Principles of Day Case Surgery

Principles of Day Case Surgery • A procedure where the patient is discharged within the same day or within 24 hours of their procedure. • • • Advantages: - Improves productivity. - Increases theatre utilisation. - Reduces surgical waitlists. - Shorter inpatient stays - Reduced risk of hospital acquired infections. - Reduces waiting lists. - Reduced hospital costs. - Reduced demand for inpatient beds. - Promotes early mobilisation and faster return to baseline performance in daily activities. Selection guidelines: - The decision is up to the anaesthetist. - Surgery and procedure considerations. - Selection of patients and anaesthesia considerations. - Recovery (PACU) and discharge arrangements. - Adequacy of resources, including personnel of the day stay procedure (DSP) of the facility. - Geographic location of the DSP facility -> rural vs city. - Type of facility -> free standing ot co-located/in close proximity to tertiary/quaternary hospital. Patient selection: - Patient should be ASA physical status of 1 or 2 or medically stable ASA 3 or 4. ✓ Physical status alone does not indicate acceptability, as this will also be influenced by surgical/procedural factors of the DSP unit. - Must be weighed against optimal management of comorbidities. - Early consultation with the anaesthesia is required. - Careful assessment of medical comorbidities: ✓ Allergies ✓ OSA and difficult airways, especially for obese patients. Patients with confirmed or suspected OSA should have minimal post-operative opioid requirement and ideally discharge analgesia should not include opioids, as they cause respiratory depression. Maximum acceptable weight for a facility will be determined by factors including mechanical rating of equipment and fixtures to allow safe manual handling, care of the patient and transport within the DSP facility. - Patients with cardiac implantable electronic devices (CIED) should have the devices checked to ensure correct functioning. - Infants and children are suitable provided specific arrangements for their treatment are made. • • Surgical/procedural considerations. - Have a minimal risk of post-operative haemorrhage. - Have a minimal risk of post-operative airway compromise. - Be amenable to post-operative pain controlled by outpatient management techniques. - Permit post-operative care to be managed by the patient and/or a reasonable adult and any special post-operative nursing requirement met by day surgery, home or district nursing facilities. - Be associated with a rapid return to normal fluid and food intake. - Be scheduled taking into account the anticipated recovery period. Where a prolonged recover anticipated the procedure should be scheduled first on the list or as close as the first as feasible. Post-anaesthesia criteria to be satisfied for discharge. - Stable vital signs - Conscious state that is similar to pre-anaesthesia levels. - Mobility level that is similar to pre-anaesthesia levels with allowance for type of surgery and/or regional anaesthesia techniques. - Adequate pain control. - Manageable nausea, vomiting or dizziness. - Tolerating oral fluids, - Minimal bleeding or wound drainage. - Patient at significant risk of urinary retention (central neural blockade, pelvic and other surgery) should have passed urine. - Written and verbal instructions for all relevant aspects of post-anaesthesia and surgical care have been provided to patients or their accompanying adult. ✓ They should be made to understand what post anaesthesia care is required and they intent to comply with these requirements, especially those relating to public safety. ✓ A contact place and number for emergency medical care should be included. - Patients have received advice as to when to resume activities such as driving and decision making. - Analgesia has been provided where necessary, with clear written instructions on how and when medications should be used. ✓ Careful consideration when prescribing opioids. - Advice has been provided on resumption of other regular medications. - Discharge has been authorised by a member of the medical team or trained nurse after discharge criteria has been satisfied. - A responsible adult (physically and mentally able to) for transport of the patient is required and they should be available to stay with the patient at least overnight of the day of discharge. ✓ Bus, tram or train are not suitable. - If the patient has to be transferred to an inpatient facility, the anaesthetist and/or the surgeon will be responsible for the patient until care has been transferred to another medical officer. Summary of what to do. • • • Before surgery: - Patient assessment and education - Safety risk assessment - Early identification and escalation of patient concerns to surgeons. - Scheduling theatre list and arranging follow-up care. - Optimisation and prehabilitation services. - Coordination of discharge support and a follow-up care plan, including a criterialed discharge pathway. Day of Surgery - Contact person for carer and patient - Documentation as per local care pathways - Monitoring and updating the follow up care plan. On discharge - Early identification and escalation pf patient concerns to surgeon. - Patient and carer education (e.g. mobility, medications, equipment). - Activity of daily living equipment provision as indicated. - Assessment and management for functional rehabilitation goals. - Contact person for carer and patient - Care coordination and onward referral as indicated.