FRCA Notes

Principles of Day-Case Surgery

Resources

  • Day surgery is defined by the admission and discharge of a patient on the same day as the surgical procedure i.e. within 23hrs
    • In 2000 the NHS Plan set a target for 75% of surgeries to be performed as day cases
    • The increase in minimally invasive surgical techniques has increased the suitability of various procedures for day surgery

Patient benefits Institutional benefits
↓ risk of hospital-acquired infection ↓ cancellations as beds not subject to pressure from emergency work
↓ risk of VTE due to early mobilisation Higher patient throughput per bed
↓ anxiety if hospital stay avoided (esp. paediatrics) ↓ costs of care
Less psychological upheaval ↓ medical/nursing supervision per patient
↑ patient satisfaction Frees inpatient beds for more complex cases
Less disruption to normal routine



Social factors Medical/surgical factors Post-operative factors
Patient understands & consents to day surgery Stable, chronic disease Post-op. pain manageable with PO analgesia
Responsible adult presence for journey home & 24hrs post-op. Short duration (<2hrs) No requirement for post-op. monitoring
Appropriate social circumstances inc. proximity to hospital Low risk major haemorrhage No requirement for post-op. IV fluids
Low risk delayed airway compromise Allows rapid mobilisation

Specific medical factors

  • BADS recommend a patient's fitness for a procedure should relate to their functional status rather than ASA physical status, age or BMI
    • Patients with stable, chronic disease do better after day surgery as there is less disruption to their normal lives
    • Elderly patients may have reduced post-operative cognitive dysfunction from being in familiar surroundings

  • Obesity itself is not a contra-indication to day surgery
    • The incidence of intra-operative or early recovery phase complications is higher
    • However, these problems often resolve by the time of discharge and overnight stay may not confer additional benefit
    • Obese patients benefit from short-duration anaesthetic techniques and early mobilisation, but may need prolonged VTE prophylaxis

  • OSA is not an absolute contraindication to day surgery
    • Pre-assessment should identify those with a history of OSA or are at risk on STOP-Bang scoring
    • Those with already diagnosed & treated OSA, and stable co-morbidities, should not be excluded from day surgery
    • Anaesthetic management should include regional anaesthetic techniques and opioid avoidance where possible
    • Patients should bring their CPAP devices with them in case of failed discharge

Paediatric patients

  • Term infants may be suitable from 44 weeks onwards
  • Those <44 weeks post-conceptual age are unsuitable, although specialist paediatric units may offer care to full-term infants from >1month old

  • Pre-term infants should be >60 weeks post-conceptual age with:
    • No recent apnoeas
    • No respiratory or cardiovascular disease
    • No family of sudden infant death syndrome
    • No adverse social circumstances

  • Other paediatric conditions precluding day surgery:
    • Inborn errors of metabolism inc. DM
    • Complex cardiac disease
    • Sickle cell disease
    • Active respiratory tract infection
    • Other poorly controlled systemic disease

  • Thorough anaesthetist-led, nurse-delivered pre-anaesthetic assessment and preparation, ideally within the same day surgery unit

  • Aims of pre-operative assessment include:
    • Identifying medical and social risk factors e.g. STOP-BANG scoring
    • Allowing time to obtain specialist opinion and optimise those with more complex medical disease
    • Educating patients about the pathway, procedure-specific information and details of post-operative care

First stage recovery

  • I.e. the theatre recovery area
  • Covers the period of time until the patient:
    • Is fully awake with return of protective reflexes
    • Has controlled levels of pain

Second stage recovery

  • I.e. the day surgery post-operative ward
  • Covers the period from leaving first-stage recovery until the patient fulfils discharge criteria
  • Includes management of early post-operative symptoms including pain, PONV and minor bleeding

Discharge

  • Protocol-driven, nurse-led discharge should occur based on fulfilment of discharge criteria:
Patient factors Logistical factors
A|B|C - stable for ≥1hr Able to stand, dress and ambulate
D - at baseline cognition and pain controlled Responsible adult accompanying home
E|F - has passed urine Journey time <2hrs
G - PONV controlled and tolerates PO fluids Responsible adult at home for 24hrs
H - minimal bleeding
  • Post-operative information should be provided, e.g. in the form of high-quality, age-appropriate leaflets
  • Information provided should include:
    • General information post-anaesthetic e.g. no driving, drinking alcohol or operating machinery for 24hrs [or 4 days if isoflurane used]
    • Procedure-specific information e.g. expected symptoms
    • Follow-up appointments e.g. wound care
    • Analgesic advice
    • A contact number for advice in case of problems
    • Discharge summary for patient and GP

  • Cancellation rate - may reflect poor patient selection
  • DNA rate - may reflect poor administration
  • Percentage of total surgeries performed as day case
  • Unexpected admission rate
  • Re-admission rate within 30 days
  • Rates of complications inc. infection
  • Audit of PONV
  • Patient satisfaction surveys
  • The British Association of Day Surgery BEAT directory; allows comparison vs. national standards