BSG Clinical Services Excellence Award 2026 3rd place submission by Prof Vikramjit Mitra & Dr Rohit Mathur, HPB Fellow.

Acknowledgements (HPB team members, University Hospital of North Tees): Prof. Deepak Dwarakanath, Consultant Gastroenterologist, Dr Rahul Sethia, Consultant Gastroenterologist, Dr John Hancock, Consultant Gastroenterologist, Dr Mohamed Elzubier, Consultant Gastroenterologist, Natalie Robson, HPB Specialist Nurse, Joanne Scattergood, HPB Specialist Nurse, Stephanie Burns, HPB Specialist Nurse, Lisa Stuart, Upper GI/ HPB coordinator, Dr Veena Rao, GI radiologist, Dr David Norton, GI radiologist, Dr Michael Carss, GI radiologist, Dorisa Machan, Endoscopy Preassessment Lead, Dr Kaushik Dasgupta, UGI / HPB Pathologist.

What were the challenges and why did the service need to change?

Obstructive jaundice is a common emergency presentation in secondary care hospital setting. Traditionally, all patients with obstructive jaundice get admitted for inpatient investigations and management irrespective of clinical stability. At University Hospital of North Tees, a busy district general hospital, this practice led to the following challenges: 

• Delays in cross-sectional imaging (CT pancreas/MRCP) due to increasing inpatient demand for CT/MRI for different medical conditions leading to increased inpatient bed occupancy for the clinically stable obstructive jaundice patient cohort.
• Lack of streamlined patient investigations due to disease management by physicians from across different medical specialities (non-gastroenterologists) during acute unselected medical intake. 
• Delays in access to appropriate endoscopic interventions (Endoscopic Ultrasound and ERCP) due to patient management by non-gastroenterologists.
• Potentially increased risks of hospital acquired infections whilst waiting for investigations and treatment 
• Increased healthcare costs due to increased bed occupancy (median 4 days for this clinically stable patient cohort) and inappropriate investigations in most patients (between 1-2 extra radiological investigations per patient)
• Poor patient experience due to unnecessary hospital admission and delayed intervention

Increased bed pressures during the winter times lead to further challenges for the organisation. A local service review by the HPB gastroenterologists identified that a significant proportion of obstructive jaundice patients were clinically stable at presentation (i.e. without any evidence of cholangitis) and did not require acute inpatient care. They were deemed potentially suitable for outpatient management. However, lack of structured ambulatory obstructive jaundice pathway represented a clinical risk if this cohort of patients were going to be discharged. 

How did you overcome the challenges?

We introduced the HPB nurse-led obstructive jaundice pathway within the Emergency Assessment Unit (EAU). The pathway includes daily consultant HPB triage to facilitate appropriate initial imaging and clinical follow up (daily hot jaundice clinic slots in HPB clinic) including treatment.

Key Interventions

The project was consultant-led but nurse-driven, promoting distributed clinical leadership. A multidisciplinary steering group (HPB gastroenterologist, HPB specialist nurse, GI radiologist, Acute Medical Team, Endoscopy Team and Patient Safety Team) was established and key interventions were agreed upon (as mentioned below):

• Development of clear inclusion/exclusion criteria for safe discharge
• HPB specialist nurse assessment in EAU
• Daily HPB consultant triage
• Standardised assessment proforma for guiding work up 
• Expedited outpatient imaging (CT/MRCP) slots for appropriately triaged patients
• Expedited EUS and ERCP slots for appropriate patients
• Prospective database and audit of the pathway including patient outcomes

Governance & Safety Measures

• Specialist consultant-led decision-making embedded into pathway
• Standardised criteria for safe discharge
• Clear safety-net advice with direct admission to EAU if clinical condition changes following discharge 
• Prospective data collection
• Monitoring of readmissions and treatment delays

This pathway ensured safe patient discharge but remained within a tightly controlled specialist framework.

What were the outcomes?

• 88 clinically stable obstructive jaundice patients (median age 61.5 years, 60.2% females) were managed through this pathway between November 2023 and December 2025
• Timely outpatient cross-sectional imaging and reporting: median 2 days (including both)
• All patients underwent appropriate first investigation following introduction of this pathway
• Median time to final diagnosis & treatment: 7 days
• 50% (n=44) underwent EUS and 42% (n=37) underwent ERCP; 19.3% had same-session access to EUS followed by ERCP 
• Significant reduction in inpatient bed utilisation for this stable cohort of patient (total 352 bed days saved) – this could be used for other acutely unwell medical patients
• Estimated cost saving from bed days during this period: £140,800
• Readmission: n=1, patient promptly treated (suggest the pathway is safe)
• No adverse events linked to pathway in this cohort of patients (suggest the pathway is safe)
• Improved patient experience: Avoidance of unnecessary hospital admission, faster access to specialist HPB care and reduced risk of hospital acquired infections.

This service model represents a safe, efficient, cost-effective, patient-centred care.

What were the learning points and how can this influence other teams?

Key Learning Points

1. Obstructive jaundice does not universally mandate hospital admission; risk stratification is achievable and safe.
2. Nurse-led pathways are safe when consultant-supported, enhances efficiency without compromising safety.
3. Structured triage and vetting process reduces unnecessary hospital admission
4. Multi-disciplinary team working amongst the EAU team, HPB gastroenterologists, radiologists, nurse specialists and the endoscopy team is the key to successful delivery of the pathway. 
5. Same-session procedures (EUS & ERCP) in appropriately selected patients significantly improve efficiency and led to better patient experience.
6. Prospective data collection is essential for governance and long-term sustainability of services.
7. Service redesign can reduce costs without compromising patient safety and can provide high quality clinical care.
8. Prospective audit enables real-time safety assurance.

Influence on Wider service delivery

This model is:

• Reproducible in other secondary and tertiary care hospital settings
• Applicable to other ambulatory pathways (e.g., GI bleed, chronic pancreatitis & anaemia pathways)
• Demonstrates the value of specialist nurse-led practice within different areas of the hospital setting to improve quality of care