DAYCARE SURGERY

Definition History Objectives Advantages Function Infrustructures Barriers Steps Assessment Selection criteria

CONTENTS…

Day care surgery is defined as scheduled surgical procedures provided to patients who do not require hospital stay overnight. It is a process of care by which suitable patients are managed with admission, treatment and discharge on the same day.

Definition..

Day care surgery ……

◦ diagnostic and therapeutic procedures

◦Under local, regional, or general anaesthesia,

◦do not carry the risk of post-operative complications but require a period of

observation in the hospital.

The earliest reference for day care surgery is mentioned as early as the beginning of the 20th Century by James Nicoll, a Glasgow surgeon who performed almost 9000 outpatient operations in children in 1903. Later, in 1912, Ralph Waters from Iowa, USA, described “The Down Town Anaesthesia Clinic”, where he gave anaesthesia for minor outpatient surgery.

History..

Rising healthcare cost Emphasis on evidence-based practice Rising patient expectations

Prof Girish Premji Joshi, University of Texas, Southwestern Medical Centre, Dallas, USA

Why Daycare?

Historically in the Ministry of Health, prior to 1987, day care procedures and day surgeries across the various disciplines were conducted at different facility locations within a hospital ranging from operation theatres, wards, specialist clinics, emergency department etc.

In 1987 the first dedicated Ambulatory Care Centre (ACC) project was in Hospital Ipoh.

◦reducing surgical waiting time to 2 – 10 weeks for selected elective procedures

◦reduction of inpatient admissions to the

surgical based departments by 28.2% .

To reduce waiting time for elective surgery To reduce inpatient admission To make surgery convenient and

comfortable for the patient To reduce disruption of personal lives To reduce hospital-acquired infection To encourage early recovery and

mobilization in a home environment with their family

To reduce cost of surgery

Objectives..

ADVANTAGES

Patient-centred Patient recovers in familiar environment Reduces complication Early return to daily living Reduce cost

Prof Girish Premji Joshi, University of Texas, Southwestern Medical Centre, Dallas, USA

Patients’ advantages

No last minute cancellation Increase bed availability Hospital can grow inpatient services Outpatient centre has greater efficiency &

cost-effectiveness (increase throughput) Health care cost reduction (25-75%)

Prof Girish Premji Joshi, University of Texas, Southwestern Medical Centre, Dallas, USA

Hospital/ Physician oriented

FUNCTIONS

provided in an integrated set-up using either the existing operating theatres or a dedicated ambulatory care facility or day care unit

admitted, operated and discharged on the same day.

standard of care shall be the same as for inpatients. from 8 am to 5 pm on weekdays

specialist based.

Patient and procedure selection criteria shall be strictly adhered to.

Function…

Effective preoperative preparation with clear verbal and written preoperative instruction.

Anaesthetic consent .

Each anaethesiologist shall develop techniques that permit the patient to undergo the surgical procedure with minimum stress and maximum comfort, and optimize chance of early discharge.

Fitness for discharge shall be protocol-driven, doctor-led discharge which is fundamental to safe and effective day care surgery. There should be clear written post-operative instructions.

discharge criteria - free from surgical and anaesthetic complication (e.g inadequate recovery)

Each day care surgery unit shall have a consultant anaesthesiologist with specific interest in day care surgery and whose remit includes development of local policies, guidelines and clinical governance.

good quality patient information for both patient and accompanying person/ family.

Effective audit is an essential component of quality care for any day care anaesthesia service.

clear documentation of anaesthetic care and recovery process

1) Location

-provided in an integrated set-up existing operating theatres, dedicated operating theatres/unit or a free standing dedicated ambulatory care facility.

-The unit should have a separate entrance and exit to the main road with ample parking space.

Infrastructure

2) Facilities Registration counter Waiting room Assessment room Changing rooms Procedure rooms Pre and post- operative wards Operating theatres Recovery room Pharmacy

3) Staffing

A consultant Anaesthesiologist, with special interest in day care surgery, shall be responsible in developing protocols, policies, audit and clinical governance.

Anaesthesiologists Medical Officers Nursing Manager/Sister Theatre Scrub Nurses General Anaesthetic (GA) nurses Ancillary staff Recovery Ward Nurses

Barriers

Barriers Failure to recognize daycare surgery as

priority- clinician’s preference- patient’s attitude

Lack of financial incentives Lack of specialized facilities Poor management and organization of

outpatient surgery unit

Prof Girish Premji Joshi, University of Texas, Southwestern Medical Centre, Dallas, USA

STEPS…

Patient Assessment

Preoperative Assessment preferably at least 2 weeks before the procedure date◦ to ensure adequate time to correct any

abnormalities ◦ allow the patient to be adequately informed and

prepared for surgery◦ reduces cancellations and failure to attend

.

Assessment should be based on social and medical criteria and agreed with the Anaesthesiology Department.

initial screening by the Surgical Team

Patient’s◦ medical and social history, ◦ clinical assessment◦ blood Ix (if indicated)◦ radiographic investigations

should be performed prior to advising patient for day surgery to ensure patient fitness for surgery and anaesthesia

Patients suitable for day surgery will be referred to the anaesthetic team for further assessments ◦ appointment should be made with the

Anaesthetic Clinic ◦ pre-operative assessment ◦ to determine suitability for day care surgery

Selection Criteria and Suitable Procedures For ACC (adopted from Penang Hospital)

When patients are referred for day surgery in ACC, it is essential to ensure that

the procedure is suitable risk of complications (from surgery and

anaesthetic) are minimised Admission to an in-patient bed following

day surgery is prevented Patients are adequately supported after

discharge home.

I) Patient Criteria

II) Social Criteria

III) Surgical Criteria and Proposed Suitable Procedures

I) Patient Criteria a) Health Status:

◦ ASA 1 and 2 ◦ ASA 3 can be selected after consultation with the

anaesthetic team provided their disease is well controlled.

B) Age Limits: - > 75 years and < 6 months should not

be selected.c) Physical Factors:

- no obvious difficult airway features - BMI < 35 kgm-2.

II) Social Criteria Patients/parents must be willing to

cooperate and able to understand, comply and cope with post-procedural instructions after receiving adequate information and an opportunity to discuss any anxieties.

Escort: who is responsible for patient’s care and able to accompany patient home and supervised their recovery at home for a minimum of 24 hours. ◦ In children, two responsible people should

accompany a child home – one to drive the car and the other to care for the child.

Transport: Suitable transport must be available to transport patient home post surgery and also to come back to the hospital in event of emergency. ◦ Travel on public transport or motorcycles following

a general anaesthetic are inappropriate.

Geography: Patients should live within 1 hour travelling distance from hospital.

Social Support: patients must have access to telephone services readily available at all times.

III) Surgical Criteria

Simple surgery < 90 minutes. minimal risk of postoperative complications e.g.

haemorrhage or airway compromise.

minimal postoperative pain that can be controlled by simple analgesia.

No special postoperative nursing required post surgery.

Patient would not have prolonged immobility after the

procedure.

Rapid return of normal food and fluid intake possible after the procedure

Suitable Procedures For Day Surgery In ACC (adopted from Penang Hospital)

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