Day surgery: Widening the selection criteria!
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Transcript of Day surgery: Widening the selection criteria!
Day surgery:Widening the selection
criteria!Dr. Rowan Thomas
MBBS FANZCA MPH
What are the selection criteria? Should the criteria be changed?
(A sociological perspective) How can it be changed?
(A policy perspective) The importance of follow up and outcome
review
Introduction
Tertiary referral HospitalDay of surgery discharge not high – 25-30%Australian average 60%
Economic or utilitarian drivers. Lower morbidity Faster mobilisation and recovery Able to be with family Free up resources for other health care
areas
Why Day surgery?
Two components. Day of surgery arrival (DOSA) + Early discharge
DOSA requires:◦ Optimisation of co-morbidities and medications◦ Early assessment, communication and consent◦ Timely arrival and fasting
Early discharge requires:◦ Good pain management◦ Resolution of unwanted effects of anaesthesia◦ Good social supports◦ Adequate time to assess surgical complications
Is “Day surgery” care different?
Pain (Not enough analgesia?) Nausea (Too much opioid?) Bleeding Unstable co-morbidity Incapable of self care
What stops people going home?
Minimally invasive techniques are widening the range of possible surgeries
Minimal risk of post-operative Haemorrhage Minimal risk of post operative airway
compromise Pain controllable by outpatient techniques Post-operative care that can be managed by
a responsible adult or home nursing facilities A rapid return to normal fluid and food intake
ANZCA Policy PS15
Surgical requirements
A willingness to have the procedure performed and an understanding and an ability to follow instructions
Patient’s place of residence within one hour’s travelling time from medical attention
ASA I or II. Stable ASA III or IV. Careful consideration for higher ASA grades.
Infants and children where associated paediatric facilities and experience exist. Should be older than 6 weeks (normal term) or greater than 52 weeks post-conceptual age if premature (< 37 gestation)
ANZCA Policy PS15
Patient requirements
A responsible person able to transport the patient home in a suitable vehicle.
A responsible person staying at least overnight with the patient.
Ensuring that the patient understand the requirements of post-anaesthetic care in regard to public safety.
The patient stay within one hour of medical attention until one day after surgery.
Ready access to a telephoneANZCA Policy PS15
Social requirements
Unstable ASA III or IV. Eg. Brittle diabetes, unstable angina, symptomatic asthma.
Morbid obesity with haemodynamic or respiratory problems
Drugs: Monoamine oxidase inhibitors or acute substance abuse esp. Cocaine.
Ex-prem infants <52 weeks post-conceptual age.
Lack of responsible adult at home to transport and care for the patient.
Contraindications to Day Surgery
Sleep apnoea Morbid obesity Elderly Malignant Hyperthermia susceptibility Anaesthetic technique – regional and
neuraxial.
Selection controversies?
Or the application of the criteria?
Is it the selection criteria that should be widened?
Greater use of regional techniques and local anaesthetic infusion catheters at home.
Better use of analgesic adjuncts. 23 hour stay units Available inpatient back up facilities Mobile day surgery Surgical techniques
◦ Laparoscopic and Robotic surgery Better management of co-morbidities
The future: what can be changed that may affect selection criteria?
Structural Functionalism Society combines to create a
homeostatic system. A change in one part creates or determines a corresponding change in another.
Also famous for describing the doctor-patient relationship and the ‘sick role’. The development of day surgery is the opposite to the traditional role he described.
Talcott Parsons
Structural functionalism
Every order or change in order will present a struggle between the proletariat (workers) and the bourgeoisie (capitalists).
Exploitation and alienation of the lower class will be hidden, but present in every economically motivated ideology.
Karl Marx
Legitimate authority: Charismatic, Traditional and Legal-rational.
Local charismatically led systems grow into bureaucracies with Legal-rational lines of authority and responsibility
Widening selection criteria may be possible at a local level, however a greater economic impact is possible when systems are developed to establish large scale change, requiring bureaucratic models to develop.
Weber
The “care system” must be looked at as a whole
Greater support, good information and consistent expectation will lead to a wider range of day surgical options
Wider criteria = comprehensive support
Distance from hospital Pain management routines Nausea management routines Preoperative optimisation and information Nursing in the home A number to call A telephone Capacity of family Ability to admit for social reasons 23 hour wards.
Supports
Policy development Consultation Iteration Description Change through agreement, commitment
and ownership.
How can the application of the criteria be changed?
Patients Government and other funding bodies Hospital administration Surgeons Anaesthetists Nurses Other Health providers
Stakeholders
Risk is difficult to evaluate on a small sample
RCTs are not appropriate for low risk outcomes
Registries and databases are being created to collect and audit outcomes from medical interventions. ◦ NSAS – National Survey of Ambulatory Surgery
www.cdc.gov/nchs/nsas.htm
Measuring what we do
Society of Thoracic Surgery: National Cardiac Surgery databaseAmerican College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP)Centre for Disease Control and Prevention – National survey of Ambulatory surgery.
Registries of clinical care -some examples
snap shot of aurora
Applying the criteria more widely is probably our actual challenge.
Selection criteria applied more widely through:◦ Technology – surgical, anaesthetic, pain
management, outcome data collection◦ Community support◦ Secondary supports, i.e. inpatient services back-
up◦ Thoughtful, local policy development◦ Measuring outcomes
Summary
Change can be difficult and it may not be right in every situation.
There are patient, surgical and social factors that need individual consideration.
Supports in the community vary from region to region.
We need to monitor, audit and evaluate outcomes to assess the work we do, because our goal of safety and comfort extends beyond the operating room, it needs to extend into the home as well.
Summary