Professional Documents
Culture Documents
Day Surgery PDF
Day Surgery PDF
2
Published by
The Association of Anaesthetists of Great Britain and Ireland,
21 Portland Place, London W1B 1PY
Telephone: 020 7631 1650, Fax: 020 7631 4352
E-mail: info@aagbi.org Website: www.aagbi.org
February 2005
Vice President
Chairman of the Working Party
Dr Hilary Aitken
Council Member
Dr Roddie McNicol
Council Member
Dr Ben Fitzwilliams
Dr Ian Jackson
President Elect,
British Association of Day Surgery
EX OFFICIO
Prof Michael Harmer
President
Dr Peter Wallace
Dr Richard Birks
Honorary Treasurer
Dr Alastair Chambers
Honorary Secretary
Dr David Whitaker
Dr Diana Dickson
Dr David Bogod
Editor-in-Chief
February 2005
To be reviewed by 2010
Contents Page
Summary
Introduction
Recent reports
Selection of patients
Documentation
10
Facilities
11
Anaesthetic management
12
14
Regional anaesthesia
16
Postoperative instructions
17
Discharge summary
18
Audit
19
Contractual arrangements
21
22
References
23
Further reading
24
FAQs
26
Appendix 1
28
Appendix 2
31
Appendix 3
32
Appendix 4
33
Appendix 5
34
Appendix 6
35
1
Summary
Day surgery is a continually evolving specialty performed in a range
of ways across different units.
The NHS plan target of 75% of elective surgery being performed as
day cases means that this will form a high proportion of the work of
most Departments of Anaesthesia.
Pre-assessment clinics should be consultant led and nurse run. The
assessment criteria should be developed in conjunction with the
local Department of Anaesthesia.
Fitness for a procedure should relate to the patients health as found
at pre-assessment and not limited by arbitrary limits such as ASA
status or age.
Whatever surgery is to be undertaken as a day case, the decision
must be based on proven safety and quality.
Good quality advice leaflets, assessment forms and protocols are in
use in many centres and are available to other units.
Every day surgery unit should have representation at Trust Board
level.
Each anaesthetist should develop techniques that permit the patient
to undergo the surgical procedure with minimum stress, maximum
comfort and optimise their chance of early discharge.
Central neural blockade can be used for day stay surgery.
Effective audit is an essential component of good day stay
anaesthesia.
Introduction
The definition of day surgery is not clear and is interpreted differently
by Trusts around the UK; the boundaries between day surgery, 23-h
stay and 2-day stay are often blurred. The principles of care outlined
in this document apply equally to patients managed within all these
formats.
Since the previous booklet was published in 1994, major changes
have taken place in day surgery. More invasive procedures are being
performed and new anaesthetic techniques, agents and analgesics
have become available. Despite these advances it would appear that
the overall performance in day surgery has been slipping across the
UK. This may be due to complacency with previous performance and
failure to realise the potential gains for both hospital and patients of
continuing to move day surgery forward. This will need to change for
many reasons. In particular, the NHS plan[1] has set a target of 75%
of elective surgery to be performed as day cases and, in paediatrics,
the European Charter of Childrens Rights [2] states Children should
be admitted to hospital only if the care they require cannot be
equally well provided at home or on a day basis. There is also
evidence of benefit for the elderly population with studies showing a
reduction in Postoperative Cognitive Dysfunction [3]. It is important
therefore for all Departments of Anaesthesia to take a lead in this
move from in-patient surgery, as all are likely to see substantial
increases in day surgery over the next few years.
Recent Reports
Over the years, many reports have been published to inform those
who wish to extend or improve the manner in which they practise
day surgery. The Audit Commission, Caring for Children in the
Hospital Service and various Department of Health organisations
have all produced papers in this field and these are helpful
background reading (See Further Reading).
The NHS Value for Money report from 1991 Day Surgery: Making it
happen is still well worth reading and everyone should consult the
latest Day Surgery: Operational Guide from the Department of
Health.
The document National Good Practice on Pre-operative Assessment
for Day Surgery from the Modernisation Agency provides guidelines
for running pre-assessment clinics and suggested selection criteria
that have superseded those produced by the Royal College of
Surgeons in 1992.
NHS Estates have recently updated their building note HBN 26 that
covers facilities for surgical procedures and this, plus the Scottish
Health Planning on accommodation for day care (See Further
Reading), give good advice to those developing new facilities.
Selection of Patients
There are various routes for referral to day surgery: from hospital
outpatient clinics, from accident and emergency departments, from
Professionals Allied to Medicine and direct from general practice. The
exact mode of referral is unimportant as long as all adhere to agreed
protocols of patient assessment. There are no absolute criteria of
fitness for day surgery; however, it is important that the criteria are
agreed locally with the Department of Anaesthesia.
Assessment falls into two main categories:
(i)
Social
(ii)
Medical
Both of these are important. However, some of these factors are not
always easy to assess by the hospital doctor who has to rely on
healthcare professionals in the community to identify potential
problems.
(i)
Social Factors:
(a)
(b)
(c)
(d)
(b)
Pre-assessment
All patients should be seen in advance of their surgery by someone
trained in pre-assessment for day surgery. Consultant led, nurse run
pre-assessment clinics provide a suitable method to attain this; it is
agreed that trained nurses are more effective than newly-trained
doctors at such work. However such clinics afford an excellent
opportunity for training of medical students and trainee doctors. Preassessment is also an important time to start educating the patient
(and their carers) about their operation and postoperative care.
Most pre-assessment takes the form of completing a set of
questionnaires with a patient. (See Appendix 1). This can be done
face-to-face in a hospital clinic, on the telephone or by a GP in their
surgery. The answers given to the set questions generate appropriate
investigations according to pre-set protocols e.g. a patient of 55 years
of age who is being treated for angina will have an ECG if one has
not been performed recently. The NICE guidelines [4] for preoperative assessment can be used to determine what is appropriate
for each unit.
Arrangements should be put in place for all appropriate tests (e.g.
blood tests, ECG and X-ray referrals) to be carried out at the time of
the pre-assessment. There must also be a mechanism in place to
review all investigations undertaken.
In units where policies have been agreed with the local Primary Care
Team, requests for further testing or investigation may be made by
6
Documentation
Not every DSU needs to design its own assessment forms; there are
large numbers of these forms in existence in Great Britain and Ireland,
and throughout the rest of the world. Those about to start, or to update,
their practice should try to obtain as many of these forms as possible to
benefit from the experience of others. A specimen form is shown in
Appendix 1 and further examples are available from the British
Association of Day Surgery, BADS*.
Information documents should describe in plain English the day care
process. Documents should outline the pre-operative preparation,
including individual hospitals fasting regimens, what patients should
wear and bring to the hospital on the day, what to expect
postoperatively and how to communicate with those involved in their
care. The anaesthetic leaflets developed jointly between the Association
and the Royal College of Anaesthetists (RCA) may also be used.
It should be remembered that for reasons of education or ethnic
background not all patients or carers will be able to fully comprehend
written instructions. The Moser Report [5] has suggested that 1 in 5
adults in the UK are not functionally literate and in 2001, a report
commissioned by the Home Office [6] concluded that a considerable
proportion of the British South Asian and Chinese communities have
little or no ability in English. This means that communicating with them
requires the use of material in Mother Tongue. Hospitals serving
communities with large immigrant populations should take account of
this and either provide translations of their booklets or offer translating
services. All hospitals should have access to local translating services.
Protocols should be available for the patient to postpone and re-book
their procedure for medical or valid social reasons. Specific
information sheets, relating to the individual planned procedure,
should also be available for the patient to take home and read at
leisure. (See Appendix 2). Examples of this type of information are
available from BADS. All involved in the patients care should agree
about the information in such packages.
The British Association of Day Surgery can be contacted through its Administrative Officer, 35-43
Lincolns Inn Fields, London. WC2A 3PN. email: bads@bads.co.uk
Facilities
Care should be provided in a facility that is set aside for day surgery.
Ideally this should be purpose-built. Alternatively day surgery should
be practised in a dedicated area within the hospital. Simple, rapid
and effective exchange of information between hospital and
community personnel must be possible.
Information technology must be provided so that adequate audit of
all aspects of patient care can take place.
Many hospitals will be providing care for day patients, who require
anaesthesia, in specialised units e.g. ophthalmology, dentistry,
psychiatry, accident and emergency. It may not be appropriate to
centralise these services into one DSU but all such patients must
receive the same high standards of selection, preparation, perioperative care, discharge and follow-up.
Children experiencing day surgical care require all the facilities and
staffing that would be expected in any paediatric unit. Those who
practise day surgery for adults and children in the same unit must
ensure that their unit meets the guidelines outlined in Caring for
Children in the Health Services 1991. Just for the Day. National
Association for the Welfare of Children in Hospital, London (see
Further Reading).
It is crucial to remember that adult facilities are rarely appropriate for
paediatric practice. Many units may need to build and staff separate
preoperative, recovery and post-operative areas for children, or utilise
existing paediatric facilities within the hospital, to ensure optimal
care for this group of patients.
Individual units will have their own practices relating to catering
facilities for both patients and their carers. Facilities and staff must be
in place to provide appropriate food and drinks to both groups.
Management must invest adequate resources to facilitate all of these
potential challenges.
11
Anaesthetic Management
Day surgery anaesthesia should be a consultant-led service. However,
as ultimately 75 % or more of all elective surgery may be taking
place in day surgery, consideration should be given to education of
trainees as recommended by the RCA. This will require organised
training schedules and the provision of suitable cover - this is
especially true of stand-alone units.
Once a patient has been selected and fully prepared for day surgery,
decisions must be made for their anaesthetic management. The
Association of Anaesthetists standards on patient monitoring and
assistance for the anaesthetist should be applied [8, 9].
Each anaesthetist should develop techniques which permit the patient
to undergo the surgical procedure with minimum stress, maximum
comfort. Analgesia is paramount and must be long-lasting but
morbidity, such as nausea and vomiting, must be minimised. For
certain procedures (e.g. laparoscopic cholecystectomy), there is
evidence that following a standard anaesthesia and analgesia plan
minimises morbidity and increases the number of patients who are
able to be discharged. Anaesthetists should adhere to such clinical
guidelines where they exist.
Policies should exist for the management of postoperative nausea and
vomiting (PONV) and discharge analgesia. There is still insufficient
evidence to recommend the use of routine prophylactic anti-emetics
in day surgery practice except in certain patient groups. These
include those with a strong history of PONV and those undergoing
certain procedures e.g. laparoscopic sterilisation, laparoscopic
cholecystectomy and tonsillectomy. Motion sickness is another strong
predictor of potential problems after anaesthesia.
However, it is important that PONV is treated seriously once it occurs
and a standard management protocol can aid the anaesthetist, the
nursing staff and the patient. (See Appendix 3).
12
Some audits suggest that the routine use of intravenous fluids can
enhance the patients feeling of wellbeing.
Prescribing discharge analgesia should be the responsibility of the
anaesthetist and each DSU should set up an agreed system with their
Department of Anaesthesia and pharmacy. There should be a choice
of analgesic regimens to allow the anaesthetist to deal with those
who cannot tolerate certain drugs (e.g. NSAIDs) and to deal with the
range of operations performed on the unit. (See Appendix 4).
13
Regional anaesthesia
Peripheral nerve blocks can provide excellent conditions for day
surgery. Patients may be discharged home with residual sensory or
motor blockade, providing the limb is protected and assistance is
available for the patient at home. The expected duration of the
blockade must be explained and the patient must receive written
instructions as to their conduct until normal power and sensation
returns. The provision of oral analgesics to be taken as the local
anaesthesia begins to wear off and then subsequently on a regular
basis must not be forgotten.
Central neural blockade can also be used for day stay surgery.
Residual blockade after spinal or caudal anaesthesia may cause
postural hypotension or urinary retention despite return of adequate
motor and sensory function. These problems can be minimised by the
choice of local anaesthetic agent used (e.g. lidocaine) or more
commonly in the UK by the use of low dose local anaesthetic opioid mixtures.
Pflug et al. [14] suggested criteria to be met before attempting
ambulation:
Return of sensation in the perianal area (S4-5)
Plantar flexion of the foot at pre-operative levels of strength
Return of proprioception in the big toe
Patient not sedated or hypovolaemic
Concerns about post dural puncture headache (PDPH) have limited use
of spinals in day stay patients in the past, but the use of smaller gauge
and pencil-point needles has reduced the incidence to less than 1%.
More and more units in the UK are now adopting subarachnoid blocks
as a preferred technique. Information about PDPH and what to do if
this occurs should be included in the patients discharge instructions as
well as the provision of alternative analgesics.
Further information on the use of spinal anaesthesia in day surgery
and examples of patient information leaflets can be found from the
BADS handbook Spinal Anaesthesia [15].
16
Postoperative Instructions
All patients should receive verbal and written instructions on
discharge. They should be warned of any symptoms that they might
experience during the first 24 postoperative hours. They should be
discharged home with a supply of appropriate analgesics, a list of
possible side effects and instructions in their use. Regular dosing with
analgesics for the first 48 hours may be preferable to on demand
dosing. A list of proprietary drugs that should not be taken should be
included e.g. paracetamol if the patient has been prescribed cocodamol.
The patient should be advised not to drink alcohol, operate
machinery or cook until the following day. The Royal College of
Surgeons guidelines in 1992 recommended that no one should drive
for 48 hours based on work with driving simulators. Recent research
suggests that, from an anaesthetic point of view, avoiding driving for
24 hours is sufficient [16].
Guidance should be given as to when sutures should be removed,
together with any specific instructions relating to the surgical
procedure. A specimen leaflet is shown in Appendix 2.
In the event of a problem, the patient must know where help or
advice can be found. A list of contact telephone numbers should be
supplied. Wherever possible these instructions should be given in the
presence of the responsible person who is to escort and care for the
patient.
17
Discharge Summary
It is essential to inform the patients GP of the nature of the
anaesthetic and surgical procedure performed and of the patients
discharge. This may be by letter, facsimile or by email. However,
whichever method is chosen it must be by a secure method of
transmission and approved by the local Caldicott Guardian.
DSUs must agree with their local Primary Care Teams how back-up is
to be provided for patients in the event of problems. Most units
currently run a help-line for the first 24 hours post discharge and
telephone the patient the next day to ensure their well-being.
Telephone follow-up is highly rated by patients and can be a useful
method of auditing any immediate problems. It is important that
discussion does take place with the Primary Care Team as changes in
the provision of out of hours Primary Care may lead to the need to
extend hospital-based support.
18
Audit
Effective audit is an essential component of good day stay
anaesthesia. The majority of patients can be discharged home after
day stay surgery but careful recording of admission rates is helpful.
Re-admission to hospital after day stay care is often cited as an
important index of a standard of care but is rarely an accurate
measure as patients may be admitted to other hospitals and thus lost
to audit.
Discharge of the patient from the DSU to the home is not the only
adequate measure of success for day surgery. Unless it can be
demonstrated that a patient is comfortable at home, with minimum
morbidity, no conclusions can be made.
There have been a variety of tools developed to determine these
results. Special questionnaires can be completed by patients and
returned to the day unit. These are notoriously inaccurate and
response rates can be very low (often below 40%). The majority of
such questionnaires are self-fulfilling or so complex that patients are
unable to complete them effectively. Conclusions drawn from such
audits are often wildly optimistic in nature. Pain, nausea, tiredness
etc. are difficult to quantify and mean different things to different
people. Phrases like severe or unacceptable pain cannot be
compared with any standard measure and should be avoided.
Telephone questionnaires have the same drawbacks, and in addition
are time consuming and often fail to reach all patients.
Many units have a telephone hot line, usually a mobile phone,
which patients may ring to obtain further advice after hours. The
details of these calls can provide useful information.
Even when data are collected it is usually difficult to correlate them
with the detailed anaesthetic record and the personnel involved with
the care wherever possible units should strive to link such results to
their electronic patient record.
19
20
Contractual Arrangements
Day surgical care is no different to any other form of hospital activity
in terms of its contractual arrangements. Theatre and ward work is
similar wherever it is performed and should be recognised as such in
any job plan both for new and old style contracts.
Pre-operative assessment is a vital aspect of such work and should be
acknowledged as such.
Clinical Leads or Directors in Day Surgery should have an increase in
their Patient Activities (PAs) to reflect the workload of this post.
21
22
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
23
12.
13.
14.
15.
16.
Further Reading
Association of Anaesthetists of Great Britain and Ireland 2001.
Pre-operative Assessment The role of the Anaesthetist.
Audit Commission 1990. A shorter cut to better services. Day
Surgery in England and Wales. HMSO, London.
Audit Commission 1991. Measuring quality: the patients view of
Day Surgery. HMSO, London.
Audit Commission 1992. All in a days work: an audit of Day
Surgery in England and Wales. HMSO, London.
Cahill CJ. Basket cases and trolleys day surgery proposals for the
millennium. The Journal of One-Day Surgery 1999;9(1): 11-12.
24
Caring for children in the Health Services 1991. Just for the Day.
National Association for the Welfare of Children in Hospital, London.
Day Surgery, Acute Hospital Portfolio, review of national findings.
Audit Commission 2001.
Day Surgery Follow-up Progress against indicators from A Short Cut
to Better Services. Audit Commission 2001.
Fundamentals of Anaesthesia & Acute Medicine Series. Day Care
Anaesthesia.
Editor Ian Smith. BMJ Publishing. 2000.
Getting the right start: National Service Framework for Children.
Standard for Hospital Services. Department of Health. 2003.
HBN 26 Facilities for surgical procedures. Volume 1. 2004. The
Stationary Office.
Scottish Health Planning Note 52 accommodation for day care. 2001.
National Health Service Management Executive, Value for Money
Unit 1991. Day Surgery: Making it happen, HMSO, London.
Wilkinson D J. Modern Day Surgery in Anaesthesia Review 10.
1993. Editor Leon Kaufman. Churchill Livingstone, London.
National Good Practice Guidance on Pre-Operative Assessment for
Day Surgery. Operating Theatre & Pre-operative Assessment
Programme. Modernisation Agency.
Practical Anaesthesia & Analgesia for Day Surgery. JM Millar, GE
Rudkin & M Hitchcock. 1997. BIOS. Oxford.
Ready for Discharge. British Association of Day Surgery Handbook
Series. 2002.
A Guide to Good Practice Day Surgery in Wales, Innovations in
Care Team, Cardiff 2004.
25
FAQ
Should all my patients be able to eat and drink prior to discharge?
Although most patients should be able to eat and drink before
discharge, not all will want to. It has been shown that too aggressive
introduction of oral intake may provoke nausea and vomiting.
Provided patients are warned of the possibility of dehydration and
given advice on what to do if they cannot keep anything down, it is
not necessary that they eat and drink before discharge.
Is there an upper BMI limit for day surgery?
The incidence of complications during the operation or in the early
recovery phase increases with increasing BMI. However, these
problems would still occur with inpatient care and have usually
resolved or been successfully treated by the time a day case patient
would be discharged. In addition, obese patients benefit form the
short-duration anaesthetic techniques and early mobilisation
associated with day surgery. Consideration should also be given to
the overall fitness of the patient and the impact of the procedure
being undertaken. It is also important to have the appropriate
equipment, personnel and time available especially when
considering moving, positioning and the first stage recovery of these
patients.
There are probably no absolute limits, but late complications are
more likely when the BMI exceeds 40 Kg/m2. Those taking an
interest in this area can still look after these patients successfully.
What advice should I give about driving?
The residual effects of general anaesthesia could make driving unsafe
and patients having a general anaesthetic should be advised not to
drive for about 24 hours. Similar advice is often given to patients
receiving sedation. More importantly, patients should not drive until
the pain or immobility from their operation allows them to safely
control their car and perform an emergency stop. This may take
several weeks, for example, following an open inguinal hernia repair.
26
27
Appendix 1
An example of a preoperative screening assessment for patients who
are being considered for day case surgery as used by the University
Hospital of North Staffordshire.
Will you:-
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
DATE COMPLETED
/
YES
NO
at rest or at night)...
YES
NO
YES
NO
If so, when?
asthma...
YES
NO
bronchitis...
YES
NO
at rest
YES
NO
YES
NO
on lying flat
YES
NO
heart murmur...
YES
NO
on exertion
YES
NO
rheumatic fever...
YES
NO
on climbing stairs
YES
NO
convulsions or fits...
YES
NO
YES
NO
YES
NO
YES
NO
NO
hepatitis...
YES
YES
NO
diabetes...
YES
NO
arthritis...
YES
NO
If yes, is it:
diet controlled
tablet controlled
or weakness...
deep vein thrombosis or blood clot in lungs (PE)...
YES
NO
YES
NO
swollen ankles...
YES
NO
YES
NO
YES
NO
28
insulin controlled
...........................
...........................
...........................
Heart rate.......................................................
...........................
Crowned teeth
Hearing aid
Pacemaker
Contact lenses
Do you:
take any regular medicines
YES
NO
smoke (cigarettes/pipe)?..
YES
NO
YES
NO
YES
NO
4.......................................
5.......................................
or 3 shorts a day?...
use any drugs recreationally?...
GA / SPINAL / LOCAL
2..................................................
GA / SPINAL / LOCAL
3..................................................
GA / SPINAL / LOCAL
4..................................................
GA / SPINAL / LOCAL
5..................................................
GA / SPINAL / LOCAL
29
TO BE COMPLETED BY SURGEON
REMARKS:
PROPOSED OPERATION:
CHECK LIST:
LA / GA
TTOS
INVESTIGATIONS COMPLETED
FBC U/E CXR PFT ECG OTHERS
WARD...................
30
Appendix 2
Example patient information sheet
31
Appendix 3
Management of the patient with postoperative nausea/vomiting.
Group 1 Patients with mild/moderate nausea
Patients will be given a single dose of antiemetic.
Cyclizine 50 mg slowly iv If have already had cyclizine then
Dexamethasone 8 mg slowly iv
Group 2 patients with severe nausea or are vomiting
Give patient 1 litre of Hartmanns over 1 hour (unless
contraindicated)
Administer cyclizine 50mg slowly iv (exclude this if has already
received a dose in recovery)
Administer dexamethasone 8mg slowly iv
Review patient at 1 hour, if still experiencing nausea and vomiting
then administer Granisetron 1mg IV
Following this, patient should be reassured that all measures have
been taken and asked whether they wish to go home or remain in
hospital overnight. It should be explained that this is a self limiting
side effect and that no further active treatment will be possible.
Policy from Day Surgery and Treatment Unit, York Hospitals NHS
Trust
32
Appendix 4
Oral Analgesia Prescription for Adult Patients
Day Surgery and Treatment Unit
Patient label
Consultant
Please prescribe oral analgesia for patients on this form. 4 choices are
provided for analgesia depending on expected severity of discomfort
following the operation. Non standard analgesia regimes may still be
prescribed on the patients discharge letter on the few occasions this should
be necessary. Each patient will receive 1 standard day unit pack of the
drugs prescribed.
Minor
Drug
Co-codamol 8/500
Dosage
2 tablets 4 - 6 hourly
Signature
Intermediate
Drug
Diclofenac (Voltarol)
Dosage
50mgs 8 hourly
Signature
Codydramol
1 - 2 tablets 4 - 6 hourly
Major
Drug
Diclofenac (Voltarol)
Dosage
50 mgs 8 hourly
Co-codamol 30/500
1 - 2 capsules 4 - 6 hourly
Signature
Dosage
1 - 2 capsules 4 - 6 hourly
Dispensed by...................................
Signature
Checked by...................................
Policy from Day Surgery and Treatment Unit, York Hospitals NHS Trust
33
Appendix 5
Modified Aldrete Score
Activity can move voluntarily on command
4 extremities
2 extremities
0 extremities
2
1
0
Respiration
Able to deep breathe and cough freely
Dyspnoea, shallow, or limited breathing
Apnoea
2
1
0
2
1
0
Consciousness
Fully awake
Rousable to speech
Not responding
2
1
0
O2 saturation
Maintains O2 saturation >92% on room air
Needs O2 supplement to maintain SpO2 > 90%
O2 saturation <90% even with O2 supplement
2
1
0
34
Appendix 6.
An example of discharge criteria following day case surgery as used by
Kings Lynn and Wisbech Hospitals.
DISCHARGE ASSESSMENT CRITERIA DISCHARGE ARRANGEMENTS
YES
NO
YES
NO
Wound checked
Venflon removed
ECG stickers removed
Passed urine, clear /
(if applicable)
Comments:
Transport
Help line number given
out of hours & unit number
Seen by physio
Block/spinal leaflets given
Notes
36