that the

cervix cannot be dilated to 10 mm in outpatients. Recent innovations have enabled such procedures to be

Page 3 of 37

undertaken under local anaesthetic without dilatation but expensive disposable instruments are required,

the tissue is vaporised and there are limits on the size of pathology which can be removed.

Some of the women requiring polyp or fibroid removal at Cardiff and Vale UHB were at very high

anaesthetic risk so 5+ years ago we started to undertake resections with the traditional equipment in

theatre under local anaesthetic. This was surprisingly successful so we extended it to all our women and

evaluation of the procedure by questionnaire was very positive, but many patients felt that the theatre

environment was very threatening. Valuable theatre space was also being used for a local anaesthetic

procedure so we wished to move the procedure to the outpatient clinic. In theatre women were admitted

for a whole morning prior to the local anaesthetic case being done at the end of the list. Cancellations were

commonplace due to major case overruns; the potential for malignancy in some polyps meant that this was

not always acceptable.

Despite being Clinical Director for almost 4 years, the project lead (RP) was unable to secure pump priming

funding to facilitate the development of an outpatient operative hysteroscopy clinic. The Health Foundation

SHINE grant made this possible.

The grant was used to run a clinic for a year with a view to undertaking 150 operative hysteroscopies

during that time. We knew we had the award in December 2009 and the project started in February 2010.

There was an enormous amount of set up work with the writing of protocol, policies, risk assessment, staff

training, development of procedure pack, surgical instruments as provided in theatre and an equipment

loan had to be secured. This meant that the clinic did not start until late May 2010. In addition one of the

consultants who was undertaking almost a third of the work had a long term sickness episode during the

project. The scope to add clinics was limited by availability of the room but despite these setbacks we will

have completed over 100 procedures during the clinic’s first year.

Originally we had anticipated that the majority of our women would be in the post-menopausal group. With

increasing experience however, we started to offer the procedure to younger women, many of whom had

not yet had children.

Page 4 of 37

1.5 Please describe the context in terms of the environment into which your innovation

was deployed

The environment was a gynaecology outpatient clinic in a tertiary care teaching hospital. The target

population was a secondary care referral group with diagnosed intrauterine polyps or fibroids requiring

removal. The team consisted of four consultant gynaecologists representing a range of backgrounds and

attitudes towards innovation. Nursing team members were enthusiastic for change. Independent

evaluation of patient experience was felt to give validity to the work so telephone interviews were

undertaken by Cedar staff one week after the procedure. The pathologists helped us by both weighing and

measuring the pathology specimens. Consultant and junior colleagues, having identified the benefits of the

clinic, referred their patients. The project received strong support from management at all levels including

the University Health Board (UHB).

1.6 Please summarise three ‘headline’ messages about the impact and meaning of this

project

The use of traditional re-useable operative hysteroscopes with electricity and glycine solution as a fluid

irrigant in an outpatient setting is technically feasible and safe despite requiring dilatation of the cervix to 10

mm. It can be successfully carried out in over 95% of cases, and outpatient nursing staff can be trained to

facilitate the procedure following theatre protocols with significant resultant job satisfaction

The procedure was very acceptable to women and low pain scores during and after the procedure were

reported. The outpatient clinic setting meant that patients did not require admission, thus reducing the time

spent in hospital and disruption to their daily lives. Rapid access for treatment has also enhanced

compliance with Referral to Treatment targets.

The procedure in outpatients may be quicker than in theatre, utilises less staff and releases scarce,

expensive operating theatre time for other cases. Cardiff and Vale UHB has not had to outsource

gynaecology procedures in order to meet Welsh Assembly targets in part due to this work as approx.

100 theatre hours have been released.

Page 5 of 37

2 The story of your SHINE project

2.1 Please provide a description of the ‘before’ and ‘after’ to demonstrate what has

changed as a result of your project

Before the SHINE project, operative hysteroscopies were all undertaken in theatre, usually under general

anaesthetic, with some being done under local anaesthetic on the project lead’s team. Subsequent to the

award a high proportion of these cases are now being undertaken in outpatients with improvements as

outlined above.

TRADITIONAL PATHWAY: GENERAL ANAESTHETIC

Out patient transvaginal scan and hysteroscopy Post menopausal Bleeding Clinic ↓

Polyp / fibroid identified ↓

Refer as urgent for Transcervical resection polyp / fibroid (TCRP/F) under General Anaesthetic ↓

Preoperative assessment clinic prior to surgery ↓

Admit day of surgery at 07.30 or 12.00 nil by mouth from 24.00 or 06.00 ↓

Change into hospital gown ↓

Admitted to bed area by named ward nurse ↓

Reviewed by Anaesthetist ↓

Reviewed and consented by surgical team ↓

Wait on ward for slot on list ↓

Anaesthetic room: general or spinal anaesthetic ↓

TCRP/F ↓

Average Glycine volume 6litres ↓

Extubated ↓

Transfer to Recovery on trolley ↓

Transfer to ward on trolley ↓

Support at home agreed prior to discharge ↓

Discharge home when recovered from Anaesthetic and passed urine

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THEATRE BASED PATHWAY: LOCAL ANAESTHETIC (LA)

Out patient hysteroscopy Post menopausal Bleeding Clinic ↓

Polyp / fibroid identified ↓

Refer as urgent for TCRP/F under Local Anaesthetic (LA) ↓

Admit day of surgery at 07.30 or 12.00 nil by mouth from 24.00 or 06.00 ↓

Change into hospital gown ↓

Admitted to bed area by named nurse ↓

Reviewed and consented by surgical team ↓

Prescribed Voltarol 100 mg and paracetamol 1 gram 45 minutes prior to procedure ↓

Wait on ward for slot on list: always last on list; increased risk of cancellation ↓

Anaesthetic room: ↓

Admit to theatre area; position on bed ↓

Supported by Vocal Local ↓

Commence LA; dilatation and TCRP/F ↓

Average Glycine volume 2 litres ↓

Transfer to trolley ↓

Transfer to Ward ↓

Rest 30 minutes discharge home

Page 7 of 37

OUTPATIENT OPERATIVE HYSTEROSCOPY PATHWAY: SHINE PROJECT

Out patient hysteroscopy General gynaecology clinic Fertility clinic Post menopausal bleeding Clinic

↓ ↓ ↓ Polyp / fibroid identified Polyp / fibroid identified by transvaginal scan (TVS) or hysteroscopy

↓ ↓ Urgent referral to SHINE Routine referral to SHINE

↓ Information sheet to home with appointment

↓ Attend Outpatients 1 hour prior to procedure

↓ Reviewed and consented by surgical team

↓ Baseline blood pressure and pulse

↓ Prescribed Voltarol 100mg and Paracetamol 1 gram

↓ Wait in clinic or WRVS for 45 minutes

↓ Procedure room

↓ Remove clothing below waist, sheet for modesty

↓ Lie on procedure couch

↓ Supported by vocal local

↓ Commence LA; dilatation and operative hysteroscopy

↓ Average Glycine volume 0.4-1 litres

↓ Get dressed

↓ Walk to resting area

↓ Baseline observations; refreshments

↓ Discharge home within 30 minutes

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2.2 Please tell us what you did over the course of the award period

The award period began as soon as we heard that the award had been granted and we could realise our

ambitions of initiating an outpatient hysteroscopy clinic. Project Board meetings were set up on a regular

basis (at least monthly) and additional stakeholders were co-opted as needed (e.g. manager of OPD

reception staff). An equipment loan (operative hysteroscopes and camera system) had to be finalised from

Karl Storz head office in Germany. Outline local agreement had been obtained from Karl Storz UK prior to

submitting the application. Appropriate drapes had to be developed with the help of the Sunlight Company.

Policies and protocols had to be adopted from elsewhere and rewritten to cover our clinic. Outpatient

nursing staff had to be trained in theatre etiquette and instrument handling and set up of the environment.

EB, our nurse practitioner, had a strong theatre background and was well qualified to provide the training.

Documentation for the procedure was developed to include a clinical record and areas to document pain

scores during the procedure and timings for prospective audit. In addition a telephone questionnaire

proforma was developed based on the questionnaire which had been used to assess the views of the

women who had undergone the procedure in theatre under local anaesthetic. A further literature review

was undertaken to support development of the questionnaire.

The clinic started on 18th May 2010. Owing to constraints on access to the procedure room we had a full

session every alternate Tuesday (RP) and a part session each Thursday with AP and PL alternating. At

first the Tuesday clinic was kept to two patients but rapidly increased to three with two slots for additional

procedures, e.g. hormone implants or Mirena coil fits. The Thursday sessions were part of a larger

procedure clinic so clinical activity remained at two patients once established, giving a total capacity of

seven procedures a fortnight. If almost all clinics had gone ahead this would have enabled at least 150

appointments a year in line with our proposal.

The clinic went surprisingly well and rather than use a wheelchair to move to the rest area, all able women

walked and spent considerably less time resting afterwards than we anticipated.

Regular Project Board meetings became less frequent and routine running of the clinic was punctuated by

the mid point report, a presentation to the Irish Gynaecological Endoscopy Society in November 2010, and

the end of year meeting in March. In parallel with writing this report we are preparing abstracts for various

meetings including the American Association of Gynaecological Endoscopy, the European and British

Association meeting and Risk and Patient Safety 2011. We intend to fast track our findings to NICE using

the QUIPP initiative and RP and PT are due to attend a seminar at the Health Foundation.

Project timeline – GANTT chart

2.3 Please tell us about your achievements, the challenges and the things that

didn’t work out quite as you planned

Clearly the fact that the clinic worked and the patients had a good experience is a major achievement.

We have gently rocked the foundations on which many outpatient operative clinics are based by

proving that it is possible to undertake resection of fibroids and polyps in outpatients under local

anaesthetic following dilatation of the cervix to 8 or 10 mm, and using glycine for uterine distension.

No patient has suffered a significant complication with the largest volume of fluid absorbed being

400 ml and the majority with no fluid absorption at all (Table 2.1).

Table 2.1 Glycine distension medium deficit during SHINE operative hysteroscopy

procedures

.

Patient numbers with fluid deficits of 0, 100ml, 20 0ml, 300ml, 400ml, versus total volumes of

fluid used

In theatre under general anaesthetic, larger fluid volumes are absorbed – if a litre is absorbed the

procedure is stopped and the patient’s electrolytes monitored in the recovery period necessitating an

extended stay, and this is not an infrequent occurrence.

The procedure was very well accepted with only four procedures failing to be undertaken. One

woman was so obese that we were unable to reach her cervix and we had the same problem under

spinal anaesthetic in theatre. Another woman was extremely anxious before commencement of the

procedure and was rescheduled under GA. A third elderly woman whose indications for the

procedure were weak changed her mind after difficulty passing the speculum, and another found the

local anaesthetic injection to the cervix intolerable. We had adopted a policy of accepting all referrals,

glycine deficit (litres)

0

24

6

8

1012

14

16

0.4-0.9 1-1.4 1.5-1.9 2.0-2.4 2.5-2.9 3.0-3.4 3.5-3.9 4.0-4.4 4.5-4.9 5.0-5.4 5.5-6.0

total volume used

num

ber

of p

atie

nts 0

0.1

0.2

0.3

0.4

0.5

Page 11 of 37

some of whom had not had a diagnostic hysteroscopy in outpatients and no screening for suitability

was undertaken. The entire team have been amazed at how well the women accepted and coped

with the procedure, and are delighted that the success rate has been so high.

Consultant colleagues within the team adapted well to the new environment and took on the

challenges of some quite difficult patients. These included several immobile women for whom

positioning was difficult, and one who was educationally challenged and difficult to communicate with

and had her husband with her for support throughout the procedure.

The best advertisement for our clinic followed one of our consultant colleagues booking herself in for

a procedure to be undertaken by her female colleague AP. Despite not having had the proper

opportunity to read the literature in advance the procedure went well and subsequently the clinic has

received numerous referrals from her team.

The clinic was set up within the constraints of available space and time within job plans and thus the

capacity was limited. Seven clinic appointments per fortnight should have enabled us to reach our

objective of 150 plus procedures in a year. Unfortunately AP developed an illness, which prevented

her from working normally from November 2010 till March 2011. Despite best efforts to lay on extra

clinics, constraints of room and staff availability meant that this was not always possible. Hence our

clinic will have only treated just over 100 women in its first year. Despite this we are very satisfied

with the numbers and the acceptability, and aim to publish on our first year’s activity. The one week

follow up telephone calls will then stop, but we will continue to monitor the clinical parameters, pain

scores during the procedure, tissue sample weights, and histological outcomes. This will help

maintain a clinical database.

Unfortunately Pat Tamplin ceased to be the Directorate Manager and moved to a patient experience

role. She was key to the application process and undertook a major role in the organisation of the

clinic and its setting up. Andrea Aquilina, her replacement, has been co-opted onto the SHINE project

team and her input is clearly key to sustainability, which seems at present to be without question.

Despite some initial misgivings from management on the governance side we had exceptionally

strong support from the entire department and upper echelons of the Trust. It has been a great

pleasure to see the health care assistants (band 2 and 3) developing their role as vocal local support

for the woman. The band 6 outpatient nurse Sarah Hill’s role has been pivotal not only at an

organisational level but also she has become the main scrub nurse for the procedures, readily

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adopting skills which must have at first been well outside her comfort zone. She has now taught her

senior Laura Groves band 7 to undertake the role and other nursing staff are keen to get involved.

Elizabeth Bruen, band 7 nurse practitioner and surgical assistant, was pivotal to the entire project

from conception to final report writing. She has undertaken a lot of training and developed the

policies and protocols at the start of the project. Without this major effort the clinic would not have

been able to start when it did.

The Cedar team have put in considerably more work than originally planned. Independence from the

clinicians adds credibility to their findings, and validity to the project. Telephone calls were slightly

more difficult to organise than anticipated and considerable detail has gone into the financial

evaluation.

Perhaps the message here is that all the team members were crucial and other units wishing to make

these changes will need an equally dedicated staff.

Interestingly if we had known how much effort the setting up might take we might never have started.

Clearly having done all this work it is important to save others having to do so.

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3 Quality Outcomes

3.1 Introduction

Assessing patient satisfaction, which included pain measurements during and after the procedure,

was vital to determine whether a change in the location of operative hysteroscopy service from day

case theatres to an outpatient clinic was acceptable for patients and whether they could tolerate this

procedure under local anaesthetic. The duration of the operative hysteroscopy procedure was also

an important outcome to evaluate as a reduction in length of procedure means increased

convenience for patients, as well as a reduction in staff costs and use of hospital facilities.

3.2 Methods

Patient satisfaction recording sheets were provided to the nursing staff to assess the pain

experienced during and immediately after the procedure, and to obtain feedback about the general

experience of each patient. In addition, the time of patient arrival, commencement of procedure, end

of procedure and time of discharge were recorded. One week after the procedure and with the

patient’s consent, an independent NHS department (the Cedar evaluation centre) carried out phone

interviews to further explore the satisfaction levels of patients after they had gone home. This survey

included questions relating to the clinic environment, the explanation provided by the clinical team

prior to the procedure, support and reassurance given by the clinical team, the patient’s overall pain

levels during the procedure, and anaesthetic preference. All feedback was anonymised and kept

separate from clinical data.

Where patients provided non-whole number pain scores they were rounded up to the nearest whole

number; and where two values were stated by the patient, the highest value was presented in this

report. Length of operative hysteroscopy procedures performed in Cardiff and Vale UHB theatres

under GA or LA was collected retrospectively from TheatreMan (theatre IT data collection system).

Statistical differences between the length of procedure in outpatients clinic (SHINE) and day case

theatres under GA and LA were analysed using a two-sample t-test in Minitab (logged data).

Page 14 of 37

3.3 Results

Eighty two women received an operative hysteroscopy procedure in the outpatient clinic at Llandough

hospital, near Cardiff between 18th May 2010 and 31st March 2011 (for the purposes of this report,

these are termed “SHINE procedures”). Mean age was 56.3 years (SD 8.7). One patient suffered

from dementia and was removed from further analysis as she was unable to conduct patient

satisfaction questionnaires without help from her husband.

Peri-operative patient satisfaction

At each stage of the procedure and 15, 30, and 45 minutes after, the patient was asked by the

support nurse to give a pain score between zero and 10 (based on Visual Analogue Scale), with zero

being no pain at all and 10 being pain as bad as possible. Patients were also asked to provide an

overall pain score, and whether they would recommend the procedure to a friend or relative. The

peri-operative pain score recording sheet was missing for one patient. Of the remaining 80 pain

recording sheets several contained missing responses. The highest mean pain score during the

procedure was 2.1 measured at injection of local anaesthetic (SD ±1.9), dilation of cervix (SD ±2.1),

and resection of tissue (SD ±2.6) (Fig. 3.1). The lowest mean pain measurement was 0.9 during

insertion of resectoscope (SD ±1.5) and re-insertion of resectoscope (SD ±1.6). At 15 minutes post-

procedure the mean pain score was 0.7 (SD ±1.4), and the overall pain score was 3.3 (SD ±2.6)

(Fig. 3.1). When patients were asked if they would recommend this procedure to a friend who

required it, 96% responded that they would. Patients were also asked if they would like to make any

further comments; the following are a selection of comments:

• “[I] thought it was great to watch the screen and interact with staff”

• “Just a little uncomfortable”

• “After getting over initial embarrassment [I] felt fine”

• “Frightened at prospect of the procedure - team very reassuring and understanding which

offset concern to some extent. Painful at points - not as bad as I though it would be”

• “Fantastic team work”

• “Really friendly supportive staff”

Page 15 of 37

Fig. 3.1 Mean patient pain scores during stages of operative hysteroscopy in outpatient clinic

(standard deviation bars shown)

0

1

2

3

4

5

6

7

8

9

10

Applic

ation

of vu

selle

um (n

=76)

Inje

ction

Cita

nest

(n=79

)

Dilatio

n to

8 / 1

0mm

(n=7

5)

Inser

tion r

esec

tosco

pe (n

=77)

Resec

tion

tissu

e (n

=78)

Polyp

forc

ep tis

sue r

etrie

val (n

=79)

Reins

ertio

n re

sect

osco

pe (n

=76)

Compl

etion

of pr

ocedu

re (n

=60)

15 m

inute

s pos

t pro

cedure

(n=54

)

30 m

inute

s po

st pr

oced

ure

(n=28

*)

45 m

inute

s po

st pr

oced

ure

(n=12

*)

Overa

ll pai

n exp

erien

ced

(n=6

6)

Mea

n P

ain

Sco

re (

0 -

10)

* Many patients were discharged before 30 minutes resulting in low number of patient responses

Seven day follow-up patient satisfaction survey

Upon completion of the procedure, the nursing team asked the patient if they were happy to be

contacted by an external assessment centre (Cedar). Each patient was then telephoned at a pre-

arranged time (preferably 7 days post-procedure), and asked a series of nine questions. Of the 81

patients who underwent operative hysteroscopy in the outpatients setting, 79 were surveyed by

Cedar. One patient was excluded because she did not feel comfortable answering the questions, and

another patient was excluded because an interpreter could not be arranged within a reasonable time

after the procedure. 82% of patients received the follow-up survey within 7 days of having the

procedure and 96% within 10 days.

Responses to the independent follow-up survey were positive, particularly those relating to the clinic

setting (99% of patients found the environment acceptable, and 99% also felt supported by the nurse

sitting with them; Table 3.1). Additionally, 90% of patients would recommend the procedure to a

friend, and 89% would choose a local anaesthetic over a general anaesthetic if they required this

treatment again in the future (Table 3.1). Of the six patients who would rather have a general

anaesthetic in the future, four cited pain as the reason, one found the experience embarrassing, and

Page 16 of 37

the other did not provide a reason. The patients who responded with N/A stated that general

anaesthetic was contraindicated. In the follow-up survey, patients were asked to provide an overall

pain score between 1 and 10. The mean pain score of the 79 patients was 3.3 (SD ±2.0) (Fig. 3.2).

Patients were also given the opportunity to express any thoughts or feelings about their experience; a

selection has been provided below:

• “[the staff] made it as pleasant as possible. I liked the fact that I knew what was happening

throughout the procedure”

• “I'd prefer this procedure to a general anaesthetic and waking up feeling groggy”

• “impressed with the relaxed environment”

• “uncomfortable rather than painful”

• “it’s not something you'd want to do every day but the anticipation was the worst bit. [I] expected

some cramping pain from it but had no after pain at all. [I] was able to reassure the next patient

that it was nothing to worry about”

• “the overall experience was great. Atmosphere was relaxed and staff were friendly”

• “nurse was very reassuring throughout”

Table 3.1 Seven day follow-up patient satisfaction survey results

Response (n=79) Question

Yes No N/A Q1. Was the environment acceptable to you? 98.7% 1.3% 0.0%

Q2. Was the verbal information reflective of your experience? 97.5% 2.5% 0.0%

Q3. Was the written information reflective of your experience?

82.3% 13.9% 3.8%

Q4. Did you feel you had enough information and explanation to prepare you for this procedure? 92.4% 6.3% 1.3%

Q6. Did any part of the procedure cause you concern? 7.6% 92.4% 0.0% Q7. Did you feel supported by the person sitting with 98.7% 1.3% 0.0% Q9. If a friend or relative required this procedure would you recommend it? 89.9% 7.6% 2.5%

Local Anaesthetic

General Anaesthetic N/A

Q8. If you required this procedure again which anaesthetic would you prefer?

88.6% 8.9% 2.5%

Page 17 of 37

Fig. 3.2 Overall pain scores for each patient (n=79 ) during outpatient operative hysteroscopy

(SHINE), measured in seven day follow-up survey

0

5

10

15

20

0 1 2 3 4 5 6 7 8 9 10

Pain Score*

Nu

mb

er

of

pa

tie

nts

Length of procedure

The following times were recorded by the nursing staff (the number of patients for whom these times

were recorded is shown in parentheses):

• Time of admittance (n=72)

• Time of procedure start (n=80)

• Time of procedure end (n=79)

• Time patient entered the resting area (n=40)

• Time of discharge (n=23)

Using these recorded times the duration of pre-operative length of stay (time between admittance and

procedure start), length of procedure (time between start and end of procedure), and post-operative

length of stay (time between end of procedure and discharge) were calculated for SHINE procedures

(Fig. 3.3). The mean length of procedure was 30.7 minutes (SD ±10.4). The mean pre- and post-

operative length of stay was 81.0 minutes (SD ±29.3) and 33.9 minutes (SD ±12.94), respectively.

Page 18 of 37

Figure 3.3. Duration of pre-operative length of sta y (A), length of procedure (B), and post-

operative length of stay (C) for SHINE procedures.

Data from operative hysteroscopy procedures performed in Cardiff and Vale UHB in day case

theatres under either local anaesthetic or general anaesthetic were also collected to enable a

comparison with length of procedure for SHINE outpatient procedures (Fig 3.4). The mean length of

procedure for SHINE (30.7 minutes; SD ±10.4) was significantly shorter that that of day case

procedures under LA (35.7 minutes; SD ±11.5; p<0.05) and under GA (45.2 minutes; SD 18.5;

p<0.001).

Fig. 3.4 Mean duration of operative hysteroscopy pr ocedures in outpatients under LA (SHINE),

day case under LA and day case under GA (standard d eviation bars are shown).

0

10

20

30

40

50

60

70

SHINE (n=79) Daycase LA (n=23) Daycase GA (n=82)

Me

an

le

ng

th o

f p

roce

du

re (

min

ute

s)

p < 0.05

p < 0.001

0

10

20

30

40

50

60

70

SHINE (n=79) Daycase LA (n=23) Daycase GA (n=82)

Me

an

le

ng

th o

f p

roce

du

re (

min

ute

s)

p < 0.05

p < 0.001

A. Pre-operative length of stay

0

5

10

15

20

25

30

35

0-29 30-59 60-89 90-119 >=120

Time (minutes)

Nu

mb

er

of

pa

tie

nts

C. Post-operative length of stay

0

1

2

3

4

5

6

7

8

9

10

0-14 15-29 30-44 >=45

Time (minutes)

Nu

mb

er

of

pa

tie

nts

B. Length of procedure

0

5

10

15

20

25

30

35

40

0-14 15-29 30-44 45-59 >=60

Time (minutes)

Nu

mb

er

of

pa

tie

nts

Page 19 of 37

Validity of data

Benefits

• Collection of peri-operative data - overall the clinical team was efficient and thorough during

peri-operative data collection (response rate during the procedure was >93% for all questions).

• Independent evaluation centre - utilising an evaluation centre which was independent of the

clinical team meant that patients felt they could be open and honest in their questionnaire

responses.

• Reporting to clinical team – anonymised patient comments were reported back to the clinical

team in order to improve ongoing care.

Limitations

• Collection of data – There were substantial missing data after completion of the procedure, often

caused by patients leaving before a time of discharge was recorded. Also, recording rates for

pain scores at 30 min and 40 min post-procedure were low, 35% and 15%, respectively.

• Validity of questionnaire – neither the peri-operative or follow-up questionnaires were validated

to ensure the questions were easily interpretable and resulted in consistent responses.

• Usefulness of questionnaire – further questions could have been added to the survey to

evaluate the impact of the procedure on patients’ lives, e.g. how long before return to work.

• Validity of GA vs LA question – patients were asked to report on whether they would prefer a

local or general anaesthetic in the future. This question presents limitations as most patients did

not have the procedure under both anaesthetic types, and therefore cannot directly compare the

two. However, it does represent the real decision that a patient might have to make.

Page 20 of 37

4 Economic evaluation

4.1 Introduction

The purpose of this report is to estimate the health service costs of operative hysteroscopies

performed in an outpatient setting using reusable equipment (SHINE procedures) versus the same

procedure performed in theatres under either general anaesthetic (GA) or local anaesthetic (LA).

Additionally, the costs were estimated for an alternative hysteroscope system (Gynecare Versascope)

which has a small diameter channel and thus minimises patient discomfort but vaporises the tissue in

the same setting as SHINE procedures was estimated.

4.2 Methods and Validity

To calculate the costs of an outpatient and day case operative hysteroscopy, data was collected

retrospectively from a range of sources. Costs which were assumed to be the same between

settings, such as the cost of instrument sterilisation, have been ignored. Details of costs can be found

in Appendices.

Staff Costs

Staffing costs were obtained from local and national sources. The Personal Social Services

Research Unit (PSSRU) report, Unit Costs of Health and Social Care 2010 (Curtis 2010), was used

as a national published source. PSSRU costs include salary, on-costs, qualifications, indirect

overheads, ongoing training, and capital overheads. Additionally, Cardiff and Vale UHB Finance

Department provided local mean of scale salaries (including national insurance and pension

contributions). Staff costs were calculated per procedure and were based on the mean length of

procedure calculated in Section 3 (Outcomes) and actual staffing levels used for operative

hysteroscopies in Cardiff and Vale UHB. The procedure performed using the Versascope system

was assumed to have the same staffing costs as SHINE.

It was not possible to obtain a reliable cost for a day case admittance without duplicating costs

associated with theatre staffing and equipment. As a result the cost for an uncomplicated General

Medicine bed-day was used as a conservative proxy for the cost of a patient admittance to day case

theatres (£266); this did not include any theatre-related costs.

Page 21 of 37

As staff costs had the largest effect on the potential savings related to SHINE procedure

implementation a sensitivity analysis using both the PSSRU-cited costs and Cardiff and Vale

UHBCardiff and Vale UHB-cited costs, with and without admittance costs, was carried out. This was

to investigate the uncertainty surrounding the potential savings stated in this report.

Equipment, consumables, and drugs

The cost of equipment was obtained from NHS Supply Chain / Welsh Health Supplies, Cardiff and

Vale UHB finance department, or manufacturers. Drug costs were obtained from the most recent

British National Formulary. ‘Per patient’ costs for reusable equipment (e.g. instrument trays) are

based on 1000 patients. Semi-consumable Storz electrodes have an estimated life-span of 15-20

procedures, which was accounted for. Sterilisation costs were assumed to be the same between

scenarios and were not included, however, the requirement for specialised chemical sterilisation for

the Versascope system should be considered.

4.3 Results

Staffing costs

Staff costs were calculated based on actual length of procedure for SHINE and day case procedures

(Table 4.1). Pre- and post-operative length of stay were based on actual values for SHINE

procedures (82 mins and 28 mins, respectively), and estimated at 240 mins for GA day case

procedures, and 240 mins pre-operatively, and 30 minutes post-operatively for LA day case

procedures (Table 4.1). Staffing levels were those actually used in Cardiff and Vale UHB. Operative

hysteroscopies with single-use equipment (Gynecare Versascope system) are not performed in

Cardiff and Vale UHB and therefore were assumed to be the same as SHINE procedures (Table 4.1).

SHINE staff costs are considerably lower than that of day case: £267 for SHINE compared to £790 for

day case (GA) and £356 for day case (LA).

Higher staff costs are almost entirely responsible for high costs associated with day case surgery

(Table 4.2). Because staff costs were the key drivers for SHINE-associated savings, we investigated

the effect of varying these inputs (sensitivity analysis). Four values were used (A-D; Table 4.2), which

ranged from the highest values of £1,056 (GA) and £622 (LA) (using the staff costs published by

PSSRU (Curtis 2010) plus an admittance cost) to the lowest values of £265 (GA) and £153 (LA)

Page 22 of 37

(using Cardiff and Vale UHB salaries with no admittance cost). We consider the PSSRU (a national

published reference which includes a wider range of staff-related costs), £915 (GA) and £428 (LA), to

be a realistic estimate of the costs associated with staffing an operative hysteroscopy. The estimated

costs for admitting a patient (£266) have not been included in the baseline day case costing, resulting

in a conservative SHINE-associated saving (Table 4.2). Additionally, the reference cost applied by

Cardiff and Vale UHB per finished consultant episode (FCE) for “resection and ablation procedures

for intra-uterine lesions” is £1,043 suggesting that the costs in this model are conservative.

Savings offered by SHINE compared to day case theatres

SHINE offers the largest per procedure saving of £651 when compared to an operative hysteroscopy

under GA in day case theatres (Table 4.2, Fig. 4.1). An operative hysteroscopy under local

anaesthetic in theatres is £145 more costly than the same procedure in an outpatient clinic setting.

Decreased staff costs are almost entirely responsible for the savings offered by SHINE in comparison

to day case theatre procedures (both GA and LA; Fig. 4.1). The substantially higher costs associated

with GA procedures is attributed to the need for increased staff (particularly an anaesthetic

consultant) in theatres, and an increased length of procedure. In the sensitivity analysis, SHINE

procedures remained cost saving even using the lowest staff costs (Table 4.2).

Savings offered by SHINE compared to the Gynecare Versascope system

The cost of SHINE procedures using a reusable, rigid resectoscope were £273 lower than operative

hysteroscopy procedures performed using the more slender Gynecare Versascope system with single

use operative sheath, electrode, and outflow cannula. The increased costs associated with single-

use equipment for the Gynecare Versascope accounts entirely for the cost saving. This system uses

a single-use electrode, cannula, and operative sheath for each patient costing £276.

Wider implications and projections

• Within Cardiff and Vale University Health Board

In 2009 / 2010, 163 elective day case procedures were carried out which were coded “resection and

ablation procedures for intra-uterine lesions” (personal communication from Cardiff and Vale UHB

finance department) and a further 50 patients had the same procedure as inpatients. These

procedures would have been performed under GA in theatres. If just half of these procedures were

Page 23 of 37

transferred to outpatients, it would result in an annual cost saving of over £69K for the UHB. Overall

the SHINE project released 100 hours of operating theatre time. This contributed to Cardiff and Vale

UHB elimination of outsourced gynaecology operative procedures at £1600 per hour, producing an

opportunity cost saving for SHINE of £160k.

• England

In England, between 2009 and 2010, 39,597 finished consultant episodes were coded as “resection

and ablation procedures for intra-uterine lesions” (data from HES online). If half of all of these were

transferred from day case to outpatient clinic it would result in an annual cost saving of more than

£12.5 million in England alone.

Page 24 of 37

Table 4.1 Details of staff cost calculations for pr e-, peri-, and post-operative care during

operative hysteroscopy procedures in outpatient (re usable equipment), day case (GA), day

case (LA) and outpatient (single-use equipment) set tings.

SourceCost per

hourCost per minute

Number of staff

LOP (mins)

Cost per procedure

Number of staff

LOP (mins)

Cost per procedure

Number of staff

LOP (mins)

Cost per procedure

Number of staff

LOP (mins)

Cost per procedure

Consultant Surgeon

£171 (per patient related hour, from PSSRU 2009/10)

£171.00 £2.85 0 82 £0.00 0 240 £0.00 0 240 £0.00 0 82 £0.00

Qualified Nurse (Band 5)

£47 (per hour of patient contact, PSSRU 2009/10)

£47.00 £0.78 0 82 £0.00 0.333 240 £62.60 0.333 240 £62.60 0 82 £0.00

Unqualified Nurse

£24 p(er hour of patient contact PSSRU 2009/10)

£24.00 £0.40 0.17 82 £5.58 0 240 £0.00 0 240 £0.00 0.17 82 £5.58

£5.58 £62.60 £62.60 £5.58

Pre-operative

Total Total Total Total

SHINE (outpatient, reusable equipment)

Day Case (GA) Day case (LA)Outpatient (single use

equipment)

SourceCost per

hourCost per minute

Number of staff

LOP (mins)

Cost per procedure

Number of staff

LOP (mins)

Cost per procedure

Number of staff

LOP (mins)

Cost per procedure

Number of staff

LOP (mins)

Cost per procedure

Consultant Surgeon£403 (per hour of operating, from PSSRU 2009/10)

£403.00 £6.72 1 30.7 £206.20 1 45.2 £303.59 1 35.7 £239.79 1 30.7 £206.20

Registrar / SHO

£39 for Foundation house officer 2 (48 h/week) PSSRU 2009/10

£39.00 £0.65 0 30.7 £0.00 2 45.2 £58.76 2 35.7 £46.41 0 30.7 £0.00

Consultant Anaesthetist

Assumed to be the same as surgical consultant

£403.00 £6.72 0 30.7 £0.00 1 45.2 £303.59 0 35.7 £0.00 0 30.7 £0.00

Anaesthetic assistant

Assumed to be the same as qualified nurse

£47.00 £0.78 0 30.7 £0.00 1 45.2 £35.41 0 35.7 £0.00 0 30.7 £0.00

Qualified Nurse£47 (per hour of patient contact) £47.00 £0.78 2 30.7 £48.10 2 45.2 £70.81 2 35.7 £55.93 2 30.7 £48.10

Unqualified Nurse£24 per hour of patient contact PSSRU

£24.00 £0.40 1 30.7 £12.28 1 45.2 £18.08 1 35.7 £14.28 1 30.7 £12.28

£266.58 £790.25 £356.41 £266.58Total

Peri-operative

Total Total Total

SHINE (outpatient, reusable equipment)

Day Case (GA) Day case (LA)Outpatient (single use

equipment)

SourceCost per

hourCost per minute

Number of staff

LOP (mins)

Cost per procedure

Number of staff

LOP (mins)

Cost per procedure

Number of staff

LOP (mins)

Cost per procedure

Number of staff

LOP (mins)

Cost per procedure

Consultant Surgeon

£171 (per patient related hour, from PSSRU 2009/10)

£171.00 £2.85 0 28 £0.00 0 240 £0.00 0 30 £0.00 0 28 £0.00

Qualified Nurse

£47 (per hour of patient contact) £47.00 £0.78 0 28 £0.00 0.333 240 £62.60 0.333 30 £7.83 0 28 £0.00

Unqualified Nurse

£24 per hour of patient contact PSSRU

£24.00 £0.40 0.17 28 £1.90 0 240 £0.00 0 30 £0.00 0.17 28 £1.90

£1.90 £62.60 £7.83 £1.90Total

Post-operative

Total Total Total

SHINE (outpatient, reusable equipment)

Day Case (GA) Day case (LA)Outpatient (single use

equipment)

LOP: Length of procedure; GA: general anaesthetic; LA: local anaesthetic

Table 4.2 Costs associated with operative hysterosc opy procedures in outpatient and day case settings

Sensitivty

AnalysisSHINE Procedure

Day Case

(GA)

Day Case

(LA)

Outpatient setting with single

use resectoscope

Anaesthetic Local Anaesthetic General Anaesthetic Local Anaesthetic None

Setting Outpatients clinic Day-case theatres Daycase theatres Outpatients clinic

ResectoscopeStorz rigid 8-10 mm, sterilisable

resectoscope

Storz rigid 8-10 mm, sterilisable

resectoscope

Storz rigid 8-10 mm, sterilisable

resectoscope

Slender Gynecare Versascope, with

single use sheath and electrodes

Single Use Equipment £23 £23 £23 £299

Reusable Equipment £9 £9 £9 £7

Drugs £7 £17 £7 £5

(A) £274 £1,056 £622 £274

(B) £274 (baseline) £915 (baseline) £427 (baseline) £274 (baseline)

(C) £58 £432 £352 £58

(D) £58 £216 £114 £58

(A) £313 £1,105 £661 £585

(B) £313 (baseline) £964 (baseline) £465 (baseline) £585 (baseline)

(C) £97 £481 £390 £369

(D) £97 £265 £153 £369

(A) -£792 -£348 -£273

(B) -£651 (baseline) -£152 (baseline) -£273 (baseline)

(C) -£384 -£294 -£273

(D) -£168 -£56 -£273

Staffing and hospital

admittance (sensitivity

analysis A-D shown)

Total

Potential cost saving

offered by SHINE

(A) highest: PSSRU staff costs plus admittance cost of £266; (B) baseline: PSSRU staff costs with no admittance cost; (C) second

lowest: Cardiff and Vale UHB salary costs with admittance cost; (D) lowest: Cardiff and Vale UHB with no admittance cost.

GA: General anaesthetic; LA: Local Anaesthetic

Figure 4.1 Component costs of operative hysteroscop y procedures performed in four settings

(baseline staffing costs)

£0

£100

£200

£300

£400

£500

£600

£700

£800

£900

£1,000

Co

sts

ass

oci

ate

d w

ith

pro

ce

du

re

SHINE Day case

(GA)

Day case

(LA)

Versascope

Drugs

Reusable equipment

Single use equipment

Staffing

Page 27 of 37

5 Impact

5.1 What impact has this project had?

Individual

The women clearly accepted this procedure in the outpatient setting. Clinically the avoidance of

anaesthetic and the low volume of glycine absorbed was beneficial. Premenopausal women

particularly those awaiting fertility treatment have also benefited from this as previously they would

have not had the option to choose LA rather than GA.

The volume and weight of tissue removed has also surpassed previous records. Although there is no

national or international formal guideline on the size of the polyp suitable for office removal the

literature would indicate less than 3 cm (Bakour et al 2006; Farrugia 2009; Vleugels 2001) although

others reported 2.0 cm - 2.5 cm (Lindheim et al 2000; Preutthipan and Herabutya 2005) and Bettocci

et al (2004) reported up to 3.7 cm in diameter.

Team

Through this process a strong team has been developed and expanded. New skills have been

acquired and the role of the outpatient nurse has altered fundamentally. Within the department other

Consultants are now directly referring patients to the SHINE clinic and it has gained widespread

acceptance.

The input from Cedar as an independent evaluator increased validity and applicability. The

information and interpretation of results clearly identified the potential benefits both locally and

nationally for the patient and health care providers. The team as a whole have also benefited greatly

from their expertise and knowledge in interpreting and presenting both the clinical and economic

results.

In order to disseminate findings and train others the entire team will make themselves available to

participate in study days or engage in one to one training. This will reflect well on the team and the

O&G department as well as on the Trust and further boost morale.

Page 28 of 37

Organisation

The most obvious benefit to the organisation is the release of theatre time and compliance with

referral to treat time (RTT). A clear cost saving has been demonstrated as well as the benefit of the

new skills which have been developed in the outpatient department.

Health Economy

The SHINE project has had a major impact for Cardiff and Vale UHB with the release of 100 hours of

theatre time per year to enable alternative use of this precious resource. Following evaluation of

costs within the most conservative cost modelling, a real saving is calculated for SHINE compared

with GA, LA in theatre, and disposable methods in outpatients. The fact that there are savings

following such a conservative model clearly indicates the financial benefits of a SHINE approach. In

addition the clinician in a SHINE clinic the opportunity between patients to undertake other

procedures if a separate room is available.

Applying similar models to the rest of the UK would result in savings of several million pounds

annually based on only a proportion of procedures being transferred to outpatients. Such findings

mandate rapid dissemination of the SHINE project findings and a government backed drive to

implement change on a national scale.

Societal

The fact that women spend a far shorter time in the SHINE environment than in the theatre

environment, particularly if a GA is employed, means that women are away from their families or

workplace for a shorter time with consequent impact on need for childcare etc. If a GA is done

someone needs to be with them overnight at home subsequently and this need is removed by using

local anaesthetic. Financial savings will also have a benefit for society, particularly in the economic

climate in which our health service currently finds itself.

Page 29 of 37

6 Sustainability and Replicability

6.1 How do you plan to sustain and build upon these changes beyond the SHINE

award period?

Sustainability

The clinic has been so successful that its continuation is really a “no brainer”. Gynaecology services

were relocated from University Hospital of Wales (UHW) to the Llandough site in order that extensive

rebuilding work could be undertaken at UHW. Return to UHW is planned this year and the SHINE

clinic is incorporated into the requirement for space, without the team having been asked for a

business case. If we are asked, and in any case as part of our plan to spread to other units we can

easily modify this report to a business case format. For the clinic to continue we will either have to

come to an extended loan arrangement with Karl Storz or make a business case for the purchase of

the equipment, which was initially on loan for a year. Clearly there will have to be a discussion at the

end of May. By then we will have sent copies of this report to the instrument company and the

University Health Board and will no doubt have received a positive response from both parties. The

next phase of spread is dependent on the continuation of the clinic so the team can’t foresee the

company wishing to redeploy their equipment loan.

Spread

Other departments in the Trust may consider taking forward some of our experience in their own area.

In order to publicise the SHINE Award and its success we will not only organise articles in the hospital

magazine ‘Vital Signs, but present the project findings to the Medical Grand Round and the University

Health Board. It is possible that the urologists could move some of their diagnostic cystoscopies to

outpatients and, if they followed our model, some bladder tumour resections may be amenable to

resection in outpatients. The University Health Board and its management structure will be helpful in

taking such ideas forward.

Scale up

Page 30 of 37

Initial plans for broadcasting our success were stated in the SHINE project application. Results need

to be presented at a variety of meetings covering the medical community, the nursing community and

for a representing hospital management public health and financial planning. The Health Foundation

may be helpful in guiding us towards the best opportunities in the later fora. Support from the

Foundation is also helping RP to make the most of an opportunity to utilise the QUIPP project to get

the success of the project seen by the National Institute of Clinical Excellence as early approval by

NICE would help drive widespread scale up.

Locally by increasing capacity in the SHINE clinic to accommodate all of the demand for resection of

polyps and fibroids we can ensure a rapid access to treatment with little or no waiting list and release

further general anaesthetic operating capacity in theatre.

6.2 How are you going to promote your innovation and convince others of its value?

Clearly publication in international journals of standing in the three areas outlined above will have

major impact on the acceptance of the SHINE clinic process and value. The lead time however

cannot be ignored and the team must make efforts to promote the adoption of our treatment

philosophy throughout the UK.

RP happens to be a new member of the Welsh Medical Committee and following a recent training

meeting the committee chair asked for suggestions for the forward work programme. A quick email

seeking that the committee look at the learning from all of the SHINE projects but particularly those

from Wales resulted in a presentation at the meeting on 1st April where the Cardiff Gynaecology

SHINE project was presented to several Public Health consultants and the CMO. There was plenty of

enthusiasm for the project and advice as to how to promote it and the Wrexham cardiology project will

be invited to present at the next meeting.

The team intends working with the Welsh Institute for Women’s Health, an educational foundation

based on the UHW site. The aim will be to identify key opinion leading gynaecologists with

experience in operative hysteroscopy including those who currently use the disposable Versapoint

system. We would then lay on a study day to which each consultant will be invited to bring their

outpatient nurse and manager. The programme will include all aspects of the set up and training for

the project in addition to the results. We will also aim to get consumers of the service involved – e.g.

our consultant colleague patient. In addition we will provide a pack with model business case and

Page 31 of 37

protocols and policies for recipient organisations to copy. Pump priming funding will be required for

the first such day and the team will approach the Health Foundation for a modest grant. There will

also be an offer of outreach support to early adopters of the philosophy and technique.

The intention is to enable health service UK to realise the savings potential of moving a significant

proportion of their operative hysteroscopies carried out under GA to outpatients whilst improving the

care pathway for women and maintaining or improving safety

6.3 What advice would you give to someone attempting to replicate your innovation

in another organisation / setting?

Follow our policies and protocols and try to tackle the simpler post menopausal patients first of all. If

we can get the support of NICE then effectively guidance will have to be implemented.

The barriers are the disbelief of consultant colleagues whose minds need to be opened, hence the

need to identify key early adopters above. Developing a strong team is essential, as is the placement

of key figures particularly in the actual clinic. For many units this may require a complete change in

current practice and to be successful needs the support and enthusiasm of all people involved.

Many outpatient units will not be able to provide purpose built areas for procedure clinics but with

cooperation and lateral thinking all areas can be adapted to provide a suitable safe area for the

development of the new clinic.

Page 32 of 37

7 Finance

7.1 Please provide a financial summary showing spending against your SHINE award budget

Amount awarded £68,603 (£51,452 received to date)

Type of cost Budgeted (total) £ Spend (total) £

Evaluation Work (Cedar) 8,000 8,250

Project Management 4,500 4,450

Clinical Involvement (1.5 clinics per week) 51,300 51,300

Project Set Up 2,500 2,500

Annual Conference 1,800 1,800

Postage/ Telephone Calls 500 450

TOTAL 68,600 68,750

Authorised signatory from finance:

Print name & position:

ANDREW GOUGH PRINCIPLE FINANCE MANAGER

Date:

20th April 2011

7.2 Please provide us with an explanation of significant over / under spends or

variations across budget types

Budget was within predicted margins.

Page 33 of 37

8 References and appendices

• Bakour et al 2006; Farrugia 2009; Vleugels 2001) although others reported 2.0 cms-2.5cms

(Lindheim et al 2000; Preutthipan and Herabutya 2005) and Bettocci et al (2004) reported up to

3.7cms in diameter.

• Bakour SH; Jones SE; O’Donovan P (2006) Ambulatory hysteroscopy: evidence-based guide to

diagnosis and therapy. Best Practice& Research Clinical Obstetrics and Gynaecology 20(6):

953-957

• Bettocchi S; Ceci O; Nappi L et al (2004) Operative office hysteroscopy without anaesthesia:

Analysis of 4863 cases performed with mechanical instruments. J AM Assoc Gynecol Laparosc

11(1):59-61

• Curtis, L. (2010) Unit Costs of Health and Social Care 2010l

• Farrugia M (2009) Modern Operative Hysteroscopy 3rd edition Italy Johnson and Johnson

Medical S.p.a

• Lindheim SR; Kavic S; Shulman SV et al (2000) Operative hysteroscopy in an office setting. J

Am Assos Gynecol Laparosc 7:65-69

• Preutthipan S; Herabutya Y (2005) Hysteroscopic polypectomy in 240 premenopausal and

postmenopausal women. Fertility and Sterility 83(3): 705-710

• Vleugels MPH (2001) Normal saline field bipolar electrosurgery in hysteroscopy: report of the

first 163 cases. Gynecologic Endoscopy 10:349-353

Page 34 of 37

Appendix 1 Single-use equipment costs

SourcePrice per

pack

Units in

pack

Price per unit

Number of

patients that each

unit is used on

Cost per patient for

unit

Number of items used per procedu

re

Cost per procedure/patie

nt

Number of items used per procedur

e

Cost per procedure/patien

t

Number of items used per

procedure

Cost per procedure/patien

t

Number of items

used per

procedure

Cost per procedure/patien

t

SINGLE USEHysteroscopy Pack (Sunlight)Bag Poly Clear C1 LDPE 762 x 711mm 1Box Corrugated C4 (Rocialle Print) 378 1Maternity Pad Unlooped Size 2M Rob 2Paper Crepe White 90x90 2Swab Gauze XRD 10 x 7.5cm 32ply 10Tray Small Card Base 280 x 245 x 18mm 2Opera Breather Bag Label + ETO Spot 2Opera Case Label + ETO Spot Blue 1Drape Underbuttock w/o pouch 89x119 cm with 18cm cuff

2

Sunlight Tamper Proof Seal 2Opera Rotrak Spec Form 4Drape Legging 75x120 Bilam green 2Cover Trolley 127 x 205cm SMS Blue 2Drape Patient Lite 90x75 SA Bilam green 2Cover Camera/video 17.5 x 240cm Blue 2Drape Under Buttock 90x100 Bilam Green, 2Breather Bag 356 x 457mm (14 x 18") 2

Outpatients Hystoscopic Treatment Pack (Sunlight)Tubing Suction Connecting 1Needle Solo Supra dental 1Towel dressing 6Gallipot 1Kidney Dish 1Tray small platform 1Paper Crepe White 1Admin Set Irrigation tube 1Cover trolley 1Drape Obs/Gyn 1Gown Surgical Large 1Swab Gauze 10Cover Camera/video 1

Versascope Single Use ItemsVERSASCOPE Outflow Cannula £110.00 10 £11.00 1 £11.00 0 0 0 £0.00 0 £0.00 1 £11.00VERSASCOPE Operative Sheath £275.00 5 £55.00 1 £55.00 0 0 0 £0.00 0 £0.00 1 £55.00Ball Tip Electrode £1,050.00 5 £210.00 1 £210.00 0 0 0 £0.00 0 £0.00 1 £210.00

TOTAL £23.00 £22.70 £22.70 £298.70

£23.00

£22.70 £22.70 1 £22.70 £22.700 1 1 1£0.00

Daycase (GA) Daycase (LA)Versascope

(Outpatients)

0 £0.00 0 £0.000 £0.00

£22.70Sunlight Rep

Ethicon 360 rep

Sunlight Rep

Outpatients (SHINE)

1 £23.00

£22.70

£23.00 £23.00 1

Page 35 of 37

Appendix 2 Reusable equipment costs

SourcePrice per

pack

Units in

pack

Price per unit

Number of

patients that each

unit is used on

Cost per patient for

unit

Number of items used per procedu

re

Cost per procedure/patie

nt

Number of items used per procedur

e

Cost per procedure/patien

t

Number of items used per

procedure

Cost per procedure/patien

t

Number of items

used per

procedure

Cost per procedure/patien

t

REUSABLE STORZ ResectoscopeTelescope 30 deg (STORZ) £2,961.00 1 £2,961.00 1000 £2.96 1 £2.96 1 £2.96 1 £2.96 0 £0.00Working Element (STORZ) £1,225.00 1 £1,225.00 1000 £1.23 1 £1.23 1 £1.23 1 £1.23 0 £0.00Sheath Inner (STORZ) £495.00 1 £495.00 1000 £0.50 1 £0.50 1 £0.50 1 £0.50 0 £0.00Sheath Outer with Taps (STORZ) £678.00 1 £678.00 1000 £0.68 1 £0.68 1 £0.68 1 £0.68 0 £0.00Obturator (STORZ) £104.00 1 £104.00 1000 £0.10 1 £0.10 1 £0.10 1 £0.10 0 £0.00Diathermy Lead (STORZ) £45.00 1 £45.00 1000 £0.05 1 £0.05 1 £0.05 1 £0.05 0 £0.00Light Lead (STORZ) £295.00 1 £295.00 1000 £0.30 1 £0.30 1 £0.30 1 £0.30 0 £0.00Cutting Loop £47.00 1 £47.00 15 £3.13 1 £3.13 1 £3.13 1 £3.13 0 £0.00

ALPHASCOPE Hysteroscope £4,650.00 1 £4,650.00 1000 £4.65 0 £0.00 0 £0.00 0 £0.00 1 £4.652mm VERSASCOPE Grasper £485.00 1 £485.00 1000 £0.49 0 £0.00 0 £0.00 0 £0.00 1 £0.492mm VERSASCOPE biopsy cup £485.00 1 £485.00 1000 £0.49 0 £0.00 0 £0.00 0 £0.00 1 £0.492mm VERSASCOPE Scissors £485.00 1 £485.00 1000 £0.49 0 £0.00 0 £0.00 0 £0.00 1 £0.49VERSASCOPE Light Cables/Adaptors £450.00 1 £450.00 1000 £0.45 0 £0.00 0 £0.00 0 £0.00 1 £0.45Cages £395.00 1 £395.00 1000 £0.40 0 £0.00 0 £0.00 0 £0.00 1 £0.40

Curette Blunt/Sharp £8.63 1 £8.63 1000 £0.01 1 £0.01 1 £0.01 1 £0.01 1 £0.01Curette Small/Sharp £8.63 1 £8.63 1000 £0.01 1 £0.01 1 £0.01 1 £0.01 1 £0.01Curette Flashing/Small £11.79 1 £11.79 1000 £0.01 1 £0.01 1 £0.01 1 £0.01 1 £0.01Curette Flashing / Large £11.79 1 £11.79 1000 £0.01 1 £0.01 1 £0.01 1 £0.01 1 £0.01Speculae Simms Medium £8.95 1 £8.95 1000 £0.01 1 £0.01 1 £0.01 1 £0.01 1 £0.01Speculae Simms Large £8.95 1 £8.95 1000 £0.01 1 £0.01 1 £0.01 1 £0.01 1 £0.01Uterine Sound £6.75 1 £6.75 1000 £0.01 1 £0.01 1 £0.01 1 £0.01 1 £0.01Dissecting Forceps Treeves Toothed £1.44 1 £1.44 1000 £0.00 1 £0.00 1 £0.00 1 £0.00 1 £0.00Dissecting Forceps Turn-over end Plain £1.24 1 £1.24 1000 £0.00 1 £0.00 1 £0.00 1 £0.00 1 £0.00Mayo Scissors Straigh 5" £12.00 1 £12.00 1000 £0.01 1 £0.01 1 £0.01 1 £0.01 1 £0.01Mayo Needle Holder 5" £25.22 1 £25.22 1000 £0.03 1 £0.03 1 £0.03 1 £0.03 1 £0.03Sponge Holders £25.26 3 £8.42 1000 £0.01 1 £0.01 1 £0.01 1 £0.01 1 £0.01Forceps Polyp £9.74 1 £9.74 1000 £0.01 1 £0.01 1 £0.01 1 £0.01 1 £0.01Forceps Vulsellae Double Toothed £20.76 2 £10.38 1000 £0.01 1 £0.01 1 £0.01 1 £0.01 1 £0.01Forceps Vulsellae Single toothed £9.12 1 £9.12 1000 £0.01 1 £0.01 1 £0.01 1 £0.01 1 £0.01(set) dilators Hawkins Size 3-16 £107.88 1 £107.88 1000 £0.11 1 £0.11 1 £0.11 1 £0.11 1 £0.11(set) dilators Hegar Size 3-16 £41.54 1 £41.54 1000 £0.04 1 £0.04 1 £0.04 1 £0.04 1 £0.04

TOTAL £9.23 £9.23 £9.23 £7.24

Daycase (GA) Daycase (LA) Versascope

NHS Supply Chain and Storz

Rep

Ethicon Rep

C&V UHB Theatres

Outpatients

Page 36 of 37

Appendix 3 Drugs and anaesthetic consumables costs

DOSECost per

pack

SOURCE

Unit (Pack)

Unit given

Cost per patient

Unit given

Cost per patientUnit

givenCost per patient

Unit given

Cost per patient

Local AnaestheticDicolfenac 100 mg £3.06 BNF 10 1 £0.31 0 £0.00 1 £0.31 1 £0.31Paracetamol 1g £10.60 BNF 5 1 £2.12 0 £0.00 1 £2.12 1 £2.12Citanest 4 Ampoules £0.17 BNF 1 4 £0.68 0 £0.00 4 £0.68 0 £0.00

General AnaestheticFentanyl 100 mic £0.54 BNF 1 0 £0.00 1 £0.54 0 £0.00 0 £0.00Propofo 20 ML £2.33 BNF 1 0 £0.00 1 £2.33 0 £0.00 0 £0.00Ondansetron 4 MG £5.39 BNF 1 0 £0.00 1 £5.39 0 £0.00 0 £0.00Ketorolac 1ML £0.94 BNF 1 0 £0.00 1 £0.94 0 £0.00 0 £0.00Intravenous cannula £0.22 WHS 1 0 £0.00 1 £0.22 0 £0.00 0 £0.00Tegaderm Plaster £31.58 WHS 100 0 £0.00 1 £0.32 0 £0.00 0 £0.00Laryngeal Mask £30.00 NHS SC 10 0 £0.00 1 £3.00 0 £0.00 0 £0.00Needles £3.11 WHS 100 0 £0.00 4 £0.12 0 £0.00 0 £0.00Syringe £9.36 WHS 100 0 £0.00 4 £0.37 0 £0.00 0 £0.00

OtherGlycine (1.5%) 3L £13.60 Baxter 4 1 £3.40 1 £3.40 1 £3.40 0 £0.00Saline (0.9%) 3L £12.00 Baxter 4 0 £0.00 0 £0.00 0 £0.00 1 £3.00

TOTAL £6.51 £16.63 £6.51 £5.43

SHINE Day Case (GA) Day case (LA)Versapoint outpatient

SHINE Final Report

Outpatient operative hysteroscopy with conventional re-useable equipment: a cost

effective alternative to day case theatre. Assessment of effectiveness, patient

acceptability and comparative health economics.

Richard Penketh